The results show a promising performance of models predicting cost and hospitalization using outpatient EHR's diagnosis and medication data. More research is needed to evaluate the benefits of other EHR data types (eg, lab values and vital signs) for risk stratification.

No abstract

Objective: The COVID pandemic has had a significant impact on the US health care system. Our primary objective was to understand the impact of the COVID pandemic on non–COVID-related health care utilization among insured individuals with chronic conditions. Our secondary objective was to examine the differential impact by individual characteristics. Main Data Source: Medical and pharmacy claims data for individuals enrolled in a large insurer across the United States. Research Design: A retrospective and repeated cross-sectional study. Overall and condition-specific health care utilization and cost metrics in (1) March 1 to June 15 and (2) June 16 to September 30, 2020 were compared with the same months during 2016–2019. Subjects: Members of all ages with a diagnosis of diabetes, cardiovascular disease, or chronic kidney disease with commercial or Medicare Advantage insurance. Results: Most non–COVID-related health care utilization decreased drastically on March 1 to June 15, 2020 [odds ratio (OR) range across condition-specific tests: 0.55–0.69; incidence rate ratio (IRR) range for hospitalization/emergency department (ED) visit/outpatient visit: 0.65–0.77] but returned to closer to pre-COVID levels by June 16 to September 30, 2020 [OR range across condition-specific tests: 0.93–1.08; IRR range for hospitalization/ED visit/outpatient visit: 0.77–0.97]. Our study found an enormous increase in telehealth use on March 1 to June 15, 2020 (90–170 times prepandemic levels). A differential impact was observed by age, sex, region of residence, and insurance type. Implications: Further investigation is needed to assess the impact of these changes in health care utilization on long-term health outcomes.

IMPORTANCE Breast cancer accounts for the largest portion of cancer-related spending in the United States. Although hypofractionated radiotherapy after breast-conserving surgery is a cost-effective and convenient treatment strategy for patients with early-stage breast cancer, less than 40% of eligible women received hypofractionated radiotherapy in 2013.OBJECTIVE To assess the association of a large commercial payer's utilization management policy with the use of hypofractionated radiotherapy among women with early-stage breast cancer and its associated cost. DESIGN, SETTING, AND PARTICIPANTSA retrospective, adjusted difference-in-differences economic analysis was conducted using administrative claims data from January 1, 2012, to June 1, 2018, of women 18 years or older with early-stage breast cancer who were eligible for hypofractionated radiotherapy according to 2011 guidelines from the American Society for Radiation Oncology and were continuously enrolled in 14 geographically diverse commercial health plans covering 6.9% of US adult women. Women who received mastectomy, brachytherapy, or less than 11 or more than 40 external beam fractions of radiotherapy were excluded. A utilization management policy was used to encourage the use of hypofractionated radiotherapy among women in fully insured and Medicare Advantage (fully insured) plans. Under the new policy, claims for extended-course radiotherapy were not reimbursed for fully insured women who were eligible for hypofractionated radiotherapy. This policy did not apply to women in self-insured or Medicare supplemental insurance (self-insured) plans, allowing these groups to serve as a comparison group. MAIN OUTCOMES AND MEASURESThe primary outcome was use of hypofractionated radiotherapy, and the secondary outcome was the cost of this type of radiotherapy. RESULTSOf 10 540 eligible women, 3619 (34.3%) were in fully insured plans and thus subject to the policy. There were no meaningful differences between the fully insured and self-insured groups in mean (SD) age at the start of radiotherapy (63.8 [8.6] vs 65.0 [8.9] years), mean (SD) Charlson Comorbidity Index score (3.0 [1.5] vs 3.2 [1.6]), or practice setting (outpatient hospital setting, 2982 of 3619 [82.4%] vs 5600 of 6921 [80.9%]). The policy was associated with an increase in use of hypofractionated radiotherapy among fully insured patients subject to the policy (adjusted percentage point difference-in-difference, 4.2%; 95% CI, 0.0%-8.4%; P = .05) and a nonsignificant decrease in radiotherapy-associated expenditures (−$2275 relative to self-insured patients; P = .09). Spillover analyses revealed a significantly higher uptake of hypofractionated radiotherapy among self-insured patients who were indirectly exposed to the policy (adjusted percentage point difference-indifference, 8.5%; 95% CI, 3.6%-13.5%; P < .001) compared with those who were not exposed. CONCLUSIONS AND RELEVANCEThis study suggests that a payer's utilization management policy was associated with direct and spillover increases in the use ...

No abstract