American Journal of Managed Care最新文献

Objectives: Screening for health-related social needs (HRSNs) has increased in importance, but screening large patient populations comes with a cost and potential burden for care delivery organizations. This study evaluated the performance of 2-stage HRSN screening that used residence in a high-poverty area to determine which patients were administered screening questions.

Study design: Screening evaluation.

Methods: Adult primary care patients in Indiana and Florida completed HRSN screening questions included in an electronic health record (EHR) system and a set of additional questionnaires that served as the gold standard for assessing HRSN presence. Responses were linked to patients' residential zip code (n = 1351). The first stage of screening applied residence in a high-poverty zip code, and the second stage was the EHR-based HRSN screening questions. Using the response to the gold-standard questions, we calculated sensitivity, specificity, positive and negative predictive values, and area under the curve (AUC) for each HRSN.

Results: The highest AUC value was for food insecurity (80%), which was largely driven by the strong performance of the EHR-based HRSN screening questions. The remaining HRSNs had lower AUC values, which were driven by the overall low sensitivities of the screening questions and the overall low performance of the first-stage area-level screen. Positive predictive values were high.

Conclusions: Two-stage HRSN screening based on geography is suboptimal. Although a 2-stage approach based on area-level socioeconomic measures can reduce the number of patients requiring individual-level HRSN screening, large percentages of patients in need would go unidentified.

Objective: The demand and the landscape of options for dementia care are growing. Standardization of care for persons with Alzheimer disease and related dementias (ADRD) lacks infrastructure across episodes of care. Use of electronic health records (EHRs) in practice settings yields valuable information that can enhance continuity of patient care. The objective of this study was to use EHR-derived variables to identify risk factors for 30-day readmissions in the ADRD population across episodes of care.

Study design: Cross-sectional, retrospective study of older adults (aged ≥ 65 years) with ADRD discharged from a large urban academic medical center between October 1, 2018, and March 31, 2022.

Methods: Data extracted across episodes of care from the EHR included demographic characteristics, medical variables, and encounter variables.

Results: A total of 14,101 patients diagnosed with ADRD were included in the study. Factors associated with patients being more likely to experience 30-day hospital readmissions included advanced age, male sex, being a non-English speaker, having more severe comorbidities, staying in the hospital for more than 5 days, having had more than 1 surgical procedure in the prior 6 months, having had 3 or more inpatient admissions in the 6 months prior to index admission, having had more than 3 physician consultations in the prior 6 months, and having been discharged to settings other than home (all P < .05).

Conclusions: By utilizing the EHR to connect medical and encounter data across episodes of care, health care providers and administrators can gain valuable insight into identifying factors contributing to readmissions, which could be used to improve continuity of care for patients and caregivers, ultimately leading to better outcomes and reduced health care costs.

Objective: To evaluate the impact of a digital platform that connects primary care providers and commercially insured adults to outpatient behavioral health services on behavioral health utilization and total medical costs.

Study design: A matched difference-in-differences approach was used to assess the effects of the intervention. Data were obtained from administrative medical claims for commercially insured adults.

Methods: The intervention group consisted of members assigned to 735 practices that adopted the platform, and the comparison group included members from 516 practices that did not. Propensity score matching was employed to balance baseline characteristics, and doubly robust difference-in-differences analysis was applied to estimate the intervention's effects on outpatient behavioral health visits, emergency department (ED) visits, inpatient admissions, and total medical costs over 18 months.

Results: The intervention group had a 68% higher likelihood of receiving outpatient behavioral health services. They were 35% less likely to have a behavioral health-related ED visit and 43% less likely to be admitted for behavioral health-related inpatient care. Despite increased outpatient utilization, total medical costs were significantly lower in the intervention group (-$27.63 per member per month at 18 months post intervention).

Conclusions: Connecting commercially insured adults to outpatient behavioral health services via a digital platform improves utilization of behavioral health care while reducing costly emergency and inpatient services. These findings suggest that enhancing access to outpatient behavioral health services can lead to better health outcomes and greater cost efficiency in managed care populations.

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 December issue features a conversation with AJMC Co-Editors in Chief A. Mark Fendrick, MD, director of the Center for Value-Based Insurance Design and a professor at the University of Michigan in Ann Arbor; and Michael E. Chernew, PhD, the Leonard D. Schaeffer Professor of Health Care Policy and the director of the Healthcare Markets and Regulation Lab at Harvard Medical School in Boston, Massachusetts.

Objective: To examine how drug manufacturers disclosed prices for new molecular entities approved by the FDA between 2022 and 2024.

Study design: Retrospective study.

Methods: We included drugs approved through new drug applications or biologics license applications, excluding imaging agents, vaccines, blood products, and drugs without an assigned National Drug Code. For each drug, we assessed whether pricing was disclosed proactively (ie, in news releases or earnings calls) or reactively (ie, in media reports citing the company without prior proactive disclosure). We sourced launch prices from public disclosures and California filings. We also recorded company market capitalization, orphan drug designation, accelerated approval status, and Institute for Clinical and Economic Review assessments.

Results: Of 150 drugs, 107 (71%) had publicly disclosed launch prices: 49 proactively and 58 reactively. Proactive disclosure was more common among public companies with smaller market capitalizations-69% for firms worth $1 billion to $10 billion, compared with 7% for those worth more than $100 billion.

Conclusions: We found that pharmaceutical companies proactively released launch prices for one-third of drugs approved from 2022 to 2024 and reactively released prices for an additional 39%. Our findings suggest that securities regulations may influence disclosure behavior, particularly for smaller public companies. Greater transparency at launch could support better-informed public discourse on drug pricing and value.

Recent trends toward payment reform in the care of chronic conditions seek to mitigate quality-related barriers to optimal diabetes management. In type 2 diabetes (T2D) management, these risk-sharing agreements are intended to improve clinical outcomes by facilitating care coordination, data reporting, and the implementation of interventions to address social determinants of health. Outside a need for systems reform, optimal diabetes management may be impeded by the underutilization of advances in care interventions, including continuous glucose monitoring (CGM). An influx of recent evidence and expert recommendations has expanded the utilization of CGM in the population with insulin-treated T2D. Considering recent evidence and guideline recommendations, a small expert panel of payer and provider stakeholders-with specific knowledge in diabetes disease management and risk-based agreements-was selected for this exploratory study to discuss opportunities for CGM-based care management in risk-sharing agreements between payers and providers. The panelists were surveyed before 2 virtual roundtable meetings in which pertinent clinical and trend data were shared. A moderated discussion allowed the expert panelists to outline key elements of potential risk-sharing agreements from the perspective of agreement design, realistic outcomes measures, and strategies to facilitate payer and provider participation.

Objectives: Medicaid holds significant responsibility for improving maternal and infant health in the US. Utilizing value-based care (VBC) that offers additional support to providers is one strategy by which the Medicaid system can improve these outcomes. In this analysis, we examined a Medicaid managed care plan's incentive-only VBC program, which is supported by a provider enablement team to assist care providers in meeting program goals.

Study design: Cross-sectional analysis of deliveries occurring between July 2020 and June 2022 from Elevance Health-affiliated Medicaid managed care plans operating in 16 states.

Methods: This study primarily relied on medical claims data to compare maternal, infant, and cost outcomes in Medicaid members with a care provider participating in a supported VBC program vs those with a care provider not participating in supported VBC. A propensity-balanced multivariable regression model was used to estimate the impact of participation vs nonparticipation in supported VBC on delivery, cost, and quality outcomes.

Results: Members with a care provider supported in the VBC program had significantly lower neonatal intensive care unit (NICU) lengths of stay, preterm births, and low birth weights; significantly better timeliness and adequacy of prenatal care rates; and significantly lower birth costs, NICU costs, and maternal and infant costs in the first year after birth.

Conclusions: These results provide insight into how payers and care providers can partner to improve maternal and infant outcomes among Medicaid members and subsequently experience cost savings.

McKesson's Precision Care Companion initiative enhances biomarker testing and targeted therapies in community oncology, improving patient outcomes and cost efficiency.

Members of the CAR T Vision Steering Committee outline key issues around US and EU reimbursement and discuss potential solutions.

Medically integrated pharmacies (MIPs) offer a multidisciplinary, patient-centered approach essential for complex oral anticancer therapy. Unlike traditional pharmacy dispensing, which creates a fragmented approach to patient care, MIPs integrate pharmacists directly into the care team, leveraging electronic health records for informed decision-making, thereby enhancing continuity and reducing costs. For patients, critical challenges associated with oral anticancer medications include abandonment, adherence, and access and affordability. Using an integrated and comprehensive approach, core activities of MIPs have demonstrated reductions in prescription abandonment rates and increases in adherence rates through proactive interventions and education. MIPs also enhance affordability by seamlessly coordinating financial assistance programs that can lead to cost savings for both patients and health care systems, presenting a compelling value proposition for managed care. High levels of patient and provider satisfaction further underscore the benefits of this integrated model. The evidence within this commentary demonstrates that MIPs help patients with cancer adhere to their oral anticancer medications while simultaneously minimizing financial burdens, thus providing a robust underpinning for patient-centered value-based care.