American Journal of Managed Care最新文献

Objectives: Hospital participation in accountable care organizations (ACOs)-Medicare's signature alternative payment model-continues to grow despite mixed evidence on spending and quality. This study examines whether hospital ACO participation is associated with changes in emergency department (ED) admission practices, hospital length of stay (LOS), and spending for unplanned admissions.

Study design: A difference-in-differences analysis of Medicare fee-for-service ED visits and hospitalizations (2008-2019).

Methods: Medicare claims were linked to ACO tracking data from Torch Insight to identify hospitals that joined an ACO between 2012 and 2017 (6 cohorts, followed for a maximum of 5 years), the start date of their initial contract, and ACO characteristics. Key outcomes included ED admission and observation stay rates, hospital LOS for emergent admissions, and total costs for an index ED event.

Results: Among the 995 hospitals (27.6% of the short-term hospitals in our study) that joined a Medicare ACO during the study period, program participation up to 5 years was not associated with changes in the rate of hospitalization from the ED, hospital LOS, or total costs of the index event. Findings remained consistent across ACO program, contract risk levels, year of program entry, and overall ACO performance (eg, whether the ACO generated shared savings).

Conclusions: Hospitals did not significantly alter care delivery for unplanned hospitalizations after joining an ACO. These findings suggest that hospital-led ACOs may have limited impact on reducing costs for emergent admissions, raising concerns about their ability to drive meaningful care transformation.

Objectives: Acupuncture therapy is a safe and effective option for acute and chronic pain conditions, particularly chronic low back pain, and is an important component of nonpharmacologic pain care. Overall trends in acupuncture billing by commercial insurers are unclear.

Study design: We conducted a retrospective, cross-sectional analysis using a large commercial insurance claims database.

Methods: Using Optum's deidentified Clinformatics Data Mart database, we tracked acupuncture billing for a large cohort of commercially insured individuals between 2012 and 2021. We measured the primary diagnoses that acupuncture providers billed for; indications of interest included low back pain, joint pain, neck pain, and headaches and migraines.

Results: The number (and share) of patients who used their insurance to pay for acupuncture increased between 2012 and 2021, from 26,596 (0.19% of covered lives) to 30,829 (0.24% of covered lives), respectively, peaking at 43,396 (0.31% of covered lives) in 2019. The most common primary indication that providers billed for was low back pain, followed by neck pain, joint pain, and headaches and migraines. Most acupuncture users were female, White or Asian, high income, and college educated.

Conclusions: Our findings indicate that a large commercial insurer is increasingly covering acupuncture therapy for multiple pain conditions.

Background: Biomarker testing is essential for guiding first-line treatment decisions in metastatic non-small cell lung cancer (mNSCLC). Despite guideline recommendations, real-world testing patterns remain variable and may contribute to disparities in outcomes.

Objectives: This study examined real-world biomarker testing patterns and their associations with first-line treatment selection, clinical characteristics, and sociodemographic factors in patients with newly diagnosed mNSCLC.

Methods: Using the Healthcare Integrated Research Database, we identified adults diagnosed with mNSCLC between January 2019 and July 2022 with continuous health plan enrollment. Patients were categorized by the type of biomarker testing they received within 90 days of diagnosis; eligible patients had: (1) no biomarker testing, (2) immunohistochemistry (IHC) only, (3) testing of fewer than 5 genes (<5GT) plus IHC, or (4) testing of at least 5 genes (≥5GT) plus IHC. Multivariable analyses assessed associations between testing, treatment patterns, and social determinants of health.

Results: Among 5611 eligible patients, 7.8% had no biomarker testing, 54.0% had IHC only, 13.2% had <5GT plus IHC, and 25.0% had ≥5GT plus IHC. Overall, 61.8% of patients did not receive guideline-concordant testing. More comprehensive biomarker testing was associated with a higher likelihood of receiving targeted therapy or immunotherapy and a lower use of chemotherapy alone. Testing and treatment patterns varied significantly by socioeconomic status, race/ethnicity, insurance type, and geographic region. Patients in higher socioeconomic quartiles, with commercial insurance, or residing in the western US were more likely to receive targeted therapies.

Conclusions: Most patients with mNSCLC did not undergo comprehensive biomarker testing, leading to potential missed opportunities for precision therapy. Disparities in testing and treatment underscore the need for expanded access to molecular diagnostics, payer support for comprehensive testing (including liquid biopsy), and alignment with national guidelines to improve outcomes and advance equitable cancer care.

Objective: To address concerns about payment adequacy in Medicare Advantage (MA) plans, a 2017 federal policy change increased risk scores and associated capitated payments for community-dwelling dually eligible beneficiaries with full Medicaid benefits. This study examined whether this payment change was associated with changes in health care utilization or mortality for dually eligible beneficiaries.

Study design: Difference-in-differences analysis comparing dually eligible beneficiaries who qualified for risk score increases (full Medicaid enrollees) vs those who did not (partial Medicaid enrollees).

Methods: CMS plan payment files for 2014-2022 provided plan-level information on mean risk scores. We linked 2013-2019 Medicare data and Minimum Data Set nursing home assessments to analyze inpatient use, nursing home use, and mortality for community-dwelling dually eligible beneficiaries. We also investigated hospital readmissions, stays lasting longer than 100 days, and mortality within 365 days among dually eligible beneficiaries with skilled nursing facility (SNF) use.

Results: Among plans in which more than half of members had full Medicaid, plan-level risk scores increased 8.9% from 2014-2016 to 2017-2022 relative to the change observed in other plans. The payment change was associated with small declines in mortality, inpatient use, and nursing home use among beneficiaries 65 years and older, but these findings were not clinically significant or robust in sensitivity analyses. No significant changes were observed for dually eligible beneficiaries younger than 65 years or among SNF users in either age group.

Conclusions: These results raise questions about whether payment increases to MA plans led to meaningful improvements in quality of care for dually eligible members. As MA participation increases among dually eligible beneficiaries, policy makers should pay attention to whether higher MA payment levels for these beneficiaries translate to improved outcomes.

Immune thrombocytopenia (ITP) is a chronic autoimmune disorder associated with platelet destruction and increased bleeding risk, substantial economic burden, and impairment of health-related quality of life. The pathophysiology of ITP involves increased platelet destruction and impaired platelet production due to a multifactorial breakdown of immune tolerance driven by dysregulated B and T cells. Advances in understanding ITP pathophysiology have led to the development of new immune-modulating therapies, such as Bruton tyrosine kinase (BTK) inhibitors. Rilzabrutinib (Wayrilz; Sanofi) is an oral BTK inhibitor recently approved for treatment of adult patients with persistent or chronic ITP who have had an insufficient response to a previous treatment. Rilzabrutinib targets several aspects of ITP disease pathophysiology by modulating multiple immune pathways. Approval was based on results from a phase 3 trial (LUNA 3 [NCT04562766]), in which patients with ITP who received rilzabrutinib demonstrated a rapid, durable platelet response and improvements in fatigue and bleeding with a tolerable safety profile.

Objective: To examine the association between the use of the grocery card supplemental benefit offered by Medicare Advantage (MA) plans and health care utilization.

Study design: Observational study utilizing 2021-2022 MA claims data.

Methods: This observational cohort study examined eligible adults who were continuously enrolled between January 1, 2021, and December 31, 2022, in MA dual-eligible special needs plans that offered a grocery card benefit from January 1, 2022, through December 31, 2022. We performed difference-in-differences analyses comparing health care utilization among dual-eligible members who opted to use grocery card supplemental benefits vs those who did not, before and after the benefit's introduction.

Results: Grocery card use was associated with an increase in the likelihood of annual wellness, primary care provider (PCP), and specialist visits (6.6%, 4.9%, and 6.6%, respectively) and increased number of office and specialist visits (2.3% and 2.8%, respectively). Frequent use (more than half of the available grocery card dollars) was analyzed separately and was associated with slightly greater increases in the likelihood and number of visits (all P <.05).

Conclusions: This observational study of dual-eligible beneficiaries found a modest relative increase in office visits, including annual wellness, PCP, and specialist visits, among beneficiaries who opted to use the grocery card supplemental benefits after they were offered compared with beneficiaries who did not. These findings suggest that policy changes that allow for nonmedical supplemental benefits have had favorable results, especially for dual-eligible beneficiaries.

Objectives: National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology recommend the assessment of 12 molecular biomarkers to determine eligibility for targeted drug therapies in metastatic non-small cell lung cancer (mNSCLC). However, variation exists in the composition of next-generation sequencing (NGS) panels. This study evaluates the inclusion of recommended mNSCLC biomarkers in commercially available targeted NGS panels.

Study design: A descriptive database review was conducted to characterize molecular testing panels.

Methods: Targeted panels were classified as 2 to 50 genes. The DEX Diagnostics Exchange Registry and the Concert Genetic Testing Unit Test Identifier database were searched for NGS-based lung and multicancer indications. Tests were excluded if their indication precluded usage in lung cancer, NGS technology was not used, or the panel was retired. Each panel was assessed for the inclusion of biomarkers from V.11.2024 NCCN guidelines: ALK, BRAF, EGFR, ERBB, KRAS, NTRK1/2/3, RET, ROS1, MET exon 14 skipping, and MET amplification.

Results: Seventy-seven targeted NGS panels were included. The mean number of biomarkers captured in lung-specific vs multicancer panels was similar (6.6 vs 6.4). Most biomarkers were single-nucleotide variants (82%), and the most common were EGFR (91%), KRAS (87%), and BRAF (86%). Fusions and rearrangements were represented in less than half (41%) of panels, and NTRK fusions were often absent, with NTRK1, NTRK2, and NTRK3 appearing in only 23%, 14%, and 19% of the included panels. The inclusion of copy number variant, specifically MET amplification, was rare (12%). Only 5 (6%) panels captured all 12 recommended biomarkers.

Conclusions: Of 77 unique panels evaluated, only 5 captured all recommended biomarkers for mNSCLC. Ensuring targeted panels assess all relevant biomarkers is crucial for optimal patient treatment.

Objective: To examine the impact on quality of care for individuals enrolled in Medicare Advantage (MA) plans or traditional Medicare (TM) during the COVID-19 pandemic.

Study design: Retrospective cohort study.

Methods: The study examined beneficiaries enrolled in Medicare from 2017 through 2021. Beneficiaries were divided into 4 cohorts based on their enrollment in TM or MA and the year of enrollment in 2019, the year before the COVID-19 pandemic, or 2021, during the COVID-19 pandemic. For each cohort, 12 clinical quality measures were constructed, including 4 screening measures requiring in-person visits and 8 medication management and adherence measures.

Results: A total of 3,190,208 Medicare beneficiaries were included (58.4% female; mean age, 73.0 years). In both 2019 and 2021, the MA program performed significantly better than TM across the 12 clinical quality measures. Compared with the year before the pandemic, both programs experienced a decrease in screening measures that required in-person visits during the pandemic, with a slightly higher decrease for the MA plans. In contrast, measures of medication management and adherence improved for both programs, but especially for MA plans.

Conclusions: MA plans continued to outperform TM on clinical quality measures during the COVID-19 pandemic.

Objectives: To compare enrollment rates in Medicare Advantage (MA) among people with disabilities (PWD) and individuals with end-stage renal disease (ESRD) in the US (50 states and District of Columbia) and Puerto Rico (PR).

Study design: This observational study utilized repeated cross-sectional data from the Master Beneficiary Summary File from 2008 to 2022.

Methods: The sample included beneficiaries who had continuous Medicare enrollment during the corresponding calendar year and were alive at the end of March 31 the following year. Partial-year MA enrollment was defined as having at least 1 month of MA coverage. Full-year MA enrollment was defined as having continuous MA coverage for all 12 months. We calculated the percentage of enrollees in MA based on their entitlement (age, disability, and ESRD). Standardized differences were calculated to compare characteristics of US and PR enrollees in 2022.

Results: Between 2008 and 2022, our study included 757,245,942 person-years from the US and 10,298,906 person-years from PR. In 2022, Medicare beneficiaries in PR exhibited a higher partial-year MA enrollment rate-nearly double that of the US (84% vs 48%; d  = 0.837; 95% CI, 0.835-0.839). In addition, in the US, the difference between partial-year and full-year MA enrollment rates was 5.7% for PWD and 9.1% for ESRD enrollees. In PR, the differences were 2.7% for PWD and 10.0% for ESRD enrollees.

Conclusions: Discrepancies between partial-year and full-year MA enrollment persisted among PWD and ESRD subpopulations, highlighting potential differences in coverage and access to care for these groups.

Recent real-world evidence on idiopathic pulmonary fibrosis (IPF) has provided important insights into survival and disease progression; however, critical patient-centered outcomes remain insufficiently addressed. The article "Real-World Data on the Course of Idiopathic Pulmonary Fibrosis," published in an October 2024 supplement to The American Journal of Managed Care , highlights this limitation by focusing predominantly on objective clinical parameters while lacking systematic evaluation of health-related quality of life (HRQOL). This gap is particularly relevant given limited evidence on how antifibrotic therapies affect symptoms, pulmonary function, and psychosocial well-being beyond radiologic progression. QOL is especially relevant in resource-limited settings, where demonstrating benefits in symptom control and functional status may influence therapeutic decisions, coverage policies, and resource allocation. Although international clinical practice guidelines, including those of the American Thoracic Society and the European Respiratory Society, recognize QOL as a key domain in IPF management, they also acknowledge the paucity of evidence addressing psychosocial and functional outcomes. Notably, major clinical trials such as INPULSIS and ASCEND, while demonstrating efficacy in slowing forced vital capacity decline, did not incorporate HRQOL as a primary outcome. Recent guideline updates propose a conceptual framework integrating validated measures of symptoms, pulmonary function, and psychosocial impact. However, these dimensions have not yet been systematically embedded in clinical research. Reanalysis of existing data and future studies using this framework are warranted. A comprehensive evaluation of quality of life is therefore a clinical and ethical imperative for advancing patient-centered and holistic care in IPF.