American Journal of Managed Care最新文献

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.

In recent years, evidence has continued to mount showing a strong relationship between diabetes, cardiovascular disease, and chronic kidney disease. This, in turn, has driven a shift to a more integrated and holistic approach in the treatment of patients with cardio-renal-metabolic (CRM) disease. The 2022 Diabetes, Cardiorenal, and Metabolic (DCRM) multispecialty practice recommendations were the first multispecialty consensus on the comprehensive management of patients with diabetes, cardiorenal, and/or metabolic diseases, providing evidence-based recommendations that are simple to implement. The recommendations provide guidance on assessments and treatments, including both lifestyle therapy and pharmacotherapy, for patients across the DCRM spectrum, and are an invaluable tool for clinicians who need to develop treatment plans for complex patients with cardio-renal-metabolic disease. This article reviews the key elements of the DCRM recommendations and summarizes the updates included in the DCRM 2.0.

Objectives: The question of what providers one has access to under their insurance coverage is crucial for patients in managed care. This study sought to examine information displayed in online provider directories and whether this information matched consumer preferences.

Study design: A national survey (N = 4007) paired with an analysis of online provider network directories.

Methods: We conducted a quantitative content analysis of online provider directories from March 1 to May 30, 2023. A national survey of American adults was fielded from June 30 to July 2, 2023, to gauge preferences for information displayed in provider directories. Preferences and perceived importance of information elements that should be displayed in provider directories were contrasted with the data elements displayed in directories.

Results: We found that provider directories showed wide variations with regard to information displayed and in the amount of navigation required by patients. There were widespread instances of disconnect between patient preferences and data availability. Important data items related to care access and provider quality that were preferred by consumers were not universally presented in directories, such as availability of telemedicine (23% presented), information about office hours (58%), and disability access (59%). Approximately 7% of directories did not indicate whether a provider was accepting new patients, despite the requirement under the No Surprises Act to display such information. Further, certain marginalized populations may find it especially challenging to acquire information about providers.

Conclusions: Lack of attention to usability in provider directories may hinder the national goal of ensuring care accessibility for all.

Objectives: Despite recent policy interest in improving access to mental health care in Medicare, little is known about how demand for care will change among the Medicare population as newer cohorts age into the program. We documented the growing rate of counseling and psychotherapy use in the decade prior to turning age 65 years among subsequent cohorts aging into Medicare. We characterized how this growth varied across demographic groups, income levels, and mental and physical health status.

Study design: We present trends using data from the 2002-2017 Medical Expenditure Panel Survey Household Component.

Methods: We categorized individuals into 5-year Medicare entry cohorts based on the year they turned age 65 years. Our outcome was an indicator for having a visit for counseling or psychotherapy in a given year. Employing a probit regression, we characterized visit rates across 5-year cohorts, presenting both unadjusted and covariate-adjusted results. We ran stratified regressions by subpopulations.

Results: Our sample included 54,666 individuals aged 55 to 64 years, weighted to be nationally representative. The cohort aging into Medicare between 2021 and 2025 was 88% (95% CI, 57%-119%) more likely to have a counseling or psychotherapy visit between the ages of 55 and 64 years compared with the cohort that gained eligibility for Medicare between 2006 and 2010 at the same age. Growth in utilization was pervasive across many subpopulations.

Conclusions: Our findings suggest that more recent cohorts aging into Medicare seek significantly more counseling and psychotherapy than prior cohorts. This increased utilization is pervasive across subpopulations, suggesting that plans must prepare to accommodate the needs of new Medicare entrants.

Metabolic dysfunction-associated steatotic liver disease (MASLD) is characterized by hepatic steatosis that is confirmed by imaging or histology in the setting of at least 1 metabolic risk factor in the absence of significant alcohol consumption. Nonalcoholic steatohepatitis, or NASH, was recently renamed metabolic dysfunction-associated steatohepatitis (MASH); it represents the progressive form of MASLD. MASH is defined by hepatic steatosis, lobular inflammation, and ballooning degeneration (hepatocellular injury) in a characteristic histologic pattern. Multiple pathophysiologic mechanisms underlie the development of MASLD, and multiple factors (eg, metabolic, hormonal, genetic, nutritional, and epigenetic components) are related to liver injury. MASH has a prevalence in the United States of 1% to 6%, and it is expected to rise in the next decade. Individuals living with MASH frequently suffer from comorbidities such as type 2 diabetes and cardiovascular disease. Several guidelines have been published to support the timely diagnosis of MASH that incorporate noninvasive tests that obviate the need for liver biopsy. Multiple MASH treatment options are in various stages of development. The THR-β agonist resmetirom, approved by FDA in March 2024, offers a liver-directed treatment for those patients living with moderate to severe fibrosis without cirrhosis. Considering the progressive nature of the disease and the availability of a treatment that can be initiated early to halt MASH progression, patients who have risk factors for MASH should urgently be encouraged to visit their health care providers for MASH screening.

Private negotiated facility fees at hospitals are on average double the ambulatory surgery center facility fees for common outpatient procedures.

Objectives: To describe (1) rebate arrangements for specialty drugs, (2) the use and influence of benefits brokers and consultants, and (3) the importance of rebate-related factors when selecting a pharmacy benefits manager (PBM) among a sample of employers with self-funded pharmacy benefits.

Study design: A national survey of employer drug benefit decision makers (N = 110) for organizations with self-insured pharmacy benefits.

Methods: We summarized respondents' current rebate agreements for specialty drugs and their perspectives on the importance of rebates and rebate guarantees overall as well as by type of rebate agreement and by the person or entity identified as most influential in rebate strategy.

Results: Nearly two-thirds of employers reported having rebate agreements with a rebate guarantee for specialty drugs (n = 69; 62.7%). The person or entity most influential to rebate strategy decisions was often a benefits consultant (37.3%), a human resources/benefits leader (29.1%), or a benefits broker (21.8%). Employers with rebate guarantees ascribed a higher level of importance to guarantees when selecting a PBM (median [IQR], 9 [7-10]) than employers receiving rebates without a guarantee (7 [6-8]) and those who do not receive rebates (7.5 [4-9]) (P = .001).

Conclusions: These findings shed light on the importance of rebate guarantees and the role of employer benefits consultants and brokers in PBM selection. As the public discourse on PBMs and drug rebates continues, it is important to recognize the role employer benefits consultants may play in perpetuating employer reliance on guaranteed rebate arrangements.

Objectives: This study describes the use of data-based feedback, such as human papillomavirus (HPV) vaccination rates, to advance HPV vaccination uptake in pediatric and family medicine clinics.

Study design: A survey of primary care clinical staff in the US who provided HPV vaccination to children aged 9 to 12 years (N = 2527; response rate, 57%).

Methods: The primary outcome was a mutually exclusive categorical variable that described the type of quality metrics for which providers received feedback in the past year: HPV vaccine, other pediatric vaccinations, other quality metrics, or none. Secondary outcomes were provider perceptions of HPV vaccine feedback helpfulness and their comfort with colleagues seeing their HPV vaccination rates. Logistic models adjusted for clinical staff and clinic characteristics.

Results: Only 36.2% (n = 916) of respondents received HPV feedback. Feedback on HPV vaccination rates was more likely in nonrural clinics (OR, 2.03; 95% CI, 1.38-2.99), clinics in systems of 5 or more (OR, 1.81; 95% CI, 1.38-2.36), and in clinics serving 50 or more children per week (OR, 3.08; 95% CI, 2.03-4.66). Hispanic, Latino, or Spanish (OR, 1.54; 95% CI, 1.00-2.36) and Black or African American clinical staff (OR, 2.12; 95% CI, 1.44-3.12) were more likely than White clinical staff to find HPV vaccine feedback helpful. Relative to pediatricians, family medicine clinical staff were less comfortable with colleagues seeing their HPV vaccination rates (OR, 0.70; 95% CI, 0.57-0.87).

Conclusions: Clinical staff seldom receive feedback about HPV vaccination in primary care.