The American journal of managed care最新文献_第5页

Are work relative value units correlated with operative duration of common surgical procedures? 功的相对价值单位与普通外科手术的手术时间相关吗?

The American journal of managed care Pub Date : 2022-04-01 DOI: 10.37765/ajmc.2022.88858

L. Haeuser, E. Cone, A. Cole, M. Marchese, Q. Trinh

{"title":"Are work relative value units correlated with operative duration of common surgical procedures?","authors":"L. Haeuser, E. Cone, A. Cole, M. Marchese, Q. Trinh","doi":"10.37765/ajmc.2022.88858","DOIUrl":"https://doi.org/10.37765/ajmc.2022.88858","url":null,"abstract":"OBJECTIVES\u0000Work relative value units (wRVUs) quantify physician workload. In theory, higher wRVU assignments for procedures recognize an increase in complexity and time required to complete the procedure. The fairness of wRVU assignment is debated across specialties, with some surgeons arguing that reimbursement may be unfairly low for longer, more complex cases. For this reason, we sought to assess the correlation of wRVUs with operative time in commonly performed surgeries.\u0000\u0000\u0000STUDY DESIGN\u0000We analyzed the National Surgical Quality Improvement Program database, selecting the 15 most performed surgical procedures across specialties in a 90-day global period, using Current Procedural Terminology codes.\u0000\u0000\u0000METHODS\u0000Calculation and comparison of mean operative time and mean wRVUs were performed for each of the 15 procedures. Cases with missing values for wRVUs or operative time and cases with an operative time of less than 15 minutes were excluded. The Spearman correlation coefficient was calculated to evaluate the strength of correlation between operative duration and wRVUs.\u0000\u0000\u0000RESULTS\u0000A total of 1,994,394 patients met criteria for analysis. The lowest mean wRVU was 7.78 (95% CI, 7.77-7.78) for inguinal hernia repair; the highest was 43.50 (95% CI, 43.37-43.60) for pancreatectomy. The shortest mean operative time was 51.0 (95% CI, 50.8-51.1) minutes for appendectomy; the longest was for pancreatectomy at 324.6 (95% CI, 323.2-326.0) minutes. The Spearman correlation coefficient was 0.81.\u0000\u0000\u0000CONCLUSIONS\u0000In our analysis, we found a strong correlation between operative duration and wRVU assignment. Thus, the reimbursement of physicians depending on wRVUs is fair for the most commonly performed surgical procedures across specialties.","PeriodicalId":267832,"journal":{"name":"The American journal of managed care","volume":"21 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131357336","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 1

OneOncology's Arrowsmith looks forward to real-time dynamics in clinical pathways. OneOncology的Arrowsmith期待在临床途径中实现实时动态。

IF 3.2

The American journal of managed care Pub Date : 2022-04-01 DOI: 10.37765/ajmc.2022.89175

Mary Caffrey, Edward Arrowsmith

引用次数: 0

Patients' access to 2018 FDA-approved drugs 1 year post approval. 患者获得2018年fda批准的药物1年后批准。

The American journal of managed care Pub Date : 2022-04-01 DOI: 10.37765/ajmc.2022.88869

A. Panzer, N. Margaretos, N. Bridger, M. Osani, Rachel C. Lai, J. Chambers

{"title":"Patients' access to 2018 FDA-approved drugs 1 year post approval.","authors":"A. Panzer, N. Margaretos, N. Bridger, M. Osani, Rachel C. Lai, J. Chambers","doi":"10.37765/ajmc.2022.88869","DOIUrl":"https://doi.org/10.37765/ajmc.2022.88869","url":null,"abstract":"OBJECTIVES\u0000To examine US commercial health plans' adoption of 2018 FDA-approved drugs.\u0000\u0000\u0000STUDY DESIGN\u0000Database analysis.\u0000\u0000\u0000METHODS\u0000We identified novel drugs that the FDA approved in 2018 and categorized them as follows: cancer treatment, orphan drug, included in an expedited review program, and biosimilar. Using a data set of 17 large health plans' drug coverage policies and formularies, we examined coverage 1 year following FDA approval.\u0000\u0000\u0000RESULTS\u0000The FDA approved 66 drugs in 2018 (5 were not yet marketed 1 year following approval). For 60 of 61 drugs, some plans issued coverage policies whereas other plans included the drug in their formularies. Plans imposed restrictions (eg, step therapy) in 37% (275/742) of coverage policies. Plans covered biosimilars, orphan drugs, and cancer treatments more generously than drugs not in those categories (P < .05). Plans imposed restrictions in their policies with different frequencies (range, 7%-52%). Plans imposed utilization management (UM) in 82% (3837/4697) of formulary entries. Of those entries, plans required prior authorizations in 98%, included drugs on the highest patient co-payment tier in 70%, and imposed step therapy in 3%. Plans most often placed orphan drugs and cancer treatments on the highest cost-sharing formulary tiers (68% and 64% of the time, respectively). Plans imposed UM in their formularies with different frequencies (range, 62%-100% of entries).\u0000\u0000\u0000CONCLUSIONS\u0000Health plans imposed fewer coverage restrictions on cancer treatments, orphan drugs, and biosimilars than on drugs not in those categories. Some plans covered 2018 FDA-approved drugs more generously than others, which has implications for patients' access to innovative therapies.","PeriodicalId":267832,"journal":{"name":"The American journal of managed care","volume":"80 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130788246","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 2

How Medicare Advantage plans use data for supplemental benefits decision-making. 医疗保险优势计划如何使用数据进行补充福利决策。

The American journal of managed care Pub Date : 2022-04-01 DOI: 10.37765/ajmc.2022.88866

L. Shields-Zeeman, Emily A. Gadbois, Michelle S Tong, J. Brazier, L. Gottlieb, K. Thomas

{"title":"How Medicare Advantage plans use data for supplemental benefits decision-making.","authors":"L. Shields-Zeeman, Emily A. Gadbois, Michelle S Tong, J. Brazier, L. Gottlieb, K. Thomas","doi":"10.37765/ajmc.2022.88866","DOIUrl":"https://doi.org/10.37765/ajmc.2022.88866","url":null,"abstract":"OBJECTIVES\u0000Health care payers are increasingly experimenting with interventions to address social risk factors. With enactment of the 2018 Bipartisan Budget Act, Medicare Advantage (MA) plans have new opportunities to offer supplemental benefits that are not \"primarily health-related.\" This article presents findings from interviews conducted with executives from MA plans regarding plan decision-making processes related to new social risk factor benefits.\u0000\u0000\u0000STUDY DESIGN\u0000Semistructured qualitative interviews with MA plan leadership.\u0000\u0000\u0000METHODS\u0000A total of 63 plan representatives from 29 unique MA plans were interviewed about the rationale for social risk-related interventions and how data are used to inform benefits expansion decisions. This paper combines qualitative interview data from 2 separate studies with similar target groups and interview guides. Interview transcripts were qualitatively analyzed to examine underlying themes.\u0000\u0000\u0000RESULTS\u0000Three main themes emerged: (1) Plans use multiple data sources to determine how to target benefits; (2) evidence gaps hinder decision-making to expand or offer new supplemental benefits; and (3) in the absence of sufficient evidence, some plans have their own research and quality improvement processes to maximize effectiveness.\u0000\u0000\u0000CONCLUSIONS\u0000Findings provide insights about opportunities and challenges that MA plans face in making decisions related to supplemental benefits designed to address members' social risk factors. Barriers include collecting, generating, and analyzing data critical to informing investments. Results highlight the need to ensure interoperability of new and existing data sources, foster shared learning opportunities, and narrow evidence gaps about specific social care interventions to inform the design and implementation of effective supplemental benefits.","PeriodicalId":267832,"journal":{"name":"The American journal of managed care","volume":"257 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124234726","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 2

Identifying complex patients using Adjusted Clinical Groups risk stratification tool. 使用调整临床组风险分层工具识别复杂患者。

The American journal of managed care Pub Date : 2022-04-01 DOI: 10.37765/ajmc.2022.88867

Shelley-Ann M Girwar, Jozefine C Verloop, M. Fiocco, Stephen P Sutch, M. Numans, M. Bruijnzeels

{"title":"Identifying complex patients using Adjusted Clinical Groups risk stratification tool.","authors":"Shelley-Ann M Girwar, Jozefine C Verloop, M. Fiocco, Stephen P Sutch, M. Numans, M. Bruijnzeels","doi":"10.37765/ajmc.2022.88867","DOIUrl":"https://doi.org/10.37765/ajmc.2022.88867","url":null,"abstract":"OBJECTIVES\u0000To produce an efficient and practically implementable method, based on primary care data exclusively, to identify patients with complex care needs who have problems in several health domains and are experiencing a mismatch of care. The Johns Hopkins ACG System was explored as a tool for identification, using its Aggregated Diagnosis Group (ADG) categories.\u0000\u0000\u0000STUDY DESIGN\u0000Retrospective cross-sectional study using general practitioners' electronic health records combined with hospital data.\u0000\u0000\u0000METHODS\u0000A prediction model for patients with complex care needs was developed using a primary care population of 105,345 individuals. Dependent variables in the model included age, sex, and the 32 ADGs. The prediction model was externally validated on 30,793 primary care patients. Discrimination and calibrations were assessed by computing C statistics and by visual inspection of the calibration plot, respectively.\u0000\u0000\u0000RESULTS\u0000Our model was able to discriminate very well between complex and noncomplex patients (C statistic = 0.9; 95% CI, 0.88-0.92), whereas the calibration plot suggests that the model provides overestimates of complex patients.\u0000\u0000\u0000CONCLUSIONS\u0000With this study, the ACG System has proven to be a useful tool in the identification of patients with complex care needs in primary care, opening up possibilities for tailored interventions of care management for this complex group of patients. Utilizing ADGs, the prediction model that we developed had a very good discriminatory ability to identify those complex patients. However, the calibrating ability of the model still needs improvement.","PeriodicalId":267832,"journal":{"name":"The American journal of managed care","volume":"28 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114160250","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 1

Insurance coverage and health care spending by state-level Medigap regulations. 保险覆盖范围和医疗保健支出由州级医疗保险制度规定。

The American journal of managed care Pub Date : 2022-04-01 DOI: 10.37765/ajmc.2022.88860

Sungchul Park, Norma B. Coe

{"title":"Insurance coverage and health care spending by state-level Medigap regulations.","authors":"Sungchul Park, Norma B. Coe","doi":"10.37765/ajmc.2022.88860","DOIUrl":"https://doi.org/10.37765/ajmc.2022.88860","url":null,"abstract":"OBJECTIVES\u0000Medigap protects traditional Medicare (TM) beneficiaries against catastrophic expenses. Federal regulations around Medigap enrollment and pricing are limited to the first 6 months after turning 65 years old. Eight states institute regulations that apply to later enrollment; half use community rating (charging everyone the same premium) and half use both community rating and guaranteed issue (requiring insurers to accept any beneficiary irrespective of health conditions). We examined the impact of state-level Medigap regulations on insurance coverage and health care spending for Medicare beneficiaries.\u0000\u0000\u0000STUDY DESIGN\u0000We used a retrospective cohort study design. Using the 2010-2016 Medicare Current Beneficiary Survey, we identified beneficiaries with TM only, TM + Medigap, or Medicare Advantage (MA) by state-level Medigap regulations.\u0000\u0000\u0000METHODS\u0000Outcomes were insurance coverage and health care spending. We used an instrumental variable approach to address endogenous insurance choice. We conducted 2-stage least squares regression while controlling for individual-level characteristics and area-level demographic characteristics. Then we used the recycled prediction methods to predict enrollment and spending outcomes for the 3 state-level Medigap regulation scenarios.\u0000\u0000\u0000RESULTS\u0000Although enrollment in TM only was consistent across regulation scenarios, the scenario with community rating and guaranteed issue had lower Medigap enrollment and higher MA enrollment than the no-regulation scenario. Despite negligible health differences, TM + Medigap beneficiaries had higher Medicare spending than TM-only beneficiaries, suggesting moral hazard.\u0000\u0000\u0000CONCLUSIONS\u0000Our findings suggest a link between additional regulations and lower Medigap and higher MA enrollment. Policy makers should consider the potential effects on insurance coverage, premiums, financial protection, and moral hazard when designing Medigap regulations.","PeriodicalId":267832,"journal":{"name":"The American journal of managed care","volume":"37 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115376406","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 1

Impacts of community-based care program on health care utilization and cost. 社区护理计划对医疗保健利用和成本的影响。

The American journal of managed care Pub Date : 2022-04-01 DOI: 10.37765/ajmc.2022.88862

Bishnu Bahadur Thapa, Xinqi Li, O. Galárraga

{"title":"Impacts of community-based care program on health care utilization and cost.","authors":"Bishnu Bahadur Thapa, Xinqi Li, O. Galárraga","doi":"10.37765/ajmc.2022.88862","DOIUrl":"https://doi.org/10.37765/ajmc.2022.88862","url":null,"abstract":"OBJECTIVES\u0000A variety of care coordination and delivery models have been used to address the social and medical needs of high-need, high-cost patient populations. However, the evidence on the effectiveness of such models is far from clear. The purpose of this study is to determine whether the Community Health Team (CHT) program, a community-based care management program in Rhode Island, had impacts on health care utilization and cost.\u0000\u0000\u0000STUDY DESIGN\u0000We used data from 2014 to 2018 to evaluate the effects of the CHT program on health care utilization and cost. Our analytical sample consisted of a total of 12,830 patients, with 2282 in the intervention group and 10,548 in the matched comparison group.\u0000\u0000\u0000METHODS\u0000We used a combination of propensity score-matched difference-in-differences framework and generalized linear models.\u0000\u0000\u0000RESULTS\u0000The program led to an overall decrease in hospitalizations (incidence rate ratio [IRR], 0.89; P = .028) and inpatient costs (IRR, 0.79; P = .024). This translates into a reduction of 7 hospitalizations per 1000 people per month and a reduction of inpatient cost of $289 per person per month. Impacts varied considerably across subgroups. For patients with 1 to 2 encounters with the program, there was a significant decrease in emergency department visits, hospitalizations, inpatient cost, outpatient cost, professional cost, and total cost. Although no significant impacts were observed for patients with 3 to 5 encounters with the program, patients with more than 6 encounters with the program saw an increase in pharmacy cost and total cost.\u0000\u0000\u0000CONCLUSIONS\u0000There is a need for a tailored approach to addressing patients' needs in primary care.","PeriodicalId":267832,"journal":{"name":"The American journal of managed care","volume":"28 4 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131360586","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Association of wound healing with quality and continuity of care and sociodemographic characteristics. 伤口愈合与护理质量和连续性以及社会人口学特征的关系。

The American journal of managed care Pub Date : 2022-04-01 DOI: 10.37765/ajmc.2022.88868

S. K. Cho, S. Mattke, M. Sheridan, W. Ennis

{"title":"Association of wound healing with quality and continuity of care and sociodemographic characteristics.","authors":"S. K. Cho, S. Mattke, M. Sheridan, W. Ennis","doi":"10.37765/ajmc.2022.88868","DOIUrl":"https://doi.org/10.37765/ajmc.2022.88868","url":null,"abstract":"OBJECTIVES\u0000To evaluate the association between clinics' wound healing performance and clinic-level measures of care continuity, clinical quality, and sociodemographic characteristics of the population in their catchment areas.\u0000\u0000\u0000STUDY DESIGN\u0000In this cross-sectional analysis, we analyzed electronic health records for 180,336 chronic wounds from 480 wound care clinics during the 2018 calendar year.\u0000\u0000\u0000METHODS\u0000We measured healing performance using a clinic's observed to expected (O/E) ratio, which is based on the rate at which chronic wounds were predicted to heal within 12 weeks given its case mix and the actual healing rate. We compared the top and bottom quintiles, in terms of the O/E ratio, of clinics. Multivariable regression was used to estimate the effect of the clinic-level measures on the O/E ratio.\u0000\u0000\u0000RESULTS\u0000Clinics in the top quintile had higher rates of care continuity and quality measures, as well as a lower proportion of disadvantaged populations in their catchment areas. In the regression model, 10% increases in a clinic's rate of weekly provider visits, nurse visits, and debridement were associated with 2.5%, 3.0% and 0.7% increases, respectively, in the O/E ratio. The weekly provider visit rate had a greater marginal effect when the proportion of African American residents in the clinic's catchment area was larger.\u0000\u0000\u0000CONCLUSIONS\u0000Clinic-level measures of care continuity, clinical quality, and sociodemographic composition of their catchment areas' population explain a meaningful part of differences in clinics' wound healing performance. Better care continuity appears to have a greater beneficial effect in disadvantaged populations.","PeriodicalId":267832,"journal":{"name":"The American journal of managed care","volume":"20 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115705734","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 3

From the editor-in-chief: we need a cancer patient bill of rights. 主编:我们需要一份癌症患者权利法案。

The American journal of managed care Pub Date : 2022-04-01 DOI: 10.37765/ajmc.2022.89130

J. Alvarnas

引用次数: 0

Comparison of mortality between Medicare Advantage and traditional Medicare beneficiaries with kidney failure. 医疗保险优势和传统医疗保险受益人肾衰竭死亡率的比较。

The American journal of managed care Pub Date : 2022-04-01 DOI: 10.37765/ajmc.2022.88861

Daeho Kim, Yoojin Lee, S. Swaminathan, R. Mehrotra, M. Rivera-Hernandez, R. Thorsness, Kevin H. Nguyen, A. Trivedi

{"title":"Comparison of mortality between Medicare Advantage and traditional Medicare beneficiaries with kidney failure.","authors":"Daeho Kim, Yoojin Lee, S. Swaminathan, R. Mehrotra, M. Rivera-Hernandez, R. Thorsness, Kevin H. Nguyen, A. Trivedi","doi":"10.37765/ajmc.2022.88861","DOIUrl":"https://doi.org/10.37765/ajmc.2022.88861","url":null,"abstract":"OBJECTIVES\u0000To compare risk-adjusted 1-year mortality between Medicare Advantage (MA) and traditional Medicare (TM) enrollees with kidney failure who initiated dialysis.\u0000\u0000\u0000STUDY DESIGN\u0000Longitudinal analysis of mortality and enrollment data for Medicare beneficiaries.\u0000\u0000\u0000METHODS\u0000The study compared mortality between MA and TM enrollees with kidney failure who initiated dialysis in 2016, accounting for their enrollment switches between MA and TM during 12 months prior to dialysis initiation. Analyses were adjusted for risk scores and fixed effects for the month of dialysis initiation and county of residence.\u0000\u0000\u0000RESULTS\u0000The difference in risk-adjusted 1-year mortality between MA stayers (Medicare beneficiaries who were continuously enrolled in MA prior to dialysis initiation) and TM stayers (those who were continuously enrolled in TM prior to initiating dialysis) was -0.1 percentage points (95% CI, -1.0 to 0.8); however, the difference increased to -1.0 percentage points (95% CI, -3.2 to 1.2) when comparing TM-to-MA switchers (those who switched from TM to MA before initiation) with TM stayers, a comparison more prone to favorable selection bias given our finding that TM-to-MA switchers were healthier than MA stayers.\u0000\u0000\u0000CONCLUSIONS\u0000Among Medicare beneficiaries with kidney failure who initiated dialysis, risk-adjusted 1-year mortality rate is not different between MA and TM stayers. If there is remaining favorable selection in MA due to unobserved health status, our finding provides a lower-bound estimate of the MA impact on mortality among beneficiaries with kidney failure.","PeriodicalId":267832,"journal":{"name":"The American journal of managed care","volume":"29 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132735156","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 1