American Journal of Managed Care最新文献

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.

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.