American Journal of Managed Care最新文献

Objective:  To evaluate the relationship between the frequency of routine primary care visits and total health care expenditures among commercially insured adults.

Study design:  Retrospective cross-sectional statistical analysis of a nationally representative data set of health care utilization and expenditures over a 2-year period.

Methods: We used multivariate regression analysis to evaluate the association between the annualized number of visits with a primary care physician for routine care and total health care expenditures for commercially insured adults younger than 65 years, adjusting for underlying clinical complexity measured through risk scoring. Data were drawn from information collected by the Agency for Healthcare Research and Quality between 2021 and 2022.

Results: For a sample cohort of 3879 participants, more frequent primary care visits were associated with incremental reductions in expenditures only for participants with high underlying clinical complexity. A relative risk level of approximately 2 times the average commercially insured adult was identified as an inflection point, above which cost reductions vs counterfactual prediction were observed, up to a limited number of visits.

Conclusions:  Our results show a relationship between primary care visit frequency and health care expenditures with similar directionality and risk dependency as has been observed in other studies for Medicare-insured adults. This finding suggests that certain commercial populations may benefit from risk-stratified, high-touch primary care models like those being employed for some Medicare populations. The health care cost reduction benefits of these models appear premised more on clinical need than coverage type. Demonstrating this relationship is useful for health care providers, insurers, and policy makers who are developing advanced primary care models.

Many states are enacting restrictions on insurers' prior authorization policies, but these laws may increase costs and lead to other undesirable consequences.

Objectives: To describe Tennessee's process for convening key stakeholders to develop uniform payment guidelines that encourage increased preventive service delivery and provide lessons learned that can inform similar work in other states.

Study design: Descriptive case study.

Methods: Observational.

Results: Tennessee's statewide multistakeholder health care extension cooperative, the Tennessee Heart Health Network, was instrumental in convening major stakeholders, including Medicaid, health plan, and safety-net provider representatives. Stakeholders reached consensus and developed and implemented common guidelines for reimbursement of health coaching services focused on cardiovascular health in the context of team-based primary care.

Conclusions: Tennessee's experience suggests that statewide multistakeholder health care extension cooperatives can facilitate Medicaid and Medicare payment policy alignment and delivery system improvement. they have potential to yield important benefits in state-based efforts to improve access and quality of care.

Effective chronic disease management must extend beyond clinical visits into the daily lives of patients, particularly in low-income communities with a disproportionate burden of illness. This study examines City Health Works' intervention model, which deploys highly trained nonclinical health coaches as tightly integrated extensions of primary care teams to support patient self-management. In a 12-month evaluation of Medicaid patients with poorly controlled diabetes and hypertension at a NYC Health + Hospitals outpatient site, the intervention achieved significant reductions in health care costs compared with a matched comparison group. These findings suggest that a technology-enabled, community-based workforce model can cost-effectively improve chronic disease management when closely linked to primary care delivery.

Objectives: This study compared all-cause health care resource use (HCRU) and costs between patients with acute oropharyngeal infections and respiratory tract infections (RTIs) receiving targeted syndromic real-time polymerase chain reaction (RT-PCR) tests with next-day results vs matched patients receiving other/no diagnostic tests.

Study design: Propensity-matched, retrospective study.

Methods: Two cohorts with International Classification of Diseases, Tenth Revision, Clinical Modification codes for diagnosis or symptom(s) of oropharyngeal infection or RTI (first diagnosis = index) on an outpatient claim were identified in the IQVIA PharMetrics Plus database (July 2020-October 2023). HCRU and costs were examined over 6 months post index across 5 subcohorts: patients receiving syndromic RT-PCR and 4 matched subcohorts (other PCR, point-of-care [POC] only, culture, or no test).

Results: The mean (SD) costs for postindex total outpatient services ($2598 [$7564] vs $2970 [$8417]; P < .0001), physician office visit ($624 [$1150] vs $689 [$1082]; P = .0002), emergency department (ED) ($290 [$1145] vs $397 [$1630]; P = .0192), and other medical services ($1684 [$6799] vs $1883 [$7568]; P < .0001) were significantly lower for the oropharyngeal RT-PCR subcohort than the matched culture subcohort. The mean (SD) postindex costs for any outpatient medical services ($2796 [$11,453] vs $3221 [$7873]; P < .0001), physician office visits ($525 [$974] vs $703 [$2635]; P = .0057), ED visits ($253 [$1036] vs $355 [$1300]; P = .0011), and other medical services ($2018 [$10,986] vs $2163 [$6458]; P < .0001) were significantly lower for the RTI RT-PCR subcohort than the matched culture subcohort. Patients in both RT-PCR subcohorts had lower utilization of other medical services and any outpatient services compared with all matched comparator subcohorts.

Conclusions: This propensity-matched study provides evidence on the economic impact of syndromic RT-PCR tests for respiratory infections, highlighting their advantages over traditional diagnostic methods.

This commentary calls for health care systems to deliver equitable care for people living with obesity by addressing weight bias and updating standards in obesity care.

The authors discuss the need to repair a house divided among research, health care, and the multisector health community.

Objectives: Substantial disparities in access to health care, including to physician specialists, hinder diagnosis, treatment, and outcomes for patients with immunological diseases; thus, more studies are needed to understand and address these disparities. This study aimed to evaluate factors associated with disparities in rheumatology, dermatology, and gastroenterology specialist access for patients with immunological conditions and the consequences of such disparities.

Study design: Systematic literature review.

Methods: Studies published between 2017 and 2023 examining US adults (≥ 18 years) with key immunological conditions receiving care by rheumatologists, dermatologists, and gastroenterologists were systematically reviewed. Thematic analyses of qualitatively synthesized data were used to evaluate disparities in specialist access (defined under "5 A's": affordability, availability, accessibility, accommodation, and acceptability) and the associated clinical/economic outcomes.

Results: Specialist access disparities and related outcomes were inconsistently evaluated across the 46 included studies, with limited evidence in gastroenterology. Common factors associated with specialist access disparities in rheumatology and dermatology included rural residence, insurance type (primarily Medicaid), Black or Hispanic race and ethnicity, and low regional specialist density. Frequent outcomes of this low access included higher disease severity, higher hospital admission and readmission rates, and higher numbers of emergency department visits. Importantly, studies described ways to improve specialist access across the 5 A's (eg, minimize structural barriers, use a multidisciplinary approach, promote telemedicine, increase health literacy, improve community partnerships).

Conclusions: Specialist access disparities were identified in rheumatology and dermatology. Conclusions in gastroenterology could not be inferred due to limited evidence. Evidence-based solutions are provided to address identified gaps in US health care.

Objectives: The Affordable Care Act (ACA), enacted in 2010, aimed to improve health insurance coverage and access to care, notably through a provision extending dependent coverage up to age 26 years. This study investigates the ACA's impact on substance use disorder (SUD)-associated emergency department (ED) visits among young adults aged 23 to 29 years.

Study design: A quasi-experimental study analyzed opioid- and alcohol-associated ED visits and inpatient admissions among young adults (aged 23-25 [treatment] vs 27-29 [comparison] years) using 2007-2019 Nationwide Emergency Department Sample data.

Methods: A difference-in-differences approach assessed the ACA's impact, adjusting for covariates including sex, comorbidities, payer source, income, residence, and hospital region. Generalized linear models estimated adjusted ORs with 95% CIs, ensuring robust analysis of the ACA's effects on substance-related health care utilization.

Results: Opioid-associated ED visits had no change between the treatment and comparison groups, whereas alcohol- associated ED visits declined more for the treatment group after the ACA (OR, 0.841; 95% CI, 0.828-0.855). No changes in inpatient admissions among opioid- or alcohol-associated visits, respectively, were seen between the 2 groups.

Conclusions: Our findings indicate that the ACA's implementation led to mixed effects on substance-associated health care utilization among young adults, with reduced alcohol-associated visits in the treatment group but unchanged discrepancies in opioid-associated ED visits and inpatient admissions between the 2 groups. Further research is warranted to explore state-level variations and population-level substance use trends along with continuous monitoring to inform interventions addressing substance-associated public health challenges.

Objectives: Access to mental health services has been shown to be particularly inadequate, with limited understanding of the efficacy of existing network adequacy regulations. State and federal regulations mandate insurance carriers to submit regulatory filings to help maintain network adequacy compliance, but the accuracy of these data remains unassessed.

Study design: We employed a secret shopper survey to verify regulatory filings and assess the congruence between the filings and provider directory listings as well as appointment availability and wait time for 8306 mental health counselors submitted by all carriers participating in Pennsylvania's Affordable Care Act (ACA) Marketplace for plan year 2024.

Methods: Descriptive analyses, with tests of proportion and t tests to assess differences between carriers and between adult and pediatric provider specialties.

Results: A total of 19.9% of filed regulatory listings (n = 1649) were not present in consumer-facing provider directories, and only 35.3% of filed listings (n = 2928) fully matched provider directory entries. Of the 2152 provider listings we were able to verify fully via secret shopper calls, 65.2% (n = 1404) exhibited at least 1 inaccuracy. Inaccurate phone number was the most common issue (56.6%; n = 1219). Appointments were available for only 321 of the 2152 providers (14.9%), with a mean of 33.2 days lapsed between call and scheduled appointment time. Although we identified substantial differences in appointment wait times by carrier, we found no difference between adult and pediatric providers.

Conclusions: ACA network adequacy assessments that rely on carrier regulatory filings and/or consumer-facing directories substantially overestimated provider availability and access to mental health services.