American Journal of Managed Care最新文献

Objective: To compare the likelihood of timely outpatient follow-up care and repeat emergency department (ED) visits and hospitalization among patients with high need and high costs (HNHC) across 4 primary care provider (PCP) types.

Study design: Our cross-sectional study analyzed 2018 eligibility and claims data of patients with HNHC enrolled in California Medicaid managed care (N = 164,543).

Methods: Outcomes were outpatient follow-up visits for primary care, specialty care, mental health, or substance use disorder (SUD) within 7 days and ED readmission and all-cause hospitalization within 30 days of the first ED visit (index ED). Our independent variable was PCP type, categorized as Health Resources and Services Administration-funded health centers, group practices, solo practices, and other community clinics. Multivariable logistic regression models examined follow-up care utilization by PCP type.

Results: One-third of index ED visits were followed by a primary care (30.3%) or specialty care (31.8%) visit within 7 days. Within 30 days of the ED index visit, approximately 22% had a repeat ED visit and 6% had a hospitalization. Health center patients were more likely to have a primary care, mental health, or SUD follow-up visit than patients of other PCPs and were less likely to have a follow-up specialty visit, ED readmission, or hospitalization.

Conclusions: Findings indicate that health centers have been successful in linking patients to outpatient services that may reduce costly hospitalizations and repeat ED visits but could improve on linkage to specialty care. Improved process-of-care approaches may reduce repeat ED visits and hospitalizations across all PCP types.

Objective: To examine whether racial concordance between telephonic care managers and Medicare Advantage beneficiaries engaged in a care management program influenced the likelihood of fulfilling a set of identified health care needs.

Study design: Retrospective study of a real-world telephonic care management program among Medicare Advantage beneficiaries.

Methods: This study involved Medicare Advantage beneficiaries identified as having at least 1 of 23 gaps in care quality at baseline who were randomly assigned to a telephonic care management program between June 2020 and March 2021. We examined participating Black beneficiaries and assigned racial concordance based on engaging with a Black (race-concordant) or White (race-discordant) care manager. The primary outcome was a measure of whether the gap in care was closed at 90 days. We used logistic regression models adjusted for beneficiary characteristics to examine the impact of racial concordance on binary measures of gap closure at the individual and gap levels.

Results: Among the study population of 12,636 Black race beneficiaries, 1291 (10.2%) had a race-concordant care manager and 11,345 (89.8%) had a race-discordant care manager. In adjusted models, beneficiary-care manager racial concordance did not impact closure of gaps in care when examined at the beneficiary level (OR, 0.98; 95% CI, 0.90-1.08) or the gap level (OR, 0.99; 95% CI, 0.88-1.12).

Conclusions: In a real-world telephonic care management program aiming to resolve gaps in care quality, beneficiary-care manager racial concordance did not impact the rate of resolving gaps in care for Black beneficiaries.

Objective: Migraine is a debilitating chronic disorder requiring multifaceted treatment approaches, including acute, preventive, and nonpharmacological interventions. Small-molecule calcitonin gene-related peptide (CGRP) receptor antagonists, also referred to as gepants , provide third-line treatment options for patients refractory to first- and second-line therapies. This study evaluates the cost-effectiveness of 3 CGRP antagonists-ubrogepant (Ubrelvy), rimegepant (Nurtec ODT), and zavegepant (Zavzpret)-compared with usual care.

Study design: Cost-effectiveness analysis of gepants vs usual care.

Methods: We used a Markov model to assess the cost-effectiveness from the US payer's perspective, incorporating 5 health states: mild, moderate, and severe pain while on treatment; no pain while on treatment; and off treatment. The analysis was conducted over a 5-year time horizon with a 48-hour cycle length, discounting costs and quality-adjusted life-years (QALYs) annually at 3%. Scenario analyses were used to determine the robustness of the results.

Results: None of the gepants were cost-effective at willingness-to-pay thresholds of $50,000, $100,000, or $150,000 per QALY. Among the 3 gepants, rimegepant was the most cost-effective option; it had an incremental cost-effectiveness ratio of $93,700.20 per QALY compared with ubrogepant and was both less costly and more effective than zavegepant.

Conclusions: Ubrogepant, rimegepant, and zavegepant are not cost-effective options for acute migraine treatment but may be appropriate for patients experiencing 2 or fewer migraines per month. If a gepant is to be prescribed, rimegepant is the most cost-effective option of the 3.

Objectives: Community-based palliative care provides support for community-dwelling individuals with elevated mortality risk, including those with dementia, who are underserved by palliative care. However, clinicians' eligibility assessment processes are not well understood. This study evaluates the relationship between the factors that clinicians indicate are important and the eligibility determinations for a community-based palliative care program.

Study design: Retrospective cohort analysis of July 2022 to December 2023 Medicare administrative claims data for a Medicare Advantage plan offering community-based palliative care. Participants included all members of the Medicare Advantage insurance plan who were identified as being at elevated risk for mortality and evaluated for palliative care need.

Methods: Multivariate logistic regression examined the relationship between eligibility determinations for a community-based palliative care program (outcome) and 4 factors that palliative care team members identify as important for determining palliative care need: diagnoses, symptom management, functional ability, and health care utilization.

Results: Of 343 palliative care evaluations (for 322 unique patients), 38% were of patients who identified as African American/Black, 38% as White, 9% as Asian/Pacific Islander, and 15% as other races; 41% were of patients who identified as Hispanic/Latino (measured separately from race); 80% were of female patients; and the mean patient age was 88 years. Of these, 169 (49%) evaluations were for patients who were eligible for palliative care. In multivariate logistic regression analysis of the factors team members deemed important when determining eligibility, only dementia was significantly associated-and negatively-with the final eligibility decision (adjusted OR, 0.45; 95% CI, 0.26-0.75; P  = .003).

Conclusions: There is a potential mismatch between what clinicians identify as important in determining palliative care need and final eligibility determinations. Patients with dementia were less likely to be referred for palliative care despite elevated risk of mortality, indicating a potential missed opportunity.

This commentary notes the superiority of targeting rising-risk patients rather than high-cost claimants for Medicaid cost containment based on analysis of 13.1 million beneficiaries across 15 states. In 2019, spending for rising-risk patients (13.6% of sample) increased by 98.5% whereas spending for high-cost claimants (0.64%) decreased by 41.6%. Significantly, 54% of high-cost claimants in the first half of 2019 fell below the cost threshold in the second half of the year, and 50% of new high-cost claimants were previously identified as rising risk. Our findings reveal the limitations of focusing solely on high-cost claimants, whose costs naturally decrease due to regression to the mean. We argue that Medicaid programs should shift from reactive, cost-management interventions to proactive, prevention-oriented outreach, particularly as new predictive algorithms become more sensitive and specific. Early identification of and intervention for rising-risk patients is a more effective way to prevent the progression of chronic conditions and manage associated costs than attempting to reduce extreme utilization, which tends to decrease naturally over time.

Objectives: To assess the interrelation between Medicare Star Ratings medication adherence measures and other intermediate and process measures.

Study design: A cross-sectional analysis was performed of the annual Medicare Star Ratings health plan performance data from Star Ratings years 2015-2025. The analysis evaluated the potential relationship between (1) renin-angiotensin system antagonist (RASA) adherence and controlling blood pressure, (2) noninsulin antidiabetic adherence and controlling blood glucose, (3) statin adherence and statin therapy for patients with cardiovascular disease (CVD), and (4) statin adherence and statin use in persons with diabetes (SUPD).

Methods: The outcomes of interest were ORs and 95% CIs evaluating the likelihood of a health plan achieving 5 stars or at least 4 stars on the intermediate or process measures if they achieved 5 stars or at least 4 stars on the medication adherence measures compared with not achieving 5 stars or at least 4 stars on the medication adherence measures.

Results: Plans that achieved 5 stars on the antidiabetic adherence measure and RASA adherence measure had significantly higher odds of achieving 5 stars on their respective intermediate measures (blood glucose control: OR, 3.50; 95% CI, 2.98-4.12; blood pressure control: OR, 4.61; 95% CI, 3.82-5.60). Plans that achieved 5 stars on the statin adherence measure had significantly higher odds of achieving 5 stars on statin therapy for patients with CVD and SUPD (CVD: OR, 4.68; 95% CI, 3.49-6.27; SUPD: OR, 4.37; 95% CI, 3.26-5.85).

Conclusions: Medicare Star Ratings medication adherence measures are significantly tied to intermediate and statin process measures. Targeted interventions to improve adherence should be a key strategy for health plans to enhance both clinical outcomes and financial incentives.

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.

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: 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.