Public Payers May Have Worse Care Coordination for Chronic Disease
Publicly insured liver transplant patients dropping off of the waitlist may indicate poor care coordination for chronic disease management.
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- Among publicly insured patients with the potentially chronic condition hepatocellular carcinoma (HCC), 35 percent had a longer wait time for a liver transplant, possibly indicating poor care coordination according to researchers from the University of California, San Francisco (UCSF).
Delays in finishing the pre-transplant evaluations and in securing upgrades on the Model for End-Stage Liver Disease (MELD) are the predominant causes for these delays. The researchers concluded that better care coordination and improved delivery would speed up the process for publicly insured patients.
“Public insurance should be recognized as a risk factor associated with waitlist dropout, and necessary steps should be implemented to mitigate the increased risk of dropout among these patients,” Neil Mehta, MD, UCSF Health gastroenterologist and associate professor of gastroenterology at UCSF said. “Our findings have increasingly meaningful implications as growing numbers of patients listed for liver transplant have public insurance.”
The group consisted of 705 patients, nearly 50 percent of whom had Kaiser Permanente insurance coverage, 22.3 percent were privately insured elsewhere, and 28.2 percent were under public insurance.
Over a third of those with public insurance dropped out of the liver transplant waitlist by the second year, with researchers pointing to one of three reasons for dropout.
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Over 50 percent of the publicly insured liver transplant patients who dropped out of the waitlist did so due to the progression of their chronic disease.
Approximately 20 percent dropped off of the waitlist due to inadequate social support, substance abuse, failure to adhere to guidelines, or they fell out of contact with the researchers.
And just under 20 percent died of liver-related causes while waiting for the transplant.
In comparison, 25.5 percent dropped out of the private insurance group.
Less than half of those on public insurance received the liver transplant within two years of being on the waitlist, whereas 64.1 percent insured by private payers did.
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Three significant factors in waitlist dropout were liver or tumor-related factors such as the patient’s score on MELD, the levels of a tumor marker called α-fetoprotein (AFP), or having three lesions at baseline.
“Importantly, our study found that, despite similar tumor- and liver disease–related characteristics at the time of listing with an HCC MELD exception, patients with public insurance were the least likely to undergo liver transplant (LT) and had the highest rate of waiting list dropout compared with patients with Kaiser Permanente or other private insurance,” the authors clarified.
The researchers noted that the difference in waiting list drop out between public and private payers, with the exception of Kaiser Permanente, was not significant. However, there was a slight distinction.
Instead, what the researchers stressed was the fact that being covered by a public payer is a risk factor for patients in need of a liver transplant.
The results confirmed that these discrepancies are not, as was previously thought, due to the more or less advanced state of publicly insured patients versus those who are privately insured, since all participants were at a similar stage in the disease’s progression.
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While the researchers did not pin down a particular cause for the discrepancy in transplant wait list dropout, they identified several potential causes.
Social determinants of health such as stable housing, education, employment, or social support may play a significant role in driving more publicly insured individuals off the waitlist. This is particularly supported by the fact that 19 percent of the patients who dropped out of the waiting list cited inadequate social support, nonadherence, substance abuse, or falling out of contact with the researchers as their primary cause.
In view of these results, the researchers recommended that greater care coordination could help improve patient outcomes and patient experience.
The UCSF study underscores that while states’ new Section 1115 waivers implementing value-based payment models for distributing liver disease treatments like hepatitis C is critical to stemming the disease, it is equally important to remember the second half of the equation, which is coordinated care.
CMS has also been fighting hepatitis C, another serious chronic condition of the liver.
Washington’s value-based payment model is called a subscription model. It allows the state to pay a fixed rate for an unlimited supply of hepatitis C treatments.
Louisiana also received CMS’s approval for a similar model, which implements a supplemental rebate agreement for hepatitis C therapies. The state has unlimited rights to use the product but the cost is fixed and paid in increments.
At the same time, public payers have not ignored care coordination.
In late April 2019, CMS tested programs for dual eligibles that hinged on care coordination.
Because Medicare and Medicaid were not originally designed to work together, beneficiaries who rely on both and who have a high propensity for chronic diseases often face disjointed, confusing care from payers and providers. CMS partnered with nine states to test capitated model demonstrations of different kinds to identify which will incentivize health plans to facilitate more integrated care as well as which will best streamline the administrative process.
As these models are tested and the results become clearer, public payers will use this information to reshape their approach to chronic disease management with an emphasis on care coordination.