American Journal of Managed Care最新文献

Objectives: To assess payer-level completeness of 2025 Transparency in Coverage (TIC) negotiated-rate files for physician, hospital outpatient, and hospital inpatient service lines.

Study design: Cross-sectional descriptive review of 2025 TIC releases from 3 national payers (Aetna, Cigna, and UnitedHealthcare).

Methods: We created cleaned analysis files by ingesting machine-readable files and parsing and deduplicating TIC data sets for the major national plan of each insurer. We compared the network size from the TIC files against marketing materials that reported how many physicians and hospitals were in-network. We calculated what percentage of the most common billing codes had negotiated rate data for large family medicine, cardiology, and orthopedic surgery physician groups, hospital outpatient departments, and inpatient hospitals.

Results: Aetna and Cigna generally listed as many-or more-physicians and hospitals as their marketing materials did, whereas UnitedHealthcare listed fewer. Negotiated-rate completeness was highest for physician specialties and lowest-often minimal-for inpatient files. UnitedHealthcare's physician groups were near complete, but inpatient data were sparse. Cigna showed high completeness for physician specialties and inpatient data, but limited hospital outpatient rates. Aetna demonstrated moderate to good physician completeness, midrange outpatient hospital data, and heterogeneous inpatient results. Overall, physician and hospital outpatient data were typically usable; inpatient data were insufficient.

Conclusions: For these payers, 2025 TIC files support analysis of physician and hospital outpatient prices but are inadequate for inpatient benchmarking. CMS should evaluate TIC completeness-internally or via an external auditor-and enforce penalties when required information is not published.

Objectives: Medicaid's Institution for Mental Diseases (IMD) exclusion bars federal funding for treatment in facilities with more than 16 psychiatric beds, but some states have obtained waivers under Section 1115 of the Social Security Act to increase options for treating serious mental illness (SMI). This retrospective claims study assessed health care resource utilization, costs, homelessness, and incarceration among Medicaid beneficiaries with SMI in states with and without waivers.

Study design: Patients were 18 years and older and had at least 1 diagnosis of SMI and 12 months of continuous enrollment pre- and post index date.

Methods: Fixed-effect models, adjusted for patient and state characteristics, estimated the waivers' impact on outcomes.

Results: The odds of having psychiatric-specific inpatient admissions and emergency department (ED) visits were lower by 14% and 26%, respectively, in the waiver cohort (n = 130,224) vs the nonwaiver cohort (n = 3,102,971). Odds of all-cause inpatient admissions and ED visits were also lower (9% for both) in the waiver cohort, but the odds of having all-cause outpatient visits were 19% greater in the waiver cohort. States with waivers had 11% fewer incarcerations, or about 250 fewer cases per year, based on an average of 23,592 incarcerations.

Conclusions: Our findings underscore the beneficial impact of IMD exclusion waivers on psychiatric-specific and all-cause health care resource utilization and costs as well as on incarceration rates for individuals with SMI. CMS may want to consider the results of this study in addition to other available data when granting waivers to states and potentially removing this exception from the Medicaid law.

Objective: To assess the correlates of changes in emergency department (ED) prices for self-pay patients from 2021 to 2023.

Study design: Retrospective longitudinal analysis of self-pay prices for ED facility fees (Current Procedural Terminology [CPT] codes 99283-99285) from 2021 to 2023, using multivariate weighted linear regression to examine the relationship between hospital- and area-level characteristics and trends in self-pay prices and correcting for selective noncompliance with price transparency reporting regulations.

Methods: We created a unique longitudinal database of self-pay rates for CPT codes 99283-99285 using national hospital price transparency data from September 29, 2021, and September 29, 2023. Hospital- and area-level characteristics were derived from the 2021 quarter 2 CMS Provider of Services File, the Agency for Healthcare Research and Quality's 2021 Compendium of US Health Systems, and the 2021 American Community Survey.

Results: From 2021 to 2023, self-pay prices increased by a mean of $98.69, $392.85, and $642.74 for CPT codes 99283, 99284, and 99285, respectively. Price increases were notably higher at for-profit hospitals compared with nonprofits, and system affiliation and serving a community with higher levels of uninsured Hispanic/Latino individuals were associated with greater relative price increases for CPT codes 99284 and 99285.

Conclusions: Self-pay patients face growing affordability issues in ED access. For-profit and system-affiliated hospitals saw the largest increases. With Medicaid enrollment declines stemming from the end of continuous coverage requirements, which started in mid-2023, the self-pay population may rise, highlighting the need to understand their financial risk exposure.

One in 6 patients with diabetes in the US reports rationing or abandoning their medications to save costs. Our objective was to describe the breadth, approach, and impact of interventions that sought to address cost-related nonadherence among patients with diabetes in 2003-2023. Studies were eligible if they were published in English, pertained to diabetes, described interventions or policies that reduced or eliminated diabetes medication costs, and evaluated medication adherence as a primary or secondary outcome. We identified studies using MEDLINE, Embase, and Scopus. Two independent reviewers assessed each article's abstract and full text in 2 phases; 29 articles met inclusion criteria. Sixteen interventions reduced diabetes-related co-payments: Seven found improvements in adherence, 6 found no improvement, and 3 did not evaluate changes over time. Eight interventions eliminated all or some diabetes-related costs: Five found improvements in adherence, 2 found no improvement, and 1 did not evaluate changes over time. Interventions that combined cost-reduction or cost-elimination strategies with wellness and disease management programs tended to lead to improved short- and long-term adherence. Six articles evaluated statewide or federal policies (eg, insulin co-payment caps), with varying effects on adherence. Interventions that eliminate diabetes-related costs and provide additional diabetes management assistance may improve access and adherence to medications. Additional work is needed to evaluate the impact of these interventions on long-term health and utilization outcomes.

Background: Among patients with focal segmental glomerulosclerosis (FSGS), proteinuria and kidney function decline may be associated with increased economic burden. This study aimed to provide current information on the epidemiology and economic burden of FSGS in the United States.

Methods: In this descriptive, noninterventional, retrospective cohort study, 9899 patients were identified between January 2016 and December 2020 in Optum de-identified Market Clarity Data based on International Classification of Diseases code or Optum proprietary natural language processing data. Descriptive statistics were reported for categorical and continuous variables. Prevalence estimates were standardized to the age, gender, and race/ethnicity distribution of the general US population using direct methods and data from the 2021 United States Census Bureau. Per-patient-per-month health care resource utilization and associated costs (2024 US $) were reported by proteinuria (≤ 1.5 g/g vs > 1.5 g/g or < 3.5 g/g vs ≥ 3.5 g/g) and chronic kidney disease stage (stage 1-5/kidney failure). The Fisher exact test was used for categorical health care resource utilization outcomes, and linear regression (mean) and the Jonckheere-Terpstra test (medians) were used for continuous health care resource utilization and cost outcomes.

Results: Estimated annual US prevalence (average for 2016-2020) of FSGS was 212.6 per 1 million. There was a consistent trend toward higher health care resource utilization and total costs with both chronic kidney disease progression (stage 1-5/kidney failure) and higher levels of proteinuria (≤ 1.5 g/g vs > 1.5 g/g or < 3 .5 g/g vs ≥ 3.5 g/g).

Conclusions: The observed prevalence of FSGS increased in the US and was highest among Black individuals. More advanced chronic kidney disease and higher levels of proteinuria were both associated with greater health care resource utilization and costs. Treatments that reduce proteinuria and slow kidney function decline have the potential to delay disease progression and to reduce the economic burden associated with FSGS.

Objectives: To demonstrate the prevalence of comorbidities documented by Chronic Conditions Data Warehouse (CCW) data for Medicare beneficiaries and to illustrate how failing to account for differences in reported comorbidities can result in information bias.

Study design: Retrospective cohort study of Medicare beneficiaries who underwent coronary artery bypass grafting (CABG) between 2008 and 2019.

Methods: A total of 1,158,701 Medicare beneficiaries underwent CABG. The prevalence of CCW-reported comorbidities was compared between beneficiaries enrolled in Medicare Advantage (MA) or traditional Medicare (TM) plans. Median survival differences (with 95% CIs) were compared in unadjusted and risk-adjusted analyses using overlap propensity score weighting, with and without inclusion of CCW-reported comorbidities during risk adjustment.

Results: The proportion of MA-enrolled CABG recipients increased annually from 17.5% in 2008 to 38.3% in 2019. MA-enrolled beneficiaries had fewer CCW-reported comorbidities than TM-enrolled beneficiaries (average standardized mean difference across 27 CCW comorbidities, 0.431). After risk adjustment for demographics, median survival differed minimally between MA- and TM-enrolled beneficiaries (10.00 vs 10.05 years; difference, -15 [95% CI, -41 to 13] days). However, when CCW-reported comorbidity data were included in risk adjustment, MA-enrolled beneficiaries demonstrated substantially lower median survival (9.52 vs 10.91 years; difference, -507 [95% CI, -538 to -466] days).

Conclusions: The prevalence of CCW-reported comorbidities differs significantly between TM-enrolled and MA-enrolled beneficiaries who underwent CABG. These differences can introduce substantial bias in risk-adjusted analyses that erroneously assume equivalent CCW-reported comorbidity documentation across insurance types. Medicare outcomes research that relies on CCW-reported comorbidity data without accounting for insurance-related differences may produce biased treatment-effect estimates, potentially misinforming clinical or policy decisions.

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.