American Journal of Managed Care最新文献

Objective: This study examines the impact of accountable care organization (ACO) maturity on inpatient costs, quality of care, and patient safety for hospitals participating in ACOs initiated by CMS relative to nonparticipants.

Study design: Quasi-experimental evaluation of hospitals before and after joining a CMS ACO using a difference-in-differences design during the period from 2010 to 2013.

Methods: Propensity score-matched groups of hospitals were used to estimate the combined effects of ACO maturity and CMS ACO participation on inpatient costs, quality, and patient safety outcomes. Total treatment costs, mortality rates for 4 common conditions, and 4 perioperative adverse events were investigated. Analyses were based on state-level data from the Healthcare Cost and Utilization Project.

Results: We matched 121 CMS ACO-participating hospitals and 853 nonparticipating hospitals. Hospitals with an ACO maturity score of 0 had significantly worse acute myocardial infarction mortality and perioperative pulmonary embolism or deep vein thrombosis rates than nonparticipants. These differences were no longer significant with increasing ACO maturity. Higher ACO maturity was associated with significant improvements in accidental punctures and lacerations among hospital CMS ACO participants. No other significant trends were observed.

Conclusions: Findings suggest a potential positive effect of hospital CMS ACO participation with increasing maturity. However, use of early ACO data, a short follow-up period, and other limitations hindered the ability to identify significant trends. Nonetheless, ACO maturity scores and new outcome measures may offer a promising approach for tracking the long-term impact of hospital ACO participation in future research and policy evaluations.

Objectives: A large academic medical center piloted a pharmacist-driven charitable medication access program. The financial and health outcomes of the program were evaluated and compared with existing benchmarks.

Study design: This retrospective cohort study analyzed electronic health records for study participants and pharmacy dispensing information. The study period was January 1, 2023, through August 31, 2024.

Methods: A pre-post analysis was performed to determine the impacts of the program. First, characterizations of the number, type, and cost of medications provided to charitable care patients via the Streamlined Medication Access for High-Risk Patients (SMART) formulary were compared with existing benchmarks. Second, emergency department (ED) and hospital utilization data were reviewed for charitable care patients after implementation of the SMART formulary and compared with utilization prior to implementation.

Results: From January 1, 2023, through August 31, 2024, the SMART formulary provided 6791 medications to 418 unique patients, totaling more than 4.5 times more prescriptions to nearly 3 times more unique patients than the benchmark charitable care spending (March 1, 2019, to June 30, 2021). Drug costs per patient and costs per prescription were reduced by 62% and 72%, respectively. Reductions in ED visits (10%) and hospitalizations (34%) occurred, reducing the total health care spend by $6163 per month. The SMART formulary team facilitated the completion of 74 patient assistance program applications and connected patients to manufacturer insulin savings programs, estimating an additional indirect cost savings of $310,168.

Conclusions: The SMART formulary reduced the total cost of care for a cohort of charitable care patients enrolled in a primary care clinic at a large urban academic medical center in Baltimore, Maryland.

Objectives: Medicaid managed care organization (MCO) care coordinators play a crucial role in assisting high-need Medicaid members with substance use disorder (SUD) and facilitating their connections with medical and social services. This study assessed challenges faced by care coordinators serving patients with SUD, including the types and frequencies of barriers, associated care coordinator and patient factors, and their relationship with burnout and job satisfaction.

Study design: Web-based survey data from 322 Virginia Medicaid MCO care coordinators.

Methods: Coordinators rated 15 barriers related to providing services to patients with SUD. Principal components analysis (PCA) identified 3 subscales categorizing these challenges (challenges accessing resources, administrative and regulatory burden, and data integration). Multivariable linear regression explored associations between coordinator and patient factors and subscales for categories of barriers. Pearson correlations were used to examine the relationship between these barriers and job satisfaction.

Results: Coordinators reported a high frequency of challenges in many care coordinating activities: Between 49% and 82% reported each barrier as "somewhat" of a problem or a "major" problem. Using PCA, 3 main categories of barriers were identified. Having a high proportion of patients with SUD was associated with greater difficulties in accessing resources (P < .01) and data integration issues (P < .05), and working for specific MCOs was associated with all 3 categories of barriers (P < .05). Job satisfaction and burnout were correlated with all 3 categories as well and were most strongly associated with administrative and regulatory burden.

Conclusions: Care coordinators face multiple challenges serving Medicaid members, particularly those with SUD. State-level Medicaid policies supporting care coordinators may help.

Objectives: We sought to determine whether patients with cardiovascular disease (CVD) or CVD risk factors and fragmented care (ie, care spread across multiple providers) perceive any gaps in communication among their providers and whether any gaps are perceived as clinically significant (ie, leading to adverse events).

Study design: We conducted a cross-sectional telephone survey of community-dwelling Medicare beneficiaries 65 years and older with CVD or at least 1 CVD risk factor and highly fragmented ambulatory care (reversed Bice-Boxerman Index score ≥ 0.85) who had been attributed to an accountable care organization in New York, New York.

Methods: Using a previously tested survey instrument, we asked about perceptions of communication among the respondents' providers, any adverse events (drug-drug interactions, duplicate tests, emergency department visits, or hospitalizations), and whether those events were preventable with better communication. We used descriptive statistics.

Results: Of 201 eligible individuals, 96 completed surveys (47.8% response rate). Of those, 94 (97.9%) reported having at least 2 ambulatory visits and at least 2 ambulatory providers in the past year and were included in our analytic sample. The mean (SD) age was 76 (6.8) years; approximately two-thirds (69%) were women. Approximately half of respondents (48%) reported a problem with, or "gap" in, communication among their providers. One in 14 respondents (7%) reported experiencing an adverse event that they thought could have been prevented with better communication.

Conclusions: Gaps in communication for patients with CVD or CVD risk factors are common and hazardous. Interventions are needed to leverage patients' observations to address gaps in communication before they cause harm.

Objectives: Value-based care models, such as the Medicare Shared Savings Program, have placed increasing emphasis on unplanned admissions among patients with multiple chronic conditions (UAMCCs) as a quality metric. However, there are limited data on which factors are associated with the highest risk of UAMCCs. This study sought to determine which factors were associated with increased risk of UAMCCs.

Study design: Retrospective study conducted among all adult patients with 2 or more chronic conditions defined by CMS presenting to 2 hospitals within a major Midwest health care system from November 1, 2022, to October 31, 2023.

Methods: Demographics, chronic conditions, primary care physician (PCP) visit utilization, and annual wellness visit (AWV) utilization were analyzed using multivariable logistic regression to identify associations with UAMCCs.

Results: Among 18,448 patients (55.8% women) included in the study, 3842 (20.8%) had at least 1 UAMCC. Patients with UAMCCs were more likely to have Medicare or Medicaid insurance; be widowed; speak Spanish; have a higher Charlson Comorbidity Index score; and have Alzheimer disease, atrial fibrillation, heart failure, chronic kidney disease, depression, chronic obstructive pulmonary disease, and/or stroke. When examining PCP visit measures, AWVs and having 1 or more PCP visits were associated with fewer UAMCCs.

Conclusions: Higher Charlson Comorbidity Index scores, several health conditions, and Spanish language were associated with increased UAMCCs. AWVs and having 1 or more PCP visits were associated with fewer UAMCCs.

Objectives: Financial toxicity (FT) represents the impact of health care expenses on patients' financial well-being and access to care. Although existing literature has mostly looked at FT in the context of cancer and other medical conditions, we sought to identify risk factors for FT on a population-wide level.

Study design: This was a cross-sectional study of the 2022 National Health Interview Survey (NHIS).

Methods: Eight financial hardship questions were selected from the 2022 NHIS to represent FT. The unweighted sum of financial hardship questions to which a person responded "yes" was calculated as the FT score (FinTox), and risk factors for FinTox were analyzed using a negative binomial model.

Results: There were 27,246 adults with a mean age of 52.96 years included for analysis, among whom 17.1% (n = 4659) responded "yes" to at least 1 FT question, of whom most had a FinTox of 1 or 2 (n = 3112; 66.8%). Increasing age (β = -0.616; P = .020), higher education (β = -1.08; P = .023), and higher income (β = -0.149; P < .001) were associated with lower FinTox, whereas involuntary unemployment (β = 0.920; P = .001), transient loss of health insurance (β = 1.075; P = .044), and high-deductible health plans (β = 0.519; P = .013) were associated with higher FinTox.

Conclusions: Understanding risk factors for FT at a population level can help identify patients at risk for catastrophic financial effects or inadequate access to care.

Objectives: To describe adoption and use of voluntary alignment throughout the Next Generation Accountable Care Organization (NGACO) model from 2016 through 2021. Voluntary alignment allows Medicare beneficiaries to self-attribute to a particular medical provider or organization by signing a form or making a selection in the MyMedicare.gov portal.

Study design: We performed mixed-methods analyses of cross-sectional survey, enrollment, and claims data and coding transcripts of interviews with NGACO leadership.

Methods: We statistically compared characteristics of NGACOs and beneficiaries that engaged in voluntary alignment compared to claims alignment. Additionally, we grouped qualitative interview responses into 2 overarching themes that emerged around NGACO leaders' perceptions, use, and experiences with voluntary alignment.

Results: Few NGACOs engaged in widespread use of voluntary alignment. NGACOs that adopted voluntary alignment were similar to those that did not in most respects, although beneficiaries aligned through voluntary alignment were sicker and more expensive than those aligned through claims only. Many NGACO leaders reported they were content with claims-based alignment and did not think implementing initiatives to increase voluntary alignment would be worthwhile.

Conclusions: The analysis suggests possible lessons for using voluntary alignment in future ACO models. NGACO leaders perceived that the use of voluntary alignment was limited by a high implementation effort, a need for patient education, and tight administrative time frames. Perceived benefits of voluntary alignment included attribution flexibility and creating opportunities for beneficiary engagement. Some leaders suggested allowing year-round voluntary alignment sign-up to better integrate voluntary alignment into their regular office workflows.

Objective: To evaluate the impact of an adult medical care coordination (AMCC) intervention on patient activation.

Study design: This observational evaluation compared AMCC with usual care (UC). Eligible patients were adults discharged home who had 2 or more chronic conditions and a high risk of readmission. AMCC involved registered nurse care coordinators providing self-management support to patients via 1 home visit and regular phone calls. The outcome was the 10-item Patient Activation Measure (PAM), a validated patient-reported outcome tool with 4 levels ranging from 1 (lower activation) to 4 (higher activation). Measurement occurred at baseline and 30, 90, and 180 days.

Methods: We evaluated patient activation as an ordinal outcome using an ordered logistic regression model, a dichotomous outcome using a linear probability model, and a continuous outcome using ordinary least squares.

Results: We identified 915 (432 AMCC, 483 UC) patients who completed both the baseline and at least 1 follow-up PAM. For the ordinal analysis, AMCC was associated with a significant increase in the percentage with a PAM of level 3 at 30, 90, and 180 days and a decrease in the percentage with a PAM of level 1 or 2 at 180 days. For the dichotomous analysis, AMCC was associated with a significant increase in the percentage of patients with a PAM of level 3 or 4 at 180 days (15.2 percentage points; 95% CI, 5.6-24.7).

Conclusions: AMCC significantly increased patient activation, particularly at the final measurement. These findings highlight the potential value of AMCC as a self-management intervention, enhancing patients' confidence to manage their health.

Objectives: Participation in the Oncology Care Model has influenced care utilization and costs relative to nonparticipating practices. Less is known, however, about how care is potentially altered by participation in similar private payer-based models. Here, we take advantage of a natural experiment in which 2 large practices from among a network of oncology practices participated in a shared savings program (SSP) with a private insurer.

Study design: Quasi-experimental (difference-in-differences) statistical analysis of oncology claims data.

Methods: We used monthly provider-level claims data from September 2014 through August 2017 for patients with breast, colon, and lung cancer from The US Oncology Network. Key outcome measures were monthly mean office visits, total costs, and buy-and-bill drug costs among patients with breast, colon, and lung cancer. We then compared the utilization and cost patterns, preintervention and post participation, among patients on this insurance at participating practices vs those of patients at nonparticipating practices.

Results: Monthly per-patient total costs in colon cancer and lung cancer were lower through the first year of participation in the program by $1391 (95% CI, -$2218 to -$563; P < .01) and $1050 (95% CI, -$1878 to -$222; P = .02), respectively. These savings increased for colon cancer but disappeared for lung cancer in the second year. The program appeared to have no significant impact on any costs for participants with breast cancer in either of the years we examined.

Conclusions: Our results suggest that private payer-based SSP models can be associated with reduced costs for colon cancer care. There is weaker evidence of effects in lung cancer and no evidence in breast cancer. Such heterogeneous effects can inform future model development.