American Journal of Managed Care最新文献

Objectives: Medicare Advantage (MA) plans provide fewer home health (HH) services than traditional Medicare (TM), but MA plans vary in how they reimburse HH agencies. Like TM, episodic MA plans allow agencies to determine the number and type of visits. Alternatively, per-visit MA plans dictate a specific number of visits and which disciplines provide them. This study examined differences in HH care delivery and patient outcomes among TM, episodic MA, and per-visit MA plans.

Study design: Secondary analysis of HH agency data from January 2019 to December 2022.

Methods: For 285,297 HH stays, we used inverse probability of treatment weighting regression to compare TM vs each MA plan type and per-visit vs episodic MA plans. We examined HH length of stay; number of visits from nursing, therapy disciplines, social work, and aides; transfer to an inpatient facility during HH; improvement in self-care and mobility function; and community discharge.

Results: Compared with TM, both MA plans had shorter stays and fewer visits from nursing, therapy, and aides, and episodic MA plans had fewer social work visits. Comparing MA plans with each other, per-visit MA had 2.3% shorter stays, 3.0% more physical therapy visits, and 6.8% fewer social work visits vs episodic MA. Differences in outcomes between MA and TM varied by MA plan type, but compared with TM, per-visit MA had a 6% higher likelihood of inpatient transfers (95% CI, 1.02-1.10). Comparing MA plans, per-visit MA had a 12% higher likelihood of inpatient transfers (95% CI, 1.06-1.18) than episodic MA.

Conclusions: Episodic MA plans, which allow HH agencies flexibility in determining visit delivery, may have fewer adverse inpatient transfer outcomes compared with MA plans that dictate the amount and type of care provided.

Objectives: To estimate the use and spending for high-revenue rare disease drugs in 2022 in the US.

Study design: Cross-sectional study.

Methods: Among the 100 prescription drugs with the highest 2022 US net sales revenue, we selected drugs exclusively approved to treat rare diseases as designated under the Orphan Drug Act. We estimated commercial, Medicare, and Medicaid spending using manufacturer-reported net sales and public Medicare and Medicaid spending data. We also estimated the number of individuals using each drug based on Medicare spending per beneficiary data.

Results: Nineteen of the 100 highest-revenue prescription drugs in 2022 were exclusively approved to treat Orphan Drug Act-designated conditions; 9 had a single indication, and 10 had multiple indications. Median annual net sales for the 19 drugs were $1.97 billion (range, $988 million-$8.36 billion). Total spending on these 19 drugs was $45.1 billion, which represented approximately 7.5% of the $603 billion in prescription drug spending in 2022. The median estimated number of individuals using each drug was 17,152 (range, 3735-71,171). Of the total spending, $23.6 billion (52.3%) was spent for individuals with Medicare, $3.5 billion (7.8%) for those with Medicaid, and $18.0 billion (39.9%) for those with commercial insurance.

Conclusions: Approximately 1 in 5 of the highest-revenue prescription drugs in the US in 2022 was approved to treat only rare conditions; these drugs were used by a small number of patients but accounted for a sizeable share of spending. Rare disease drugs should be included in federal and state policies aimed at improving the affordability of prescription drugs for patients and the health care system.

This study examines the clinical settings of first-time psychotic spectrum disorder diagnoses in an integrated health system.

Objective: Migraine affects millions of individuals in the US, resulting in high health care costs and productivity loss. Traditional medications are often limited in effectiveness and tolerability, creating a need for accessible nonpharmacologic options. This coverage with evidence development (CED) study assessed the necessity of the remote electrical neuromodulation (REN) wearable device for migraine treatment as a standard payer-covered treatment.

Study design: Real-world postmarketing CED study in 2 clinics for 14 months.

Methods: Members (aged 12-75 years) of a major US health insurer (Highmark Inc) diagnosed with migraine were prescribed REN as part of their clinical care. Effectiveness was evaluated by change in Migraine Disability Assessment (MIDAS) score from baseline to 3 months of treatment and by prospective pain and disability reports 2 hours post treatment. Utilization was measured through prescription fulfillment and safety via adverse event reports.

Results: A total of 381 patients (mean [SD] age, 40.5 [13.2] years; 91.1% female) participated. Change in MIDAS score was calculated from all participants who answered the questionnaire twice (n = 116), showing a significant and clinically meaningful mean (SD) improvement of -12.1 (51.8) points (P = .014), from 58.3 (59.0) to 46.2 (44.1). Of the participants, 77.8% reported pain relief and 33.3% reported pain freedom; 70.6% and 50.0% reported relief and freedom from functional disability, respectively. Patients used a mean (SD) of 4.0 (3.1) devices annually (extrapolated). Three minor adverse events were reported. These positive outcomes led to the inclusion of REN as a standard treatment for migraine under Highmark policy.

Conclusions: REN leads to significant clinical and functional benefits in patients with migraine. Additional health insurers are encouraged to consider REN as a standard covered treatment.

Objective: To compare the likelihood of timely outpatient follow-up care and repeat emergency department (ED) visits and hospitalization among patients with high need and high costs (HNHC) across 4 primary care provider (PCP) types.

Study design: Our cross-sectional study analyzed 2018 eligibility and claims data of patients with HNHC enrolled in California Medicaid managed care (N = 164,543).

Methods: Outcomes were outpatient follow-up visits for primary care, specialty care, mental health, or substance use disorder (SUD) within 7 days and ED readmission and all-cause hospitalization within 30 days of the first ED visit (index ED). Our independent variable was PCP type, categorized as Health Resources and Services Administration-funded health centers, group practices, solo practices, and other community clinics. Multivariable logistic regression models examined follow-up care utilization by PCP type.

Results: One-third of index ED visits were followed by a primary care (30.3%) or specialty care (31.8%) visit within 7 days. Within 30 days of the ED index visit, approximately 22% had a repeat ED visit and 6% had a hospitalization. Health center patients were more likely to have a primary care, mental health, or SUD follow-up visit than patients of other PCPs and were less likely to have a follow-up specialty visit, ED readmission, or hospitalization.

Conclusions: Findings indicate that health centers have been successful in linking patients to outpatient services that may reduce costly hospitalizations and repeat ED visits but could improve on linkage to specialty care. Improved process-of-care approaches may reduce repeat ED visits and hospitalizations across all PCP types.

Objective: To examine whether racial concordance between telephonic care managers and Medicare Advantage beneficiaries engaged in a care management program influenced the likelihood of fulfilling a set of identified health care needs.

Study design: Retrospective study of a real-world telephonic care management program among Medicare Advantage beneficiaries.

Methods: This study involved Medicare Advantage beneficiaries identified as having at least 1 of 23 gaps in care quality at baseline who were randomly assigned to a telephonic care management program between June 2020 and March 2021. We examined participating Black beneficiaries and assigned racial concordance based on engaging with a Black (race-concordant) or White (race-discordant) care manager. The primary outcome was a measure of whether the gap in care was closed at 90 days. We used logistic regression models adjusted for beneficiary characteristics to examine the impact of racial concordance on binary measures of gap closure at the individual and gap levels.

Results: Among the study population of 12,636 Black race beneficiaries, 1291 (10.2%) had a race-concordant care manager and 11,345 (89.8%) had a race-discordant care manager. In adjusted models, beneficiary-care manager racial concordance did not impact closure of gaps in care when examined at the beneficiary level (OR, 0.98; 95% CI, 0.90-1.08) or the gap level (OR, 0.99; 95% CI, 0.88-1.12).

Conclusions: In a real-world telephonic care management program aiming to resolve gaps in care quality, beneficiary-care manager racial concordance did not impact the rate of resolving gaps in care for Black beneficiaries.

Objectives: Community-based palliative care provides support for community-dwelling individuals with elevated mortality risk, including those with dementia, who are underserved by palliative care. However, clinicians' eligibility assessment processes are not well understood. This study evaluates the relationship between the factors that clinicians indicate are important and the eligibility determinations for a community-based palliative care program.

Study design: Retrospective cohort analysis of July 2022 to December 2023 Medicare administrative claims data for a Medicare Advantage plan offering community-based palliative care. Participants included all members of the Medicare Advantage insurance plan who were identified as being at elevated risk for mortality and evaluated for palliative care need.

Methods: Multivariate logistic regression examined the relationship between eligibility determinations for a community-based palliative care program (outcome) and 4 factors that palliative care team members identify as important for determining palliative care need: diagnoses, symptom management, functional ability, and health care utilization.

Results: Of 343 palliative care evaluations (for 322 unique patients), 38% were of patients who identified as African American/Black, 38% as White, 9% as Asian/Pacific Islander, and 15% as other races; 41% were of patients who identified as Hispanic/Latino (measured separately from race); 80% were of female patients; and the mean patient age was 88 years. Of these, 169 (49%) evaluations were for patients who were eligible for palliative care. In multivariate logistic regression analysis of the factors team members deemed important when determining eligibility, only dementia was significantly associated-and negatively-with the final eligibility decision (adjusted OR, 0.45; 95% CI, 0.26-0.75; P  = .003).

Conclusions: There is a potential mismatch between what clinicians identify as important in determining palliative care need and final eligibility determinations. Patients with dementia were less likely to be referred for palliative care despite elevated risk of mortality, indicating a potential missed opportunity.

Objective: Migraine is a debilitating chronic disorder requiring multifaceted treatment approaches, including acute, preventive, and nonpharmacological interventions. Small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists, also referred to as gepants , provide third-line treatment options for patients refractory to first- and second-line therapies. This study evaluates the cost-effectiveness of 3 CGRP antagonists-ubrogepant (Ubrelvy), rimegepant (Nurtec ODT), and zavegepant (Zavzpret)-compared with usual care.

Study design: Cost-effectiveness analysis of gepants vs usual care.

Methods: We used a Markov model to assess the cost-effectiveness from the US payer's perspective, incorporating 5 health states: mild, moderate, and severe pain while on treatment; no pain while on treatment; and off treatment. The analysis was conducted over a 5-year time horizon with a 48-hour cycle length, discounting costs and quality-adjusted life-years (QALYs) annually at 3%. Scenario analyses were used to determine the robustness of the results.

Results: None of the gepants were cost-effective at willingness-to-pay thresholds of $50,000, $100,000, or $150,000 per QALY. Among the 3 gepants, rimegepant was the most cost-effective option; it had an incremental cost-effectiveness ratio of $93,700.20 per QALY compared with ubrogepant and was both less costly and more effective than zavegepant.

Conclusions: Ubrogepant, rimegepant, and zavegepant are not cost-effective options for acute migraine treatment but may be appropriate for patients experiencing 2 or fewer migraines per month. If a gepant is to be prescribed, rimegepant is the most cost-effective option of the 3.

This commentary notes the superiority of targeting rising-risk patients rather than high-cost claimants for Medicaid cost containment based on analysis of 13.1 million beneficiaries across 15 states. In 2019, spending for rising-risk patients (13.6% of sample) increased by 98.5% whereas spending for high-cost claimants (0.64%) decreased by 41.6%. Significantly, 54% of high-cost claimants in the first half of 2019 fell below the cost threshold in the second half of the year, and 50% of new high-cost claimants were previously identified as rising risk. Our findings reveal the limitations of focusing solely on high-cost claimants, whose costs naturally decrease due to regression to the mean. We argue that Medicaid programs should shift from reactive, cost-management interventions to proactive, prevention-oriented outreach, particularly as new predictive algorithms become more sensitive and specific. Early identification of and intervention for rising-risk patients is a more effective way to prevent the progression of chronic conditions and manage associated costs than attempting to reduce extreme utilization, which tends to decrease naturally over time.

Objectives: To assess the interrelation between Medicare Star Ratings medication adherence measures and other intermediate and process measures.

Study design: A cross-sectional analysis was performed of the annual Medicare Star Ratings health plan performance data from Star Ratings years 2015-2025. The analysis evaluated the potential relationship between (1) renin-angiotensin system antagonist (RASA) adherence and controlling blood pressure, (2) noninsulin antidiabetic adherence and controlling blood glucose, (3) statin adherence and statin therapy for patients with cardiovascular disease (CVD), and (4) statin adherence and statin use in persons with diabetes (SUPD).

Methods: The outcomes of interest were ORs and 95% CIs evaluating the likelihood of a health plan achieving 5 stars or at least 4 stars on the intermediate or process measures if they achieved 5 stars or at least 4 stars on the medication adherence measures compared with not achieving 5 stars or at least 4 stars on the medication adherence measures.

Results: Plans that achieved 5 stars on the antidiabetic adherence measure and RASA adherence measure had significantly higher odds of achieving 5 stars on their respective intermediate measures (blood glucose control: OR, 3.50; 95% CI, 2.98-4.12; blood pressure control: OR, 4.61; 95% CI, 3.82-5.60). Plans that achieved 5 stars on the statin adherence measure had significantly higher odds of achieving 5 stars on statin therapy for patients with CVD and SUPD (CVD: OR, 4.68; 95% CI, 3.49-6.27; SUPD: OR, 4.37; 95% CI, 3.26-5.85).

Conclusions: Medicare Star Ratings medication adherence measures are significantly tied to intermediate and statin process measures. Targeted interventions to improve adherence should be a key strategy for health plans to enhance both clinical outcomes and financial incentives.