American Journal of Managed Care最新文献

Objectives: Multicancer early detection (MCED) testing could result in earlier cancer diagnosis, thereby improving survival and reducing treatment costs. This study evaluated the cost-effectiveness of MCED testing plus usual care (UC) screening while accounting for the impact of clinical uncertainty and population heterogeneity for an MCED test with broad coverage of solid cancer incidence.

Study design: Cost-effectiveness analysis of MCED testing plus UC vs UC alone in an adult population in the US.

Methods: A hybrid cohort-level model compared annual MCED testing plus UC with UC alone in detecting cancer among individuals aged 50 to 79 years over a lifetime horizon from a US payer perspective. Sensitivity and scenario analyses were conducted to explore the impact of key clinical uncertainties and population heterogeneity in valuing MCED, including differential survival by cell-free DNA detectability status, cancer progression rate, and how the test is likely to be implemented in clinical practice.

Results: Among 100,000 individuals, MCED testing plus UC shifted 7200 cancers to earlier stages at diagnosis compared with UC alone, resulting in an additional 0.14 quality-adjusted life-years (QALYs) and $5241 treatment cost savings per person screened and an incremental cost-effectiveness ratio (ICER) of $66,048/QALY gained at $949 test price. Among analyses of clinical uncertainties, differential survival had the greatest impact on cost-effectiveness. In probabilistic sensitivity analyses, MCED testing plus UC was cost-effective in all analyses with a maximum ICER of $91,092/QALY.

Conclusions: Under a range of likely clinical scenarios, MCED testing was estimated to be cost-effective, improving survival and reducing treatment costs.

The authors evaluate features of the Transforming Episode Accountability Model and discuss its benefits and limitations.

Cardio-kidney-metabolic (CKM) syndrome is a term to describe the interconnection between cardiovascular disease, type 2 diabetes, and chronic kidney disease. The National Health and Nutrition Examination Survey from 1999 to 2020 estimated that 25% of participants had at least 1 CKM condition. It is proposed that CKM syndrome originates in excess and/or dysfunctional adipose tissue, which secretes proinflammatory and prooxidative products leading to damaged tissues in arteries, the heart, and the kidney, and reduction in insulin sensitivity. CKM syndrome is classified into 4 stages based on the presence of risk factors and clinical signs. Risk factors associated with progression of CKM syndrome include chronic inflammatory conditions, family history of diabetes or kidney disease, mental health and sleep disorders, increased levels of elevated high-sensitivity C-reactive protein, and sex-specific risk enhancers. There are substantial racial and ethnic differences, although they are likely due to social determinants of health (SDOH). The American Heart Association suggests that CKM syndrome screening should include both biological factors and SDOH. Interventions in patients with stages 0 to 3 CKM syndrome focus on preventing future cardiovascular events by management of excess adiposity, mainly through diet and exercise in the early stages, then through pharmacological treatment of metabolic syndrome components in later stages. There is a general acceptance that treatment of CKM syndrome should involve a holistic approach to prevention, screening, and management to improve outcomes and reduce long-term morbidity and mortality.

Objectives: This study evaluated the uptake and costs of 3 biosimilars among Medicare and Medicaid populations for 2019 to 2022: rituximab-abbs (Truxima), rituximab-pvvr (Ruxience), and rituximab-arrx (Riabni).

Study design: A retrospective, descriptive study.

Methods: Using the annually aggregated, product-level utilization and cost data of biologic and biosimilar rituximab products from CMS drug spending data, total claims and costs (reimbursement and out of pocket) for all rituximab products were identified and extracted from Medicare Part B, Medicare Part D, and Medicaid. Average spending per dosage unit (ASPDU) of individual rituximab products was also extracted, and their annual growth rates in 2022 (vs 2021) were calculated. Descriptive data analyses were performed using Microsoft Excel 2016.

Results: Four years after entering the US market, rituximab biosimilar use increased from between 0% and 7% in 2019 to 60%, 41%, and 61% of all rituximab claims paid by Medicare Part B, Medicare Part D, and Medicaid, respectively, in 2022. Corresponding total costs for rituximab biosimilars also reached 45%, 32%, and 47% of all rituximab products. The ASPDU of biologic rituximab increased 2% in Medicare Part B in 2022 (vs 2021) but decreased by 2% in Medicaid. The ASPDU of rituximab biosimilars (rituximab-abbs and rituximab-pvvr) decreased between 15% and 26% in 2022 in Medicare Part B and Medicaid, while their ASPDU slightly increased between 1% and 2% in Medicare Part D.

Conclusions: Significant uptake of rituximab biosimilars in Medicare and Medicaid occurred within the first 4 years of marketing in the US.

The US is facing a growing epidemic of sexually transmitted infections (STIs), with over 2.5 million cases of chlamydia, gonorrhea, and syphilis reported in 2021 and again in 2022. This public health crisis disproportionately affects youth and racial and ethnic minority communities, exacerbating barriers to accessing sexual health services. Untreated STIs can lead to severe health consequences, including infertility, pelvic inflammatory disease, and increased risk of HIV transmission and acquisition. Managed care organizations (MCOs) within Medicaid play a pivotal role in improving sexual health service delivery and addressing the rise in STIs. This commentary explores opportunities for Medicaid MCOs to enhance STI prevention, screening, and treatment. It was informed by reviews of Medicaid managed care contracts, plan provider manuals, and interviews with Medicaid plan officials and other experts. It presents a set of opportunities to enhance STI prevention, including incentivizing syphilis screening during pregnancy through existing perinatal and maternal health efforts, leveraging extended postpartum coverage for sexual health education, integrating STI services with substance use disorder programs, supporting community-based organizations that serve relevant communities, training community-facing workers in STI care and sexual health, coordinating with local health departments, and providing enrollee access to condoms and home STI tests. Implementing these strategies could reduce STI rates and improve health outcomes, particularly among vulnerable populations. Although this commentary draws on research focused on Medicaid MCOs, a coordinated approach that includes commercial plans and coordination with health departments could ultimately enhance the consistency and quality of STI services and sexual health care across the health care system.

Objectives: To develop a tool for measuring performance of a coordinated care center against the criteria of an integrated practice unit (IPU) and test it against an established care center in the Military Health System (MHS).

Study design: Characteristics of 4 patient care coordination models were sorted using the 11 criteria of the IPU.

Methods: Subject matter experts evaluated characteristics and criteria for inclusion or exclusion based on the needs of specialty care in the MHS. The consolidated tool was tested using the example of the National Intrepid Center of Excellence (NICoE), which provides coordinated, colocated care for patients with traumatic brain injury, using responses of yes, partial, no, not applicable, or incomplete.

Results: The final tool contained 7 IPU criteria subdivided into 18 measures. NICoE was found in 2020 to meet 11 measures fully and 6 partially, with 1 deemed not applicable. In 2023 it met 17 of 18 measures, with the remaining (translation services) available as an enterprise-wide resource. The tool was seen to need improvement in clarification of 3 measures and in 1 criterion that is evaluated differently by patients vs providers.

Conclusions: This IPU assessment tool accurately captures both the strengths and weaknesses of a coordinated care facility within the MHS. Iterative refinement of the tool is expected to inform ongoing discussion of the transformation of care in the MHS and the US and to provide a framework by which to measure the care performance of centers wishing to reorganize as IPUs.

Objective: To examine the relationship between adoption of direct oral anticoagulants (DOACs) and health and cost outcomes for patients with nonvalvular atrial fibrillation.

Study design: Real-world cohort study.

Methods: US adults who newly initiated treatment for nonvalvular atrial fibrillation were identified from claims data. DOAC adoption and stroke rates were assessed at metropolitan statistical area (MSA) and individual levels. The MSA-level cross-sectional analysis examined the relationship between the adoption rate of a DOAC (vs warfarin) and an ischemic stroke. The individual-level instrumental variable analysis examined the impact of treatment choice predicted by regional adoption on stroke within 1 year after treatment initiation. Results were extrapolated to estimate the strokes and costs averted by patients moving from a slow-adopting (10th percentile) MSA to a rapid-adopting (90th percentile) MSA.

Results: DOAC uptake rates in MSAs at the 10th and 90th uptake percentile were 53.1% and 78.5%, respectively, in 2014. Overall DOAC uptake increased from 66.3% in 2014 to 91.4% in 2018. Increased DOAC adoption reduced average stroke rates by 1.41 percentage points or 63.2% (P = .002) using the MSA-level descriptive analysis and 1.08 percentage points or 71.2% (P = .002) using the individual-level instrumental variable analysis. Nationally, shifting DOAC rates from those seen in slow-adopting MSAs to those seen in rapid-adopting MSAs could avert up to 32,000 strokes and save up to $1.04 billion annually.

Conclusions: More rapid adoption of newly approved nonvalvular atrial fibrillation treatments was associated with reduced stroke rates and high cost savings. Managed care organizations should consider how delays in the uptake of innovative medications impact health and economic outcomes.

Objective:  To determine whether an intensive value-based care educational program that includes a standardized end-stage renal disease (ESRD) transition pathway would improve the number of optimal starts within Kidney Contracting Entities (KCEs).

Study design: Retrospective cohort study.

Methods:  We recorded optimal starts, defined as the initiation of dialysis without a central venous catheter, and the initial modality type (hemodialysis vs peritoneal dialysis [PD]) in adult Medicare patients in a Comprehensive Kidney Care Contracting program. The setting was 4 KCEs within a single physician-led nephrology organization. Data were recorded each quarter (Q) during 2022. During Q1-Q2, patients and clinicians received formal instruction on the benefits of optimal starts. Starting in Q3, we implemented a standardized care pathway for patients at high risk for transition to ESRD. The proportion of optimal starts and the proportion of initial PD from Q1-Q2 vs Q3-Q4 were compared using the χ2 test.

Results: A total of 328 study-eligible patients initiated dialysis in 2022, including 166 (50.6%) in Q1-Q2. The proportion of optimal starts increased from 42.8% (71/166) in Q1-Q2 to 58.0% (94/162) in Q3-Q4 (P = .006). The proportion of PD starts increased from 18.7% (31/166) in Q1-Q2 to 28.4% (46/162) in Q3-Q4 (P = .038).

Conclusions:  Optimal starts are a key metric of success in value-based care models. We observed a significant increase in optimal starts and in the number of patients starting on PD after implementing a standardized ESRD transition pathway as part of an intensive value-based care educational program.

The Center for Integrated and Novel Approaches in Vascular-Metabolic Disease (CINEMA) program is an innovative, patient-centered system of care developed by the University Hospitals Harrington Heart and Vascular Institute in Cleveland, Ohio in the US for the management of high-risk patients with type 2 diabetes (T2D) and prediabetes at high risk for cardiovascular-kidney-metabolic (CKM) syndrome and its consequences. At its core, CINEMA is a multidisciplinary team of care experts, working together outside of traditional silos. The patient meets with the entire team up to 4 times each year to address all aspects of cardiovascular (CV) and T2D care. At the first visit, the team formulates a personalized approach that is evidence based and centered on optimal strategies to improve the patient's lifestyle, reduce their risk of CV and kidney disease events, and increase their access and adherence to guideline-directed pharmacologic therapies. A community health worker is utilized to address social determinants of health as needed. The program has a substantial research component, with the intent of developing evidence for novel care paradigms. The multiyear results of the CINEMA program indicate that a multidisciplinary approach to management of high-risk patients is highly effective in reducing CKM syndrome risk factors and increases use of guideline-directed therapies. The aim of this review is to describe the structure, operation, and eligibility criteria for admission to the CINEMA program, provide an overview of how CKM syndrome risks are determined and managed for each patient, and discuss how the integrated approach to care is supported by current recommendations from professional societies and results from other coordinated care/multidisciplinary programs. Lastly, the scalability challenges of a wider rollout of the CINEMA program are considered.