American Journal of Managed Care最新文献

Objectives: Unused medical appointments affect both patient care and clinic operations, and the frequency of cancellations due to clinic reasons is underreported. The prevalence of these unused appointments in primary care in the Veterans Affairs Health Care System (VA) is unknown. This study examined the prevalence of unused primary care appointments and compared the relative frequency of cancellations and no-shows for patient and clinic reasons.

Study design: In this retrospective, observational study, we collected all in-person and virtual VA primary care appointments from October 1, 2018, to April 1, 2024.

Methods: We examined the proportion of appointments canceled on the same day as the appointment and classified these into canceled by patient, canceled by clinic, and no-show.

Results: Of more than 90 million in-person and nearly 24 million virtual primary care appointments, 11.9 million (10.87%) were canceled on the day of the appointment. For in-person care cancellations, the most common reasons were canceled by the patient (3.92%; n = 3,531,016), no-show (3.87%; n = 3,487,944), and clinic cancellation (3.08%; n = 2,780,259).

Conclusions: Although this study shows that same-day cancellations of primary care appointments in the VA are common, comparisons with other providers and health care systems indicate similar or lower levels of unused appointments in the VA.

Objectives: Medicaid is the largest payer of mental health (MH) services in the US, and more than 80% of its enrollees are covered by Medicaid managed care (MMC). States are required to establish quantitative network adequacy standards (NAS) to regulate MMC plans' MH care access. We examined the association between quantitative NAS and MH care access among Medicaid-enrolled adults and among those with MH conditions.

Study design: Cross-sectional study with a difference-in-differences design.

Methods: Using the 2016-2019 National Survey on Drug Use and Health, we included Medicaid enrollees aged 18 to 64 years in 15 states. Subgroup analyses included enrollees with MH conditions who experienced in the past year (1) serious psychological distress, (2) a major depressive episode, and/or (3) suicidal thoughts. Outcomes assessed whether in the past year the enrollee had any (1) MH services, (2) inpatient MH stays, (3) outpatient MH visits, (4) MH prescription, and (5) unmet MH care needs.

Results: Among 9300 adults aged 18 to 64 years, 27.2% had MH conditions. Among all adults, NAS were marginally associated with increased use of any MH services (adjusted OR, 1.4; 95% CI, 1.0-2.1; P = .055) but were not associated with other outcomes. Among enrollees with MH conditions, no statistically significant association between NAS and MH care access was observed.

Conclusions: Current quantitative NAS requirements may have few impacts on improving MH care access for adults and those with MH conditions without the implementation of additional interventions. States should consider adjusting enforcement strategies and adopting other interventions alongside NAS.

Objective: To assess the effects of a nurse-led personalized care plan on the duration of olaparib therapy among patients with cancer.

Study design: Cohort study conducted from January 2020 to June 2022.

Methods: Data from an independent specialty pharmacy were used to identify patients 18 years and older with at least 1 olaparib (Lynparza) prescription who were at high risk for olaparib nonadherence as assessed using a pharmacy intake survey. We compared olaparib therapy duration between patients with and without a nurse-led personalized care plan. Multivariable Cox proportional hazards regression was used to estimate adjusted HRs (aHRs) for therapy discontinuation.

Results: Of 560 patients at high risk for olaparib nonadherence, 163 received a care plan and 397 did not. Commonly reported symptoms included fatigue, nausea, gastrointestinal tract problems, depression, anxiety, and pain. The care plan group had significantly longer olaparib therapy (median [IQR], 6.7 [2.5-14.3] months vs 4.9 [1.9-10.4] months; P < .001) and a lower risk of discontinuing treatment (aHR, 0.77; 95% CI, 0.64-0.94) than the controls. Within the care plan group, patients experiencing resolution of at least 1 symptom (median therapy duration [IQR], 10.3 [4.8-19.0] months vs 3.9 [1.9-11.4] months; P < .001) or at least 1 dose modification (median therapy duration [IQR], 11.9 [6.7-17.8] months vs 4.7 [1.9-11.8] months; P < .001) had approximately 2.5 times longer olaparib therapy duration than patients who did not.

Conclusions: A nurse-led personalized care approach effectively increased medication persistence among patients receiving olaparib for treatment of cancer, and the effect was more apparent among care plan patients who experienced symptom resolution or dose modification.

Objective: To examine the effect of physiologic insulin resensitization (PIR) on the cost of treating patients with diabetes and chronic kidney disease (CKD).

Study design: The mean 1-year cost of treating 66 Medicare Advantage patients with diabetes and CKD who were receiving PIR was compared with that of treating 1301 Medicare Advantage patients with diabetes and CKD not receiving PIR. Differences in disease severity were compared using mean risk adjustment factor scores.

Methods: Cost comparisons were made for CKD stages 2, 3a, 3b, 4, and 5. The total cost of treating the PIR patients was then compared with the total costs of treating the same number of non-PIR patients to determine cost differences potentially incurred.

Results: The mean annual cost of treating PIR patients with stage 2 CKD was $11,251 vs $18,058 for the non-PIR group. For patients with stage 3a CKD, the mean PIR cost was $10,974 vs $18,563 for the non-PIR group. For patients with stage 3b CKD, the mean costs were $19,520 and $18,398, respectively. The mean costs for stages 4/5 CKD were $14,042 vs $22,124, respectively. The costs for an equal number of non-PIR patients at each stage were $345,830 higher than the actual costs of the PIR patients. There were no significant differences in the mean risk adjustment factor scores between the 2 groups.

Conclusions: PIR is a possible method of reducing the cost of treating patients with diabetes and CKD. Given the rapidly increasing numbers of patients with diabetes and CKD who are Medicare Advantage beneficiaries, PIR should be considered for use by managed care organizations.

Objectives: To assess the capacity of Medicaid providers to take on new patients during a time of unprecedented growth in program enrollment due to Medicaid expansion and the COVID-19 public health emergency.

Study design: We conducted a survey of Medicaid providers in Missouri in 2023 about their patient load and capacity to accept new patients.

Methods: We recruited 141 Missouri Medicaid providers through probability sampling and 109 additional providers through convenience sampling for a total sample size of 250, representing 0.8% of all Medicaid providers in Missouri. Our survey was informed by semistructured interviews with 15 providers conducted earlier in the year. We analyzed results using sample percentages with 95% CIs.

Results: As expected, a large majority of respondents reported that their patient load had increased since 2021. Nonetheless, 53% (47%-59%) reported that they personally had the capacity to take on additional patients, and 70% (65%-75%) reported that their larger practice had the capacity to do so. We found no evidence that these responses differed between large metropolitan areas and other areas of the state. Majorities also reported that their practices either had recently hired additional personnel (both staff and providers) or planned to do so, and substantial percentages reported other capacity-expanding changes.

Conclusions: Our results suggest that the health care system in Missouri can accommodate even historic growth in Medicaid enrollment and patient loads without compromising access to care as perceived by providers. Further research is needed from the patient side and focused on rural areas.

Objectives: Although cardiac rehabilitation (CR) improves cardiovascular outcomes, adherence remains low. Higher patient-incurred out-of-pocket (OOP) spending may be a barrier to CR adherence. We evaluated the association between OOP spending for the first CR session and adherence.

Study design: Retrospective analysis.

Methods: Commercial and Medicare supplemental beneficiaries with a CR-qualifying event between 2016 and 2020 who attended at least 1 CR session within 6 months of discharge were identified in the MarketScan Commercial Database. OOP spending for the first session was categorized as zero or into 1 of 3 increasing tertiles of OOP spending. Poisson regression was used to determine the association between OOP-spending tertile and CR adherence, defined as the number of CR sessions attended within 6 months of discharge.

Results: A total of 43,992 beneficiaries attended at least 1 CR session. Of these, 35,883 (81.6%) paid $0, 2702 (6.1%) paid $0.01 to $25.39, 2704 (6.1%) paid $25.40 to $82.41, and 2703 (6.1%) paid at least $82.42 for the first session, constituting the first, second, and third OOP-spending tertiles, respectively. Compared with the zero-OOP cohort, the first-tertile cohort attended 13.5% (95% CI, 1.4%-27.1%; P  = .028) more CR sessions and the second- and third-tertile cohorts attended 11.9% (95% CI, -16.4% to -7.1%; P  < .001) and 30.9% (95% CI, -40.8% to -19.4%; P  < .001) fewer CR sessions on average, respectively. For every additional $10 spent OOP on the first CR session, patients attended 0.41 fewer sessions on average (95% CI, -0.65 to -0.17; P  < .001).

Conclusion: Among patients with OOP spending, higher spending was associated with lower CR adherence, dose dependently. Reducing OOP costs for CR may improve adherence for beneficiaries with cost sharing.

Objectives: In 2016, Dallas Nephrology Associates recognized that the economic, humanistic, and societal burden of end-stage kidney disease was unsustainable and the fee-for-service model of reimbursement did not support a value-based care approach. We decided to be proactive by creating new workflows, education, and disease management so that patients could make well-informed choices, ultimately resulting in better outcomes.

Methods: Our shift toward value-based care focused on patient engagement, education, integrated infrastructure, collaboration, and monitoring of metrics associated with improved outcomes. Our practice invested millions of dollars in a population health division, which includes nurse navigators and data analysts focused on managing chronic kidney disease (CKD), delaying progression, and promoting transplantation and home-based dialysis.

Results: This retrospective review demonstrates improved outcomes, lower costs, and increased quality of care. Performance metrics have consistently met or exceeded targets. Seventy-three percent of patients now experience an optimal planned start to dialysis. Preemptive transplantation referrals have increased from 7% in 2017 to 61% through June 2023. Referral of patients with stage 4 CKD to educational workshops increased from 38% to 68%, and medical nutrition therapy referrals increased from 23% to 67%. Although reimbursement challenges persist, our commitment to improving care and slowing CKD progression remains steadfast. We emphasize teamwork, robust analytics, and continuous improvement. Future initiatives include encouraging patients receiving in-center hemodialysis to convert to home-based dialysis, addressing behavioral health, and focusing on preventable complications in high-risk patients.

Conclusions: By embracing value-based models, we have demonstrated that a patient-centered approach can lead to improved outcomes and value for payers.

Objectives: To explain key challenges to evaluating Center for Medicare and Medicaid Innovation (CMMI) accountable care organization (ACO) models and ways to address those challenges.

Study design: We enumerate the challenges, beginning with the conception of the alternative payment model and extending through the decision to scale up the model should the initial evaluation suggest that the model is successful. The challenges include churn at the provider and ACO levels, beneficiary leakage and spillover, participation in prior payment models, and determinants of shared savings and penalties.

Methods: We explain challenges posed in evaluations of voluntary ACO models vs models in which ACOs are randomly assigned to the treatment group. We also note the relationship between the design used in an evaluation and subsequent plans for scaling up successful models.

Results: The optimal research design is inextricably tied to the plans for scaling up a successful model. Decisions regarding churn, leakage, spillover, and participating in past payment models can alter the estimated effects of the intervention on participants in the model.

Conclusions: If CMMI intends to offer the model to a larger, but similar, group of volunteers, then the estimated treatment effect based on voluntary participants may be the most policy-relevant parameter. However, if the scaled-up population has different characteristics than the evaluation sample, perhaps due to mandatory participation, then the evaluator will need to employ pseudo-randomization appropriate for observational data.

Objectives: To describe the prevalence and characteristics of preferred skilled nursing facility (SNF) networks established by Medicare accountable care organizations (ACOs).

Study design: Cross-sectional analysis of a 2019 Medicare ACO survey.

Methods: We analyzed surveys from 138 Medicare ACOs to assess preferred SNF network prevalence, characteristics, and challenges. Chi-square tests compared ACOs by proportion of ACO Medicare admissions going to preferred SNFs (higher vs lower network use).

Results: Results focus on the 77 ACOs that reported having a preferred SNF network (n = 77), with 38% being relatively new (formed in 2018 or 2019). Most ACOs (91%) did not offer financial incentives for preferred SNFs. ACOs reported a range of expectations of preferred SNFs, the most common being cost/quality data sharing (62%), automatic notification of patient admission or discharge (53%), and meeting length-of-stay targets (52%). ACOs also reported some clinical collaboration with preferred SNFs, with the top activity being developing condition-specific care pathways (49%). Commonly reported challenges included poor hospital discharge practices, SNFs' willingness to accept complex patients, and the availability of high-quality SNFs. ACOs with lower use of their preferred SNF network reported more difficulty impacting hospital referral patterns and receiving timely SNF admission notifications.

Conclusions: Establishing preferred SNF networks is a known strategy among Medicare ACOs to manage postacute care spending and quality. Future research should document these partnerships more in depth and evaluate operational and financial alignment strategies among ACOs, hospitals, and SNFs in managing postacute care.

Neither care delivery nor public health systems have grappled with widening disparities as life expectancy gaps increase in the US. Reimagining health care and public health requires aligned incentives including attention to vulnerable populations, financial incentives to improve total population health, effective deployment of community assets, and adoption of a continuous learning system. We argue that Big Hairy Audacious Goals-targets for a Health GDP (similar to the economy's gross domestic product [GDP]), Life Expectancy, Safe and Sound Children, One Earth Policy, Social Spending, and Political Healing-can focus our attention and propel needed action.