American Journal of Managed Care最新文献

Semaglutide, a glucagon-like peptide-1 receptor agonist, is FDA approved under the brand names Ozempic for treatment of type 2 diabetes and Wegovy for the treatment of overweight or obesity. The soaring popularity of these drugs, driven by social media and their overall efficacy, has resulted in nationwide shortages. The high costs associated with the FDA-approved products for both insurers and patients have also led to additional restrictions in access. In response to the unmet growing demand for semaglutide, suppliers have started to sell compounded versions of these products, both legally and illegally. This narrative review examines the implications of these compounded products on our health care system, highlighting concerns regarding their safety, efficacy, and regulatory status. Compounding, when done following federal and state regulations, can fill an important need in our health care marketplace. However, the compounded semaglutide products currently available to patients may lack the quality controls historically seen with compounded formulations, resulting in risks for dosing errors and adverse health outcomes. In addition, the compounded semaglutide market worldwide has seen batches of fraudulent products. Pharmacists and other health care providers have a unique opportunity to help guide patients in navigating this compounded semaglutide market, including directing them to lawful sources of compounded semaglutide, providing counseling on dosage and administration, and minimizing safety concerns.

Objectives: Assisted reproductive technology (ART) is a treatment option available to patients diagnosed with infertility. This study evaluated the impact of infertility benefit coverage on ART utilization and pregnancy-related outcomes, addressing a gap in previous research.

Study design: Retrospective analysis.

Methods: This study utilized the Workpartners Research Reference Database containing claims from self-insured employers in the US from 2010 to 2022. Women aged 18 to 42 years with at least 1 infertility diagnosis and at least 2 years of continuous enrollment after the initial infertility diagnosis were classified into 1 of 2 cohorts: high cohort (those with both infertility diagnostic and treatment coverage) or low cohort (those with only diagnostic coverage or no diagnostic nor treatment coverage). Binary outcomes were analyzed using logistic regression and continuous outcomes were analyzed using 2-stage stepwise regressions. Models controlled for differences in employee demographics, job-related variables (exempt status, full-time status, hourly vs salary, annual salary), and number of insured dependents.

Results: Of the 10,820 women who met the inclusion criteria, 7589 (70.1%) were in the high cohort and 3231 (29.9%) were in the low cohort, with mean (SE) ages of 34.4 (0.06) vs 33.5 (0.11) years, respectively (P < .0001). The high cohort had a higher adjusted likelihood than the low cohort of using ART medications (P < .0001) and having ART procedures performed (P < .0001). The high cohort also used a higher number of unique ART medications and procedures. The likelihood of becoming pregnant with any ART utilization was 69.6% for the high cohort and 65.3% for the low cohort (P = .0089). The only significant difference in pregnancy-related complications was claims for oligohydramnios (9.3% vs 7.2%, respectively; P = .0294).

Conclusions: Health benefit design that includes infertility treatment coverage resulted in significantly higher use of unique ART medications, number of ART procedures performed, and successful pregnancy outcomes.

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 August issue features a conversation with Charles N. (Chip) Kahn III, MPH, the president and CEO of the Federation of American Hospitals and a longtime member of the AJMC editorial board.

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the US, with nearly 40% of eligible individuals not current on lifesaving CRC screening. Although stool-based screening tests offer accessible initial options, the CRC screening process is incomplete without a follow-up colonoscopy after a positive result. Unfortunately, low follow-up rates-particularly among socioeconomically disadvantaged groups-undermine the potential health benefits. Recent policies eliminating patient cost sharing for follow-up colonoscopies address one critical barrier but fail to overcome the systemic obstacles that impede screening completion. Patient navigation programs are a proven strategy to bridge these gaps. By addressing logistical, financial, and educational challenges, navigation services significantly improve follow-up colonoscopy rates. However, inadequate reimbursement has hindered their widespread implementation. Current funding models, including CMS' Principal Illness Navigation services, fall short of supporting preventive care such as CRC screening. To fully realize the potential of CRC screening, investments in patient navigation, enhanced clinician reimbursement for follow-up colonoscopies, and systemic reforms are essential. Modeling studies reveal a "win-win-win" scenario: Clinicians receive appropriate compensation for their critical role in follow-up care, payers achieve cost savings through efficient screening processes, and investments in navigation services help close disparities in CRC screening. Expanding navigation programs and incentivizing follow-up colonoscopies would increase screening rates, reduce disparities, and achieve population health gains. These investments represent a rare opportunity to align stakeholder interests, prevent CRC deaths, and advance health equity.

Objectives: To examine the effects of price transparency and prosocial messaging on price-protected consumers' health care choices as a potential cost-saving strategy to manage rising US health care expenditures.

Study design: Cross-sectional study. Participants were recruited to complete a basic questionnaire via Amazon's Mechanical Turk program. Participants' selections were subsequently collected and analyzed.

Methods: Participants (N = 567) selected a sleep study provider from 5 options, with manipulations including financial responsibility, provision of price information, and a prosocial message encouraging high-value options.

Results: Price transparency increased the selection of lower-cost options among participants who were solely responsible for paying for their own health care expenses. For participants whose insurance paid for health care expenses, both price transparency and prosocial messaging were necessary to choose lower-cost options.

Conclusions: The study highlights the importance of considering both financial and social factors in patient engagement initiatives, suggesting that a combination of price transparency and prosocial messaging can influence health care choices and potentially contribute to cost-saving strategies in the US health care system.

Objectives: Biologics have substantially improved health outcomes for patients with immunologic conditions. However, not all patients have equitable access to these important medications. Accordingly, we conducted a systematic review to understand US health care disparities in biologics access and associated clinical and economic outcomes, including health care resource use, across immunology (ie, rheumatology, gastroenterology, and dermatology).

Study design: Systematic literature review.

Methods: We searched PubMed, Web of Science, and Embase databases for studies published between 2017 and 2023 focused on access to biologic treatments for US adult patients (≥ 18 years) diagnosed with immunologic conditions.

Results: Across the 21 studies included in this systematic review, disparities in biologics access were inconsistently studied, and only 8 studies (38%) evaluated clinical or economic outcomes of low biologics access. The factors most frequently associated with disparities in access to biologics included insurance type; Black, Hispanic, or Asian race or ethnicity; high out-of-pocket costs; and insurance prior authorization requirements. These disparities were associated with worse clinical and economic outcomes, including higher hospital admission and readmission, higher number of emergency department visits, and treatment delays. However, some studies found no association between some of these disparities and access to biologics, highlighting the complexity of the issue.

Conclusions: We identified key factors that influence disparities in biologics access within immunology across the US, which were associated with worse clinical and economic outcomes. We highlight potential solutions to minimize disparities in biologics access and the need for more in-depth research to address these disparities.

Objective: To describe trends in employer preventive drug list (PDL) offerings and associations of employer PDL offerings with employer and workforce characteristics.

Study design: Observational and cross-sectional descriptive study.

Methods: Using a large administrative health claims database, we studied employer offering of PDLs between January 2005 and December 2017.

Results: The percentage of employers offering PDLs increased between 2005 and 2017, and this was most pronounced among larger employers. In 2017, almost 43.0% (95% CI, 35.7%-50.1%) of employers with 5000 or more insured employees offered PDLs, 4 times more than employers with 50 to 199 employees (10%; 95% CI, 9.3%-10.3%). Among employers with at least 85% of their insured workforce in high-deductible health plans with health savings accounts (HDHP-HSAs; n = 24,632; 8.9%) across the study period, 32.0% offered PDLs in the last benefit year, and 13.0% of non-HDHP-HSA employers did. In adjusted analyses, HDHP-HSA employers with older workforces (OR, 1.45; 95% CI, 1.43-1.48) and those with more chronically ill employees (eg, more than 75% of employees with diabetes) (OR, 1.20; 95% CI, 1.17-1.23) were more likely to offer PDLs than employers with workforces living in poorer neighborhoods (OR, 0.79; 95% CI, 0.77-0.81).

Conclusions: More employers offered PDLs over time, particularly large employers and employers with most employees in an HDHP-HSA. These findings suggest an encouraging trend toward improved health care access among commercially insured adults.

Objective: The relationship between Medicare Advantage (MA) risk payment arrangements and outcomes for patients in traditional Medicare (TM) has not been empirically examined. The objective of this study was to determine whether providers with greater exposure to MA risk payments are associated with superior outcomes for their TM patients.

Study design: Retrospective, cross-sectional regression analysis.

Methods: Using 2016-2019 Medicare claims, this analysis of TM beneficiaries compared quality and efficiency when care is provided by physicians with high exposure to MA risk payments vs physicians with lower risk exposure. The exposure was physician group exposure to MA risk payments, and the main outcomes were 26 quality and efficiency measures.

Results: Our overall sample comprised 22,257,955 TM beneficiary-years. After we adjusted for demographic differences and risk scores, receiving care from a physician with high risk exposure was associated with higher quality and efficiency across 22 of 26 measures. Improvements in the 22 measures ranged from 3% to 82%.

Conclusions: Our study is the first to examine the association between providers' exposure to MA risk payments and the outcomes they achieve beyond MA, specifically for their TM patients. We found that quality and efficiency outcomes for TM patients were higher under physician groups with high MA risk exposure. Although our study is not causal in nature, to the extent that such a relationship exists, it suggests that the benefits of MA risk payment arrangements extend beyond MA. Consequently, if more MA lives become subject to risk payment arrangements, the magnitude of potential benefits to the TM program could further increase.

Objective: Obesity affects more than 40% of US adults, increasing risks for cardiovascular disease and type 2 diabetes. Glucagon-like peptide 1 receptor agonists (GLP-1 RAs), initially indicated for diabetes, show promise in weight loss but face coverage issues, high costs, and premature prescribing from physicians. Research is needed to assess prescribing patterns, especially in patients without diabetes.

Study design: We conducted a retrospective, population-based, observational study using the Merative MarketScan Commercial Database and the Merative MarketScan Medicare Supplemental Database, which capture person-specific clinical utilization and expenditures. We analyzed GLP-1 RA prescribing rates from 2018 to 2023, comparing semaglutide with other GLP-1 RAs and stratifying by diabetes and overweight/obesity indications.

Methods: The study included individuals 18 years or older with 12 months of continuous enrollment from 2018 to 2023, categorizing GLP-1 RA users into 4 groups based on diabetes and obesity/overweight diagnosis codes within a year of their index date.

Results: Prescribing of GLP-1 RA medications, particularly semaglutides, increased notably over the years, whereas dulaglutide, liraglutide, and exenatide use declined. When investigating possible premature prescribing by examining users with no diabetes indication, the number of prediabetes or abnormal glucose diagnoses increased slightly before the index GLP-1 RA prescribing index date. However, less than 9% received a diabetes or prediabetes diagnosis 30 days after starting a GLP-1 RA.

Conclusions: From 2018 to 2023, GLP-1 RA prescribing increased significantly, with semaglutide approved for weight loss rising to 60% share in the nondiabetic obese/overweight group. Trends showed a notable rise in prescriptions for nondiabetic and obese/overweight patients.