Journal of managed care & specialty pharmacy最新文献

{"title":"Emerging trends in pharmacy operations: Perspectives on the 2024 AMCP Foundation Survey.","authors":"Brian Nightengale, Todd Huseby","doi":"10.18553/jmcp.2025.31.1-b.s25","DOIUrl":"10.18553/jmcp.2025.31.1-b.s25","url":null,"abstract":"","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"31 1-b Suppl","pages":"S25-S28"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11780267/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143052670","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Emerging trends in managed care pharmacy: A mixed-method study.","authors":"T Joseph Mattingly, Laura E Happe, Laura Cranston","doi":"10.18553/jmcp.2025.31.1-b.s2","DOIUrl":"10.18553/jmcp.2025.31.1-b.s2","url":null,"abstract":"<p><strong>Background: </strong>Over the past 5 years, managed care pharmacy has been shaped by a global pandemic, advancements in generative artificial intelligence (AI), Medicare drug price negotiation policies, and significant therapeutic developments. Collective intelligence methods can be used to anticipate future developments in practice to help organizations plan and develop new strategies around those changes.</p><p><strong>Objective: </strong>To identify emerging trends in managed care pharmacy.</p><p><strong>Methods: </strong>In this sequential mixed-method study, we invited experts to participate in a multidisciplinary advisory panel to develop a survey with 5 overarching domains. The qualitative analysis for our advisory panel meetings used a thematic analysis approach. To analyze the cross-sectional survey results, we used descriptive statistics and exploratory bivariate statistics to test for possible relationships with survey respondent demographics and likelihood predictions. To assess respondent opinions on the overall likelihood of an event occurring in the next 5 years, we combined \"Highly likely/Somewhat likely\" responses and compared with \"Highly unlikely/Somewhat unlikely\" responses.</p><p><strong>Results: </strong>Following our advisory panel focus groups, a total of 53 scenarios were developed for inclusion in the quantitative survey under the domains of (1) information technology, (2) therapeutics and diagnostics, (3) payment models, (4) pharmacy operations, and (5) public policy. A total of 1,238 individuals were invited to participate in the survey. Of eligible participants, 201 complete survey responses were received for a final response rate of 16.2%. Survey participants rated increased use of glucagon-like peptide-1 receptor agonists by at least 25%, at least 1 major data breach, more than 10 new orphan drug approvals, and AI use in more than half of prior authorization reviews as the most likely scenarios to occur in the next 5 years. Respondents identified the following broad issues as those most likely to impact their organizations (employers) in the next 5 years: federal and state policy changes impacting managed care, cell and gene therapies, impact of AI on managed care operations, and emerging payment models.</p><p><strong>Conclusions: </strong>This study provides valuable insights into the emerging trends that are expected to shape managed care pharmacy over the next 5 years. The integration of advanced technologies, such as AI, along with the increasing focus on specialty therapeutics, represents both opportunities and challenges for managed care organizations. However, areas with lower consensus highlight the need for caution in strategic planning.</p>","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"31 1-b Suppl","pages":"S2-S10"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11780272/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143052662","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Health care resource utilization and costs of Medicare-enrolled patients with HR+/HER2- metastatic breast cancer treated with a CDK4/6i in the first-line setting.","authors":"Emma Behan, David L Veenstra, Aasthaa Bansal","doi":"10.18553/jmcp.2025.31.1.6","DOIUrl":"10.18553/jmcp.2025.31.1.6","url":null,"abstract":"<p><strong>Background: </strong>The introduction of cyclin-dependent kinases 4 and 6 inhibitors (CDK4/6is) has transformed the treatment landscape for patients with hormone receptor positive (HR+) and human epidermal growth factor receptor 2 negative (HER2-) metastatic breast cancer (MBC). To our knowledge, no studies have quantified health care resource utilization (HRU) or economic burden following CDK4/6i initiation in the Medicare population.</p><p><strong>Objective: </strong>To describe HRU and quantify health care costs among Medicare-enrolled patients with HR+ HER2- MBC treated with CDK4/6is in the first-line setting.</p><p><strong>Methods: </strong>We conducted a retrospective cohort study on Medicare-enrolled patients with HR+ HER2- MBC who initiated a CDK4/6i in the first-line setting between February 2, 2016, and December 31, 2022, using claims from the Merative MarketScan database. We examined all-cause HRU by summarizing the number of inpatient (IP), outpatient (OP), and emergency department (ED) visits as well as the length of stay during the 6 months following CDK4/6i initiation. Additionally, we assessed all-cause health care costs, including IP, OP, ED, and pharmacy, over the 1 year following CDK4/6i initiation using the Kaplan-Meier sample average estimator to account for censoring. We reported total health care costs as the sum of IP, OP, ED, and pharmacy costs.</p><p><strong>Results: </strong>901 patients met the inclusion criteria with a mean age of 74 years (SD = 6.84). Nearly 24% (n = 214) had an IP admission in the 6 months following CDK4/6i initiation. Among patients with an IP admission, the mean number of admissions per patient was 1.65 (SD = 0.98) with a mean length of stay per admission of 5.98 (SD = 6.25) days. Roughly 30% (n = 271) of patients had an ED visit, with a mean of 2.1 (SD = 1.54) visits per patient among those who had a visit. Most patients (n = 868, 96.44%) had an OP service, and among those with an OP service, the mean number of days with OP services was 19.96 (SD = 12.29). Mean total health care costs over the 1-year period following CDK4/6is were $62,228 (95% CI = 52,281-73,029) per patient with the main drivers being OP services ($31,686 [95% CI = 27,168-36,925]) and pharmacy costs ($22,727 [95% CI = 19,273-25,931]).</p><p><strong>Conclusions: </strong>There are numerous sources of HRU and cost in patients following CDK4/6i initiation in the Medicare population. Patients with HR+ HER2- MBC incur high HRU, providing insights for health care decision-makers to optimize treatment strategies and resource allocation for this population.</p>","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"31 1","pages":"6-14"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11695835/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142921865","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Emerging trends in public policy: Perspectives on the 2024 AMCP Foundation Survey.","authors":"Melissa J Andel, Daniel Tomaszewski","doi":"10.18553/jmcp.2025.31.1-b.s29","DOIUrl":"10.18553/jmcp.2025.31.1-b.s29","url":null,"abstract":"","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"31 1-b Suppl","pages":"S29-S33"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11780268/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143052673","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Geographic atrophy and factors associated with disease progression among Medicare Advantage enrollees.","authors":"Vishal Saundankar, Mark Borns, Kelly Broderick, Birva Shah, Stuart Cowburn, Steven McFadden, Brandon Suehs","doi":"10.18553/jmcp.2025.31.1.42","DOIUrl":"10.18553/jmcp.2025.31.1.42","url":null,"abstract":"<p><strong>Background: </strong>Geographic atrophy (GA) is a form of advanced age-related macular degeneration (AMD) that can cause irreversible vision impairment and is responsible for approximately 20% of legal blindness in the United States. There is limited real-world evidence assessing health outcomes and health care resource use (HCRU) among individuals with GA.</p><p><strong>Objective: </strong>To examine the progression from GA without subfoveal involvement (SFI) to GA with SFI, progression to irreversible blindness, and HCRU among older individuals with GA enrolled in Medicare Advantage Prescription Drug (MAPD) plans.</p><p><strong>Methods: </strong>This retrospective study used claims data for MAPD-plan enrollees aged at least 65 years with an AMD diagnosis between 2018 and 2021. To assess progression of GA, development of blindness, and HCRU, propensity score matched cohorts of individuals with GA and without GA were identified and compared. For GA progression analysis, at least 12 months of follow-up was required, and patients were followed until the end of either follow-up or study period.</p><p><strong>Results: </strong>Total 9,511 individuals with GA were matched 1:1 to individuals without GA. Among individuals with GA, initial diagnosis was primarily by an ophthalmologist (58.6%) followed by an optometrist (30.9%). The most common diagnostic imaging procedure at index was optical coherence tomography (53.0%). Mean follow-up time was 2.3 years. At index, 4,781 (50.3%) individuals had GA without SFI and 4,697 (49.4%) had GA with SFI. Among individuals with GA without SFI at index, 479 (10.2%) progressed to GA with SFI during the 12-month follow-up. Among individuals with GA without SFI at index, 173 (3.6%) developed irreversible blindness, compared to 312 (6.6%) of those with SFI, and 51 (0.5%) individuals without GA. Kaplan-Meier analysis indicated fastest progression to irreversible blindness among individuals with GA with SFI, followed by those without SFI (log-rank test <i>P</i> < 0.001). Both diagnosis of GA without SFI (hazard ratio [HR] [CI] = 6.77 [4.98-9.35], <i>P</i> < 0.001) and diagnosis of GA with SFI (HR [CI] = 12.59 [9.43-17.16], <i>P</i> < 0.001) were strongly associated with increased risk of developing irreversible blindness. Significant predictors of progression to GA with SFI were wet AMD at baseline (HR [CI] = 5.70 [4.63-6.99], <i>P</i> < 0.001), Elixhauser comorbidity score of 4-5 (HR [CI] = 1.46 [1.12-1.91], <i>P</i> = 0.006), and more than 5 (HR [CI] = 1.40 [1.02-1.89], <i>P</i> = 0.035).</p><p><strong>Conclusions: </strong>GA with or without SFI was associated with progression to irreversible blindness in an MAPD-plan population. Patients with GA with SFI progressed to irreversible blindness faster than patients with GA without SFI. With the recent approval of GA treatments, future research is needed to assess the impacts on disease progression, including blindness.</p>","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"31 1","pages":"42-52"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11695847/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142921862","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of social determinants of health on esketamine nasal spray initiation among patients with treatment-resistant depression in the United States.","authors":"Kristin Clemens, Maryia Zhdanava, Amanda Teeple, Arthur Voegel, Kruti Joshi, Aditi Shah, Cindy Chen, Dominic Pilon","doi":"10.18553/jmcp.2025.24240","DOIUrl":"10.18553/jmcp.2025.24240","url":null,"abstract":"<p><strong>Background: </strong>Disparities in mental health care access and health outcomes based on sociodemographic factors in the United States have been extensively documented. However, there is limited knowledge regarding these socioeconomic factors with respect to initiation of esketamine nasal spray, a novel therapy for treatment-resistant depression (TRD).</p><p><strong>Objective: </strong>To evaluate the association of socioeconomic factors with the initiation of esketamine nasal spray.</p><p><strong>Methods: </strong>Adults with TRD and commercial or Medicare Advantage (MA) insurance (Commercial-MA cohort) were included from Optum's deidentified Clinformatics Data Mart Database (January 2016-June 2022) and adults with Medicaid insurance (Medicaid cohort) were included from Merative MarketScan Multi-State Medicaid Database (January 2016-June 2022). The baseline period spanned 12 months before the index date (latter of evidence of TRD or US esketamine approval date); follow-up period spanned the index date until the end of health plan eligibility/data availability. Multivariate Cox proportional hazard models were used, separately for each cohort, to evaluate the association of characteristics with time to esketamine initiation; patients who did not initiate esketamine were censored at the end of follow-up.</p><p><strong>Results: </strong>In the Commercial-MA cohort, 201,937 patients were included (75.0% female, mean age 62.3 years, 80.9% White, 82.8% having less than a bachelor's degree, 60.3% with a household income less than $75,000). Having both an education of less than a bachelor's degree and a household income less than $75,000 reduced the chance of esketamine initiation by 37% (hazard ratio [HR] = 0.63, <i>P</i> < 0.001). In the Medicaid cohort, 51,206 patients were included (77.8% female, mean age 43.2 years, 78.6% White). In both cohorts, chances of initiation trended to be lower in females (Commercial-MA: HR = 0.63, <i>P</i> < 0.001; Medicaid: HR = 0.68, <i>P</i> = 0.088), whereas racial or ethnic minorities had similar chances of initiation to White patients (Commercial-MA: HR = 1.23, <i>P</i> = 0.104; Medicaid: HR = 0.79, <i>P</i> = 0.376).</p><p><strong>Conclusions: </strong>Disparities in esketamine nasal spray initiation were observed based on education, income, and gender highlighting a potential health equity gap.</p>","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":" ","pages":"101-111"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11695841/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142864527","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Annual prevalence of geographic atrophy and wet age-related macular degeneration among Medicare Advantage enrollees in a US health plan.","authors":"Vishal Saundankar, Mark Borns, Kelly Broderick, Birva Shah, Stuart Cowburn, Steven McFadden, Brandon Suehs","doi":"10.18553/jmcp.2025.31.1.88","DOIUrl":"10.18553/jmcp.2025.31.1.88","url":null,"abstract":"<p><strong>Background: </strong>Geographic atrophy (GA) is an advanced form of dry age-related macular degeneration (AMD) that can lead to visual impairment. Published studies estimate approximately 1 million people in the United States have GA in at least 1 eye. There is a lack of real-world evidence from the US payer perspective on the prevalence of AMD and GA among Medicare Advantage prescription drug (MAPD) plan enrollees.</p><p><strong>Objective: </strong>To estimate the annual prevalence of GA, wet AMD, and co-occurring GA and wet AMD among MAPD plan enrollees from 2018 through 2021.</p><p><strong>Methods: </strong>This retrospective, cross-sectional study estimated the prevalence of GA and AMD based on Medicare Advantage enrollee claims data. Individuals aged 65 years and older who had continuous enrollment throughout each calendar year constituted the denominator for each annual prevalence calculation. Enrollees with at least 1 medical claim with a diagnosis code for GA or wet AMD during each year were identified to estimate annual prevalence for that respective calendar year.</p><p><strong>Results: </strong>The total number of patients in the denominator was 2,175,803 (2018); 2,445,163 (2019); 2,680,322 (2020); and 2,905,366 (2021). The annual prevalence of GA was 0.56% (2018), 0.55% (2019), 0.48% (2020), and 0.51% (2021). The annual prevalence of wet AMD was 1.2% (2018), 1.3% (2019), 1.2% (2020), and 1.3% (2021). The prevalence of GA was highest among individuals classified as White race (annual range 0.61% to 0.71%) and among patients with GA aged 75 years and older (range 0.95% to 1.11%). The proportion of patients with GA with co-occurring wet AMD was 25.6% to 28.0%. The annual prevalence of advanced AMD (GA or wet AMD) was 1.6% to 1.7%.</p><p><strong>Conclusions: </strong>In the Medicare populations, the prevalence of GA was greatest among patients aged 75 years and older and individuals classified as White race. A substantial proportion of individuals with GA had evidence of co-occurring wet AMD. MAPD plans should evaluate how their membership may be impacted by the recently approved medications for the treatment of GA.</p>","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"31 1","pages":"88-94"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11695844/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142921825","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Dynamic changes in medication burden leading to fall and hospital readmissions in older adults: Toward a strategy for improving risk and managing costs.","authors":"Rafia S Rasu, Christy Xavier, Nahid Rianon","doi":"10.18553/jmcp.2025.31.1.96","DOIUrl":"10.18553/jmcp.2025.31.1.96","url":null,"abstract":"&lt;p&gt;&lt;p&gt;The majority of a health plan's performance and designated Star Rating is related to medication-related behavior, eg, medication adherence, medication review, and reconciliation, that are intricately related to adverse drug events (ADEs). Altered pharmacodynamics and pharmacokinetics owing to aging make older adults more vulnerable to ADEs like falls, fractures, hospitalizations, and mortality. Prevention of avoidable risk factors such as medication burden can help maintain quality of life. Studies of multiple populations have established drug burden index (DBI), a dose-dependent measure of anticholinergic and sedative burden, to be strongly associated with worsening vertigo, dizziness, and balance, which all predicate falls. The mean difference in DBI greater than 0.1 provides greater predictive power for adverse events, such as falls and 30-day readmission rates. Inclusion of a DBI delta metric especially on an electronic medical record has the potential to reduce fall incidence and associated health outcomes such as hospitalizations and death; this presents an opportunity to improve Centers for Medicare & Medicaid Services Star Ratings by using meaningful tools to foster engagement among informed and active Medicare beneficiaries. We believe this information is extremely relevant in real-world decision-making for health care professionals, specifically when the changes are dynamic and happen very quickly. Moreover, managed care organizations are now dedicated to eliciting a deeper understanding and mitigation of social inequalities in medication use and consequences. Among the proposed solutions includes tailoring prescription utilization management tools with DBI to decrease avoidable incidences of complications and unintended costs. Understanding the dynamic relationship between medication exposures causing ADEs and associated health care utilization and costs to third-party payments remains vital because in the United States, approximately one-third of hospital admissions in older adults occur because of ADEs. This can be achieved by emphasizing equitable therapy and tailoring quality initiatives that minimize racial disparities and avoidable costs that affect the financial burden of these patients. Importantly, this approach becomes even more critical as health care systems increasingly emphasize star ratings, which reflect the quality of care delivered to patients. By prioritizing DBI metrics in these ratings, we can ensure that care is not only clinically effective but also equitable and focused on improving patients' overall well-being. Lastly, as the future directions, the timely application of advanced technologies like artificial intelligence and machine learning in analyzing DBI metrics could enhance our ability to predict the value of DBI adjustments and their correlation with falls and other unintended ADEs. These real-world technologies can process vast amounts of data quickly and accurately, identifying patterns and potent","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"31 1","pages":"96-100"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11695846/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142921846","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Emerging trends in patient experience data: Perspectives on the 2024 AMCP Foundation Survey.","authors":"Eleanor M Perfetto","doi":"10.18553/jmcp.2025.31.1-b.s34","DOIUrl":"10.18553/jmcp.2025.31.1-b.s34","url":null,"abstract":"","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"31 1-b Suppl","pages":"S34-S37"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11780269/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143052665","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Estimating optimal thresholds for adherence to RASA medications among older adults with hypertension.","authors":"Megha A Parikh, Sujith Ramachandran, Irene Nsiah, Patrick J Campbell, Melissa Castora-Binkley, Taruja Karmakar, Heather Black, John P Bentley","doi":"10.18553/jmcp.2025.31.1.25","DOIUrl":"10.18553/jmcp.2025.31.1.25","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;The Centers for Medicare and Medicaid Services (CMS) Star Ratings program incentivizes health plans in Medicare to improve performance on a variety of quality measures such as adherence to renin-angiotensin system antagonists (RASAs). Adherence to RASA medications, defined as having a proportion of days covered (PDC) of at least 80%, has been improving for several years, suggesting that further investigation is needed to assess the appropriateness of the current 80% PDC threshold for medication adherence as an indicator of quality. The 80% PDC threshold has been found to be associated with improved health care resource utilization outcomes; however, little evidence exists to show that this threshold is optimal.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt;To evaluate the association between adherence to RASA medications and health care resource utilization outcomes within a Medicare Advantage population and to identify the optimal PDC threshold that maximizes economic and utilization benefits.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;This retrospective cohort study used de-identified administrative claims data from the 2015 to 2018 in Optum's de-identified Clinformatics Data Mart Database. Inclusion in the study was based on measure specifications for the RASA adherence measure used in the Medicare Part D Star Ratings program. Adherence was assessed over a 1-year period, and health care utilization and medical costs were assessed in the subsequent year. Multivariable logistic regression models were used to assess the relationship between adherence and economic outcomes after accounting for hypothesized confounders.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;A total of 1,006,901 individuals were included in the study with an average PDC of 87.5% (SD = 17.8%). During the follow-up period, 12.1% of individuals experienced a hospitalization, 14.81% used an emergency department (ED), and 32.3% visited a non-ED outpatient facility. Each percentage point increase in PDC was significantly associated with decreased odds of hospitalization (odds ratio [OR] = 0.997; 95% CI = 0.997-0.997) and ED visit (OR = 0.997; 95% CI = 0.996-0.997), being in the top decile of payer medical costs (OR = 0.998; 95% CI = 0.997-0.998), and increased odds of outpatient visits (adjusted OR = 1.001; 95% CI = 1.001-1.002). Receiver operator characteristic curve analyses found the optimal PDC thresholds to be 91.5%, 90.7%, 90.7%, and 90.4% for hospitalization (area under the curve [AUC] = 0.527), ED visit (AUC = 0.534), outpatient visit (AUC = 0.501), and medical costs (AUC = 0.532), respectively.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;This study demonstrated the importance of medication adherence for preventing undesirable outcomes, such as future hospitalizations, ED visits, and high medical costs, among individuals with hypertension enrolled in Medicare Advantage. The optimal threshold for PDC related to health care resource utilization outcomes was found to be greater than that ","PeriodicalId":16170,"journal":{"name":"Journal of managed care & specialty pharmacy","volume":"31 1","pages":"25-32"},"PeriodicalIF":2.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11695845/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142921849","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}