American Journal of Managed Care最新文献

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.

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.

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.

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.