American Journal of Managed Care最新文献

Objectives: To compare all-cause readmission or mortality between patients with heart failure (HF) with discharge ordered before noon (DOBN) and those with discharge ordered after noon (DOAN).

Study design: A retrospective multicenter study of 14,469 patients hospitalized for acute decompensated HF at 17 hospitals in 4 US states (admitted January 2010-December 2022 and followed through May 2023).

Methods: Patients were grouped by discharge timing: DOBN (00:00-12:00) and DOAN (12:01-23:59). We assessed all-cause readmission or mortality at 7 days, 30 days, and 3 years post discharge.

Results: Of all patients, 2844 (19.7%) were in the DOBN group and 11,625 (80.3%) were in the DOAN group. The DOBN group had higher mortality than the DOAN group at 7 days (2.6% vs 1.3%; HR, 1.39; 95% CI, 1.05-1.86), 30 days (8.9% vs 5.2%; HR, 1.34; 95% CI, 1.15-1.58), and 3 years (50.6% vs 41.4%; HR, 1.13, 95% CI, 1.06-1.21) post discharge. The DOBN group also had a higher readmission rate within 7 days (8.3% vs 6.4%; HR 1.99; 95% CI, 1.61-2.48) post discharge but similar readmission rates to the DOAN group at 30 days (16.0% vs 15.2%; HR, 1.07; 95% CI, 0.97-1.20) and 3 years (48.6% vs 49.7%; HR, 0.96; 95% CI, 0.90-1.02). The differences persisted after categorizing patients into 2 timeline groups (2010-2016 and 2017-2022), with DOBN patients having shorter median times to mortality and readmission than DOAN patients.

Conclusions: In hospitalized patients with HF, DOBN was independently associated with higher all-cause mortality both in the short and long term as well as increased early readmission rates. These findings have implications for discharge policies.

Physicians often rely on follow-up appointments to help patients achieve their health care goals. This is particularly true of primary care, where physicians rely on longitudinal care practices to manage chronic illnesses such as diabetes and hypertension. However, although patients are often scheduled to return for a follow-up visit in 3 to 6 months, there is little evidence supporting these recommendations. In other words, revisit interval (RVI) assignment is often left exclusively to the provider's discretion. The lack of standards means RVIs may vary from physician to physician, impacted by subjective factors such as provider sex, geographical location, clinical heuristics, and administrative practice patterns. This inconsistency has serious implications. Scheduling revisits too frequently may result in resource overuse and increased administrative burden. Conversely, waiting too long before revisits may result in discontinuity of treatment, decreased physician-patient rapport, and, subsequently, suboptimal patient outcomes. The first and foremost step in ameliorating this issue involves investigating the relationship among RVIs, patient outcomes, and cost of care. Collecting data on the most efficacious RVIs for patients with varying disease states and severities will allow the development of evidence-based guidelines for RVI assignment. The garnered information could then be used to establish an algorithm capable of recommending optimal RVI based solely on patient characteristics. By eliminating variability in RVI assignment, unnecessary health care costs associated with resource overuse could be reduced and patient health outcomes enhanced.

Objective: To examine how site of care and insurance network contribute to price differences for common adult outpatient surgeries paid by commercial insurers.

Study design: Observational study using a 50-state sample of commercial medical claims data.

Methods: We compared insurer-paid amounts, patient out-of-pocket payments, and balance billing amounts for 4 common adult outpatient surgeries (arthroscopy, cataract, colonoscopy, and upper gastrointestinal procedures) by site of care (ambulatory surgery center [ASC] vs hospital outpatient department [HOPD]) and insurance network status (in network vs out of network).

Results: Compared with a surgery occurring at an in-network ASC, insurers paid $306 (32%) more to an out-of-network ASC, $1042 (110%) more to an in-network HOPD, and $1041 (110%) more to an out-of-network HOPD. Patients paid $186 more out of pocket at an in-network HOPD than at an in-network ASC, which both had cost-sharing rates lower than out-of-network facilities.

Conclusions: Patients saved money by choosing in-network facilities regardless of the site of care, whereas insurers saved by increasing the usage of ASCs for common adult outpatient surgeries paid by commercial insurers. Insurance models that better align patient and insurer incentives could increase utilization of ASCs and lower overall spending on outpatient surgeries.

Objective: Neonatology care can be costly for commercially insured families with minimal opportunities to choose in-network providers. Out-of-network neonatologists may surprise families with balance billings. This study examined the effects of state balance billing laws on neonatology prices and provider network participation.

Study design: This study used a quasi-experimental, difference-in-differences design with 7 states that implemented balance billing regulations for out-of-network providers at in-network hospitals.

Methods: We used claims data from 2012 to 2019. We analyzed data for patients in fully insured plans who received neonatology services to compare price and surprise billing changes, before and after the policy, relative to controls. The main outcome measures were in-network, out-of-network, and combined total prices, as well as the proportion of claims billed in network to indicate provider network participation.

Results: For both independent dispute resolution (IDR) and benchmark rating approaches, the event studies did not show changes in in-network prices or combined prices, compared with control states, but they showed out-of-network price increases in states with the IDR approach. State-specific analyses indicated mixed results for both IDR and benchmark rating approaches.

Conclusions:  The federal No Surprises Act, which went into effect in 2022, has allowed state regulations to continue to govern fully insured plans. We found substantial variation in the effects of state laws on pricing for neonatology services. There was no consistent evidence that state policies influenced prices or network participation of neonatology clinicians.

Objectives: To determine Medicare expenditures and potential beneficiary out-of-pocket liability for Medicare beneficiaries with amyotrophic lateral sclerosis (ALS), including costs related to drug treatments.

Study design: This cohort study utilized the 100% Medicare fee-for-service claims for 2017-2021, including Part A and Part B medical claims and Part D prescription drug event data.

Methods: Eligible Medicare beneficiaries with ALS were identified based on 1 or more inpatient or 2 or more outpatient claims with an International Statistical Classification of Diseases, Tenth Revision diagnosis code for ALS (G12.21) between 2017 and 2020. Health care expenditures and beneficiary liability were assessed for the 12-month study period.

Results: At 1 year post index, Medicare beneficiaries with ALS had more than 3 times the Medicare expenditures of beneficiaries without ALS ($47,450 vs $13,889, respectively). Similar patterns were observed for beneficiary liability. Approximately one-third of Medicare beneficiaries used either edaravone or riluzole in the first 12 months following ALS diagnosis. The cost of care for beneficiaries using these drugs was notably higher than for beneficiaries with ALS overall.

Conclusions: Approximately one-third of people with ALS on Medicare receive disease-modifying medication. ALS is a burdensome disease with significant financial implications for people with ALS and the Medicare program. Treatment for ALS presents affordability challenges, and policy makers must consider how current Medicare policy addresses the costs of care.

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: 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.