American Journal of Managed Care最新文献

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.

Objectives: To understand the perceptions of patients and primary care physicians as well as barriers to and facilitators of engaging with a safety-net program for patients with hypercholesterolemia.

Study design: A cross-sectional telephone survey of patients and qualitative interviews with PCPs.

Methods: Patients' reasons for adherence or nonadherence to statins and completion of laboratory tests and their perceptions of the safety-net program were ascertained. PCPs were asked to describe their familiarity with the safety-net program and perceived patient barriers to filling a new statin prescription and completing laboratory tests.

Results: Among 59 participating patients, 86% did and 14% did not fill their statin. Patients reported statin adherence because their doctor prescribed it (100%), to lower cholesterol (94%), and to prevent a heart attack/stroke (51%). Reasons for nonadherence included wanting to try lifestyle modification (63%), general medication concerns (50%), and fear of adverse events (38%). Among patients filling their prescription, 94% completed a follow-up lipid panel. Among 14 PCPs interviewed, 8 were aware of the safety-net program. PCPs cited in-basket volume and lack of an automated reminder system as common barriers to following up with patients with high low-density lipoprotein cholesterol levels. PCPs perceived (1) patients' fear of statins and (2) forgetfulness as the main reasons for not filling their prescriptions and not completing lipid panels, respectively. PCPs suggested that more frequent patient and provider reminders could improve prescription fills and laboratory test completions.

Conclusions: Interventions focused on improving patients' knowledge of statins and educating PCPs about outreach programs may facilitate patient-provider communication and improve statin adherence.

Semaglutide, a glucagon-like peptide-1 receptor agonist, is FDA approved under the brand names Ozempic for treatment of type 2 diabetes and Wegovy for the treatment of overweight or obesity. The soaring popularity of these drugs, driven by social media and their overall efficacy, has resulted in nationwide shortages. The high costs associated with the FDA-approved products for both insurers and patients have also led to additional restrictions in access. In response to the unmet growing demand for semaglutide, suppliers have started to sell compounded versions of these products, both legally and illegally. This narrative review examines the implications of these compounded products on our health care system, highlighting concerns regarding their safety, efficacy, and regulatory status. Compounding, when done following federal and state regulations, can fill an important need in our health care marketplace. However, the compounded semaglutide products currently available to patients may lack the quality controls historically seen with compounded formulations, resulting in risks for dosing errors and adverse health outcomes. In addition, the compounded semaglutide market worldwide has seen batches of fraudulent products. Pharmacists and other health care providers have a unique opportunity to help guide patients in navigating this compounded semaglutide market, including directing them to lawful sources of compounded semaglutide, providing counseling on dosage and administration, and minimizing safety concerns.

Objectives: Hospital participation in accountable care organizations (ACOs)-Medicare's signature alternative payment model-continues to grow despite mixed evidence on spending and quality. This study examines whether hospital ACO participation is associated with changes in emergency department (ED) admission practices, hospital length of stay (LOS), and spending for unplanned admissions.

Study design: A difference-in-differences analysis of Medicare fee-for-service ED visits and hospitalizations (2008-2019).

Methods: Medicare claims were linked to ACO tracking data from Torch Insight to identify hospitals that joined an ACO between 2012 and 2017 (6 cohorts, followed for a maximum of 5 years), the start date of their initial contract, and ACO characteristics. Key outcomes included ED admission and observation stay rates, hospital LOS for emergent admissions, and total costs for an index ED event.

Results: Among the 995 hospitals (27.6% of the short-term hospitals in our study) that joined a Medicare ACO during the study period, program participation up to 5 years was not associated with changes in the rate of hospitalization from the ED, hospital LOS, or total costs of the index event. Findings remained consistent across ACO program, contract risk levels, year of program entry, and overall ACO performance (eg, whether the ACO generated shared savings).

Conclusions: Hospitals did not significantly alter care delivery for unplanned hospitalizations after joining an ACO. These findings suggest that hospital-led ACOs may have limited impact on reducing costs for emergent admissions, raising concerns about their ability to drive meaningful care transformation.

Objectives: Ambulatory cardiac monitors (ACMs) enable heart rhythm monitoring for various durations, including Holter monitors (0-48 hours), long-term continuous monitors (LTCMs; 3-14 days), and external ambulatory event monitors (AEMs; up to 30 days). These devices detect intermittent or asymptomatic arrhythmias that might go unnoticed with a standard electrocardiogram. Previous research has explored variations in ACM use among Medicare beneficiaries. This study assessed the incidence of clinical and economic outcomes among commercially insured patients who had never had an arrhythmia diagnosis and received their first ACM.

Study design: Retrospective cohort study using a large commercial claims database focused on patients without prior arrhythmia diagnoses who received their first ACM between 2016 and 2023.

Methods: Outcomes included new arrhythmia diagnoses, repeat ACM testing, cardiovascular (CV) events, and health care resource use and costs. Results were stratified by major ACM manufacturers using National Provider Identifiers. To minimize confounding, inverse probability of treatment weighting was used to balance covariates, and adjusted regression models were used to evaluate outcomes during follow-up.

Results: Of 428,707 patients meeting inclusion criteria, 36% used LTCMs, 36% used Holter monitors, and 27% used external AEMs. Adjusted analyses showed that a certain LTCM brand was associated with higher odds of a new arrhythmia diagnosis, fewer retests (except vs AEMs), lower odds of CV events, and less follow-up health care resource use and costs than other ACM types and manufacturers.

Conclusions: Clinical and economic outcomes can vary by ACM type among commercially insured patients. A specific LTCM manufacturer demonstrated superior performance, with greater diagnoses of arrhythmia, fewer repeat tests, and fewer CV events compared with other ACM types and manufacturers.

Objective: To examine the impact on quality of care for individuals enrolled in Medicare Advantage (MA) plans or traditional Medicare (TM) during the COVID-19 pandemic.

Study design: Retrospective cohort study.

Methods: The study examined beneficiaries enrolled in Medicare from 2017 through 2021. Beneficiaries were divided into 4 cohorts based on their enrollment in TM or MA and the year of enrollment in 2019, the year before the COVID-19 pandemic, or 2021, during the COVID-19 pandemic. For each cohort, 12 clinical quality measures were constructed, including 4 screening measures requiring in-person visits and 8 medication management and adherence measures.

Results: A total of 3,190,208 Medicare beneficiaries were included (58.4% female; mean age, 73.0 years). In both 2019 and 2021, the MA program performed significantly better than TM across the 12 clinical quality measures. Compared with the year before the pandemic, both programs experienced a decrease in screening measures that required in-person visits during the pandemic, with a slightly higher decrease for the MA plans. In contrast, measures of medication management and adherence improved for both programs, but especially for MA plans.

Conclusions: MA plans continued to outperform TM on clinical quality measures during the COVID-19 pandemic.

Objectives: Assisted reproductive technology (ART) is a treatment option available to patients diagnosed with infertility. This study evaluated the impact of infertility benefit coverage on ART utilization and pregnancy-related outcomes, addressing a gap in previous research.

Study design: Retrospective analysis.

Methods: This study utilized the Workpartners Research Reference Database containing claims from self-insured employers in the US from 2010 to 2022. Women aged 18 to 42 years with at least 1 infertility diagnosis and at least 2 years of continuous enrollment after the initial infertility diagnosis were classified into 1 of 2 cohorts: high cohort (those with both infertility diagnostic and treatment coverage) or low cohort (those with only diagnostic coverage or no diagnostic nor treatment coverage). Binary outcomes were analyzed using logistic regression and continuous outcomes were analyzed using 2-stage stepwise regressions. Models controlled for differences in employee demographics, job-related variables (exempt status, full-time status, hourly vs salary, annual salary), and number of insured dependents.

Results: Of the 10,820 women who met the inclusion criteria, 7589 (70.1%) were in the high cohort and 3231 (29.9%) were in the low cohort, with mean (SE) ages of 34.4 (0.06) vs 33.5 (0.11) years, respectively (P < .0001). The high cohort had a higher adjusted likelihood than the low cohort of using ART medications (P < .0001) and having ART procedures performed (P < .0001). The high cohort also used a higher number of unique ART medications and procedures. The likelihood of becoming pregnant with any ART utilization was 69.6% for the high cohort and 65.3% for the low cohort (P = .0089). The only significant difference in pregnancy-related complications was claims for oligohydramnios (9.3% vs 7.2%, respectively; P = .0294).

Conclusions: Health benefit design that includes infertility treatment coverage resulted in significantly higher use of unique ART medications, number of ART procedures performed, and successful pregnancy outcomes.

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 August issue features a conversation with Charles N. (Chip) Kahn III, MPH, the president and CEO of the Federation of American Hospitals and a longtime member of the AJMC editorial board.

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the US, with nearly 40% of eligible individuals not current on lifesaving CRC screening. Although stool-based screening tests offer accessible initial options, the CRC screening process is incomplete without a follow-up colonoscopy after a positive result. Unfortunately, low follow-up rates-particularly among socioeconomically disadvantaged groups-undermine the potential health benefits. Recent policies eliminating patient cost sharing for follow-up colonoscopies address one critical barrier but fail to overcome the systemic obstacles that impede screening completion. Patient navigation programs are a proven strategy to bridge these gaps. By addressing logistical, financial, and educational challenges, navigation services significantly improve follow-up colonoscopy rates. However, inadequate reimbursement has hindered their widespread implementation. Current funding models, including CMS' Principal Illness Navigation services, fall short of supporting preventive care such as CRC screening. To fully realize the potential of CRC screening, investments in patient navigation, enhanced clinician reimbursement for follow-up colonoscopies, and systemic reforms are essential. Modeling studies reveal a "win-win-win" scenario: Clinicians receive appropriate compensation for their critical role in follow-up care, payers achieve cost savings through efficient screening processes, and investments in navigation services help close disparities in CRC screening. Expanding navigation programs and incentivizing follow-up colonoscopies would increase screening rates, reduce disparities, and achieve population health gains. These investments represent a rare opportunity to align stakeholder interests, prevent CRC deaths, and advance health equity.