American Journal of Managed Care最新文献

Dallas Nephrology Associates' journey to value-based care.

IF 2.5 4区医学

American Journal of Managed Care Pub Date : 2024-12-01 DOI: 10.37765/ajmc.2024.89656

Belinda Tommey, Paul Skluzacek, Melissa Echols, LeAnn Phelps, Mollyn Shew, Alexander Liang

{"title":"Dallas Nephrology Associates' journey to value-based care.","authors":"Belinda Tommey, Paul Skluzacek, Melissa Echols, LeAnn Phelps, Mollyn Shew, Alexander Liang","doi":"10.37765/ajmc.2024.89656","DOIUrl":"https://doi.org/10.37765/ajmc.2024.89656","url":null,"abstract":"Objectives: In 2016, Dallas Nephrology Associates recognized that the economic, humanistic, and societal burden of end-stage kidney disease was unsustainable and the fee-for-service model of reimbursement did not support a value-based care approach. We decided to be proactive by creating new workflows, education, and disease management so that patients could make well-informed choices, ultimately resulting in better outcomes.Methods: Our shift toward value-based care focused on patient engagement, education, integrated infrastructure, collaboration, and monitoring of metrics associated with improved outcomes. Our practice invested millions of dollars in a population health division, which includes nurse navigators and data analysts focused on managing chronic kidney disease (CKD), delaying progression, and promoting transplantation and home-based dialysis.Results: This retrospective review demonstrates improved outcomes, lower costs, and increased quality of care. Performance metrics have consistently met or exceeded targets. Seventy-three percent of patients now experience an optimal planned start to dialysis. Preemptive transplantation referrals have increased from 7% in 2017 to 61% through June 2023. Referral of patients with stage 4 CKD to educational workshops increased from 38% to 68%, and medical nutrition therapy referrals increased from 23% to 67%. Although reimbursement challenges persist, our commitment to improving care and slowing CKD progression remains steadfast. We emphasize teamwork, robust analytics, and continuous improvement. Future initiatives include encouraging patients receiving in-center hemodialysis to convert to home-based dialysis, addressing behavioral health, and focusing on preventable complications in high-risk patients.Conclusions: By embracing value-based models, we have demonstrated that a patient-centered approach can lead to improved outcomes and value for payers.","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"30 Spec. No. 13","pages":"SP999-SP1012"},"PeriodicalIF":2.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142822933","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}

引用次数: 0

Searching for the policy-relevant treatment effect in Medicare's ACO evaluations.

IF 2.5 4区医学

American Journal of Managed Care Pub Date : 2024-12-01 DOI: 10.37765/ajmc.2024.89647

Bryan E Dowd, Roger D Feldman, Woolton Lee, Kathleen Rowan, Shriram Parashuram, Katie White

{"title":"Searching for the policy-relevant treatment effect in Medicare's ACO evaluations.","authors":"Bryan E Dowd, Roger D Feldman, Woolton Lee, Kathleen Rowan, Shriram Parashuram, Katie White","doi":"10.37765/ajmc.2024.89647","DOIUrl":"https://doi.org/10.37765/ajmc.2024.89647","url":null,"abstract":"Objectives: To explain key challenges to evaluating Center for Medicare and Medicaid Innovation (CMMI) accountable care organization (ACO) models and ways to address those challenges.Study design: We enumerate the challenges, beginning with the conception of the alternative payment model and extending through the decision to scale up the model should the initial evaluation suggest that the model is successful. The challenges include churn at the provider and ACO levels, beneficiary leakage and spillover, participation in prior payment models, and determinants of shared savings and penalties.Methods: We explain challenges posed in evaluations of voluntary ACO models vs models in which ACOs are randomly assigned to the treatment group. We also note the relationship between the design used in an evaluation and subsequent plans for scaling up successful models.Results: The optimal research design is inextricably tied to the plans for scaling up a successful model. Decisions regarding churn, leakage, spillover, and participating in past payment models can alter the estimated effects of the intervention on participants in the model.Conclusions: If CMMI intends to offer the model to a larger, but similar, group of volunteers, then the estimated treatment effect based on voluntary participants may be the most policy-relevant parameter. However, if the scaled-up population has different characteristics than the evaluation sample, perhaps due to mandatory participation, then the evaluator will need to employ pseudo-randomization appropriate for observational data.","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"30 Spec. No. 13","pages":"SP978-SP984"},"PeriodicalIF":2.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142822935","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}

引用次数: 0

BHAGs for aligning incentives and building a learning system to improve total population health.

IF 2.5 4区医学

American Journal of Managed Care Pub Date : 2024-12-01 DOI: 10.37765/ajmc.2024.89649

Paul Hughes-Cromwick, Sanne J Magnan

引用次数: 0

Overcoming barriers to HIV prevention: population health considerations on optimizing PrEP access.

IF 2.5 4区医学

American Journal of Managed Care Pub Date : 2024-12-01 DOI: 10.37765/ajmc.2024.89654

Patrick Sullivan, Diana Brixner, Jerika T Lam, Alice Hsiao

{"title":"Overcoming barriers to HIV prevention: population health considerations on optimizing PrEP access.","authors":"Patrick Sullivan, Diana Brixner, Jerika T Lam, Alice Hsiao","doi":"10.37765/ajmc.2024.89654","DOIUrl":"10.37765/ajmc.2024.89654","url":null,"abstract":"The HIV epidemic remains a critical public health priority in the United States. The Ending the HIV Epidemic (EHE) initiative seeks to reduce HIV diagnoses by 75% by 2025 and by 90% by 2030. Certain demographic groups-including transgender women, cisgender Black women, and Black/African American and Hispanic/Latino men who have sex with men-are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) has proven effective in reducing HIV transmission. Real-world data indicate that the states with higher PrEP coverage have experienced steeper declines in new HIV diagnoses; however, several barriers hinder equitable PrEP access and uptake. Challenges such as stigma, discrimination, lack of education, and insurance barriers contribute to disparities in PrEP uptake and access to care, particularly in underserved communities. Population health decision-makers, including managed care organizations and federal and state policy makers, can play a vital role in expanding PrEP coverage and uptake by addressing these barriers and ensuring zero out-of-pocket costs for individuals who need PrEP. Enhancing health care provider education and person-centered HIV prevention strategies (eg, same-day PrEP services, telePrEP programs) also can increase PrEP uptake and adherence and patient satisfaction. A continuous focus on improving PrEP access can substantially contribute to achieving the EHE initiative's goal to end the HIV epidemic.","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"30 11 Suppl","pages":"S207-S215"},"PeriodicalIF":2.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142803256","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}

引用次数: 0

Mandatory Medicare bundled payment and the future of hospital reimbursement.

IF 2.5 4区医学

American Journal of Managed Care Pub Date : 2024-12-01 DOI: 10.37765/ajmc.2024.89653

Robert E Mechanic, Jennifer Perloff, Daniel Koppel

引用次数: 0

An integrated practice unit tool for the Military Health System.

IF 2.5 4区医学

American Journal of Managed Care Pub Date : 2024-12-01 DOI: 10.37765/ajmc.2024.89648

Thomas DeGraba, Tracey Pérez Koehlmoos, Cathaleen Madsen, Aroon Karra, Michael Dinneen

{"title":"An integrated practice unit tool for the Military Health System.","authors":"Thomas DeGraba, Tracey Pérez Koehlmoos, Cathaleen Madsen, Aroon Karra, Michael Dinneen","doi":"10.37765/ajmc.2024.89648","DOIUrl":"https://doi.org/10.37765/ajmc.2024.89648","url":null,"abstract":"Objectives: To develop a tool for measuring performance of a coordinated care center against the criteria of an integrated practice unit (IPU) and test it against an established care center in the Military Health System (MHS).Study design: Characteristics of 4 patient care coordination models were sorted using the 11 criteria of the IPU.Methods: Subject matter experts evaluated characteristics and criteria for inclusion or exclusion based on the needs of specialty care in the MHS. The consolidated tool was tested using the example of the National Intrepid Center of Excellence (NICoE), which provides coordinated, colocated care for patients with traumatic brain injury, using responses of yes, partial, no, not applicable, or incomplete.Results: The final tool contained 7 IPU criteria subdivided into 18 measures. NICoE was found in 2020 to meet 11 measures fully and 6 partially, with 1 deemed not applicable. In 2023 it met 17 of 18 measures, with the remaining (translation services) available as an enterprise-wide resource. The tool was seen to need improvement in clarification of 3 measures and in 1 criterion that is evaluated differently by patients vs providers.Conclusions: This IPU assessment tool accurately captures both the strengths and weaknesses of a coordinated care facility within the MHS. Iterative refinement of the tool is expected to inform ongoing discussion of the transformation of care in the MHS and the US and to provide a framework by which to measure the care performance of centers wishing to reorganize as IPUs.","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"30 Spec. No. 13","pages":"SP985-SP998"},"PeriodicalIF":2.5,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142822931","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}

引用次数: 0

Recent cohorts aging into Medicare use more counseling and psychotherapy than past cohorts. 最近加入医疗保险的老年人群比过去的老年人群使用更多的咨询和心理治疗。

IF 2.5 4区医学

American Journal of Managed Care Pub Date : 2024-11-01 DOI: 10.37765/ajmc.2024.89631

Grace McCormack, Erin L Duffy, Adam Biener

{"title":"Recent cohorts aging into Medicare use more counseling and psychotherapy than past cohorts.","authors":"Grace McCormack, Erin L Duffy, Adam Biener","doi":"10.37765/ajmc.2024.89631","DOIUrl":"10.37765/ajmc.2024.89631","url":null,"abstract":"Objectives: Despite recent policy interest in improving access to mental health care in Medicare, little is known about how demand for care will change among the Medicare population as newer cohorts age into the program. We documented the growing rate of counseling and psychotherapy use in the decade prior to turning age 65 years among subsequent cohorts aging into Medicare. We characterized how this growth varied across demographic groups, income levels, and mental and physical health status.Study design: We present trends using data from the 2002-2017 Medical Expenditure Panel Survey Household Component.Methods: We categorized individuals into 5-year Medicare entry cohorts based on the year they turned age 65 years. Our outcome was an indicator for having a visit for counseling or psychotherapy in a given year. Employing a probit regression, we characterized visit rates across 5-year cohorts, presenting both unadjusted and covariate-adjusted results. We ran stratified regressions by subpopulations.Results: Our sample included 54,666 individuals aged 55 to 64 years, weighted to be nationally representative. The cohort aging into Medicare between 2021 and 2025 was 88% (95% CI, 57%-119%) more likely to have a counseling or psychotherapy visit between the ages of 55 and 64 years compared with the cohort that gained eligibility for Medicare between 2006 and 2010 at the same age. Growth in utilization was pervasive across many subpopulations.Conclusions: Our findings suggest that more recent cohorts aging into Medicare seek significantly more counseling and psychotherapy than prior cohorts. This increased utilization is pervasive across subpopulations, suggesting that plans must prepare to accommodate the needs of new Medicare entrants.","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"30 11","pages":"e337-e340"},"PeriodicalIF":2.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142640156","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}

引用次数: 0

Management strategies for metabolic dysfunction-associated steatotic liver disease (MASLD). 代谢功能障碍相关性脂肪性肝病 (MASLD) 的管理策略。

IF 2.5 4区医学

American Journal of Managed Care Pub Date : 2024-11-01 DOI: 10.37765/ajmc.2024.89635

Naim Alkhouri, Mazen Noureddin

{"title":"Management strategies for metabolic dysfunction-associated steatotic liver disease (MASLD).","authors":"Naim Alkhouri, Mazen Noureddin","doi":"10.37765/ajmc.2024.89635","DOIUrl":"10.37765/ajmc.2024.89635","url":null,"abstract":"Metabolic dysfunction-associated steatotic liver disease (MASLD) is characterized by hepatic steatosis that is confirmed by imaging or histology in the setting of at least 1 metabolic risk factor in the absence of significant alcohol consumption. Nonalcoholic steatohepatitis, or NASH, was recently renamed metabolic dysfunction-associated steatohepatitis (MASH); it represents the progressive form of MASLD. MASH is defined by hepatic steatosis, lobular inflammation, and ballooning degeneration (hepatocellular injury) in a characteristic histologic pattern. Multiple pathophysiologic mechanisms underlie the development of MASLD, and multiple factors (eg, metabolic, hormonal, genetic, nutritional, and epigenetic components) are related to liver injury. MASH has a prevalence in the United States of 1% to 6%, and it is expected to rise in the next decade. Individuals living with MASH frequently suffer from comorbidities such as type 2 diabetes and cardiovascular disease. Several guidelines have been published to support the timely diagnosis of MASH that incorporate noninvasive tests that obviate the need for liver biopsy. Multiple MASH treatment options are in various stages of development. The THR-β agonist resmetirom, approved by FDA in March 2024, offers a liver-directed treatment for those patients living with moderate to severe fibrosis without cirrhosis. Considering the progressive nature of the disease and the availability of a treatment that can be initiated early to halt MASH progression, patients who have risk factors for MASH should urgently be encouraged to visit their health care providers for MASH screening.","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"30 9 Suppl","pages":"S159-S174"},"PeriodicalIF":2.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142606574","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}

引用次数: 0

Privately negotiated facility fees at ambulatory surgery centers and hospitals. 在门诊手术中心和医院私下协商设施费用。

IF 2.5 4区医学

American Journal of Managed Care Pub Date : 2024-11-01 DOI: 10.37765/ajmc.2024.89624

Daphne T Hao, Vinay K Rathi, Joseph S Ross, Rosh K V Sethi, Roy Xiao

引用次数: 0

Prescription rebate guarantees: employer insights. 处方回扣保障：雇主的见解。

IF 2.5 4区医学

American Journal of Managed Care Pub Date : 2024-11-01 DOI: 10.37765/ajmc.2024.89585

Rochelle Henderson, Julie Patterson, John Michael O'Brien

{"title":"Prescription rebate guarantees: employer insights.","authors":"Rochelle Henderson, Julie Patterson, John Michael O'Brien","doi":"10.37765/ajmc.2024.89585","DOIUrl":"https://doi.org/10.37765/ajmc.2024.89585","url":null,"abstract":"Objectives: To describe (1) rebate arrangements for specialty drugs, (2) the use and influence of benefits brokers and consultants, and (3) the importance of rebate-related factors when selecting a pharmacy benefits manager (PBM) among a sample of employers with self-funded pharmacy benefits.Study design: A national survey of employer drug benefit decision makers (N = 110) for organizations with self-insured pharmacy benefits.Methods: We summarized respondents' current rebate agreements for specialty drugs and their perspectives on the importance of rebates and rebate guarantees overall as well as by type of rebate agreement and by the person or entity identified as most influential in rebate strategy.Results: Nearly two-thirds of employers reported having rebate agreements with a rebate guarantee for specialty drugs (n = 69; 62.7%). The person or entity most influential to rebate strategy decisions was often a benefits consultant (37.3%), a human resources/benefits leader (29.1%), or a benefits broker (21.8%). Employers with rebate guarantees ascribed a higher level of importance to guarantees when selecting a PBM (median [IQR], 9 [7-10]) than employers receiving rebates without a guarantee (7 [6-8]) and those who do not receive rebates (7.5 [4-9]) (P = .001).Conclusions: These findings shed light on the importance of rebate guarantees and the role of employer benefits consultants and brokers in PBM selection. As the public discourse on PBMs and drug rebates continues, it is important to recognize the role employer benefits consultants may play in perpetuating employer reliance on guaranteed rebate arrangements.","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"30 11","pages":"574-580"},"PeriodicalIF":2.5,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142640214","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}

引用次数: 0