Publications

IMPORTANCE

Regulatory limits on consumer cost sharing permit wide variation in the prices charged for screening and diagnostic tests such as colonoscopy. Employers are experimenting with reference payment initiatives that offer full insurance coverage at low-priced facilities but require substantial cost sharing if patients select high-priced alternatives.

OBJECTIVE

To ascertain the effect of reference payment on facility choice, insurer spending, consumer cost sharing, and procedural complications for colonoscopy.

DESIGN, SETTING, AND PARTICIPANTS

The California Public Employees' Retirement System (CalPERS) implemented reference payment in January 2012. We obtained data on 21 644 CalPERS enrollees who underwent colonoscopy in the 3 years prior to implementation and on 13 551 patients in the 2 years after implementation. Control group data were obtained on 258 616 Anthem Blue Cross enrollees who underwent colonoscopy and who were not subject to reference payment initiatives during this 5-year period.

MAIN OUTCOMES AND MEASURES

Consumer choice of facility, price paid per procedure, total insurer spending, consumer cost sharing, and procedural complications.

EXPOSURES

Choices, prices, and complications were compared for CalPERS and Anthem patients before and after implementation of reference payments, using difference-in-difference multivariable regressions to adjust for patient demographic characteristics and comorbidities, procedure indications, and geographic location.

RESULTS

Utilization of low-priced facilities for CalPERS members increased from 68.6% in 2009 to 90.5% in 2013. After adjusting for patient demographic characteristics, comorbidities, and other factors, the implementation of reference payment increased use of low-priced facilities by 17.6 percentage points (95% CI, 11.8 to 23.4; P < .001). The mean price paid for colonoscopy for the CalPERS population increased from $1587 (95% CI, $1555-$1618) in 2009 to $1716 (95% CI, $1678-$1753) in 2011 and then decreased to $1508 (95% CI, $1469-$1548) in 2013 for patients subject to reference payment. After adjustment for other relevant factors, reference payment was responsible for a 21.0% (95% CI, -26.0% to -15.6%, P < .001) reduction in the price. Reference payment was associated with a small but statistically insignificant decline in procedural complications, from 2.1% in 2009 to 2.0% in 2013 (P = .47). In the first 2 years after implementation, CalPERS saved $7.0 million (28%) on spending for the procedure.

CONCLUSIONS AND RELEVANCE

Implementation of reference payment for colonoscopy was associated with reduced spending and no change in complications.

Acute exacerbations of chronic obstructive pulmonary disease (COPD) are thought to be associated with--and perhaps to mediate--accelerated loss of lung function in COPD. Although the application of culture-independent methods for detection of bacteria have shown COPD to be associated with marked differences in the burden, diversity, and composition of the bronchial bacterial microbiome, few studies have examined the changes associated with community-acquired exacerbations of the disease. In a longitudinal cohort study of COPD, the availability of sputum samples from subjects obtained at the onset of an exacerbation and during periods of clinical stability before and after the event enabled us to recently address this gap in knowledge, using culture-independent, 16S rRNA-based analysis methods combined with in silico inference of metagenomic functions. We observed sputum bacterial composition to be generally stable over the preexacerbation period of clinical stability, but to change at the time of exacerbation, with specific enrichment in not only typical COPD-associated bacterial species (e.g., Haemophilus influenzae) but also other phylogenetically related species with pathogenic potential. Concurrently, we observed depleted abundance of other bacteria whose predicted metagenomes suggest functional capacities to produce a variety of antiinflammatory compounds. Most strikingly, we found that resolution of these exacerbation-related changes in sputum microbiota composition differed significantly, depending on the exacerbation treatments prescribed. Treatment with corticosteroids resulted in microbiome enrichment for a number of bacterial communities, mostly members of the Proteobacteria phylum, whereas prolonged suppression of microbiota was seen in those treated with antibiotics alone. Taken together, our findings suggest that exacerbations of COPD are associated with heterogeneous changes in the bronchial microbiome, with increases in the abundance of species related to typical COPD pathogens and decreases in microbiota members that contribute to compositional and functional homeostasis. The findings further suggest that exacerbation treatments may have very different impacts on the bronchial microbiome's rate of return toward baseline composition.

BACKGROUND

Smoking cessation treatment service is concerned to be a critical element in methadone maintenance treatment (MMT) in order to diminish the effect of smoke on health outcomes. To implement the smoking cessation services in Vietnam, we examined the stages of change to quit and determined associated factors among MMT patients.

METHODS

We conducted a cross-sectional survey with 1016 MMT patients in five clinics in Hanoi and Nam Dinh province, of those, 932 (91.7%) were ever-smokers. Patients were classified into four groups: "pre-contemplation," "contemplation," "preparation," and "action and maintenance" by using the transtheoretical model. Multivariate logistic regression was applied to determine the associated factor for intention and action to quit smoking.

RESULTS

Overall, 96% were not actively trying to quit or maintain abstinence. Age older than 45, HIV-positive status, and residence in Hanoi were negatively associated with intention to quit. Meanwhile, higher levels of nicotine dependence and number of years of smoking negatively associated with quitting and abstinence.

CONCLUSIONS

The study indicated the high rate of MMT smokers being in pre-contemplation stage but low proportion of quitting and maintaining abstinence. It emphasizes the importance of availability and accessibility of information about smoking cessation therapies and services. Integrating cessation programs into health-care services should be considered to provide tailored interventions for different patient groups.