American Journal of Managed Care最新文献

The COVID-19 pandemic accelerated the adoption of the hospital at home (HAH) model, driven by the 2020 CMS Acute Hospital Care at Home waiver that removed financial barriers to reimbursement. With more than 330 hospitals across 130 health systems implementing HAH, this care model offers promising outcomes and experiences while addressing rising health care costs and an aging population. However, further research is needed to define its scalability, appropriate patient populations, and long-term viability. To address these gaps, Cleveland Clinic and Mayo Clinic established the Cleveland Clinic-Mayo Clinic (CCMC) Home-Based Care Research Consortium. The consortium focuses on creating a national registry, standardizing data, and developing evidence-based care pathways to evaluate the impact of HAH on patient safety, outcomes, and costs. Additionally, it aims to identify which populations and conditions can benefit most, ensuring equitable and high-quality care delivery. The consortium also prioritizes caregiver well-being, exploring virtual and hybrid models to address workforce challenges and enhance provider satisfaction. Recognizing health equity as essential, it emphasizes enrolling diverse populations and collaborating with community organizations to address social determinants of health. The consortium will also focus on true cost savings, workforce efficiency, and integration with home-based care programs, taking into account recent advances in technology and artificial intelligence. By fostering collaboration and rigorous research, the CCMC Consortium seeks to refine HAH into a scalable, sustainable, and equitable care model that meets the evolving demands of modern health care.

Background: Current financial toxicity (FT) screening tools rely on patient-reported risk factors. Underrepresented populations may not be forthcoming about FT fears due to cultural concerns of treatment withholding or migratory repercussions, if applicable. Identifying objective risk factors, such as social determinants of health (SDOH) and disease-specific factors (DSF), could reduce FT in patients with cancer and throughout health care systems.

Methods: This was a multicenter retrospective study evaluating SDOH and DSF associated with FT (defined as ≥ $15,000 owed) related to cancer treatment. Inferential statistics were used to evaluate differences between the FT cohort and those who owed less than $15,000. Continuous data were compared with a Student t test or Mann-Whitney test, depending on distribution. Categorical outcomes were compared with a χ² test. A logistic regression model was used to evaluate multivariate associations with FT, using a P value of less than .05 to define significant results.

Results: The sample comprised 162 records, 81 in each group. Univariate analyses demonstrated participants' differences in age, relationship with a primary care provider, country of origin, insurance status, education level, need for an English interpreter, whether their disease was stage IV at diagnosis, recurrent or metastatic disease, use of immune checkpoint inhibitors, and use of targeted molecular therapy. Employment status and marital status were not statistically different. The logistic regression model showed that lack of insurance and having stage IV disease at diagnosis were significantly associated with FT (P = .001 and P = .0495, respectively).

Conclusions: Objective FT screening can minimize response bias and incidence in those at increased risk. In our study, we found that individuals who are first-generation Hispanic immigrants and lack English proficiency faced significant barriers to receiving help for the high financial costs of medical care. These findings identify specific subpopulations at risk for FT and will guide prospective interventions looking to minimize FT. Health care systems should analyze objective measures of FT while considering loco-regional and subcultural SDOH/DSF to overcome response bias.

Objectives: To establish baseline prevalence rates associated with nurse practitioner (NP) use of 3 of the most commonly observed primary care low-value-care (LVC) services and to examine whether practice location and patient characteristics impact NP LVC use.

Study design: Cross-sectional, secondary analysis.

Methods: Data for 14,579 adult beneficiaries in the 2021 Merative MarketScan Commercial and Medicare databases in Arizona, Nevada, and New Mexico were analyzed. Outpatient claims associated with NP care were used to examine the use of low-value lumbar x-ray, antibiotics for acute upper respiratory infection (aURI), and routine electrocardiogram (ECG) as described by the Choosing Wisely initiative. International Statistical Classification of Diseases, Tenth Revision and Current Procedural Terminology codes were used to apply inclusion and exclusion criteria. Relationships between LVC use and the state where a beneficiary received care, rural-urban practice location, and beneficiary sex and age were examined.

Results: Prevalence rates of NP use of low-value lumbar x-ray (13%), aURI antibiotic (42%), and ECG (6%) were lower or relatively similar to those found in other studies. Older beneficiary age was significantly associated with more low-value ECGs used (P < .001), but when adults 45 years and older were examined, age no longer remained significantly related. No significant relationships between NP LVC use and practice location or beneficiary sex were found.

Conclusions: NP LVC use in primary care was lower or relatively similar compared with the general clinician population. MarketScan may underrepresent rural care, and the relationship between NP LVC use and rural-urban location should be reexamined using an alternative classification system. To deimplement NP LVC use, other factors, such as NP characteristics, must be explored.

Objectives: CMS has provided full coverage of the Medicare Diabetes Prevention Program (MDPP) since 2018. However, the MDPP's potential to impact public health has been limited by the lack of program suppliers and participants. This study describes the opportunities and obstacles associated with MDPP implementation from the novel perspective of program coordinators across the US.

Study design: We conducted a qualitative study with a sample of program coordinators from MDPP suppliers listed in the CMS database.

Methods: We conducted individual interviews with 12 program coordinators to learn about their experiences becoming a Medicare-designated program supplier and delivering the MDPP. Data were analyzed using the Rapid Group Analysis Process.

Results: Six themes emerged: 2 about opportunities and 4 about obstacles. Opportunity themes reflected (1) supportive organizational cultures and (2) committed staff who were passionate about and invested in offering the MDPP. Obstacle themes revealed (1) challenges around obtaining Medicare designation, (2) logistics of submitting claims and receiving reimbursement, (3) insufficient payment associated with the pay-for-performance model and Medicare Advantage plans, and (4) overwhelming and conflicting government requirements. Program coordinators offered recommendations to support organizations in providing the MDPP, including peer mentors for onboarding and continued assistance and a more traditional fee-for-service payment model.

Conclusions: These findings highlight organizational culture as a strength for MDPP implementation and suggest policy changes to address MDPP obstacles. Wider program dissemination is urgently needed to prevent type 2 diabetes among the approximately 5.2 million eligible Medicare beneficiaries.

Health care and outcomes in Puerto Rico (PR) have been impacted by US federal policies, including those pertaining to the Medicare Advantage (MA) program. The MA enrollment rate in the US mainland is 54%, but in PR, it is more than 90%. In addition to this stark difference in MA enrollment rate, MA plan payments and quality-which may impact mortality of enrollees-also differ between PR and the US. Despite these differences, little is known about the mortality gap between PR and the US among MA enrollees. We compared mortality rates between Hispanic MA enrollees in PR and Hispanic and White enrollees in the US from 2010 to 2022, adjusting for age and sex in each year. We found that among MA enrollees, the mortality of Hispanic enrollees in PR was significantly higher than that of Hispanic enrollees in the US. The findings may be explained by lower quality of care provided to PR Hispanic enrollees compared with US Hispanic enrollees, particularly within MA plans. Our results provide insights into existing disparities among MA enrollees in PR and the US mainland.

Objectives:  To compare quality and health resource utilization among beneficiaries under 2-sided risk Medicare Advantage (MA) payment arrangements (at-risk MA) vs traditional Medicare (TM).

Study design: Retrospective cross-sectional regression analyses of claims and enrollment data from 2016 to 2019 examining 20 performance measures. All patients were cared for by the same 17 physician groups and 15,488 physicians across 35 health insurers.

Methods: Logistic regressions adjusted for demographics, geography, and comorbidities for 20 quality and utilization measures across 4 domains of care. Estimates were reported using marginal risk and marginal risk difference per 1000 across the study period.

Results:  The sample comprised 6,564,538 person-years (30.3% at-risk MA and 69.7% TM). Sixteen of the 20 measures favored at-risk MA, including lower acute inpatient admissions, lower 30-day readmissions, avoidance of emergency department utilization across 4 measures, avoidance of disease-specific inpatient admissions in 7 of 9 measures, lower high-risk medication use and office visits, and higher medication adherence to renin-angiotensin system drugs. The other 4 measures were statistically equivalent.

Conclusions: Given the CMS goal of moving all beneficiaries to fully accountable care arrangements by 2030, it is critical to understand the differences in quality and health resource utilization between at-risk MA and fee-for-service TM to inform policies on payment and service delivery. Although the associations are not causal, in this cross-sectional study, at-risk MA relative to TM was associated with 11.3% to 54.0% higher quality and efficiency in 16 of 20 measures after adjusting for differences in demographics, comorbidities, and other health characteristics.

Objective: The US health care system contributes to approximately 9% of domestic US greenhouse gas emissions, exacerbating climate change and threatening human health. By substituting for in-person visits, telemedicine may represent a means of emission avoidance.

Study design: Leveraging multipayer claims data, we developed models based on various assumptions to estimate ranges of emissions from travel averted by telemedicine utilization between April 1, 2023, and June 30, 2023.

Methods: We estimated the carbon dioxide (CO2) emissions averted from the avoidance of travel by patients using telemedicine as a substitute for their usual source of in-person care at post-public health emergency rates through a modeling analysis of nationwide multipayer claims data representing 19% of US insured adults; findings were extrapolated to the entire US insured adult population.

Results: We quantified a monthly average of 1,481,530 US telemedicine visits (65,733 rural) during the study period. Between 740,765 and 1,348,192 of these were estimated to have substituted for in-person visits. Using inputs of 2021 electric vehicle (EV) production share and emissions per mile, we estimated that between 4,075,065 and 7,489,486 kg of CO2 are averted due to telemedicine use each month. Estimates accounting for different assumptions including EV and public transportation use produce a range of 4 million (most conservative) to 8.9 million (least conservative) kg of CO2 averted per month. Extrapolating to the entire US adult population, we estimate that monthly emissions averted range from 21.4 to 47.6 million kg of CO2-roughly equivalent to the monthly emissions of 61,255 to 130,076 gasoline-powered passenger vehicles.

Conclusion: Our results suggest that telemedicine use at 2023 rates modestly decreases the carbon footprint of US health care delivery.

Objectives: To develop an index using publicly available data to measure progress in addressing health care disparities.

Study design: Given inherent socioeconomic differences between individuals insured by commercial/private insurance and those insured by Medicaid, we selected, based on set criteria, a portfolio of metrics comparing the national average performance between these 2 product lines from the Healthcare Effectiveness Data and Information Set (HEDIS).

Methods: Using data from the National Committee for Quality Assurance publicly reported national averages for HEDIS quality metrics from commercial/private insurance and Medicaid managed care, observed differences for these measures were aggregated to establish the index.

Results: The Health Insurance Disparities Index (HeIDI) demonstrated a gradual worsening of disparities nationally between individuals with commercial/private insurance and individuals with Medicaid insurance from 2017 to 2022, with a substantial deterioration during and after the COVID-19 pandemic years.

Conclusions: Because HeIDI assesses the status of health care disparities impacting individuals of lower socioeconomic status by insurance lines, it is useful for assessing performance for health plans, states, regions, and health systems utilizing verified HEDIS data.

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 September issue features a conversation with Dora Hughes, MD, MPH, chief medical officer and director of the Center for Clinical Standards and Quality at CMS.

Objectives: The cost and quality problems of health care in the US have been aggravated by separate silos for research and care delivery that limit the pragmatic value of research questions and delay the implementation and spread of what is learned. We describe a variation on the learning health system concept that engaged various stakeholders in a single state to work together on simultaneous knowledge generation and dissemination built on research questions that arose from the user community.

Study design: Observational study.

Methods: We identified the 12 strategies used by the leaders of this project to develop and operationalize an observational study in a large sample of primary care clinics in Minnesota that had implemented care coordination as part of attaining certification as health care homes.

Results: The collaboration included the state health department, a research institute embedded in a health system, the 5 main payers, a measurement/reporting organization, 42 care systems with 316 primary care clinics, patient partners, and national consultants. This community developed a research proposal for an observational study about how to improve care coordination in primary care. We describe how this collaborative implemented and disseminated the study findings.

Conclusions: By employing 12 strategies to answer questions that arose from the health care community, we opened a door between the 2 halves of the house of medicine.