American Journal of Managed Care最新文献

Objectives: To compare rates and analyze health facility determinants of emergency department visits and hospitalizations for ambulatory care-sensitive conditions (ACSCs) among Medicaid patients by geographical location.

Study design: Retrospective cross-sectional analysis of 48.3 million patients receiving Medicaid and their acute care visits across 34 states and the District of Columbia in 2019.

Methods: Descriptive analyses of county-level variations in emergency department visits and hospitalizations (acute care) for ACSCs, and multivariate regressions of proximity to and density of health facility infrastructure as correlates to utilization and spending. Regression models were adjusted for county-level poverty rates, chronic disease rates, and state fixed effects.

Results: Among the studied patient population receiving Medicaid, nearly 40% of acute care visits were for ACSCs, with variations across and within states. Rates ranged from 17.8 per 1000 member-months in Vermont to 39.0 in Mississippi, and from 5.9 to 77.9 between counties within states. Longer distances to the nearest urgent care center and primary care shortage area designation correlated to higher acute care visits for ACSCs (+4.3 per 1000 member-months for every 100 miles; 95% CI, 2.9-5.7; P < .001; +1.5 per 1000 member-months if shortage area; 95% CI, 0.4-2.6; P = .006). Counties with more rural health clinics had fewer acute care visits for ACSCs (-3.4 fewer visits per rural clinic per 1000 population; 95% CI, -4.6 to -2.2; P < .001). Among 6 states with additional spending data, 4.2% of total Medicaid spending was attributable to acute care visits for ACSCs.

Conclusions: Our evaluation revealed more than 13-fold variation in acute care utilization for ACSCs between Medicaid counties within the same state. Proximity to urgent care facilities and density of rural health clinics were major explanatory variables for these variations, underscoring the importance of local health infrastructure in reducing acute care utilization for ACSCs.

Objectives: Provider directory inaccuracies have important implications for care navigation and access as well as ongoing regulatory efforts. We assessed the extent to which identified provider directory inaccuracies persisted across 7 specialties (cardiology, dermatology, endocrinology, gastroenterology, neurology, obstetrics-gynecology, primary care) and 5 carriers in the Pennsylvania Affordable Care Act insurance marketplace.

Study design: A secret shopper survey recontacted inaccurately listed providers (N = 1802) between 403 and 574 days after they were identified in an earlier secret shopper survey.

Methods: Descriptive analyses, with tests of proportion and t tests to assess whether differences across carriers, specialties, and geographic locations were statistically significant.

Results: Of 1802 inaccurate provider listings, 451 (25.0%) had been removed at follow-up, 966 providers (53.6%) were successfully contacted, and 385 providers (21.4%) could not be reached. Of the recontacted providers, 240 (13.3%) were listed accurately at follow-up and 726 (40.3%) were listed with various inaccuracies, including 31.0% (n = 558) with inaccurate contact information, 11.2% (n = 201) listed under the wrong specialty, and 1.9% (n = 34) erroneously listed as being in network despite being out of network. We found substantial differences across carriers and specialties but not by rurality. Inaccuracies also were less likely to persist in the state's 2 metropolitan areas. Among inaccurate provider listings, on average, 540 days (median, 544 days) had passed between the initial and subsequent contacts.

Conclusions: A large number of provider directory inaccuracies persist well beyond the 90-day expectation mandated by federal regulations, raising substantial concerns about compliance. These inaccuracies may impose substantial barriers to patient access and may render existing assessments of network adequacy ineffective.

Objective: To describe the results of a program developed to manage institutional postacute care (IPAC) (postacute skilled nursing, inpatient rehabilitation facility, and long-term acute care) in a CMS Bundled Payments for Care Improvement (BPCI) project for coronary artery bypass graft (CABG) surgery.

Study design: We compared pre- and postutilization patterns during a 3-year period by evaluating risk-adjusted national, state, and other BPCI participant comparisons using a difference-in-differences (DID) analysis in a large urban community tertiary center with a CABG surgery program. Included in the analysis were all Medicare patients receiving CABG surgery at the institution (n = 504), across the nation (n = 213,423), and at other BPCI institutions (n = 4939).

Methods: The intervention included (1) use of a standardized tool for evaluation and prognostication of patient placement, (2) programmatic changes to manage patient functional recovery, and (3) patient and family engagement in postacute placement and functional recovery plan.

Results: Physical therapist/occupational therapist time with patients who had undergone CABG surgery increased by more than 179% between the pre- and postintervention periods. This was associated with a 41.2% and 51.6% decline in IPAC use at the institution on an observed basis and adjusted basis, respectively. DID comparison demonstrated a 14.40% (95% CI, -19.30% to -9.60%) greater reduction at the target hospital than at other participating BPCI hospitals.

Conclusions: A strong association exists between a focused patient functional recovery program and IPAC use reduction after CABG surgery. Using a structured approach to clinical analytics and hypothesis testing of redesign efforts when managing postacute care populations removes waste from care delivery.

Objectives: This study aims to investigate the relocation of older adults in the US from community living to long-term care facilities (LTCFs). Specifically, it examines the predictive roles of possible and probable dementia and hospital stays in this complex health care transition.

Study design: Utilizing data from the National Health and Aging Trends Study, a longitudinal cohort study (2011-2019), we employed a panel data approach, which consists of multiple observations over time for the same participants, allowing us to account for both cross-sectional variations (differences between participants) and time-series variations (changes in the same participant over time).

Methods: The analysis involved longitudinal logistic regression models. Using the AD8 dementia screening interview, clock drawing test, immediate and delayed word recall test, orientation, and history of dementia diagnosis, we placed participants into categories of having no dementia, possible dementia, and probable dementia. A survey asked about hospital stays in the past year. Relocation to LTCFs was examined based on the changes to the living location.

Results: The proportion of individuals transitioning to LTCFs tripled between 2011 and 2019, emphasizing the need to understand and manage this health care transition. Hospital stays significantly increased the probability of moving to LTCFs, especially nursing homes. Probable dementia demonstrated a 3-fold increase, aligning with the rising prevalence of Alzheimer disease. Difficulty walking and climbing stairs significantly increased relocation probabilities.

Conclusions: The study findings emphasize complexity in late-life relocations influenced by dementia and hospital stays. Screening for cognitive function among community-dwelling older adults, particularly those with a history of hospital stays and mobility difficulties, can inform interventions and policies. Implications extend to health care policy, geriatric care, and the imperative for targeted interventions considering demographic variations. Future research should explore additional variables and address limitations to refine our understanding of the relocation process.

Objectives: To examine associations between accountable care organization (ACO) membership and human papillomavirus (HPV) vaccination and to evaluate variation in HPV vaccination across ACO providers.

Study design: Retrospective cohort study.

Methods: We analyzed the records of commercially insured children and adolescents aged 11 to 14 years using Connecticut's All-Payer Claims Database from January 2012 to December 2017.

Results: A total of 23,911 adolescents receiving care from 933 ACO-attributable providers and 923 non-ACO-attributable providers were included. The mean rate of HPV vaccine initiation was 53% overall (51% among boys, 55% among girls). Among those who initiated the vaccine, the mean rate of HPV vaccine completion was 69% (67% among boys, 70% among girls). Adolescents receiving care at ACOs vs non-ACOs were significantly more likely to receive initial HPV vaccination (OR, 1.80; 95% CI, 1.69-1.91) and to complete the HPV vaccine series (OR, 1.12; 95% CI, 1.01-1.23). Among adolescents receiving care in ACOs, providers were responsible for 14% of variability in HPV vaccine initiation and 10% of variability in HPV vaccine completion and ACOs were responsible for less than 1% of variability in HPV vaccine initiation and completion.

Conclusions: Adolescents receiving care from ACOs were significantly more likely to initiate and complete HPV vaccination than were adolescents receiving care in non-ACO settings. Variation in HPV vaccine uptake attributable to providers within ACOs dwarfed variation attributable to ACOs, indicating that vaccine uptake was more dependent on the provider irrespective of the ACO with which they were affiliated. Efforts to improve HPV vaccination rates may require provider-focused interventions regardless of the overall performance of their health care system or provider organization.

Interstitial lung disease (ILD) causes significant morbidity and mortality in patients with systemic autoimmune rheumatic diseases. Patients at high risk of ILD should be screened using high-resolution CT (HRCT), but there is no consensus as to which risk factors-or combination of risk factors-should prompt referral for HRCT. The course of autoimmune disease-associated ILD is highly variable, and it may not mirror the activity of the underlying autoimmune disease. Patients require close monitoring with periodic pulmonary function testing and symptom assessment and with repeat HRCT considered based on clinical assessment. The relevance of clinical and radiologic signs of progression-and their implications for management-ideally should be discussed by a multidisciplinary team. Management of autoimmune disease-associated ILD may involve immunosuppressant and/or antifibrotic therapy in addition to supportive care. It is important that treatment decisions be individualized to the needs and wishes of the patient. Regular follow-up is important to monitor disease progression and manage the adverse effects related to treatment.

Objectives: To assess the congruence between patient assignment and established patients as well as their association with Healthcare Effectiveness Data and Information Set (HEDIS) quality performance.

Study design: A retrospective cross-sectional analysis from January 2020 to February 2022.

Methods: The study setting is a fully integrated health care delivery system in Phoenix, Arizona. The study population includes Medicaid patients who received primary care services or were assigned to a primary care physician (PCP) at the study setting by 5 Medicaid managed care organizations (MCOs). We identified 4 possible relationships between the established patients (2 primary care visits) and the assigned patients (assigned by the MCO to the study setting): true-positive, false-positive, true-negative, and false-negative classifications. Precision and recall measures were used to assess congruence (or incongruence). Outcome measures were HEDIS quality metrics.

Results: A total of 100,030 Medicaid enrollees (adults and children) were established and/or assigned to the study setting from 5 separate payers. Only 15% were congruently established and assigned to the physician (true-positive). The overall precision was 21%, and the overall recall was 37%. The HEDIS quality performance was significantly higher (P < .05) for established patients for 5 of 6 metrics compared with patients who were not established.

Conclusions: The vast majority of assigned patients were not treated by the assigned PCP, yet better patient outcomes were seen with an established patient. As the health system rapidly adopts value-based payments, more rigorous methodologies are essential to identify physician-patient relationships.

Objective: To determine the health care cost savings from the Wellth app, a mobile health intervention that uses financial incentives to increase medication adherence.

Study design: An observational study of members in one of Arizona's Medicaid managed care plans, part of Arizona Health Care Cost Containment System (AHCCCS), using the Wellth app from March 28, 2020, to January 12, 2021. One-to-one matching was used to identify comparable nonparticipants, and a difference-in-differences approach was used to estimate the impact of the Wellth intervention on outcomes defined over the 9 months before and after using Wellth.

Methods: An AHCCCS managed care health plan provided claims data that contained drug prescription, health care utilization, and health care cost information for all participants, and Wellth provided app usage data and contextual information about the Wellth intervention.

Results: On average, the Wellth intervention increased medication adherence by 5.0 percentage points (95% CI, 2.9-7.1; P = .008) and reduced emergency department (-0.02; 95% CI, -0.03 to -0.01; P = .002), inpatient (-0.04; 95% CI, -0.06 to -0.02; P = .001), and mental health clinic (-0.06; 95% CI, -0.10 to -0.01; P = .013) visits relative to nonparticipants over 9 months. Short-term reductions in utilization had an estimated mean cost savings over 9 months of $88.15 (95% CI, $31.07-$136.40), with greater reductions for those with chronic obstructive pulmonary disease, schizophrenia, or major depression.

Conclusions:  Given the relatively low cost of the Wellth intervention, our findings provide preliminary evidence of cost savings from implementing Wellth among adults with several common chronic conditions.

The term "progressive pulmonary fibrosis" or "PPF" is generally used to describe progressive lung fibrosis in an individual with an interstitial lung disease (ILD) other than idiopathic pulmonary fibrosis (IPF). Several sets of criteria have been proposed for the identification of PPF, most of which are based on a combination of a decline in forced vital capacity, worsening of respiratory symptoms, and increase in the extent of fibrosis on radiology. Although some risk factors for faster progression of fibrosing ILD have been identified, it remains challenging to predict which individuals will develop PPF. Close monitoring, including regular pulmonary function tests, is required to detect the earliest signs of worsening disease. PPF is associated with high rates of hospitalization and death. Management of PPF requires a multidisciplinary and multimodal approach, including pharmacological therapy and supportive care. Discussions about palliative care should begin at an early stage, individualized to the needs of the patient.

Objective: To compare racial and ethnic disparities in cost-related medical care and dental care barriers and use of vision care among near-poor Medicare beneficiaries in Medicare Advantage (MA) vs traditional Medicare (TM) overall and stratified by supplemental insurance enrollment.

Study design: Cross-sectional analysis of 2015-2019 data from the nationally representative Medicare Current Beneficiary Survey.

Methods: Propensity score-weighted difference-in-disparities analyses comparing Black-White and Hispanic-White disparities in MA vs TM among near-poor Medicare beneficiaries with incomes between 101% and 250% of the federal poverty level. We assessed differences in cost-related medical care barriers and cost-related dental care barriers as well as receipt of annual eye exams in MA vs TM.

Results: For cost-related barriers to medical care, Hispanic-White disparities were narrower by 8.8 (95% CI, -14.0 to -3.6) percentage points in MA relative to TM but differences in Black-White disparities were not statistically significant. MA was not associated with narrower differences in Hispanic-White or Black-White disparities in dental care access. Higher proportions of Black and Hispanic beneficiaries in MA received an annual eye exam vs White beneficiaries in both MA and TM. MA was associated with narrower racial disparities primarily compared with TM without supplemental insurance.

Conclusions: Among near-poor Black and Hispanic Medicare beneficiaries, MA was associated with greater use of vision care and narrowing of some disparities in cost-related access barriers vs TM. However, MA did not uniformly narrow racial/ethnic disparities in access and use. These findings highlight the importance of maintaining and enhancing features of Medicare coverage that may promote equitable access to care, including additional benefits and lower cost sharing.