William Schpero


Ndumele CD, Schpero WL, Trivedi AN. Medicaid Expansion and Health Plan Quality in Medicaid Managed Care. Health Services Research. 2018;53(S1):2821-2838.


OBJECTIVE: To assess the effect of the 2014 Medicaid expansion on Medicaid managed care plan quality.

DATA SOURCES: Three composite measures of plan-level quality constructed from the Health Care Effectiveness Data and Information Set.

STUDY SETTING: One hundred and sixty-three plans in 27 Medicaid expansion states and 100 plans in 14 nonexpansion states.

STUDY DESIGN: Quasi-experimental difference-in-differences (DID) analysis, comparing quality before (2011-13) and after (2014-15) Medicaid expansion in states that elected to expand Medicaid eligibility and those that did not.

PRINCIPAL FINDINGS: Mean plan enrollment increased from 130,533 to 274,259 in expansion states and from 105,449 to 148,194 in nonexpansion states. The proportion of enrollees receiving recommended preventive care increased from 62.6 to 65.2 percent in expansion states and from 59.3 to 62.5 percent in nonexpansion states (adjusted DID: -0.7 percentage points [95% CI -2.2, 0.7]). The proportion of enrollees receiving recommended chronic disease care management increased from 65.4 to 66.0 percent in expansion states and from 62.5 to 63.1 percent in nonexpansion states (adjusted DID: 1.1 percentage points [95% CI -0.5, 2.6]). We observed similar patterns for the receipt of recommended maternity care.

CONCLUSIONS: Medicaid expansion increased enrollment in managed care plans, but it did not result in erosion of quality.


Cohen MS, Schpero WL. Household Immigration Status Had Differential Impact On Medicaid Enrollment In Expansion And Nonexpansion States. Health Affairs. 2018;37(3):394–402.


Recent research has shown that concern about the apprehension and deportation of undocumented immigrants can affect how members of their households who are eligible for public benefits choose to participate in public programs. The extent to which this "chilling effect" broadly affects adults' Medicaid enrollment nationally remains unclear, in part because of the difficulty of isolating undocumented immigrants in survey data. In this study we identified households that likely included undocumented immigrants and then examined whether gains in health care coverage due to the expansion of Medicaid eligibility under the Affordable Care Act (ACA) were dampened for eligible people living in households with mixed immigration status. We found no significant differences in coverage gains for people in mixed- relative to non-mixed-status households in expansion states. Coverage gains were significantly lower, however, for people in mixed-status households relative to those in non-mixed-status households in nonexpansion states. These findings suggest that household immigration status may have dampened the "woodwork effect," whereby the ACA enhanced knowledge about program availability, in turn increasing Medicaid enrollment in nonexpansion states among people previously eligible for the program but not enrolled in it.

Ndumele CD, Schpero WL, Schlesinger MJ, Trivedi AN. Association Between Health Plan Exit from Medicaid Managed Care and Quality of Care, 2006-2014. JAMA. 2017;317(24):2524-2531.


IMPORTANCE: State Medicaid programs have increasingly contracted with insurers to provide medical care services for enrollees (Medicaid managed care plans). Insurers that provide these plans can exit Medicaid programs each year, with unclear effects on quality of care and health care experiences.

OBJECTIVE: To determine the frequency and interstate variation of health plan exit from Medicaid managed care and evaluate the relationship between health plan exit and market-level quality.

DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort of all comprehensive Medicaid managed care plans (N = 390) during the interval 2006-2014.

EXPOSURES: Plan exit, defined as the withdrawal of a managed care plan from a state's Medicaid program.

MAIN OUTCOMES AND MEASURES: Eight measures from the Healthcare Effectiveness Data and Information Set were used to construct 3 composite indicators of quality (preventive care, chronic disease care management, and maternity care). Four measures from the Consumer Assessment of Healthcare Providers and Systems were combined into a composite indicator of patient experience, reflecting the proportion of beneficiaries rating experiences as 8 or above on a 0-to-10-point scale. Outcome data were available for 248 plans (68% of plans operating prior to 2014, representing 78% of beneficiaries).

RESULTS: Of the 366 comprehensive Medicaid managed care plans operating prior to 2014, 106 exited Medicaid. These exiting plans enrolled 4 848 310 Medicaid beneficiaries, with a mean of 606 039 beneficiaries affected by plan exits annually. Six states had a mean of greater than 10% of Medicaid managed care recipients enrolled in plans that exited, whereas 10 states experienced no plan exits. Plans that exited from a state's Medicaid market performed significantly worse prior to exiting than those that remained in terms of preventive care (57.5% vs 60.4%; difference, 2.9% [95% CI, 0.3% to 5.5%]), maternity care (69.7% vs 73.6%; difference, 3.8% [95% CI, 1.7% to 6.0%]), and patient experience (73.5% vs 74.8%; difference, 1.3% [95% CI, 0.6% to 1.9%]). There was no significant difference between exiting and nonexiting plans for the quality of chronic disease care management (76.2% vs 77.1%; difference, 1.0% [95% CI, -2.1% to 4.0%]). There was also no significant change in overall market performance before and after the exit of a plan: 0.7-percentage point improvement in preventive care quality (95% CI, -4.9 to 6.3); 0.2-percentage point improvement in chronic disease care management quality (95% CI, -5.8 to 6.2); 0.7-percentage point decrease in maternity care quality (95% CI, -6.4 to 5.0]); and a 0.6-percentage point improvement in patient experience ratings (95% CI, -3.9 to 5.1). Medicaid beneficiaries enrolled in exiting plans had access to coverage for a higher-quality plan, with 78% of plans in the same county having higher quality for preventive care, 71.1% for chronic disease management, 65.5% for maternity care, and 80.8% for patient experience.

CONCLUSIONS AND RELEVANCE: Between 2006 and 2014, health plan exit from the US Medicaid program was frequent. Plans that exited generally had lower quality ratings than those that remained, and the exits were not associated with significant overall changes in quality or patient experience in the plans in the Medicaid market.

Schpero WL, Morden NE, Sequist TD, Rosenthal MB, Gottlieb DJ, Colla CH. For Selected Services, Blacks And Hispanics More Likely To Receive Low-Value Care Than Whites. Health Affairs. 2017;36(6):1065-1069.

US minority populations receive fewer effective health services than whites. Using Medicare administrative data for 2006-11, we found no consistent, corresponding protection against the receipt of ineffective health services. Compared with whites, blacks and Hispanics were often more likely to receive the low-value services studied.

Friedman AS, Schpero WL, Busch SH. Evidence Suggests That The ACA's Tobacco Surcharges Reduced Insurance Take-Up And Did Not Increase Smoking Cessation. Health Affairs. 2016;35(7):1176-1183.

To account for tobacco users' excess health care costs and encourage cessation, the Affordable Care Act (ACA) allowed insurers to impose a surcharge on tobacco users' premiums for plans offered on the health insurance exchanges, or Marketplaces. Low-income tax credits for Marketplace coverage were based on premiums for non-tobacco users, which means that these credits did not offset any surcharge costs. Thus, this policy greatly increased out-of-pocket premiums for many tobacco users. Using data for 2011-14 from the Behavioral Risk Factor Surveillance System, we examined the effect of tobacco surcharges on insurance status and smoking cessation in the first year of the exchanges' implementation, among adults most likely to purchase insurance from them. Relative to smokers who faced no surcharges, smokers facing medium or high surcharges had significantly reduced coverage (reductions of 4.3 percentage points and 11.6 percentage points, respectively), but no significant differences in smoking cessation. In contrast, those facing low surcharges showed significantly less smoking cessation. Taken together, these findings suggest that tobacco surcharges conflicted with a major goal of the ACA-increased financial protection-without increasing smoking cessation. States should consider these potential effects when deciding whether to limit surcharges to less than the federal maximum.

Colla CH, Morden NE, Sequist TD, Schpero WL, Rosenthal MB. Choosing Wisely: Prevalence and Correlates of Low-Value Health Care Services in the United States. Journal of General Internal Medicine. 2015;30(2):221-228.


BACKGROUND: Specialty societies in the United States identified low-value tests and procedures that contribute to waste and poor health care quality via implementation of the American Board of Internal Medicine Foundation's Choosing Wisely initiative.

OBJECTIVE: To develop claims-based algorithms, to use them to estimate the prevalence of select Choosing Wisely services and to examine the demographic, health and health care system correlates of low-value care at a regional level.

DESIGN: Using Medicare data from 2006 to 2011, we created claims-based algorithms to measure the prevalence of 11 Choosing Wisely-identified low-value services and examined geographic variation across hospital referral regions (HRRs). We created a composite low-value care score for each HRR and used linear regression to identify regional characteristics associated with more intense use of low-value services.

PATIENTS: Fee-for-service Medicare beneficiaries over age 65.

MAIN MEASURES: Prevalence of selected Choosing Wisely low-value services.

KEY RESULTS: The national average annual prevalence of the selected Choosing Wisely low-value services ranged from 1.2% (upper urinary tract imaging in men with benign prostatic hyperplasia) to 46.5% (preoperative cardiac testing for low-risk, non-cardiac procedures). Prevalence across HRRs varied significantly. Regional characteristics associated with higher use of low-value services included greater overall per capita spending, a higher specialist to primary care ratio and higher proportion of minority beneficiaries.

CONCLUSIONS: Identifying and measuring low-value health services is a prerequisite for improving quality and eliminating waste. Our findings suggest that the delivery of wasteful and potentially harmful services may be a fruitful area for further research and policy intervention for HRRs with higher per-capita spending. These findings should inform action by physicians, health systems, policymakers, payers and consumer educators to improve the value of health care by targeting services and areas with greater use of potentially inappropriate care.

Colla CH, Sequist TD, Rosenthal MB, Schpero WL, Gottlieb DJ, Morden NE. Use of Non-Indicated Cardiac Testing in Low-Risk Patients: Choosing Wisely. BMJ Quality & Safety. 2015;24:149-153.

Using Medicare administrative data from 2006 to 2011, we estimated the proportion of low-risk Medicare beneficiaries receiving non-invasive cardiac screening tests without a clear, pertinent symptomatic indication, as well as the regional variation in and spending associated with these tests. For comparison and as a validation of our patient risk assignment, we measured cardiac testing in beneficiaries with or at high risk for cardiac disease.

Lewis VA, Colla CH, Schpero WL, Shortell SM, Fisher ES. ACO Contracting with Private and Public Payers: A Baseline Comparative Analysis. American Journal of Managed Care. 2014;20(12):1008-1014.


OBJECTIVES: The accountable care organization (ACO) model is currently being pursued by private insurers, as well as federal and state governments. Little is known, however, about the prevalence of private payer ACO contracts and the characteristics of contract structures or how these compare with public ACO contracts.

STUDY DESIGN AND METHODS: Cross-sectional analysis of the National Survey of Accountable Care Organizations (n=173) on ACO contracts with public and private payers and private payer contract characteristics.

RESULTS: Most ACOs had only 1 ACO contract (57%). About half of ACOs had a contract with a private payer. The single most common private payer ACO contract was an upside-only shared savings model (41%), although the majority of private contracts included some form of downside risk (56%). A large majority of contracts made shared savings contingent upon quality performance (79%), and some included bonus payments for quality performance (39%). Most private payer contracts included upfront payments, such as care management payments (56%) or capital investment (17%). Organizations with private ACO contracts were larger and more advanced than ACOs with only public payer contracts.

CONCLUSIONS: While there are fewer ACOs with commercial contracts than public contracts, commercial contracts are more likely to include both downside risk and upfront payments.

Colla CH, Schpero WL, Gottlieb DJ, McClurg AB, Albert PG, Baum N, Finison K, Franzini L, Kitching G, Knudson S, Parikh R, Symes R, Fisher ES. Tracking Spending Among Commercially Insured Beneficiaries Using a Distributed Data Model. American Journal of Managed Care. 2014;20(8):650-657.


OBJECTIVES: To explore the feasibility of using a distributed data model for ongoing reporting of local healthcare spending, specifically to investigate the contribution of utilization and pricing to geographic variation and trends in reimbursements for commercially insured beneficiaries younger than 65 years.

STUDY DESIGN: Retrospective descriptive analysis.

METHODS: Commercial claims were obtained for beneficiaries in 5 states for the years 2008 to 2010 using a distributed data model. Claims were aggregated to the hospital service area (HSA) level and healthcare utilization was quantified using a novel, National Quality Forum-endorsed measure that is independent of price and allows for the calculation of resource use across all services in standardized units. We examined trends in utilization, prices, and reimbursements over time. To examine geographic variation, we mapped resource use by HSA in the 3 states from which we had data from multiple insurers. We calculated the correlation between commercial and Medicare reimbursements and utilization. Medicare claims were obtained from the Dartmouth Atlas.

RESULTS: We found that much of the recent growth in reimbursements for the commercially insured from 2008 to 2010 was due to increases in prices, particularly for outpatient services. As in the Medicare population, resource use by this population varied by HSA. While overall resource use patterns in the commercially insured did not mirror those among Medicare beneficiaries, we observed a strong correlation in inpatient hospital use.

CONCLUSIONS: This research demonstrates the feasibility and value of public reporting of standardized area-level utilization and price data using a distributed data model to understand variation and trends in reimbursements.

Morden NE, Schpero WL, Zaha R, Sequist TD, Colla CH. Overuse of Short-Interval Bone Densitometry: Assessing Rates of Low-Value Care. Osteoporosis International. 2014;25(9):2307-2311.


INTRODUCTION: The American College of Rheumatology, through the Choosing Wisely initiative, identified measuring bone density more often than every 2 years as care "physicians and patients should question." We measured the prevalence and described the geographic variation of short-interval (repeated in under 2 years) DXAs among Medicare beneficiaries and estimated the cost of this testing and its responsiveness to payment change.

METHODS: Using 100 % Medicare claims data, 2006-2011, we identified DXAs and short-interval DXAs for female Medicare beneficiaries over age 66. We determined the population rate of DXAs and short-interval DXAs, as well as Medicare spending on short-interval DXAs, nationally and by hospital referral region (HRR).

RESULTS: DXA use was stable 2008-2011 (12.4 to 11.5 DXAs per 100 women). DXA use varied across HRRs: in 2011, overall DXA use ranged from 6.3 to 23.0 per 100 women (coefficient of variation = 0.18), and short-interval DXAs ranged from 0.3 to 8.0 per 100 women (coefficient of variation = 0.64). Short-interval DXA use fluctuated substantially with payment changes; other DXAs did not. Short-interval DXAs, which represented 10.1 % of all DXAs, cost Medicare approximately US$16 million in 2011.

CONCLUSIONS: One out of ten DXAs was administered in a time frame shorter than recommended and at a substantial cost to Medicare. DXA use varied across regions. Short-interval DXA use was responsive to reimbursement changes, suggesting carefully designed policy and payment reform may reduce this care identified by rheumatologists as low value.

Hourdequin KC, Schpero WL, McKenna DR, Piazik BL, Larson RJ. Toxic effect of chemotherapy dosing using actual body weight in obese versus normal-weight patients: a systematic review and meta-analysis. Annals of Oncology. 2013;24(12):2952-2962.


BACKGROUND: Many oncologists reduce chemotherapy doses in obese patients due to fear of excess toxic effect from very large weight-based calculations. While recent guidelines advise against this practice, quantitative summarization of the supporting evidence is not available.

MATERIALS AND METHODS: We systematically identified studies that compared toxic effect or survival outcomes between obese and normal-weight adults receiving chemotherapy dosed by actual body weight (ABW). We pooled odds ratios (OR) and 95% confidence intervals (CI) using random-effects models.

RESULTS: Of 5490 records screened, 12 studies representing 9314 relevant patients met inclusion criteria. The large majority of reported toxic effect and survival outcomes did not statistically differ between obese and normal-weight subjects. Exceptions included five studies in which one or more toxic effect or survival outcomes statistically favored obese patients, and one study that statistically favored normal-weight patients. Pooling usable data, rates of toxic effects were similar or lower in obese patients (grade 3/4 hematologic toxic effect: OR 0.73, CI 0.55-0.98, 4 studies; grade 3/4 nonhematologic toxic effect: OR 0.98, CI 0.76-1.26, 3 subgroups; any grade 3/4 toxic effect: OR 0.75, CI 0.65-0.87, three studies).

CONCLUSIONS: Obese patients receiving chemotherapy based on ABW experience similar or lower rates of toxic effects compared with normal-weight patients, and survival outcomes do not differ.

Wasiuk A, Dalton DK, Schpero WL, Stan RV, Conejo-Garcia JR, Noelle RJ. Mast cells impair the development of protective anti-tumor immunity. Cancer Immunology, Immunotherapy. 2012;61(12):2273-2282.

Mast cells have emerged as critical intermediaries in the regulation of peripheral tolerance. Their presence in many precancerous lesions and tumors is associated with a poor prognosis, suggesting mast cells may promote an immunosuppressive tumor microenvironment and impede the development of protective anti-tumor immunity. The studies presented herein investigate how mast cells influence tumor-specific T cell responses. Male MB49 tumor cells, expressing HY antigens, induce anti-tumor IFN-γ(+) T cell responses in female mice. However, normal female mice cannot control progressive MB49 tumor growth. In contrast, mast cell-deficient c-Kit(Wsh) (W(sh)) female mice controlled tumor growth and exhibited enhanced survival. The role of mast cells in curtailing the development of protective immunity was shown by increased mortality in mast cell-reconstituted W(sh) mice with tumors. Confirmation of enhanced immunity in female W(sh) mice was provided by (1) higher frequency of tumor-specific IFN-γ(+) CD8(+) T cells in tumor-draining lymph nodes compared with WT females and (2) significantly increased ratios of intratumoral CD4(+) and CD8(+) T effector cells relative to tumor cells in W(sh) mice compared to WT. These studies are the first to reveal that mast cells impair both regional adaptive immune responses and responses within the tumor microenvironment to diminish protective anti-tumor immunity.

Benson MJ, Elgueta R, Schpero W, Molloy M, Zhang W, Casola S, Rajewsky K, Usherwood E, Noelle RJ. Distinction of the memory B cell response to cognate antigen versus bystander inflammatory signals. Journal of Experimental Medicine. 2009;206(9):2013-2025.

The hypothesis that bystander inflammatory signals promote memory B cell (B(MEM)) self-renewal and differentiation in an antigen-independent manner is critically evaluated herein. To comprehensively address this hypothesis, a detailed analysis is presented examining the response profiles of B-2 lineage B220(+)IgG(+) B(MEM) toward cognate protein antigen in comparison to bystander inflammatory signals. After in vivo antigen encounter, quiescent B(MEM) clonally expand. Surprisingly, proliferating B(MEM) do not acquire germinal center (GC) B cell markers before generating daughter B(MEM) and differentiating into plasma cells or form structurally identifiable GCs. In striking contrast to cognate antigen, inflammatory stimuli, including Toll-like receptor agonists or bystander T cell activation, fail to induce even low levels of B(MEM) proliferation or differentiation in vivo. Under the extreme conditions of adjuvanted protein vaccination or acute viral infection, no detectable bystander proliferation or differentiation of B(MEM) occurred. The absence of a B(MEM) response to nonspecific inflammatory signals clearly shows that B(MEM) proliferation and differentiation is a process tightly controlled by the availability of cognate antigen.

Strid J, Roberts SJ, Filler RB, Lewis JM, Kwong BY, Schpero W, Kaplan DH, Hayday AC, Girardi M. Acute upregulation of an NKG2D ligand promotes rapid reorganization of a local immune compartment with pleiotropic effects on carcinogenesis. Nature Immunology. 2008;9(2):146-154.

The self-encoded ligands MICA (human) and Rae-1 (mouse) for the cytotoxic lymphocyte activating receptor NKG2D are highly expressed in carcinomas and inflammatory lesions and have been linked to immunosurveillance and graft rejection. However, whether NKG2D ligands have an intrinsic ability to acutely regulate tissue-associated immune compartments is not known. Here we show that epidermis-specific upregulation of Rae-1 induced rapid, coincident and reversible changes in the organization of tissue-resident V(gamma)5V(delta)1 TCRgammadelta+ intraepithelial T cells and Langerhans cells, swiftly followed by epithelial infiltration by unconventional alphabeta T cells. Whereas local V(gamma)5V(delta)1+ T cells limited carcinogenesis, Langerhans cells unexpectedly promoted it. These results provide unique insight into the early phases of tissue immunosurveillance and indicate that acute changes in NKG2D ligands may alone initiate a rapid, multifaceted immunosurveillance response in vivo.


Schpero WL. Limiting Low-Value Care by “Choosing Wisely.” American Medical Association Journal of Ethics. 2014;16(2):131-134.

Fisher ES, Schpero WL, Corrigan JM. Measuring What Matters for ACOs. The Commonwealth Fund Blog. 2014.