Medical Care最新文献

{"title":"The State of Medical Care for Adults With Intellectual and/or Developmental Disabilities.","authors":"David A Ervin","doi":"10.1097/MLR.0000000000001977","DOIUrl":"10.1097/MLR.0000000000001977","url":null,"abstract":"<p><p>For more than 2 decades, medical care for adults with intellectual and/or developmental disabilities (IDDs) has been difficult to access and has not substantially changed the persistently poor health status that is common in this population cohort. While there has been some progress in the development of models of care that are designed with and for adults with IDD, it has been slow and sporadic, with little data or analyses of efficacy or effectiveness. Very few medical schools and other health science professional education in the United States include curricular content on adults with IDD, resulting in health care practitioners being under or altogether unprepared to provide care to them. Public and private health care policy and financing are not responsive to the medical care needs and experiences of adults with IDD. More recently, the impact of the COVID-19 pandemic on adults with IDD was disproportionally more severe, with significantly higher rates of morbidity and mortality than on adults without IDD, having nothing to do with the presence of an IDD itself. This commentary reviews persistent barriers to accessible, responsive medical care for adults with IDD and reviews a number of health care models that have been developed since the turn of the 21st century. It also offers a brief review of Medicaid Managed Care as a potential policy and financing solution to long-standing financing and related obstacles to optimal medical care.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":"63 1 Suppl 1","pages":"S1-S7"},"PeriodicalIF":3.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142789469","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Quality of Medical Care for Adults With Intellectual/Developmental Disabilities.","authors":"","doi":"10.1097/MLR.0000000000002104","DOIUrl":"10.1097/MLR.0000000000002104","url":null,"abstract":"","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":"63 1 Suppl 1","pages":"i"},"PeriodicalIF":3.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142789467","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Innovation in Medical Education on Intellectual/Developmental Disabilities: Report on the National Inclusive Curriculum for Health Education-Medical Initiative.","authors":"Priya Chandan, Emily J Noonan, Kayla Diggs Brody, Claire Feller, Emily Lauer","doi":"10.1097/MLR.0000000000002079","DOIUrl":"10.1097/MLR.0000000000002079","url":null,"abstract":"<p><p>The lack of physician training in serving patients with intellectual and developmental disabilities (IDDs) has been highlighted as a key modifiable root cause of health disparities experienced by this high-priority public health population. To address gaps in medical education regarding the lack of IDD curriculum, lack of evaluation/assessment, and lack of coordination across institutions, the American Academy of Developmental Medicine and Dentistry created the National Inclusive Curriculum for Health Education-Medical (NICHE-MED) Initiative in 2016. The aims of NICHE-MED are to: (1) impact medical students' attitudes and/or knowledge to address underlying ableism and address how future physicians think about disability; (2) apply a lens of health equity and intersectionality, centering people with IDD, but fostering conversation and learning about issues faced by other disability and minoritized populations; and (3) support community-engaged scholarship within medical education. As of 2024, the NICHE-MED initiative consists of close to 40 Medical School Partners, each with their own community-engaged disability curriculum intervention paired with a rigorous evaluation that ties centrally to coordinated program evaluation. The NICHE-MED initiative demonstrates implementation success at scale and is a successful community-engaged curriculum change model that may be replicated regarding disability more broadly and regarding necessary medical education efforts that center other marginalized populations.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":"63 1 Suppl 1","pages":"S25-S30"},"PeriodicalIF":3.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11617082/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142789652","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cost-effectiveness of a Low-cost Educational Messaging and Prescription-fill Reminder Intervention to Improve Medication Adherence Among Individuals With Intellectual and Developmental Disability and Hypertension.","authors":"Brian Chen, Suzanne McDermott, Deborah Salzberg, Wanfang Zhang, James W Hardin","doi":"10.1097/MLR.0000000000001946","DOIUrl":"10.1097/MLR.0000000000001946","url":null,"abstract":"<p><strong>Background: </strong>Adults with intellectual and developmental disabilities (IDDs) have a similar prevalence of hypertension as the general population, but a higher rate of medication nonadherence at 50% compared with the average of 30%.</p><p><strong>Objectives: </strong>To assess the cost-effectiveness of educational messaging and prescription-fill reminders to adults with IDD and hypertension and their helpers among Medicaid members in a randomized control trial.</p><p><strong>Research design: </strong>The authors calculated net cost savings by subtracting per-participant intervention costs from differences in spending between preintervention/postintervention cases versus controls. Using bootstrap samples, they assessed the probability of positive cost savings. They used quantile and logistic regression to examine which members contributed to the cost savings and to identify future high-cost members at baseline.</p><p><strong>Subjects: </strong>Four hundred twelve members with IDD and their helpers were recruited from the South Carolina Medicaid agency in 2018.</p><p><strong>Measures: </strong>Intervention costs were determined using labor and communication costs. Health expenditures were obtained from South Carolina's all-payer claims database, using actual Medicaid expenditures and total all-payer expenditures estimated with cost-to-charge ratios.</p><p><strong>Results: </strong>The intervention, which cost $26.10 per member, saved $1008.02 in all-payer spending and $1126.42 in Medicaid payments per member, respectively, with 78% and 91% confidence. Cost savings occurred among members above the 85th percentile of spending, and those using the emergency department or inpatient services at least twice at baseline were predicted to be future high-cost members.</p><p><strong>Conclusions: </strong>The intervention is cost-saving, and insurers can prospectively identify and target members who will likely benefit.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":"63 1 Suppl 1","pages":"S15-S24"},"PeriodicalIF":3.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11617081/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142789650","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Health System Expansion and Changes in Medicare Beneficiary Utilization of Safety Net Providers.","authors":"Kun Li, José J Escarce, Shiyuan Zhang, Denis Agniel, Maria DeYoreo, Justin W Timbie","doi":"10.1097/MLR.0000000000002083","DOIUrl":"https://doi.org/10.1097/MLR.0000000000002083","url":null,"abstract":"<p><strong>Background: </strong>Evidence is limited on insured patients' use of safety net providers as vertically integrated health systems spread throughout the United States.</p><p><strong>Objectives: </strong>To examine whether market-level health system penetration is associated with: (1) switches in Medicare beneficiaries' usual source of primary care from federally qualified health centers (FQHCs) to health systems; and (2) FQHCs' overall Medicare patient and visit volume.</p><p><strong>Research design: </strong>Beneficiary-level discrete-time survival analysis and market-level linear regression analysis using Medicare fee-for-service claims data from 2013 to 2018.</p><p><strong>Subjects: </strong>A total of 659,652 Medicare fee-for-service beneficiaries aged 65 and older lived in one of 27,386 empirically derived primary care markets whose usual source of care in 2013 was an FQHC or a non-FQHC-independent physician organization that predominantly served low-income patients.</p><p><strong>Measures: </strong>Beneficiary-year measure of the probability of switching to health system-affiliated physician organizations and market-year measures of the number of FQHC visits by Medicare beneficiaries, number of beneficiaries attributed to FQHCs, and FQHC Medicare market shares.</p><p><strong>Results: </strong>During 2013-2018, 16.5% of beneficiaries who sought care from FQHCs switched to health systems. When health system penetration increases from the 25th to 75th percentile, the probability of Medicare FQHC patient switching increases by 4.6 percentage points, with 22 fewer Medicare FQHC visits and 4 fewer beneficiaries attributed to FQHCs per market year. Complex patients and patients who sought care from non-FQHC, independent physician organizations exhibited higher rates of switching to health systems.</p><p><strong>Conclusions: </strong>Health system expansion was associated with the loss of Medicare patients by FQHCs, suggesting potential negative spillovers of vertical integration on independent safety net providers.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":"63 1","pages":"18-26"},"PeriodicalIF":3.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142789644","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Higher Percentage of Virtual Primary Care Associated With Minimal Differences in Achievement of Quality Metrics.","authors":"Jodi B Segal, Lisa Yanek, Leah Jager, Ebele Okoli, Elham Hatef, Maqbool Dada, K Davina Frick","doi":"10.1097/MLR.0000000000002094","DOIUrl":"10.1097/MLR.0000000000002094","url":null,"abstract":"<p><strong>Objective: </strong>To test the impact of virtual care usage on quality metrics used for performance measurement.</p><p><strong>Background: </strong>Virtual care improves access to primary care; however, the quality of care must not be adversely impacted by its use.</p><p><strong>Methods: </strong>This is a mixed-design etiologic study using data from patients receiving primary care in a large, regional health system from January 2020 through December 2021. Eligible patients had at least one primary care contact. Eligible physicians had 10 or more patient contacts. The quartile of virtual visits per physician per month is calculated as the percentage of total visits conducted by phone or video (Q1 is the lowest). Six metrics used for value-based reimbursement were chosen for modeling with generalized linear mixed models.</p><p><strong>Results: </strong>The data included 200,090 patients of 683 physicians in 42 clinics over 24 months. Virtual care usage peaked in April 2020 at 78% and then stabilized at 18%. The blood pressure metric was met in 66% (95% CI: 63%-69%) of physician months in Q1 and 65% (95% CI: 63%-68%) in Q4 ( P = 0.003). The hemoglobin A1c metric was met in 73% (95% CI: 70%-76%) of physician months in Q1 and 72% (95% CI: 69%-75%) in Q4, not a significant difference. Breast cancer screening completion and colon cancer screening completion did not differ across virtual care quartiles. Medicare annual wellness visits were completed in 55% (95% CI: 50%-60%) of Q1 physician months and 54% in each of Q2, Q3, and Q4 ( P < 0.0001).</p><p><strong>Conclusions: </strong>Some quality metrics were modestly impacted by high virtual primary care usage; the absolute differences in rates were small. This may provide reassurance to physicians and their health systems that telemedicine use may not adversely impact quality metrics.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":" ","pages":"70-76"},"PeriodicalIF":3.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142623598","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Investigating the Impact of Caregiver Adverse Childhood Experiences Screening and Pediatrician-Led Discussions on Posttraumatic Stress Disorder Symptoms in a Majority-Hispanic Pediatric Primary Care Clinic Setting.","authors":"Chiara M Bettale, Melyrene Pomales, Angie Boy, Tim Moran, Maneesha Agarwal, Abigail Powers","doi":"10.1097/MLR.0000000000002065","DOIUrl":"10.1097/MLR.0000000000002065","url":null,"abstract":"<p><strong>Background: </strong>Evidence suggests that screening and provider-led discussions of parental adverse childhood experiences (ACEs) may help identify at-risk families and be linked to positive health outcomes in caregivers and their children. However, the direct effect of ACEs screening and discussions on posttraumatic stress disorder (PTSD) has yet to be studied.</p><p><strong>Objectives: </strong>To determine if screening or provider-led discussions of parental ACEs are associated with inadvertent worsening of PTSD symptoms 1 week after screening.</p><p><strong>Research design: </strong>Data was obtained as part of a cluster randomized controlled trial to examine the effects of ACEs screening and provider-led discussions on child health care utilization outcomes. Baseline surveys were completed before scheduled infant well child checks (WCCs). Providers were randomized into the standard of care or intervention (discussion) conditions. Intervention providers were trained in delivering brief trauma-informed discussions about the impact of ACEs on parenting during WCCs.</p><p><strong>Subjects: </strong>Caregivers in a pediatric primary care clinic serving predominantly Hispanic and low socioeconomically resourced families (N=179, 93% female, 87% Hispanic).</p><p><strong>Measures: </strong>The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5), Brief Resilience Scale (BRS), and ACEs screening were completed at baseline. PC-PTSD-5 was repeated 1-week after screening.</p><p><strong>Results: </strong>Mixed-effects ordinal logistic regression analysis of PTSD scores from baseline to 1-week postscreening with the full sample showed no significant effect of time [odds ratio (OR)=1.21, P=0.68], group (OR=1.68, P=0.33), or their interaction (OR=0.48, P=0.21).</p><p><strong>Conclusions: </strong>Screening or brief discussion of ACEs with providers trained in trauma-informed care were not associated with worsening PTSD symptoms.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":"63 1","pages":"38-42"},"PeriodicalIF":3.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11617077/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142789646","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Mental Health Care Needs and Access to Care for Adults With Intellectual Disabilities.","authors":"Jean A Frazier, Laura Hanratty, Amy K Weinstock","doi":"10.1097/MLR.0000000000002089","DOIUrl":"10.1097/MLR.0000000000002089","url":null,"abstract":"<p><strong>Background: </strong>Adults with intellectual disabilities (IDs) are at greater risk for psychiatric disorders than the general population. Yet, they have limited access to mental health services.</p><p><strong>Objectives: </strong>To examine the prevalence of psychiatric disorders in adults with ID. To describe evidence-based interventions for this population, their access to mental health care, and outline opportunities for improved access.</p><p><strong>Design: </strong>This manuscript summarizes literature regarding psychiatric disorders in adults with ID and their access to behavioral health care. We considered articles referencing mental health care for adults with ID. PubMed and a variety of search terms were used. Studies published in English from 2010 to the date of the searches were included. Quantitative and qualitative study designs, review articles, program descriptions, and opinion papers were considered for inclusion. Additional references from the selected articles were also considered.</p><p><strong>Results: </strong>We identified 2864 records. One hundred two records were included, consisting of work commenting on mental health and ID and access to care in the United States. The articles describe increased psychiatric comorbidities in adults with ID. They highlight the few evidence-based interventions for psychiatric comorbidities and the limited access to care.</p><p><strong>Conclusions: </strong>Our mental health care providers generally have minimal training and experience with people with ID, limiting access to appropriate care for these individuals. Improved access could be created by increasing education and experiences with these populations for mental health providers. Aligning policies, financing, and adequate insurance reimbursement to develop a continuum of care will be critical for these individuals.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":"63 1 Suppl 1","pages":"S8-S14"},"PeriodicalIF":3.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142789654","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Trainee's Role in Curriculum Advocacy Within Disability Medical Education.","authors":"Jessica A Prokup, Lauren Clarke, Shannon Strader","doi":"10.1097/MLR.0000000000001988","DOIUrl":"10.1097/MLR.0000000000001988","url":null,"abstract":"","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":"63 1 Suppl 1","pages":"S31-S39"},"PeriodicalIF":3.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142789470","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Adult Pharmacy Costs and Characteristics of Very High-Cost Prescription Drug Users in the United States, 2018-2022.","authors":"Jennifer L Nguyen, Duy Do, Elizabeth C Swart, Tiffany Lee, Samuel K Peasah, Urvashi Patel, Chester B Good","doi":"10.1097/MLR.0000000000002045","DOIUrl":"https://doi.org/10.1097/MLR.0000000000002045","url":null,"abstract":"<p><strong>Objective: </strong>This study sought to identify: (1) the demographic and clinical characteristics of very high-cost users (defined as patients with pharmaceutical expenditures that were equal to or greater than the 99th percentile), (2) whether or not these characteristics changed over time, (3) sociodemographic and clinical correlates of being very high-cost users, (4) the average pharmaceutical costs of very-high cost users, and (5) the therapeutic classes and medications that contributed to these high costs.</p><p><strong>Background: </strong>There are growing public concerns about rising drug costs, in part due to increased availability, greater effectiveness, and market considerations. There is a concentrated portion of patients that accounts for a disproportionately large portion of pharmaceutical expenditures.</p><p><strong>Methods: </strong>A large serial cross-sectional study was conducted with De-identified, member-level pharmacy claims (n = 65,739,791) from a large, national pharmacy benefits manager from January 1, 2018 to December 31, 2022. The main outcome and measures were 2018-2022 pharmaceutical expenditures; amounts were adjusted for inflation to reflect 2022-dollar values.</p><p><strong>Results: </strong>Across the study period, the odds of being classified as a very high-cost user were 1.31 times as high for those 45-64 years old compared with those 18-44 years old (reference category); the odds were 1.42 times as high for males compared with females; 1.13 times as high before those identifying as non-Hispanic Black compared with non-Hispanic white; 1.11 times as high for those enrolled in a health care exchange plan compared with a commercial plan. In addition, very high-cost users lived in areas with higher social needs. Human immunodeficiency virus, inflammatory conditions, multiple sclerosis, and cancer accounted for the largest share of costs among this group.</p><p><strong>Conclusions: </strong>This study identified the unique characteristics of very high-cost pharmaceutical users and identified the top conditions and prescription drugs that drove high pharmaceutical expenditures among this population. These findings are essential to understanding rising pharmaceutical costs in the United States and can help identify the issues and solutions of specific cost drivers within our health care policies.</p>","PeriodicalId":18364,"journal":{"name":"Medical Care","volume":"63 1","pages":"1-8"},"PeriodicalIF":3.3,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142789642","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}