Blue Cross Blue Shield of Massachusetts

Background: Among all ambulatory antibiotic prescriptions, about 20% are non-visit-based (ordered outside of an in-person clinical encounter), and about 30% are not associated with an infection-related diagnosis code. Objective/Methods: To identify the rationale for ambulatory antibiotic prescribing, we queried the electronic health record (EHR) of a single, large health system in the Midwest United States to identify all oral antibiotics prescribed from November 2018 to February 2019 and examined visit, procedure, lab, department, and diagnosis codes. For the remaining antibiotic prescriptions—mostly non-visit-based, no-infectious-diagnosis-documented—we randomly selected and manually reviewed the EHR to identify a prescribing rationale and, if none was present, surveyed prescribers for their rationale. Results: During the study period, there were 47,619 antibiotic prescriptions from 1177 clinicians to 41,935 patients, of which 2608 (6%) were eligible non-visit-based, no-infectious-diagnosis-documented. We randomly selected 2298. There was a documented rationale for 2116 (92%) prescriptions. The most common documented reasons—not mutually exclusive—were patient-reported symptoms (71%), persistence of symptoms after initial management (18%), travel (17%), and responding to lab or imaging results (11%). We contacted 160 clinicians who did not document any prescribing rationale in the EHR and received responses from 62 (39%). Clinicians’ stated reasons included upcoming or current patient travel (19%), the antibiotic was for the prescriber’s own family member (19%), or the clinician made a diagnosis but did not document it in the EHR (18%). Conclusions: Non-visit-based, no-infectious-diagnosis-documented antibiotic prescriptions were most often in response to patient-reported symptoms, though they also occur for a variety of other reasons, some problematic, like in the absence of documentation or for a family member.

IntroductionAmid growing primary care shortages and increased use of value-based care (VBC), we evaluated whether adopting a multipayer, full-risk VBC model for Traditional Medicare (TM) and Medicare Advantage beneficiaries–supported by an enablement organization–affected primary care providers' (PCPs) acceptance of new patients with TM insurance.MethodsUsing a difference-in-differences analysis of 2019-2023 claims, we compared 2 groups of PCPs with at least 50 TM patients in their panels: 208 PCPs who received support to adopt a VBC model for TM and Medicare Advantage patients in 2022, and 3657 similar PCPs who maintained their existing payment models.Between the preadoption period and 2023, access to new patient visits for patients with TM insurance declined more for nonadopters than adopters.ResultsPrimary care providers’ in the VBC group saw, on average, 8 more new TM patients annually than nonadopters. This change is sizable relative to their 22.6 new TM patients in 2023. Additionally, the VBC group kept their panels open to new patients with TM insurance for 0.7 more months per year, on average, than nonadopters, relative to preadoption.ConclusionThese findings suggest that a VBC model with support may help sustain access to primary care for TM beneficiaries, even as overall availability declines.

Sickle cell disease (SCD) has a history of health inequity, as patients with SCD are primarily Black and often marginalized from the health care system. Although recent health care and treatment advancements have prolonged life expectancy, it may be insufficient to support the complex needs of the growing population of older adults with SCD. This retrospective study used a cohort (N = 812) of Medicare Advantage beneficiaries 45 years and older (ages: 45-54, 55-64, 65-74, 75-89) with SCD to identify associations of SCD-related complications and comorbidities with emergency department (ED) visits, potentially avoidable ED visits, all-cause hospitalization, and potentially avoidable hospitalizations, 2018-2020. The 75-89 age group had lower odds of an ED visit (OR 0.56; 95% CI 0.32-1.00), 65-74 age group had lower odds of an ED visit (OR 0.49; 95% CI 0.31-0.78) and hospitalization (OR 0.50; 95% CI 0.31-0.79), compared with the 45-54 age group. Acute chest syndrome was associated with increased odds of an ED visit (OR 2.02; 95% CI 1.10-3.71), avoidable ED visit (OR 1.87; 95% CI 1.14-3.06), and hospitalization (OR 3.61; 95% CI 2.06-6.31). Pain was associated with increased odds of an ED visit (OR 2.64; 95% CI 1.85-3.76), an avoidable ED visit (OR 3.08; 95% CI 1.90-4.98), hospitalization (OR 1.51; 95% CI 1.02-2.24), and avoidable hospitalization (OR 6.42; 95% CI 1.74-23.74). Older adults with SCD have been living with SCD for decades, often while managing pain crises and complications associated increased incidence of an ED visit and hospitalization. The characteristics and needs of this population must continue to be examined to increase preventative care and reduce costly emergent health care resource utilization.

We examined 3,046,538 acute respiratory infection (ARI) encounters with 6,103 national telehealth physicians from January 2019 to October 2021. The antibiotic prescribing rates were 44% for all ARIs; 46% were antibiotic appropriate; 65% were potentially appropriate; 19% resulted from inappropriate diagnoses; and 10% were related to coronavirus disease 2019 (COVID-19) diagnosis.

This article describes the key stakeholders and process involved in developing an insurance policy in the United States to establish medical necessity criteria for lymphatic surgery procedures. Lymphedema is a chronic health issue that impacts over 1.2 million patients and is associated with lifelong health, economic, and psychosocial costs. Patients affected have been described as "medical nomads," as they often interface with multiple providers before receiving an accurate diagnosis and treatment. This underscores the lack of attention and understanding about this disease across all sectors of the medical system. Unlike nations including Sweden and the United Kingdom, which provide insurance coverage for treatment, the United States has lagged behind. As a country, we have neglected to fully recognize the consequences of inadequate treatment of lymphedema, including chronic morbidities such as loss of mobility, psychosocial sequelae, recurrent infections, and even death. Recently, the authors' lymphatic center had the unique opportunity to help develop a policy that merged their clinical experience, recently established lymphatic care center of excellence criteria, and third-party payer policy expertise. This experience spanned 1 year from June of 2018 to June of 2019. The authors identify how key partnerships helped fill evidentiary gaps that ultimately resulted in policy change.

In the present data-centric environment, maintaining the accuracy and dependability of data by means of ETL (Extract, Transform, Load) pipelines serves not only a technical but also a commercial purpose. By means of a practical methodology, this article demonstrates how data validation and quality assurance (QA) included in ETL processes help decision-making, compliance, and operational efficiency. Automated validation rules, schema enforcement, anomaly detection systems, and reconciliation processesall cohesively deployed into pipeline phasescombine to form the foundation of the strategy and rapidly uncover and fix data problems. Apart from tools and techniques, the article addresses typical real-world issues such as schema drift, inconsistent source data, delayed ingestion, and quality degradation across transformation phases. Solutions cover scalable data profiling methods, modular QA tests, adaptive validation layers, and real-time alarms. Leveraging real-world experience in large-scale installations, the paper emphasizes results from applying these methodssuch as greatly reduced data downtime, enhanced stakeholder confidence, and accelerated resolution cyclesthat amply demonstrate the obvious benefits of proactive validation. This work attempts to provide a human-centric, empirically validated paradigm for constructing strong and functionally sound ETL pipelines for architects, QA analysts, and data engineers