American Journal of Managed Care最新文献

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 November issue features a conversation with Laurie C. Zephyrin, MD, MPH, MBA, senior vice president for achieving equitable outcomes at the Commonwealth Fund.

Objectives: To evaluate the effects of the introduction of infliximab biosimilars on the cost of infliximab originator, the associated cost savings with infliximab biosimilars, and the market utilization of infliximab products in the first 5 years after infliximab biosimilars became available in the US.

Study design: Retrospective longitudinal analysis.

Methods: A retrospective longitudinal analysis with an interrupted time series analysis was performed using the Merative MarketScan Commercial Claims and Encounters Database for outpatient infliximab claims from January 1, 2015, to December 31, 2021, for patients aged 0 to 64 years with commercial insurance. Outcomes of interest included market share of all infliximab products, cost per vial and infusion, and projected cost savings to the health care system after adjusting for inflation using the US Bureau of Labor Statistics Consumer Price Index for medical care.

Results: A total of 471,731 claims from 42,099 unique patients met the inclusion criteria. Using an interrupted time series analysis, there was a 13-month lag before infliximab biosimilar utilization began to affect originator drug cost. Infliximab utilization increased to 26% by December 2021, and the price per infusion and per vial of infliximab originator decreased by 53% and 62%, respectively, from December 2017 to December 2021. The introduction of infliximab biosimilars has saved the US health care system an estimated $260 million to $842 million.

Conclusions: Utilization of infliximab biosimilars steadily increased in the first 5 years after market entry. The competition created by biosimilars has contributed to significant health care savings and a decrease in the total cost of both the infliximab originator drug and its biosimilars.

Objectives: This study aimed to evaluate the effectiveness of value-based care (VBC) interventions in slowing the progression of chronic kidney disease (CKD), as measured by changes in estimated glomerular filtration rate (eGFR) over time.

Study design: This retrospective cohort study used eGFR values from 2017 to 2023 to evaluate 623 patients with stage 3b or 4 CKD with routine eGFR testing who received VBC intervention. The focus was on comparing rates of eGFR decline before and after enrollment in the VBC.

Methods: Linear regression was used to model patient-specific trajectories of kidney function across time using eGFR, with the slope serving as an estimate for the rate of disease progression.Patients were grouped into cohorts by disease stage, and mixed-effects models were used to compare the rates of eGFR decline pre- and post VBC intervention.

Results: The rate of eGFR decline was slower across all CKD stages after enrollment compared with before, with a 77.2% reduction in the median rate of eGFR decline in stage 3b (P < .001) and 65.2% in stage 4 (P < .001). As a result of the reduced rates of disease progression, patients had higher median eGFR values at their latest month of eGFR measurement post enrollment compared with the eGFR values expected without a VBC intervention (stage 3b, 1.9 mL/min/1.73 m2 higher; stage 4, 3.5 mL/min/1.73 m2 higher).

Conclusions: Our findings indicate statistically significant differences in the rate of eGFR decline after enrollment in a VBC model, particularly for those in advanced CKD stages.

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 October issue features a conversation with Ge Bai, PhD, CPA, professor of accounting at Johns Hopkins Carey Business School and professor of health policy and management at Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland.

Objectives: To compare all-cause readmission or mortality between patients with heart failure (HF) with discharge ordered before noon (DOBN) and those with discharge ordered after noon (DOAN).

Study design: A retrospective multicenter study of 14,469 patients hospitalized for acute decompensated HF at 17 hospitals in 4 US states (admitted January 2010-December 2022 and followed through May 2023).

Methods: Patients were grouped by discharge timing: DOBN (00:00-12:00) and DOAN (12:01-23:59). We assessed all-cause readmission or mortality at 7 days, 30 days, and 3 years post discharge.

Results: Of all patients, 2844 (19.7%) were in the DOBN group and 11,625 (80.3%) were in the DOAN group. The DOBN group had higher mortality than the DOAN group at 7 days (2.6% vs 1.3%; HR, 1.39; 95% CI, 1.05-1.86), 30 days (8.9% vs 5.2%; HR, 1.34; 95% CI, 1.15-1.58), and 3 years (50.6% vs 41.4%; HR, 1.13, 95% CI, 1.06-1.21) post discharge. The DOBN group also had a higher readmission rate within 7 days (8.3% vs 6.4%; HR 1.99; 95% CI, 1.61-2.48) post discharge but similar readmission rates to the DOAN group at 30 days (16.0% vs 15.2%; HR, 1.07; 95% CI, 0.97-1.20) and 3 years (48.6% vs 49.7%; HR, 0.96; 95% CI, 0.90-1.02). The differences persisted after categorizing patients into 2 timeline groups (2010-2016 and 2017-2022), with DOBN patients having shorter median times to mortality and readmission than DOAN patients.

Conclusions: In hospitalized patients with HF, DOBN was independently associated with higher all-cause mortality both in the short and long term as well as increased early readmission rates. These findings have implications for discharge policies.

Physicians often rely on follow-up appointments to help patients achieve their health care goals. This is particularly true of primary care, where physicians rely on longitudinal care practices to manage chronic illnesses such as diabetes and hypertension. However, although patients are often scheduled to return for a follow-up visit in 3 to 6 months, there is little evidence supporting these recommendations. In other words, revisit interval (RVI) assignment is often left exclusively to the provider's discretion. The lack of standards means RVIs may vary from physician to physician, impacted by subjective factors such as provider sex, geographical location, clinical heuristics, and administrative practice patterns. This inconsistency has serious implications. Scheduling revisits too frequently may result in resource overuse and increased administrative burden. Conversely, waiting too long before revisits may result in discontinuity of treatment, decreased physician-patient rapport, and, subsequently, suboptimal patient outcomes. The first and foremost step in ameliorating this issue involves investigating the relationship among RVIs, patient outcomes, and cost of care. Collecting data on the most efficacious RVIs for patients with varying disease states and severities will allow the development of evidence-based guidelines for RVI assignment. The garnered information could then be used to establish an algorithm capable of recommending optimal RVI based solely on patient characteristics. By eliminating variability in RVI assignment, unnecessary health care costs associated with resource overuse could be reduced and patient health outcomes enhanced.

Objective: To examine how site of care and insurance network contribute to price differences for common adult outpatient surgeries paid by commercial insurers.

Study design: Observational study using a 50-state sample of commercial medical claims data.

Methods: We compared insurer-paid amounts, patient out-of-pocket payments, and balance billing amounts for 4 common adult outpatient surgeries (arthroscopy, cataract, colonoscopy, and upper gastrointestinal procedures) by site of care (ambulatory surgery center [ASC] vs hospital outpatient department [HOPD]) and insurance network status (in network vs out of network).

Results: Compared with a surgery occurring at an in-network ASC, insurers paid $306 (32%) more to an out-of-network ASC, $1042 (110%) more to an in-network HOPD, and $1041 (110%) more to an out-of-network HOPD. Patients paid $186 more out of pocket at an in-network HOPD than at an in-network ASC, which both had cost-sharing rates lower than out-of-network facilities.

Conclusions: Patients saved money by choosing in-network facilities regardless of the site of care, whereas insurers saved by increasing the usage of ASCs for common adult outpatient surgeries paid by commercial insurers. Insurance models that better align patient and insurer incentives could increase utilization of ASCs and lower overall spending on outpatient surgeries.

Objectives: To determine Medicare expenditures and potential beneficiary out-of-pocket liability for Medicare beneficiaries with amyotrophic lateral sclerosis (ALS), including costs related to drug treatments.

Study design: This cohort study utilized the 100% Medicare fee-for-service claims for 2017-2021, including Part A and Part B medical claims and Part D prescription drug event data.

Methods: Eligible Medicare beneficiaries with ALS were identified based on 1 or more inpatient or 2 or more outpatient claims with an International Statistical Classification of Diseases, Tenth Revision diagnosis code for ALS (G12.21) between 2017 and 2020. Health care expenditures and beneficiary liability were assessed for the 12-month study period.

Results: At 1 year post index, Medicare beneficiaries with ALS had more than 3 times the Medicare expenditures of beneficiaries without ALS ($47,450 vs $13,889, respectively). Similar patterns were observed for beneficiary liability. Approximately one-third of Medicare beneficiaries used either edaravone or riluzole in the first 12 months following ALS diagnosis. The cost of care for beneficiaries using these drugs was notably higher than for beneficiaries with ALS overall.

Conclusions: Approximately one-third of people with ALS on Medicare receive disease-modifying medication. ALS is a burdensome disease with significant financial implications for people with ALS and the Medicare program. Treatment for ALS presents affordability challenges, and policy makers must consider how current Medicare policy addresses the costs of care.

Objective: Neonatology care can be costly for commercially insured families with minimal opportunities to choose in-network providers. Out-of-network neonatologists may surprise families with balance billings. This study examined the effects of state balance billing laws on neonatology prices and provider network participation.

Study design: This study used a quasi-experimental, difference-in-differences design with 7 states that implemented balance billing regulations for out-of-network providers at in-network hospitals.

Methods: We used claims data from 2012 to 2019. We analyzed data for patients in fully insured plans who received neonatology services to compare price and surprise billing changes, before and after the policy, relative to controls. The main outcome measures were in-network, out-of-network, and combined total prices, as well as the proportion of claims billed in network to indicate provider network participation.

Results: For both independent dispute resolution (IDR) and benchmark rating approaches, the event studies did not show changes in in-network prices or combined prices, compared with control states, but they showed out-of-network price increases in states with the IDR approach. State-specific analyses indicated mixed results for both IDR and benchmark rating approaches.

Conclusions:  The federal No Surprises Act, which went into effect in 2022, has allowed state regulations to continue to govern fully insured plans. We found substantial variation in the effects of state laws on pricing for neonatology services. There was no consistent evidence that state policies influenced prices or network participation of neonatology clinicians.