American Journal of Managed Care最新文献

Objective: To determine whether the CMS Comprehensive Care for Joint Replacement (CJR) Model, which incentivizes coordinated and efficient care, increased home health care (HHC) uptake among patients referred to HHC after major joint replacement surgery.

Study design: Cohort study using a difference-in-differences design comparing hospitals in 75 metropolitan statistical areas randomized into CJR by CMS with non-CJR hospitals in 119 areas as controls.

Methods: The primary outcome was the case mix-adjusted, hospital-level HHC uptake rate, which is the rate of patients referred to HHC at hospital discharge receiving an HHC visit within 14 days. Secondary outcomes included HHC uptake rate by race/ethnicity and the quality of HHC agencies used among referrals, which was measured by agency-level improvement in ambulation, unplanned hospitalizations, emergency department visits, time to the first home health visit, and distinct number of agencies.

Results: After the launch of CJR, HHC uptake decreased nationally but there was a 3.73-percentage point (4.5%) lower decrease in CJR hospitals; this was driven by White patients (3.54-percentage point differential; P = .026). A marginally statistically significant (P = .054) 5.05-percentage point differential increase for Black patients was observed due to a slight increase in the treatment group and a large decrease in the control group. There was no statistically significant change for Hispanic or Asian American/Pacific Islander populations. No statistically significant increases were observed in the quality of HHC used.

Conclusions: CJR mitigated a trend of decreased HHC uptake, but more work is needed to improve uptake for larger portions of the patient population. Our results suggest that addressing care coordination incentives via CJR may mitigate some racial disparities.

Objective: To determine whether longer prior appointment durations are associated with reduced missed appointment rates.

Study design: Retrospective cohort study at a large Texas federally qualified health center network.

Methods: The dependent variable was missed appointments, and the primary independent variable was prior appointment duration. Other independent variables included sociodemographic (age, sex, race/ethnicity, insurance status), geographic (distance to the clinic, residence in a medically underserved area [MUA]), and clinical (visit history, visit type, visit dates, days between visits) factors. We used mixed-effects logistic regression to examine the relationship between prior appointment duration and missed appointments.

Results: The study sample included 28,090 unique patients who had 56,180 appointments. The regression model demonstrated that longer prior appointment duration was associated with a lower likelihood of a missed appointment (OR, 0.90; 95% CI, 0.88-0.92). Being Hispanic or non-Hispanic Black (Hispanic: OR, 1.08; 95% CI, 1.03-1.15; Black: OR, 1.49; 95% CI, 1.38-1.61), lacking insurance (OR, 1.47; 95% CI, 1.38-1.57), and living 40 or more miles from the clinic (OR, 1.21; 95% CI, 1.08-1.36) were associated with higher odds of missing appointments. In contrast, living in an MUA (OR, 0.92; 95% CI, 0.82-0.96), having 3 or more previous visits (3-4 visits: OR, 0.87; 95% CI, 0.82-0.93), having more days between visits (91-180 days between visits: OR, 0.54; 95% CI, 0.50-0.59), and scheduling visits with physicians (OR, 0.90; 95% CI, 0.86-0.95) were associated with lower odds of missing appointments.

Conclusions: Duration of past appointments is inversely correlated with future missed appointment rates. Efforts to lengthen appointment times may have important effects on quality and health outcomes.

Objectives: A polysocial risk score, which summarizes multiple health-related social needs (HRSNs) into a single likelihood of risk, could support more effective population health management. Nevertheless, a polysocial risk score faces uncertainties and challenges due to the HRSNs' differing etiologies and interventions, cooccurrence, and variation in information availability.

Study design: A national expert panel provided guidance on the development and potential application of a polysocial risk score in a 3-round Delphi process.

Methods: Expert panel members from across the US included physicians (n = 8), social service professionals and staff (n = 9), and patients (n = 6). Round 1 obtained an initial sense of the importance of HRSNs for general health and well-being and total health care cost. Panelists also suggested additional HRSNs. Responses served as discussion points for round 2, during which 5 focus groups explored how HRSNs should be ranked, additional HRSNs to include, timing of measurements, management of nonresponse and missing data, and concerns about bias and equity. We analyzed the transcripts using a consensus coding approach. Panelists then completed a follow-up survey (round 3).

Results: Panelists identified 17 HRSNs relevant to health and well-being for inclusion in a polysocial risk score. Methodology concerns included the sources and quality of data, nonrandom missing information, data timeliness, and the need for different risk scores by population. Panelists also raised concerns about potential bias and misapplication of a polysocial risk score.

Conclusions: A polysocial risk score is a potentially useful addition to the growing methodologies to better understand and address HRSNs. Nevertheless, development is potentially complicated and fraught with challenges.

Objective: Cancer and dementia are prevalent chronic conditions among older adults. Despite the complexities involved in caring for individuals with both conditions, the patterns of hospitalization in this specific group are not well understood. This study aimed to examine the associations between the presence of dementia and hospitalization-related outcomes.

Study design: A multiyear cross-sectional analysis using 2016-2019 National Inpatient Sample data.

Methods: We examined hospitalization pattern disparities between patients with cancer 65 years and older with and without dementia at high risk of mortality. The influence of dementia on multiple hospitalization-related outcomes (eg, emergency admission, hospital charges) was investigated using a series of multivariable regression models.

Results: The study involved 774,812 hospital discharges of patients with cancer 65 years and older, including 8.7% with comorbid dementia. The prevalence of dementia varied across different cancer types, ranging from 5.5% for pancreatic cancer and esophageal cancer to 18.9% for nonmelanoma skin cancer. Multiple adjusted logistic regression models indicated that patients with cancer and dementia were more likely to be admitted through the emergency department (adjusted OR [AOR], 1.48; 95% CI, 1.44-1.52), to have nonelective admissions (AOR, 1.67; 95% CI, 1.61-1.74), and to be discharged to skilled nursing or related facilities (AOR, 2.16; 95% CI, 2.12-2.19), and they had approximately 6.9% lower hospital charges but a 6.8% longer length of stay compared with those without dementia (all  P  < .001).

Conclusions: Dementia was prevalent among older patients with cancer, particularly those with nonmelanoma, prostate, and bladder cancers. Comorbid dementia was associated with unplanned or unnecessary hospitalization, highlighting the need to enhance health care management and tailored strategies for this population.

To mark the 30th anniversary of The American Journal of Managed Care (AJMC), each issue in 2025 includes reflections from a thought leader on what has changed over the past 3 decades and what's next for managed care. The February issue features a retrospective by Richard J. Gilfillan, MD, former director of the Center for Medicare and Medicaid Innovation; and Donald M. Berwick, MD, MPP, former administrator of CMS.

Objective: To describe the effect of geographically limited disasters on health plan (ie, contract) quality performance scores using a broad set of clinical quality and patient experience measures.

Study design: Retrospective analyses to assess the impact of disasters on Medicare Advantage contracts' quality-of-care performance scores in 2017 and 2018 for 11 Part C clinical quality and patient experience measures used in the Medicare Advantage Star Ratings.

Methods: We calculated each Medicare Advantage contract's disaster exposure using the percentage of the contract's beneficiaries residing in a Federal Emergency Management Agency-designated disaster area during the measurement period. Using linear mixed models, we estimated the association between contract-level disaster exposures and performance scores during the performance period measured, with random effects for contract and fixed effects for year, contract characteristics, and the disaster exposure, using repeated cross-sectional data on contracts from 2016 to 2018.

Results: We found no evidence that geographically limited disasters meaningfully affected contract quality performance scores. The disasters studied were associated with statistically significant but small changes in performance scores for 1 of 11 measures in both years.

Conclusions: The lack of evidence that being in a disaster-affected area had a meaningful negative impact on quality measure performance suggests that performance measurement programs are robust to the impact of short-term localized disasters and continue to function as intended.

Objectives: To evaluate medical policy determinations for pharmacogenetic (PGx) testing for 65 clinically relevant drug-gene pairs and evidence cited to support determinations across major US health plans and laboratory benefit managers (LBMs).

Study design: Landscape analysis of available PGx medical policies to determine coverage status of certain drug-gene pairs.

Methods: PGx medical policies as of February 1, 2024, were ascertained through Policy Reporter for top national insurers, LBMs, and the Palmetto GBA Molecular Diagnostic Services (MolDX) Program, which determines whether a molecular diagnostic test is covered by Medicare. Data elements included date of last policy update, coverage status for each drug-gene pair, and evidence cited for or against coverage. A drug-gene pair was considered covered if the policy indicated that a PGx test was deemed medically necessary and/or meets coverage criteria.

Results: Policies from 8 insurers, 3 LBMs, and MolDX were available and reviewed. MolDX covered all 65 individual drug-gene pairs, followed by Avalon Healthcare Solutions (n = 50) and UnitedHealthcare (n = 45); these 3 also covered multigene panels. Eight policies covered 10 or fewer drug-gene pairs. HLA-B*57:01 testing prior to abacavir initiation and HLA-B*15:02 testing prior to carbamazepine initiation were covered across all policies. Drug-gene pairs with Clinical Pharmacogenetics Implementation Consortium guidelines and/or included in the FDA's Table of Pharmacogenetic Associations Section 1 were more commonly covered. Society guidelines were the most frequently cited evidence (413 times), and cost-effectiveness studies were infrequently cited (43 times).

Conclusions: We found significant variability in medical policy determinations and evidence cited for clinically relevant PGx tests among major US health insurers and LBMs. A collaborative effort between payers and the PGx community to standardize evidence evaluation may lead to more consistent coverage and improve patient access to PGx tests meeting evidence requirements.

Objectives: US military veterans have multiple options for health insurance coverage, including the Veterans Health Administration (VHA) and Medicare programs, which can lead to strategic selection of coverage and potentially inefficient budgetary allocations. Because coverage choices are likely to be a function of coverage availability and benefit value, understanding the relationship between benefit value and reliance on coverage is critical.

Study design: Analysis of cross-sectional, nationally representative survey data.

Methods: This analysis relied on a novel measure of benefit value for the VHA and Medicare Advantage (MA) programs and nationally representative survey data of veterans and their health care use for 2016 through 2019. Linear regressions controlling for beneficiary and market characteristics with state and year fixed effects were used to first estimate the effect of VHA benefit value relative to MA benefit value on MA enrollment, and then on veteran reliance on VHA-paid care conditional on MA enrollment.

Results: We found that a $1 increase in relative VHA benefit value leads to at most a 0.2% (SE = 0.04) reduction in the probability of MA enrollment and a 0.3-percentage point (SE = 0.1) increase in reliance on VHA-paid care. Results were consistent across subgroups of enrollees, with slightly larger effects for enrollees with less generous benefits.

Conclusions: For most veterans, benefit value has a small, often nonsignificant, effect on reliance. These results imply that changes in VHA benefit value are unlikely to have major effects on veteran reliance on the VHA.

The US HIV/AIDS Strategy and Ending the HIV Epidemic (EHE) initiatives aim to reduce HIV transmission by 90% by 2030 through targeted care and prevention initiatives such as the Undetectable = Untransmittable strategy. Effective HIV management involves implementation of widely available testing to ensure early diagnosis, immediate or early initiation of antiretroviral therapy (ART), patient adherence to medication, and retention in care to achieve viral suppression and improve clinical outcomes. A disproportionate burden of HIV incidence is experienced by certain populations that include Black/African American and Hispanic/Latinx people, transgender individuals, those who inject drugs, older adults, and people living in the southeastern US. People with HIV (PWH) in vulnerable and underserved populations are more likely to be affected by the negative impacts of structural and social determinants of health-such as experiencing HIV-related stigma, poverty, and homelessness-resulting in barriers to accessing HIV care and achieving favorable treatment outcomes. Suboptimal HIV care negatively impacts outcomes for both individuals and society. Overall and comorbidity-free life expectancies are lower for individuals who start ART late than for the overall PWH population, and a lack of viral suppression increases community transmission rates. These poor outcomes increase costs for both patients and health care systems. Maintaining access to high-quality care by optimizing ART regimens, decreasing delays in ART initiation, and engaging patients in care by building trust and empowering patient choice will improve individual and population-level outcomes and support the EHE initiative. This manuscript examines strategies to improve HIV care access and outcomes for underserved populations, focusing on social determinants of health, stigma, geographic disparities, and treatment adherence, while highlighting the role of national initiatives and managed care programs in advancing health equity.