American Journal of Managed Care最新文献

{"title":"Impact of COVID-19 on specialty televisits in a large integrated health care system.","authors":"Joyce J Kim, Robert G Holleman, Lewei Allison Lin, Sameer D Saini, Megan A Adams","doi":"10.37765/ajmc.2025.89749","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89749","url":null,"abstract":"<p><strong>Objectives: </strong>The COVID-19 pandemic stimulated an unprecedented expansion in use of video and telephone visits (televisits) for routine specialty care as a substitute for in-person clinic visits. However, the sustainability of televisit use for specialty care delivery following the pandemic is unclear.</p><p><strong>Study design/methods: </strong>In this descriptive, retro-spective study of national Veterans Health Administration (VHA) data, we assessed total outpatient visit volume by month in 9 specialties (cardiology, dermatology, eye care, gastroenterology [GI]/hepatology, neurosurgery, orthopedics, podiatry, substance use disorder [SUD], and urology) at all VHA facilities in the US between January 2019 (pre-COVID-19) and September 2023 (representing late phases of health system recovery post COVID-19). We also categorized outpatient visits by modality (in person, telephone, video) and assessed time trends in the proportion of total outpatient visits in each specialty delivered by televisit. Descriptive statistics were used to summarize the study findings.</p><p><strong>Results: </strong>Although total visit volumes in most VHA specialties had returned to pre-COVID-19 baselines by the end of the study period, they did not fully rebound in others, suggesting persistent care gaps. Televisit use increased from a mean of 7% in quarter 1 (Q1) 2019 to 54% in Q2 2020, then decreased modestly to 27% of all specialty visits by Q3 2023. The specialties with the highest sustained televisit use in Q3 2023 were SUD and GI, despite restored in-person visit availability. The use of telephone visits exceeded the use of video visits throughout the study period.</p><p><strong>Conclusions: </strong>Our findings suggest that televisits will likely remain an important visit modality for patients in the postpandemic era.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 6","pages":"296-300"},"PeriodicalIF":2.5,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144477748","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Factors that increase utilization management risk: a proof of concept.","authors":"Jason Shafrin, Jacob Fajnor, Shurui Zhang, Donald E Nichols","doi":"10.37765/ajmc.2025.89748","DOIUrl":"10.37765/ajmc.2025.89748","url":null,"abstract":"<p><strong>Objectives: </strong>To (1) develop a metric that quantitatively measures the risk that utilization management (UM) policies pose to patients and (2) measure the relationship between this metric and payers' real-world UM use.</p><p><strong>Study design: </strong>We conducted a targeted literature review and an expert elicitation exercise to create the Data-Based Utilization Management Risk Designation (BURDEN) score. Real-world data analysis measured the relationship between BURDEN and actual payer policies.</p><p><strong>Methods: </strong>The BURDEN score was based on 9 UM factors impacting patient outcomes. Factors were weighted based on an expert elicitation procedure with 6 stakeholders. UM policy restrictions were drawn from Tufts Medical Center's Specialty Drug Evidence and Coverage database, and net price data came from SSR Health. Ordinary least square regressions were performed to examine the relationship between the BURDEN score and coverage policies.</p><p><strong>Results: </strong>Among 98 treatments identified across 30 unique diseases, UM policies on treatments for myasthenia gravis, multiple myeloma, and lupus nephritis posed the highest risk to patients, according to the BURDEN score. When treatments had a high BURDEN score, payers were 22.0% less likely to impose any UM restriction (P = .041) and 36.2% less likely to impose step edits (P = .039).</p><p><strong>Conclusions: </strong>This study developed a quantitative measure (BURDEN) to estimate the relative risk to patients of payer UM policies. Payers appeared modestly sensitive to treatments that posed a high risk to patients should UM be implemented. However, coverage decisions did not appear to be fully patient-centered, as some higher BURDEN products experienced increased UM usage.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 6","pages":"288-294"},"PeriodicalIF":2.5,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144477746","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Outcomes for hospitals participating in more- and less-mature ACOs.","authors":"Askar Chukmaitov, David W Harless, David B Muhlestein","doi":"10.37765/ajmc.2025.89756","DOIUrl":"10.37765/ajmc.2025.89756","url":null,"abstract":"<p><strong>Objective: </strong>This study examines the impact of accountable care organization (ACO) maturity on inpatient costs, quality of care, and patient safety for hospitals participating in ACOs initiated by CMS relative to nonparticipants.</p><p><strong>Study design: </strong>Quasi-experimental evaluation of hospitals before and after joining a CMS ACO using a difference-in-differences design during the period from 2010 to 2013.</p><p><strong>Methods: </strong>Propensity score-matched groups of hospitals were used to estimate the combined effects of ACO maturity and CMS ACO participation on inpatient costs, quality, and patient safety outcomes. Total treatment costs, mortality rates for 4 common conditions, and 4 perioperative adverse events were investigated. Analyses were based on state-level data from the Healthcare Cost and Utilization Project.</p><p><strong>Results: </strong>We matched 121 CMS ACO-participating hospitals and 853 nonparticipating hospitals. Hospitals with an ACO maturity score of 0 had significantly worse acute myocardial infarction mortality and perioperative pulmonary embolism or deep vein thrombosis rates than nonparticipants. These differences were no longer significant with increasing ACO maturity. Higher ACO maturity was associated with significant improvements in accidental punctures and lacerations among hospital CMS ACO participants. No other significant trends were observed.</p><p><strong>Conclusions: </strong>Findings suggest a potential positive effect of hospital CMS ACO participation with increasing maturity. However, use of early ACO data, a short follow-up period, and other limitations hindered the ability to identify significant trends. Nonetheless, ACO maturity scores and new outcome measures may offer a promising approach for tracking the long-term impact of hospital ACO participation in future research and policy evaluations.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 Spec. No. 6","pages":"SP322-SP336"},"PeriodicalIF":2.5,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144486842","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Pharmacist-driven SMART formulary improves pharmacoequity.","authors":"Erin Van Meter, Caitlin Dowd-Green, Shay Roth, Robert Green, Amanda Bertram, Rosalyn Stewart","doi":"10.37765/ajmc.2025.89738","DOIUrl":"10.37765/ajmc.2025.89738","url":null,"abstract":"<p><strong>Objectives: </strong>A large academic medical center piloted a pharmacist-driven charitable medication access program. The financial and health outcomes of the program were evaluated and compared with existing benchmarks.</p><p><strong>Study design: </strong>This retrospective cohort study analyzed electronic health records for study participants and pharmacy dispensing information. The study period was January 1, 2023, through August 31, 2024.</p><p><strong>Methods: </strong>A pre-post analysis was performed to determine the impacts of the program. First, characterizations of the number, type, and cost of medications provided to charitable care patients via the Streamlined Medication Access for High-Risk Patients (SMART) formulary were compared with existing benchmarks. Second, emergency department (ED) and hospital utilization data were reviewed for charitable care patients after implementation of the SMART formulary and compared with utilization prior to implementation.</p><p><strong>Results: </strong>From January 1, 2023, through August 31, 2024, the SMART formulary provided 6791 medications to 418 unique patients, totaling more than 4.5 times more prescriptions to nearly 3 times more unique patients than the benchmark charitable care spending (March 1, 2019, to June 30, 2021). Drug costs per patient and costs per prescription were reduced by 62% and 72%, respectively. Reductions in ED visits (10%) and hospitalizations (34%) occurred, reducing the total health care spend by $6163 per month. The SMART formulary team facilitated the completion of 74 patient assistance program applications and connected patients to manufacturer insulin savings programs, estimating an additional indirect cost savings of $310,168.</p><p><strong>Conclusions: </strong>The SMART formulary reduced the total cost of care for a cohort of charitable care patients enrolled in a primary care clinic at a large urban academic medical center in Baltimore, Maryland.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 6","pages":"e167-e172"},"PeriodicalIF":2.5,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144477751","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Scaling early palliative care in value-based community oncology: a technology-enabled approach.","authors":"Biqi Zhang, Samyukta Mullangi, Alphan Kirayoglu, Stephen G Divers, Julia L Frydman","doi":"10.37765/ajmc.2025.89762","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89762","url":null,"abstract":"","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 Spec. No. 7","pages":"SP394-SP396"},"PeriodicalIF":2.5,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144486846","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Factors associated with unplanned admissions among patients with chronic conditions.","authors":"Michael Gottlieb, Natalia Golovashkina, Brian D Stein, Paul Casey, Garth Walker, Doug Thompson","doi":"10.37765/ajmc.2025.89755","DOIUrl":"10.37765/ajmc.2025.89755","url":null,"abstract":"<p><strong>Objectives: </strong>Value-based care models, such as the Medicare Shared Savings Program, have placed increasing emphasis on unplanned admissions among patients with multiple chronic conditions (UAMCCs) as a quality metric. However, there are limited data on which factors are associated with the highest risk of UAMCCs. This study sought to determine which factors were associated with increased risk of UAMCCs.</p><p><strong>Study design: </strong>Retrospective study conducted among all adult patients with 2 or more chronic conditions defined by CMS presenting to 2 hospitals within a major Midwest health care system from November 1, 2022, to October 31, 2023.</p><p><strong>Methods: </strong>Demographics, chronic conditions, primary care physician (PCP) visit utilization, and annual wellness visit (AWV) utilization were analyzed using multivariable logistic regression to identify associations with UAMCCs.</p><p><strong>Results: </strong>Among 18,448 patients (55.8% women) included in the study, 3842 (20.8%) had at least 1 UAMCC. Patients with UAMCCs were more likely to have Medicare or Medicaid insurance; be widowed; speak Spanish; have a higher Charlson Comorbidity Index score; and have Alzheimer disease, atrial fibrillation, heart failure, chronic kidney disease, depression, chronic obstructive pulmonary disease, and/or stroke. When examining PCP visit measures, AWVs and having 1 or more PCP visits were associated with fewer UAMCCs.</p><p><strong>Conclusions: </strong>Higher Charlson Comorbidity Index scores, several health conditions, and Spanish language were associated with increased UAMCCs. AWVs and having 1 or more PCP visits were associated with fewer UAMCCs.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 Spec. No. 6","pages":"SP312-SP321"},"PeriodicalIF":2.5,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144486841","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Risk factors for financial toxicity in health care.","authors":"Randall A Bloch, Louis L Nguyen","doi":"10.37765/ajmc.2025.89757","DOIUrl":"10.37765/ajmc.2025.89757","url":null,"abstract":"<p><strong>Objectives: </strong>Financial toxicity (FT) represents the impact of health care expenses on patients' financial well-being and access to care. Although existing literature has mostly looked at FT in the context of cancer and other medical conditions, we sought to identify risk factors for FT on a population-wide level.</p><p><strong>Study design: </strong>This was a cross-sectional study of the 2022 National Health Interview Survey (NHIS).</p><p><strong>Methods: </strong>Eight financial hardship questions were selected from the 2022 NHIS to represent FT. The unweighted sum of financial hardship questions to which a person responded \"yes\" was calculated as the FT score (FinTox), and risk factors for FinTox were analyzed using a negative binomial model.</p><p><strong>Results: </strong>There were 27,246 adults with a mean age of 52.96 years included for analysis, among whom 17.1% (n = 4659) responded \"yes\" to at least 1 FT question, of whom most had a FinTox of 1 or 2 (n = 3112; 66.8%). Increasing age (β = -0.616; P = .020), higher education (β = -1.08; P = .023), and higher income (β = -0.149; P < .001) were associated with lower FinTox, whereas involuntary unemployment (β = 0.920; P = .001), transient loss of health insurance (β = 1.075; P = .044), and high-deductible health plans (β = 0.519; P = .013) were associated with higher FinTox.</p><p><strong>Conclusions: </strong>Understanding risk factors for FT at a population level can help identify patients at risk for catastrophic financial effects or inadequate access to care.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 Spec. No. 6","pages":"SP337-SP350"},"PeriodicalIF":2.5,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144486844","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Challenges faced by Medicaid managed care coordinators working with members with substance use disorder.","authors":"Sarah J Marks, Valentina Vega, David Zhu, Hannah Shadowen, Ashley Harrell, Jason Lowe, Andrew Mitchell, Andrew J Barnes, Peter J Cunningham","doi":"10.37765/ajmc.2025.89752","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89752","url":null,"abstract":"<p><strong>Objectives: </strong>Medicaid managed care organization (MCO) care coordinators play a crucial role in assisting high-need Medicaid members with substance use disorder (SUD) and facilitating their connections with medical and social services. This study assessed challenges faced by care coordinators serving patients with SUD, including the types and frequencies of barriers, associated care coordinator and patient factors, and their relationship with burnout and job satisfaction.</p><p><strong>Study design: </strong>Web-based survey data from 322 Virginia Medicaid MCO care coordinators.</p><p><strong>Methods: </strong>Coordinators rated 15 barriers related to providing services to patients with SUD. Principal components analysis (PCA) identified 3 subscales categorizing these challenges (challenges accessing resources, administrative and regulatory burden, and data integration). Multivariable linear regression explored associations between coordinator and patient factors and subscales for categories of barriers. Pearson correlations were used to examine the relationship between these barriers and job satisfaction.</p><p><strong>Results: </strong>Coordinators reported a high frequency of challenges in many care coordinating activities: Between 49% and 82% reported each barrier as \"somewhat\" of a problem or a \"major\" problem. Using PCA, 3 main categories of barriers were identified. Having a high proportion of patients with SUD was associated with greater difficulties in accessing resources (P < .01) and data integration issues (P < .05), and working for specific MCOs was associated with all 3 categories of barriers (P < .05). Job satisfaction and burnout were correlated with all 3 categories as well and were most strongly associated with administrative and regulatory burden.</p><p><strong>Conclusions: </strong>Care coordinators face multiple challenges serving Medicaid members, particularly those with SUD. State-level Medicaid policies supporting care coordinators may help.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 6","pages":"e159-e166"},"PeriodicalIF":2.5,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144477745","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Gaps in the coordination of care for older adults with or at risk for cardiovascular disease.","authors":"Lisa M Kern, Joselyne E Aucapina, Samprit Banerjee, Joanna B Ringel, Jonathan N Tobin, Semhar Fisseha, Helena Meiri, Madeline R Sterling, Kurt C Stange, Monika M Safford, Paul N Casale","doi":"10.37765/ajmc.2025.89746","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89746","url":null,"abstract":"<p><strong>Objectives: </strong>We sought to determine whether patients with cardiovascular disease (CVD) or CVD risk factors and fragmented care (ie, care spread across multiple providers) perceive any gaps in communication among their providers and whether any gaps are perceived as clinically significant (ie, leading to adverse events).</p><p><strong>Study design: </strong>We conducted a cross-sectional telephone survey of community-dwelling Medicare beneficiaries 65 years and older with CVD or at least 1 CVD risk factor and highly fragmented ambulatory care (reversed Bice-Boxerman Index score ≥ 0.85) who had been attributed to an accountable care organization in New York, New York.</p><p><strong>Methods: </strong>Using a previously tested survey instrument, we asked about perceptions of communication among the respondents' providers, any adverse events (drug-drug interactions, duplicate tests, emergency department visits, or hospitalizations), and whether those events were preventable with better communication. We used descriptive statistics.</p><p><strong>Results: </strong>Of 201 eligible individuals, 96 completed surveys (47.8% response rate). Of those, 94 (97.9%) reported having at least 2 ambulatory visits and at least 2 ambulatory providers in the past year and were included in our analytic sample. The mean (SD) age was 76 (6.8) years; approximately two-thirds (69%) were women. Approximately half of respondents (48%) reported a problem with, or \"gap\" in, communication among their providers. One in 14 respondents (7%) reported experiencing an adverse event that they thought could have been prevented with better communication.</p><p><strong>Conclusions: </strong>Gaps in communication for patients with CVD or CVD risk factors are common and hazardous. Interventions are needed to leverage patients' observations to address gaps in communication before they cause harm.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 6","pages":"268-273"},"PeriodicalIF":2.5,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144477747","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Use of voluntary alignment in the Next Generation ACO model.","authors":"Tyler Boese, Bryan E Dowd, Roger D Feldman, Kathleen Rowan, Woolton Lee, Devi Chelluri, Susan Cahn, Shriram Parashuram","doi":"10.37765/ajmc.2025.89739","DOIUrl":"10.37765/ajmc.2025.89739","url":null,"abstract":"<p><strong>Objectives: </strong>To describe adoption and use of voluntary alignment throughout the Next Generation Accountable Care Organization (NGACO) model from 2016 through 2021. Voluntary alignment allows Medicare beneficiaries to self-attribute to a particular medical provider or organization by signing a form or making a selection in the MyMedicare.gov portal.</p><p><strong>Study design: </strong>We performed mixed-methods analyses of cross-sectional survey, enrollment, and claims data and coding transcripts of interviews with NGACO leadership.</p><p><strong>Methods: </strong>We statistically compared characteristics of NGACOs and beneficiaries that engaged in voluntary alignment compared to claims alignment. Additionally, we grouped qualitative interview responses into 2 overarching themes that emerged around NGACO leaders' perceptions, use, and experiences with voluntary alignment.</p><p><strong>Results: </strong>Few NGACOs engaged in widespread use of voluntary alignment. NGACOs that adopted voluntary alignment were similar to those that did not in most respects, although beneficiaries aligned through voluntary alignment were sicker and more expensive than those aligned through claims only. Many NGACO leaders reported they were content with claims-based alignment and did not think implementing initiatives to increase voluntary alignment would be worthwhile.</p><p><strong>Conclusions: </strong>The analysis suggests possible lessons for using voluntary alignment in future ACO models. NGACO leaders perceived that the use of voluntary alignment was limited by a high implementation effort, a need for patient education, and tight administrative time frames. Perceived benefits of voluntary alignment included attribution flexibility and creating opportunities for beneficiary engagement. Some leaders suggested allowing year-round voluntary alignment sign-up to better integrate voluntary alignment into their regular office workflows.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 6","pages":"e153-e158"},"PeriodicalIF":2.5,"publicationDate":"2025-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144477666","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}