American Journal of Managed Care最新文献

Objectives: Patients who revisit the emergency department (ED) shortly after discharge are a high-risk group for complications and death, and these revisits may have been seriously affected by the COVID-19 pandemic. Detecting suspected COVID-19 cases in EDs is resource intensive. We examined the associations of screening workload for suspected COVID-19 cases with in-hospital mortality and intensive care unit (ICU) admission during short-term ED revisits.

Study design: We conducted a retrospective cohort study using electronic health record data from a tertiary teaching hospital.

Methods: We analyzed all 72-hour ED-revisiting patients at the Taipei Veterans General Hospital ED in Taiwan between January 27, 2020, and December 31, 2020. Screening workload for suspected COVID-19 cases was measured with the daily number of suspected COVID-19 cases. Multivariate logistic regression models were used after adjustment for patient characteristics to examine the associations of screening workload with in-hospital mortality and ICU admission.

Results: A total of 1107 patients were included. The mean number of daily suspected COVID-19 cases was 9.4. The rates of subsequent in-hospital mortality and ICU admission were 2.1% and 3.2%, respectively. The volume of daily suspected COVID-19 cases was significantly associated with increased subsequent in-hospital mortality (adjusted OR, 1.073 with each additional daily suspected COVID-19 case; P  = .005).

Conclusions: This is the first study to our knowledge to identify that screening for suspected COVID-19 cases in EDs can adversely affect patient outcomes during short ED revisits. Identifying this association could enable ED providers and policy makers to optimize emergency service delivery during an epidemic and help patients.

To mark the 30th anniversary of The American Journal of Managed Care (AJMC), each issue in 2025 includes a special feature: reflections from a thought leader on what has changed-and what has not-over the past 3 decades and what's next for managed care. The January issue features a conversation with longtime editorial board member Jan E. Berger, MD, MJ, the CEO of Health Intelligence Partners.

The authors advocate for the implementation of value-based principles to address the underutilization and limited supply of home care and rehabilitation services.

Objectives: Patient experience surveys are essential to measuring patient-centered care, a key component of health care quality. Low response rates in underserved groups may limit their representation in overall measure performance and hamper efforts to assess health equity. Telephone follow-up improves response rates in many health care settings, yet little recent work has examined this for surveys of Medicare enrollees, including those with Medicare Advantage. Our objective was to describe response rates to the 2022 Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) surveys and the completion mode (mail or telephone), overall and by person-level characteristics.

Study design: Cross-sectional survey.

Methods: Participants were 1,092,434 individuals with Medicare who were selected to receive the 2022 MCAHPS survey in the 50 states and the District of Columbia and who were representative of the Medicare population. Study measures were survey response and completion mode.

Results: The overall response rate was 33.7% (31.3% by mail and 2.3% by telephone), with 6.9% of responses by telephone. Despite the low overall telephone response rate, the phone was used at markedly higher rates by respondents in some groups with lower overall response rates who are thus underrepresented among respondents, including those who were younger than 65 years (eligible for Medicare due to disability: 16.5% of responses by telephone), Black (16.1%), or Hispanic (14.1%) or had limited income and assets (14.6%).

Conclusions: Including a telephone component in the administration of the MCAHPS survey continues to have value because several groups still show a relative preference for survey completion by telephone. Steps should be taken to improve response rates by telephone.

Objectives: Patients are often discharged to a skilled nursing facility (SNF) for postacute rehabilitation. Functional outcomes achieved in SNFs are variable, and costs are high. Especially for accountable care organizations (ACOs), home-based postacute rehabilitation offers a high-value option if outcomes are not compromised. The objective was to compare outcomes for episodes in a novel high-intensity home-based rehabilitation (HIHR) model vs an SNF.

Study design: Retrospective cohort study.

Methods: Medicare patients from a large integrated multihospital health system who had low to moderate medical complexity and mild to moderate mobility deficits at hospital discharge were included. The primary exposure was discharge to HIHR (intervention) or an SNF (control) after hospitalization. The primary outcome was Activity Measure for Post-Acute Care (AM-PAC) mobility score. Secondary outcomes were Medicare costs within 30 and 90 days post hospitalization, 30-day readmission rate, and index hospital length of stay (LOS). Inverse probability of treatment-weighted regression was used for comparison between cohorts.

Results: There were 171 patients discharged to HIHR and 841 to SNFs. The adjusted AM-PAC mobility T-score was 8.2 (95% CI, 6.3-10.1) points higher after HIHR vs SNF. Adjusted Medicare costs were lower for the HIHR cohort (within 90 days, -$17,123; 95% CI, -$20,757 to -$13,490). Hospital LOS and odds for readmission did not differ between cohorts.

Conclusions: The HIHR cohort demonstrated better functional outcomes and lower posthospital costs. HIHR may be a high-value option for patients attributed to a Medicare ACO who have moderate medical complexity and moderate functional deficits at the time of hospital discharge.

Objectives: To assess trends in the medical loss ratio (MLR) and understand how health insurance premiums in the large group market are driven by medical claims spending and insurer margins.

Study design: Study of approximately 500 insurers covering more than 40 million lives annually in the large group market that submitted an MLR submission form (2014-2022).

Methods: We assessed trends in the MLR, premiums, medical claims spending, administrative costs, quality improvement spending, and margins among all insurers in the large group market.

Results: The mean MLR was 90.0% (2014-2020), which increased to 91.8% in 2021 before declining in 2022. Spending on both administrative costs and quality improvement was small and stable during this period. In contrast, premiums and medical claims spending grew between 2014 and 2020, with claims spending increasing 9.4% between 2020 and 2021 compared with just 3.9% for premiums. This mirrored the observed trend in insurer margins, which increased from 2014 to 2020 before experiencing a temporary decline in 2021.

Conclusions: Medical spending is the primary driver of premiums in the large group market. Efforts to address growing health insurance premiums in the US will require consideration of how medical spending contributes to this growth.

Objective: To describe the outcomes of a partnership between a drug plan and pharmacists to switch patients from brand name dipeptidyl-peptidase-4 inhibitors to the generic alogliptin.

Study design: Single-center, retrospective chart review.

Methods: Clinical pharmacists contacted patients with primary care providers within the health system affiliated with the drug plan to facilitate the switch. Drug plan members with external primary care providers were sent letters communicating the formulary change without contact from the clinical pharmacist. Outcomes included the proportion of patients successfully switched to alogliptin, reasons for not switching, changes in hemoglobin A1C (HbA1C), and cost savings.

Results: Initially, more than 50% of patients contacted by pharmacists agreed to switch to alogliptin; however, only 44% were successfully switched to alogliptin per prescription claims data. One patient from the group that received letters without clinical pharmacy intervention switched to alogliptin. Overall, there was no significant difference in the mean HbA 1C level for the patients switched to alogliptin. At the end of the year-long study period, only 12 of the 67 patients successfully switched to alogliptin were still taking alogliptin. Reverting to a branded product and switching to a glucagon-like peptide-1 receptor agonist were the most common reasons that alogliptin was discontinued. Cost savings to the health plan were $220,717, or $0.17 per member per month over 1 year.

Conclusions: The use of pharmacists was beneficial in switching patients to alogliptin and yielded cost savings without compromising patient outcomes.

Objectives: Unused medical appointments affect both patient care and clinic operations, and the frequency of cancellations due to clinic reasons is underreported. The prevalence of these unused appointments in primary care in the Veterans Affairs Health Care System (VA) is unknown. This study examined the prevalence of unused primary care appointments and compared the relative frequency of cancellations and no-shows for patient and clinic reasons.

Study design: In this retrospective, observational study, we collected all in-person and virtual VA primary care appointments from October 1, 2018, to April 1, 2024.

Methods: We examined the proportion of appointments canceled on the same day as the appointment and classified these into canceled by patient, canceled by clinic, and no-show.

Results: Of more than 90 million in-person and nearly 24 million virtual primary care appointments, 11.9 million (10.87%) were canceled on the day of the appointment. For in-person care cancellations, the most common reasons were canceled by the patient (3.92%; n = 3,531,016), no-show (3.87%; n = 3,487,944), and clinic cancellation (3.08%; n = 2,780,259).

Conclusions: Although this study shows that same-day cancellations of primary care appointments in the VA are common, comparisons with other providers and health care systems indicate similar or lower levels of unused appointments in the VA.

Objectives: Medicaid is the largest payer of mental health (MH) services in the US, and more than 80% of its enrollees are covered by Medicaid managed care (MMC). States are required to establish quantitative network adequacy standards (NAS) to regulate MMC plans' MH care access. We examined the association between quantitative NAS and MH care access among Medicaid-enrolled adults and among those with MH conditions.

Study design: Cross-sectional study with a difference-in-differences design.

Methods: Using the 2016-2019 National Survey on Drug Use and Health, we included Medicaid enrollees aged 18 to 64 years in 15 states. Subgroup analyses included enrollees with MH conditions who experienced in the past year (1) serious psychological distress, (2) a major depressive episode, and/or (3) suicidal thoughts. Outcomes assessed whether in the past year the enrollee had any (1) MH services, (2) inpatient MH stays, (3) outpatient MH visits, (4) MH prescription, and (5) unmet MH care needs.

Results: Among 9300 adults aged 18 to 64 years, 27.2% had MH conditions. Among all adults, NAS were marginally associated with increased use of any MH services (adjusted OR, 1.4; 95% CI, 1.0-2.1; P = .055) but were not associated with other outcomes. Among enrollees with MH conditions, no statistically significant association between NAS and MH care access was observed.

Conclusions: Current quantitative NAS requirements may have few impacts on improving MH care access for adults and those with MH conditions without the implementation of additional interventions. States should consider adjusting enforcement strategies and adopting other interventions alongside NAS.