Cigna (United States)

e13568 Background: Evidence shows that cancer case management improves patient’s quality-of-life and reduces hospital admissions [1] . When case management (CM) is done by payers, there is a start delay since case managers must wait for the diagnosis information through authorization to start a case. This delay hinders the case manager’s ability to support patients early in their cancer journey as they are making impactful treatment decisions. Researchers at Evernorth Health Services created an Early Identification (EID) machine learning model that allows Evernorth to identify possible breast oncology case management-appropriate patients early. The goal is to shorten the time from diagnosis to engagement in oncology CM. We evaluated how the model impacts CM program metrics. Methods: Implementation of the breast oncology EID program started on April 2022. The list of potential patients identified by the model is sent to case managers on a weekly cadence for outreach and engagement. If the diagnosis is confirmed, they are referred to the oncology care management program. We compared the likelihood of engagement with CM for patients referred to us by the EID model vs. those referred to us by other means (e.g., prior authorization, other case management programs, etc.). We included patients identified by the model between April 2022 and December 2023. We had 3,484 patients in the EID sample and 3,750 in the non-EID initial sample after exclusions. We used Coarsen Exact Matching (CEM) to adjust for demographic, plan type and disease differences between the two groups. In addition, we compared behavioral health integration (measured as having a claim for behavioral health services after engagement in case management) and CM program completion (measured as completing the case goals) for those identified through EID and engaged in CM vs. those engaged in CM and referred to the program through other means. Results: The unadjusted average difference in time from diagnosis to the opening of the oncology CM case is 10 days. The adjusted results show a 21% statistically significant increase in likelihood of engagement for EID identified patients. For engaged patients, the results show a slightly lower rate of CM program completion, but the result is not statistically significant. Finally, EID patients engaged in case management have a 40% statistically significant increase in risk of getting a behavioral health claim after engagement. Conclusions: The Evernorth EID model demonstrates a positive impact on engagement in CM for breast oncology patients as well as a positive impact on behavioral health integration for engaged patients. The model has no significant impact on CM program completion.

Drug pricing reform to increase affordability has historically relied on increases in regulation often with a focus on administrative pricing for public programs in order to try to lower drug costs. This paper examines the consequences of this strategy, pointing out that regulated prices fail to drive affordability, create unintended, hidden costs to the system, and drive demand for a body of ever-growing regulatory interventions to address shortfalls created by prior policies. Within this context, the paper examines examples of regulations affecting large percentages of government payments the Medicaid Drug Rebate, the Inflation Reduction Act Maximum Fair Price, and the Average Sales Price formula in Medicare B enumerating how each of these programs that direct funds to Medicare or Medicaid only create hidden systematic costs when considered from the total market perspective. Next, a new paradigm for drug pricing reform philosophy is suggested, with a focus on market-based interventions to reform existing government regulation aimed at improving competition and consider examples of effective private market policies including co-insurance/copayment reform, private formularies, specialty pharmacies, and value-based contracting. The paper concludes by arguing that shifting from a programmatic view of affordability to an understanding of the regulatory effect on costs in the drug market, including regulatory burden reduction, is the best way to drive affordability for payers and thus ultimately for employers and consumers.

All authors have no conflicts of interest.

9129 Background: National oncology guidelines advocate for broad molecular profiling to detect potentially actionable driver mutations prior to initiation of first-line therapy for patients with advanced non-small cell lung cancer (NSCLC). Results of genomic tests can confirm the presence of specific cancer tumor mutations that are best treated with more targeted therapies. Recent studies have shown that up to 30% of lung cancer patients may not receive the most effective treatment due to a lack of guideline-concordant genomic testing. We analyzed data from our prior authorization medical oncology program to determine adherence to national guidelines recommendations, and then developed a program to improve adherence to broad molecular profiling utilizing our proprietary prior authorization algorithms and our proactive peer consultation model. Methods: eviCore healthcare uses the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) to support its proprietary program for medical oncology drug management, and requires attestation on the results of NCCN recommended genomic/molecular test results in advanced NSCLC during prior authorization of systemic therapy. In November 2019, we implemented a next-generation sequencing (NGS) testing results requirement for metastatic non-squamous NSCLC patients prior to first-line therapy approval. If testing had not been completed, a peer to peer consultation was performed to advocate for testing prior to initiation of chemoimmunotherapy regimens. The rate of appropriate tumor testing is defined by provider attestation of test results prior to initiation of therapy. We define the control period (pre- implementation) as October 2018 through September 2019 ( n = 667). The measurement period (post-implementation) is January 2020 through December 2020 ( n = 390). Results: From pre to post there was a 35% increase in testing adherence (p < 0.001). After the testing requirement was implemented, the appropriate tumor testing rate increased to 99% by the second half of 2020, compared to the control period (62%). Additionally, after the testing requirement began, pembrolizumab utilization for advanced stage NSCLC decreased by a net 4.2% per month. This decrease in pembrolizumab utilization likely reflected patients being matched to more appropriate targeted therapy based on genomic testing results. Conclusions: We demonstrate that by combining medical oncology prior authorization with focused peer consultation, adherence to national society recommendations for broad molecular profiling prior to initiating first line therapy in advanced NSCLC can be significantly improved. By improving testing adherence, the most effective and appropriate therapy can be matched to the patient.

Recent studies have suggested that extended duration oral contraceptive pills (OCP), such as the 12-month duration, have a positive impact on pregnancy rates but negative impact on pill wastage. Several states have since been mandating health plans to offer extended duration OCP as an option for women. The objective of the study was to evaluate the impact of these mandates on utilization of extended duration OCPs. Using claims data of a large pharmacy benefit manager for commercially insured women from 2018 to 2019, use, adherence, continuity, and wastage of OCPs by women dispensed one-month only, three-months only, 6 or 12-months only, and other months (which includes other months and mixed duration OCP) was retrospectively analyzed. OCP dispensed by year, and adherence, continuity, wastage over a 15-month period were summarized using Chi square and ANOVA. There were 874,420 and 875,914 women in this study in 2018 and 2019 respectively. Of these, 34% were from states with the mandate (SWM). Most women filled the one-month and three-month duration, with very low overall 6 or 12-month duration claims. Proportion of utilizers of 6 or 12- month duration was higher in SWM than in those without, although differences in absolute rates were very low. Patients with OCP discontinuation, gaps ≥7 and 14 days, were fewer among those filling 6 or 12-month duration but conversely, wastage was higher in this group compared to those filling one or three-month duration. Our findings suggest that, among commercially insured women, extended duration OCP mandates have so far not had much influence on use of 6 or 12-month duration OCP prescriptions.

Approximately 32% (75 million) of adults have hypertension in the United States, leading to 1,100 daily deaths and costing more than $48 billion annually in medical expenditures. Approximately 25% of patients with hypertension require triple combination therapy to reach recommended blood pressure. Currently, only 3 single-pill triple-combination therapies are available in the market for the treatment of hypertension. Medication adherence has become a major concern for the health care system, and nonadherence is associated with higher risks of morbidity and mortality. To compare medication adherence rates among single-pill triple-combination therapy, free triple-combination therapy, and fixed-dose dual-combination therapy plus a third agent in hypertensive patients enrolled in a Medicare Advantage prescription drug plan using 2 adherence definitions. A retrospective cohort study was conducted using Cigna-HealthSpring's medical claims database from January 2014 to December 2016. Antihypertensive combination therapy users were classified into a single-pill triple-combination group, a fixed-dose dual-combination plus a third agent group, and a free triple-combination group. Adherence rates using proportion of days covered (PDC) were calculated for each group within a 1-year follow-up period using 2 definitions: a strict one requiring all antihypertensive agents during follow-up and a more relaxed definition requiring any antihypertensive agent during follow-up. Descriptive statistics were examined, and group differences were assessed using chi-square and analysis of variance. Multivariate logistic regression was conducted to control confounders of adherence using both definitions. 10,836 triple-combination users were identified. In the multivariate model using the first definition, fixed-dose dual-combination plus a third agent was significantly associated with lower adherence compared with single-pill triple therapy (OR = 0.177; 95% CI = 0.119-0.263; P < 0.001). No significant difference was detected between single-pill triple-combination therapy in comparison with free-combination therapy. In the multivariate model using the second definition, fixed-dose dual-combination plus a third agent and free-combination therapy were significantly associated with better adherence in comparison with single-pill triple combination therapy (OR = 3.62, 95% CI = 2.59-5.05; OR = 4.31, 95% CI = 2.15-8.64, respectively). Younger age, female gender, language (Spanish), some comorbidities, and previous hospitalization had a negative effect on adherence. Measuring adherence to multiple concurrent regimens is complicated and different adherence definitions can result in significant variations in adherence measures. Future research evaluating clinical outcomes with various definitions is needed. No outside funding supported this study. Abughosh reports grants from Sanofi, Regeneron, Valeant Pharmaceuticals, BMS/Pfizer, and PhRMA, not related to this study. Serna reports employement with CareAllies, a Cigna company. The other authors have no conflicts of interest to disclose.

Prior research documents gender gaps in cardiovascular risk management, with women receiving poorer quality routine care on average, even in managed care systems. Although population health management tools and quality improvement efforts have led to better overall care quality and narrowing of racial/ethnic gaps for a variety of measures, we sought to quantify persistent gender gaps in cardiovascular risk management and to assess the performance of routinely used commercial population health management tools in helping systems narrow gender gaps. Using 2013 through 2014 claims and enrollment data from more than 1 million members of a large national health insurance plan, we assessed performance on seven evidence-based quality measures for the management of coronary artery disease and diabetes mellitus, a cardiac risk factor, across and within four metropolitan areas. We used logistic regression to adjust for region, demographics, and risk factors commonly tracked in population health management tools. Low-density lipoprotein (LDL) cholesterol control (LDL<100mg/dL) rates were 5 and 15 percentage points lower for women than men with diabetes mellitus (p<.0001), and coronary artery disease (p<.0001), respectively. Adjusted analyses showed women were more likely to have gaps in LDL control, with an odds ratio of 1.31 (95% confidence interval, 1.27-1.38) in diabetes mellitus and 1.88 (95% confidence interval, 1.65-2.10) in coronary artery disease. Given our findings that gender gaps persist across both clinical and geographic variation, we identified additional steps health plans can take to reduce disparities. For measures where gaps have been consistently identified, we recommend that gender-stratified quality reporting and analysis be used to complement widely used algorithms to identify individuals with unmet needs for referral to population health and wellness behavior support programs.

BackgroundThe impact of employee health on productivity in the workplace is generally evidenced through absenteeism and presenteeism. Multicomponent worksite health programmes, with significant online elements, have gained in popularity over the last two decades, due in part to their scalability and low cost of implementation. However, little is known about the impact of digital-only interventions on health-related outcomes in employee groups. The aim of this systematic review was to assess the impact of pure digital health interventions in the workplace on health-related outcomes.MethodsMultiple databases, including MEDLINE, EMBASE, PubMed and PsycINFO, were used to review the literature using PRISMA guidelines.ResultsOf 1345 records screened, 22 randomized controlled trial studies were found to be eligible. Although there was a high level of heterogeneity across these studies, significant improvements were found for a broad range of outcomes such as sleep, mental health, sedentary behaviours and physical activity levels. Standardized measures were not always used to quantify intervention impact. All but one study resulted in at least one significantly improved health-related outcome, but attrition rates ranged widely, suggesting sustaining engagement was an issue. Risk of bias assessment was low for one-third of the studies and unclear for the remaining ones.ConclusionsThis review found modest evidence that digital-only interventions have a positive impact on health-related outcomes in the workplace. High heterogeneity impacted the ability to confirm what interventions might work best for which health outcomes, although less complex health outcomes appeared to be more likely to be impacted. A focus on engagement along with the use of standardized measures and reporting of active intervention components would be helpful in future evaluations.