American Journal of Managed Care最新文献

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.

Idiopathic pulmonary fibrosis (IPF) is characterized by a progressive decline in lung function, worsening quality of life, and high mortality. However, the rate and pattern of progression of IPF are variable. Real-world studies, which include a broader population of patients than clinical trials and collect data over longer periods, have provided important information on the clinical course of IPF and further insights into the efficacy and safety of antifibrotic therapies. They also highlight the worsening of patients' quality of life as lung function is lost, the high frequency of hospitalizations, and the impact of acute exacerbations on mortality in patients with IPF. Data from patient registries and analyses of claims data suggest that antifibrotic therapy is more likely to be used in patients who have worse lung function and that its use is associated with an improvement in life expectancy. The safety profile of antifibrotic therapies in real-world populations is consistent with that observed in clinical trials. Further real-world studies are needed to improve understanding of the course and impact of IPF in specific groups of patients and how the care provided to these patients might be improved.

Objective: Prior authorization is used to ensure providers treat patients with medically accepted treatments. Our objective was to evaluate prior authorization decisions in cancer care by race/ethnicity for commercially insured patients.

Study design: Retrospective study of 18,041 patients diagnosed with cancer between January 1, 2017, and April 1, 2020.

Methods: Using commercial longitudinal data from a large national insurer, we described the racial and ethnic composition in terms of prior authorization process outcomes for individuals diagnosed with cancer. We then used linear regression models to evaluate whether disparities by race or ethnicity emerged in prior authorization process outcomes.

Results: The self-identified composition of the sample was 85% White, 3% Asian, 10% Black, and 1% Hispanic; 64% were female, and the mean age was 53 years. The average prior authorization denial rate was 10%, and the denial rate specifically due to no medical necessity was 5%. Hispanic patients had the highest prior authorization denial rate (12%), and Black patients had the lowest prior authorization denial rate (8%). Regressions results did not identify racial or ethnic disparities in prior authorization outcomes for Black and Hispanic patients compared with White patients. We observed that Asian patients had lower rates of prior authorization denials compared with White patients.

Conclusions: We observed no differences in the prior authorization process for Black and Hispanic patients with cancer and higher rates of prior authorization approvals for Asian patients compared with White patients.

Objectives: We previously described a 6-item teamwork index (TEAM) with a strong relationship to provider experience, lower burnout, and intent to stay. We now sought to determine whether (1) TEAM relates to higher patient Net Promoter Score (NPS, or likelihood of patient referring to the organization) and (2) teamwork mediates a provider experience-NPS relationship.

Study design: A provider wellness survey was administered in the fall of 2019 in 6 care delivery organizations (CDOs) with patient NPS data.

Methods: Measures included a validated burnout item, 6-item TEAM measure, provider experience metric, standard intent-to-stay question, and NPS data from 79,254 patients matched to CDO. Regression analyses modeled relationships among TEAM, provider experience, and NPS. Open-ended comments were reviewed to confirm patient NPS findings.

Results: There were 1386 provider respondents (53% physicians, 47% advanced practice clinicians, 58% female, 62% White, 58% in primary care; response rate, 55.7%). Median NPS was 83%. TEAM was associated with patient NPS greater than the median (53% with high TEAM and high NPS vs 44% with low TEAM and high NPS; P < .001), as was provider experience (52% vs 45%; P < .05). In regression analyses, patient NPS was strongly related to TEAM (adjusted OR, 1.41; 95% CI, 1.25-1.60; P < .001). The provider experience-patient NPS relationship was partly mediated by TEAM. Open-ended comments confirmed positive or negative sentiments related to NPS.

Conclusions: Teamwork and provider experience relate to patient NPS, and the provider experience-NPS relationship appears to be mediated by teamwork.

Economic incentives and patent protections drive development of innovative medications. Drug prices are determined by consumer demand, not production costs. Therefore, governmental regulation risks future investment in research and development.

Objectives: The annual mean spending measures typically used to study longitudinal trends mask distributional and seasonal variation that is relevant to patients' perceptions of health care affordability and, in turn, provider collections. This study describes shifts in the distribution and seasonality of plan and patient out-of-pocket spending from 2012 through 2021.

Study design: Analysis of multipayer commercial claims data.

Methods: Medical spending per enrollee was calculated by summing inpatient, outpatient, and professional services, which comprised plan payments and out-of-pocket payments (deductible, coinsurance, co-payment). To account for the long right tail of the spending distribution, enrollees were stratified by their decile of annual medical spending, and annual mean spending estimates were calculated overall and by decile. Mean spending estimates were also calculated by quarter-year.

Results: Inflation-adjusted medical spending grew most quickly among the highest decile of spenders, without proportional growth in their out-of-pocket expenses. Out-of-pocket spending increased for the majority of enrollees in our sample prior to the COVID-19 pandemic, in real dollars and as a share of total medical spending. Out-of-pocket spending was increasingly concentrated in the early months of the calendar year, driven by deductible spending, and was lower in 2020 and 2021, plausibly due to policies limiting cost sharing for COVID-19-related services.

Conclusions: Insurance is working well to protect the highest spenders at the cost of reduced insurance generosity among spenders elsewhere in the distribution. The increasing cross-subsidization among enrollees through cost-sharing design-vs premiums-is a trend to watch among rising public concerns about underinsurance and medical debt.