Tag Archives: Prevention

How can lung cancer screening be enhanced?

More people die from lung cancer globally than any other form of cancer. The disease is expected to kill over 154,000 people in the United States alone in 2018. Most recent reports about treating lung cancer have focused on innovative treatments around immunotherapy. But an alternative form of disease management exists that has been getting press attention: catching the disease early via CT scan.

Jim Mulshine, a thoracic medical oncologist by training who spent 25 years at the National Cancer Institute, and Bruce Pyenson, a consulting actuary at Milliman, sat down for a Q&A to discuss lung cancer and provide a medical and actuarial take around finding lung cancer early via CT scan.

In this Q&A, Mulshine, now at Rush University Medical Center, and Pyenson discuss the prognosis and progression of lung cancer, various treatments for the disease, including CT screening, and what future treatment could look like.

Ambulatory care: Measuring quality and the impact of nursing

Jones-PattyThe shift of medical care from the inpatient to outpatient setting coupled with the emphasis on transformative designed patient-centered medical home models provides measurement challenges and opportunities. The challenges are how to effectively measure quality in this setting given the range of services that are provided—from routine preventive care to complex surgical and invasive procedures. The concurrent opportunity is to measure and promote the role of nurses in providing and leading the care and coordination services that are at the core of ensuring improved patient experiences and outcomes in the outpatient setting.

Table 1: Percentage Share of Inpatient vs. Outpatient Surgeries (1988-2008)[1]

Ambulatory Care  Measuring Quality and the Impact of Nursing

Table 2: Trends in Inpatient and Outpatient Utilization (1987-2007) [2]

Ambulatory Care  Measuring Quality and the Impact of Nursing 2

Professional nursing associations have taken notice of these trends and are accelerating the effort to improve the measurement of both quality and nursing impact in the ambulatory setting. In January of this year the American Nurse Association (ANA), American Nurses Credentialing Center (ANCC), and American Nurses Foundation (ANF) hosted the Ambulatory Measurement Summit. This meeting, and the work leading up to the summit, involved 40 nursing leaders representing stakeholders in national/specialty nursing organizations, payors with delivery systems, measure developers (including Milliman), delivery systems, and payors.

The charge to this group was to come to consensus on five existing measures that warranted further investigation and potential adaptation as an ambulatory nursing measure. Participating in this exercise with this impressive set of nursing leaders representing a wide range of interests, I was struck by several observations:

• There is a clear need to develop outpatient measures that go beyond preventive and chronic care and address other quality concerns. Ambulatory care (especially procedure-based care) involves complex services with risks and consequences that are not well addressed by today’s measures of processes such as immunization and screening rates.
• There is a continued opportunity to pilot new measures of coordination. There is clear recognition that the new value to consumers (and opportunity for nursing) will be the ability of the healthcare system to help them successfully move from one service to another and it will take innovative minds to design these measures.
• It is hard to measure the impact of nursing independent of other factors. As you examine specific measures it is difficult to claim nursing as the driver of performance in that measure but perhaps this serves to emphasize even more that healthcare involves teams and ultimately identify that nursing remains a key part of that team.

At the close of the summit the attendees reached consensus on five nationally endorsed measures, as having high relevance to nursing impact:

1. Medication reconciliation (NQF #0097)
2. Controlling high blood pressure (HEDIS measure)
3. Depression assessment conducted (NQF #0518)
4. Pain assessment and follow-up (NQF #0420)
5. All-cause readmissions (NQF #1768)

The next step will be for the ANA and the National Database of Nursing Quality Indicators® to undertake further review of the five consensus measures for possible refinement and testing for use within the ambulatory setting. We will watch this initiative closely as we refine Milliman’s measurement tools to fully reflect the changes underway in the healthcare system, as well as the role of stakeholders such as the nursing profession, and to improve the ability to measure the impact of these changes.

[1] Frakt, Austin (October 2010). Inpatient vs. outpatient surgeries. The Incidental Economist. http://theincidentaleconomist.com/wordpress/inpatient-vs-outpatient-surgeries
[2] Johnson, Tracy K. (May 2010). Ambulatory care stands out under reform. Healthcare Financial Management. http://www.hss-inc.com/healthcare-report/ambulatory-care-stands-out-under-reform.pdf

This article first appeared at Milliman MedInsight.

Preventive care: Colonoscopy screening and comparing costs

Bates-DougAccording to the 2008 U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening for colorectal cancer, colorectal cancer is the second-leading cause of cancer death in the United States and appropriate screening could save thousands of lives a year.

The USPSTF recommends colorectal screening for everyone between 50 and 75 years of age. There are several screening tests currently available and modeling conducted by the USPSTF suggests that any of three screening programs would be “equally effective in life-years gained, assuming 100% adherence to the same regimen for that period”:

1. Annual high-sensitivity fecal occult blood testing
2. Sigmoidoscopy every five years combined with high-sensitivity fecal blood testing every three years
3. Screening colonoscopy at intervals of 10 years

Although other screening programs are less expensive and less invasive, and effectiveness is dependent upon the experience and expertise of those performing the procedure, well-performed colonoscopies were assessed to have higher sensitivity and specificity for detecting colon cancer. This finding, along with Medicare and the Patient Protection and Affordable Care Act (ACA) mandating no cost-sharing for colonoscopies and increased public awareness, has greatly increased the number of colonoscopies performed each year.

As the number of colonoscopies performed has increased, so has the variance in total cost for the procedure. Allowed charges can vary by thousands of dollars depending on the provider, place of service, and other variables. Monitoring utilization and evaluating the charges for these procedures has become increasingly important for health plans striving to improve health while managing costs.

The 2013 version of the Milliman Health Cost Guidelines™ (HCG) grouper includes separate detail lines to track utilization and cost of facility, as well as professional costs associated with preventive colonoscopy.

Using illustrative data from three health plans, allowable charges and utilization counts for facility and professional services associated with preventive colonoscopy are shown in Figures 1 and 2 below. These data include claims for patients between the ages of 50 and 75. HCG 051b represents outpatient facility services and HCG P40b represents professional services for a preventive colonoscopy. Note that there could be related services submitted on separate claims that are not captured in these totals.

Colonoscopy Screening (1)

Utilization units are counted separately for the facility and professional services. The utilization count associated with professional services represents the total number of preventive colonoscopies because some procedures will be provided in an office setting and will not have a separate facility record.

To compare utilization rates and average allowable charges for preventive colonoscopies across the three plans, sum the allowable charges for both HCG detail lines but use only the professional unit counts to avoid double-counting of procedures, as shown in Figure 2.

Colonoscopy Screening (2)

This simple analysis compares the cost and utilization of preventive colonoscopies across three plans, but additional analyses comparing costs across places of service (e.g., office, ambulatory surgery center, and outpatient hospital) provide further insights into cost drivers associated with these procedures.

This article first appeared at Milliman MedInsight.

Lung cancer screening reading list

Milliman’s actuarial research has played a key role in the establishment of an evidence-based case for lung cancer screening. The announcement by the U.S. Preventive Services Task Force (USPSTF) stating it will now recommend lung cancer screening for certain high-risk populations follows a series of actuarial studies that helped make the value case for such screenings.

The following reading list highlights the actuarial research and also provides links to other lung cancer-related content.

An actuarial approach to comparing early stage and late stage lung cancer mortality and survival (subscription required)
This actuarial analysis of lung cancer mortality published in Population Health Management provides evidence that early detection of lung cancer generates genuine mortality reductions not associated with lead time bias, and therefore could reduce late stage deaths by over 70,000 people in the United States each year.

An actuarial analysis shows that offering lung cancer screening as an insurance benefit would save lives at relatively low cost
Using actuarial models, this study published in Health Affairs estimates the costs and benefits of annual lung cancer screening if offered as a commercial insurance benefit in the high-risk U.S. population, ages 50 to 64.

Improved lung cancer screening could lead to earlier detection
In this interview, the authors and sponsors of the first actuarial analysis of lung cancer mortality discuss the broader implications their research may have in the effort to reduce deaths associated with the disease.

An actuarial analysis of lung cancer screening
This blog post highlights Bruce Pyenson’s presentation on lung cancer screening at Health Affairs’ “Value in Cancer Care” briefing in 2012.

An actuarial analysis of lung cancer screening

Bruce Pyenson presented his study on lung cancer screening at Health Affair’s “Value in Cancer Care” briefing on April 12 in Washington DC. Watch his presentation at HealthAffairs.org – scroll down to “The Case For Lung Cancer Screening of High-Risk Patients & Improving Payment And Delivery Of Cancer Care.”

Also, here is the study’s abstract:
Continue reading

Moving towards prevention?

Edward JhuJason NowakowskiAccording to a recent article in the Washington Post, early data shows recent upticks in utilization of some preventive services by Medicare patients, presumably triggered by provisions in the healthcare reform law encouraging use of preventive care. Medicare enrollees can now obtain wellness checkups and screening tests for cancer and other serious conditions at no cost, for example.

Interestingly, the article notes that so far only the more general procedures, wellness exams, have seen significant bumps in utilization. At this early stage, it appears that utilization of more invasive screening procedures such as mammograms or colonoscopies is relatively flat even with the removal of cost sharing under health reform.

This could well speak to the heart of the preventive challenge itself, and certainly raises many questions: Will we ultimately see utilization remain stubbornly close to current benchmarks for some procedures? If removing copays is not sufficient, what kinds of incentives are necessary to get people to use the clinically-recommended levels of services? Where does education fit into the larger goal of persuading people to use them? If the right kind of utilization is incented, what will be the long-term cost implications?

Moving forward, it will be more important than ever for providers and carriers to attempt to answer these questions. Our recent report, “Benchmarking Preventive Care Utilization,” points out that there are “numerous problems that actuaries and other analysts may expect to encounter as they attempt to set baselines and benchmarks for preventive services”—not the least of them is agreeing on and communicating a definition of “preventive services” in the first place. Other issues are related to claim coding complexities, billing, medical innovations, considerations for “at-risk” patients, and finding ways to distinguish screening and diagnostic procedures.

The Washington Post article is only an early indicator, and it introduces more questions than answers. The march toward increased use of preventive care will be one of the more interesting aspects of reform to monitor as the American healthcare system goes through this period of evolution.