Hawaii Medical Service Association

Hawaii Medical Service Association (HMSA), the Blue Cross Blue Shield of Hawaii, introduced Population-based Payments for Primary Care (3PC), a new capitation-based primary care payment system, in 2016. The effect of this system on quality measures has not been evaluated. To evaluate whether the 3PC system was associated with changes in quality, utilization, or spending in its first year. Observational study using HMSA claims and clinical registry data from January 1, 2012, to December 31, 2016, and a propensity-weighted difference-in-differences method to compare 77 225 HMSA members in Hawaii attributed to 107 primary care physicians (PCPs) and 4 physician organizations participating in the first wave of the 3PC and 222 233 members attributed to 312 PCPs and 14 physician organizations that continued in a fee-for-service model in 2016 but had 3PC start dates thereafter. Participation in the 3PC system. The primary outcome was the change in a composite measure score reflecting the probability that a member achieved an eligible measure out of 13 pooled Healthcare Effectiveness Data and Information Set quality measures. Primary care visits and total cost of care were among 15 secondary outcomes. In total, the study included 299 458 HMSA members (mean age, 42.1 years; 51.5% women) and 419 primary care physicians (mean age, 54.9 years; 34.8% women). The risk-standardized composite measure scores for 2012 to 2016 changed from 75.1% to 86.6% (+11.5 percentage points) in the 3PC group and 74.3% to 83.5% (+9.2 percentage points) in the non-3PC group (differential change, 2.3 percentage points [95% CI, 2.1 to 2.6 percentage points]; P < .001). Of 15 prespecified secondary end points for utilization and spending, 11 showed no significant difference. Compared with the non-3PC group, the 3PC system was associated with a significant reduction in the mean number of primary care visits (3.3 to 3.0 visits vs 3.3 to 3.1 visits; adjusted differential change, -3.9 percentage points [95% CI, -4.6 to -3.2 percentage points]; P < .001), but there was no significant difference in mean total cost of care ($3344 to $4087 vs $2977 to $3564; adjusted differential change, 1.0% [95% CI, -1.3% to 3.4%]; P = .39). In its first year, the 3PC population-based primary care payment system in Hawaii was associated with small improvements in quality and a reduction in PCP visits but no significant difference in the total cost of care. Additional research is needed to assess longer-term outcomes as the program is more fully implemented and to determine whether results are generalizable to other health care markets.

Studies worldwide in emergency departments (ED) find that a substantial proportion of patients seek care for non-urgent conditions. Managed care programs may help address this overuse of ED facilities, but non-urgent ED care is not easily identified outside of ED settings. This article employed an algorithm using insurance data to identify and characterize patients having low urgency ED visits. Non-urgentis the term used in the ED literature for ED visits that might have been managed outside an ED setting such as in a physician office. Low urgency ED visits could include visits that require an ED setting but for less severe conditions than high urgency ED visits. Analysis of ED visits by members of the largest health insurer in Hawaii. Visits were defined as low urgency if classified by the ED as low severity and if, in addition, the patients required no procedures beyond physician and nursing care. A simple example would be a physician order for a laboratory test. Even if the test was routine, the fact the doctor ordered the test during the ED visit suggests the result might be needed right away to make a management decision. Another example of a procedure would be a radiograph. Medicaid participants, children age 1 to 5, and people living on less populated Hawaiian Islands most frequently had low urgency visits. The visits were also more common on weekends than weekdays, and more common among males compared to females. Of all low urgency visits by Medicaid participants, 32% were by repeat users of the ED. The percentage for members of non-Medicaid plans was 16%. People with one low urgency visit in the past year were more than twice as likely as others to have a similar visit in the next year. People with two or more low urgency visits in the past year were five times as likely to have a low urgency ED visit in the next year. The results identify several areas such as youth, island of residence, and past history of low urgency ED visits that might become the focus of managed care programs.

Efforts to reform the U.S. health care system have placed considerable attention on patients' financial burden from out-of-pocket drug costs.2][3][4] Physicians may be reluctant to initiate these cost discussions because some cost-cutting strategies involve potential tradeoffs such as increased dosing frequency, or risk of side effects, or lower treatment effectiveness. 1 Knowing patients' willingness to consider such less than optimal costlowering strategies could encourage physicians to discuss drug costs with their patients.

Objective: To present project design and baseline characteristics of a project promoting life-long physical activity (PA) in an elementary after-school program. Methods: The project incorporates a two group design with delayed treatment control. PA and context observations and surveys (n=533; grades 4-6; attitude, enjoyment, intention, subjective norm, confidence, PA behavior, and fruit and vegetable consumption) were conducted. Results: Students spend almost 90 minutes standing, sitting and lying down and less than 17 minutes in moderate and vigorous PA during the after-school program. Students were strenuously active 3.89 days per week, moderately active 3.12 days per week, and mildly active 3.06 days per week, and watched television or played video games for 3.71 hours per day during leisure time. Attitudes, enjoyment, intention, and subjective norms differentiated students in different stages of PA. Discussion: There is an opportunity for PA promotion during after school, and stage specific interventions are indicated to facilitate PA.

This case report describes a qualitative and preliminary quantitative assessment of a quality-based physician compensation program. The Hawaii Medical Service Association's Physician Quality and Service Recognition program offers an innovative and effective approach for improving delivery of high-quality and cost-effective care to patients enrolled in preferred provider organizations. Support for the program is demonstrated through increasing numbers of voluntarily participating physicians. Preliminary assessment of population outcomes reveals sustained improvements in many clinical areas and mixed findings in others. This study contributes to the body of knowledge available to payers and policy makers considering alternative payment methods to reward improved performance.

To determine if patient assessments (reports and ratings) of primary care differ by patient ethnicity. A self-administered patient survey of 6,092 Massachusetts employees measured seven defining characteristics of primary care: (1) access (financial, organizational); (2) continuity (longitudinal, visit based); (3) comprehensiveness (knowledge of patient, preventive counseling); (4) integration; (5) clinical interaction (communication, thoroughness of physical examinations); (6) interpersonal treatment; and (7) trust. The study employed a cross-sectional observational design. Asians had the lowest primary care performance assessments of any ethnic group after adjustment for socioeconomic and other factors. For example, compared to whites, Asians had lower scores for communication (69 vs. 79, p = .001) and comprehensive knowledge of patient (56 vs. 48, p = .002), African Americans and Latinos had less access to care, and African Americans had less longitudinal continuity than whites. We do not know what accounts for the observed differences in patient assessments of primary care. The fact that patient reports as well as the more subjective ratings of care differed by ethnicity suggests that quality differences might exist that need to be addressed.

We examined the associations of two biochemical markers of bone turnover with lifestyle factors in 340 postmenopausal women in Hawaii, ages 45-59 years, from the Early Postmenopausal Intervention Cohort. Physical activity, calcium supplement use, smoking and alcohol use in the prior 2 weeks were measured and examined as independent variables in multiple regression analyses with bone turnover markers as dependent variables, adjusted for weight, height, whole body bone mass, serum estradiol, years since menopause, and ethnicity. Calcium supplement and alcohol use were significantly associated with reduced levels of urinary type I collagen cross-linked N-telopeptides (NTX). The mean NTX level was 12% lower among women using > or = 250 mg of calcium supplements per day as compared with other women, and 20% lower among alcohol users compared with nonusers. Both calcium supplement use and alcohol intake were associated with lower mean serum osteocalcin (a marker of bone formation) and NTX z-scores. By contrast, smoking was associated with lower osteocalcin levels, without any effect on NTX. The osteocalcin level was 12% lower among smokers compared with nonsmokers. In addition, the z-score difference between NTX and osteocalcin was significantly associated with smoking, with a shift towards more NTX than osteocalcin. Physical activity was not significantly associated with either of the markers. These findings suggest that biochemical markers may help to identify lifestyle factors that affect bone, and provide estimates of the relative magnitude of these effects on bone formation and resorption, independent of each other.