American Journal of Managed Care最新文献

{"title":"Impact of telemedicine use on outpatient-related CO2 emissions: estimate from a national cohort.","authors":"Benjo Delarmente, Artem Romanov, Manying Cui, Chi-Hong Tseng, Melody Craff, Dale Skinner, Michael Hadfield, Catherine A Sarkisian, Cheryl L Damberg, A Mark Fendrick, John N Mafi","doi":"10.37765/ajmc.2025.89714","DOIUrl":"10.37765/ajmc.2025.89714","url":null,"abstract":"<p><strong>Objective: </strong>The US health care system contributes to approximately 9% of domestic US greenhouse gas emissions, exacerbating climate change and threatening human health. By substituting for in-person visits, telemedicine may represent a means of emission avoidance.</p><p><strong>Study design: </strong>Leveraging multipayer claims data, we developed models based on various assumptions to estimate ranges of emissions from travel averted by telemedicine utilization between April 1, 2023, and June 30, 2023.</p><p><strong>Methods: </strong>We estimated the carbon dioxide (CO2) emissions averted from the avoidance of travel by patients using telemedicine as a substitute for their usual source of in-person care at post-public health emergency rates through a modeling analysis of nationwide multipayer claims data representing 19% of US insured adults; findings were extrapolated to the entire US insured adult population.</p><p><strong>Results: </strong>We quantified a monthly average of 1,481,530 US telemedicine visits (65,733 rural) during the study period. Between 740,765 and 1,348,192 of these were estimated to have substituted for in-person visits. Using inputs of 2021 electric vehicle (EV) production share and emissions per mile, we estimated that between 4,075,065 and 7,489,486 kg of CO2 are averted due to telemedicine use each month. Estimates accounting for different assumptions including EV and public transportation use produce a range of 4 million (most conservative) to 8.9 million (least conservative) kg of CO2 averted per month. Extrapolating to the entire US adult population, we estimate that monthly emissions averted range from 21.4 to 47.6 million kg of CO2-roughly equivalent to the monthly emissions of 61,255 to 130,076 gasoline-powered passenger vehicles.</p><p><strong>Conclusion: </strong>Our results suggest that telemedicine use at 2023 rates modestly decreases the carbon footprint of US health care delivery.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":" ","pages":"447-451"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144977552","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":"Addressing health care disparities using a health plan quality measures index.","authors":"Joseph A Stankaitis, Samyukta Singh, Sean Nicholson","doi":"10.37765/ajmc.2025.89701","DOIUrl":"10.37765/ajmc.2025.89701","url":null,"abstract":"<p><strong>Objectives: </strong>To develop an index using publicly available data to measure progress in addressing health care disparities.</p><p><strong>Study design: </strong>Given inherent socioeconomic differences between individuals insured by commercial/private insurance and those insured by Medicaid, we selected, based on set criteria, a portfolio of metrics comparing the national average performance between these 2 product lines from the Healthcare Effectiveness Data and Information Set (HEDIS).</p><p><strong>Methods: </strong>Using data from the National Committee for Quality Assurance publicly reported national averages for HEDIS quality metrics from commercial/private insurance and Medicaid managed care, observed differences for these measures were aggregated to establish the index.</p><p><strong>Results: </strong>The Health Insurance Disparities Index (HeIDI) demonstrated a gradual worsening of disparities nationally between individuals with commercial/private insurance and individuals with Medicaid insurance from 2017 to 2022, with a substantial deterioration during and after the COVID-19 pandemic years.</p><p><strong>Conclusions: </strong>Because HeIDI assesses the status of health care disparities impacting individuals of lower socioeconomic status by insurance lines, it is useful for assessing performance for health plans, states, regions, and health systems utilizing verified HEDIS data.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":" ","pages":"468-475"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144977543","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":"Managed care reflections: a Q&A with Dora Hughes, MD, MPH.","authors":"Dora Hughes, Christina Mattina","doi":"10.37765/ajmc.2025.89784","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89784","url":null,"abstract":"<p><p>To mark the 30th anniversary of The American Journal of Managed Care (AJMC), each issue in 2025 includes a special feature: reflections from a thought leader on what has changed-and what has not-over the past 3 decades and what's next for managed care. The September issue features a conversation with Dora Hughes, MD, MPH, chief medical officer and director of the Center for Clinical Standards and Quality at CMS.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 9","pages":"441-442"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145087841","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":"A learning health care community: integrating research and practice at scale.","authors":"Leif I Solberg, David Kurtzon, Elizabeth Cinqueonce, Glyn Elwyn, Steven P Dehmer","doi":"10.37765/ajmc.2025.89795","DOIUrl":"10.37765/ajmc.2025.89795","url":null,"abstract":"<p><strong>Objectives: </strong>The cost and quality problems of health care in the US have been aggravated by separate silos for research and care delivery that limit the pragmatic value of research questions and delay the implementation and spread of what is learned. We describe a variation on the learning health system concept that engaged various stakeholders in a single state to work together on simultaneous knowledge generation and dissemination built on research questions that arose from the user community.</p><p><strong>Study design: </strong>Observational study.</p><p><strong>Methods: </strong>We identified the 12 strategies used by the leaders of this project to develop and operationalize an observational study in a large sample of primary care clinics in Minnesota that had implemented care coordination as part of attaining certification as health care homes.</p><p><strong>Results: </strong>The collaboration included the state health department, a research institute embedded in a health system, the 5 main payers, a measurement/reporting organization, 42 care systems with 316 primary care clinics, patient partners, and national consultants. This community developed a research proposal for an observational study about how to improve care coordination in primary care. We describe how this collaborative implemented and disseminated the study findings.</p><p><strong>Conclusions: </strong>By employing 12 strategies to answer questions that arose from the health care community, we opened a door between the 2 halves of the house of medicine.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 Spec. No. 10","pages":"SP691-SP697"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145056063","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":"Impact of more primary care visits on commercial health care costs.","authors":"Tory M Wolff, Jacob Wiesenthal","doi":"10.37765/ajmc.2025.89786","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89786","url":null,"abstract":"<p><strong>Objective: </strong> To evaluate the relationship between the frequency of routine primary care visits and total health care expenditures among commercially insured adults.</p><p><strong>Study design: </strong> Retrospective cross-sectional statistical analysis of a nationally representative data set of health care utilization and expenditures over a 2-year period.</p><p><strong>Methods: </strong>We used multivariate regression analysis to evaluate the association between the annualized number of visits with a primary care physician for routine care and total health care expenditures for commercially insured adults younger than 65 years, adjusting for underlying clinical complexity measured through risk scoring. Data were drawn from information collected by the Agency for Healthcare Research and Quality between 2021 and 2022.</p><p><strong>Results: </strong>For a sample cohort of 3879 participants, more frequent primary care visits were associated with incremental reductions in expenditures only for participants with high underlying clinical complexity. A relative risk level of approximately 2 times the average commercially insured adult was identified as an inflection point, above which cost reductions vs counterfactual prediction were observed, up to a limited number of visits.</p><p><strong>Conclusions: </strong> Our results show a relationship between primary care visit frequency and health care expenditures with similar directionality and risk dependency as has been observed in other studies for Medicare-insured adults. This finding suggests that certain commercial populations may benefit from risk-stratified, high-touch primary care models like those being employed for some Medicare populations. The health care cost reduction benefits of these models appear premised more on clinical need than coverage type. Demonstrating this relationship is useful for health care providers, insurers, and policy makers who are developing advanced primary care models.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 9","pages":"457-461"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145087858","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":"State restrictions on prior authorization.","authors":"David H Howard, Alissa Durakovic","doi":"10.37765/ajmc.2025.89785","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89785","url":null,"abstract":"<p><p>Many states are enacting restrictions on insurers' prior authorization policies, but these laws may increase costs and lead to other undesirable consequences.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 9","pages":"444-445"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145087971","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":"Building a payment model for health coaching in primary care: lessons from Tennessee.","authors":"James E Bailey, Susan W Butterworth, Ashley Ellis, Jesse C Crosson, Cy Huffman","doi":"10.37765/ajmc.2025.89797","DOIUrl":"10.37765/ajmc.2025.89797","url":null,"abstract":"<p><strong>Objectives: </strong>To describe Tennessee's process for convening key stakeholders to develop uniform payment guidelines that encourage increased preventive service delivery and provide lessons learned that can inform similar work in other states.</p><p><strong>Study design: </strong>Descriptive case study.</p><p><strong>Methods: </strong>Observational.</p><p><strong>Results: </strong>Tennessee's statewide multistakeholder health care extension cooperative, the Tennessee Heart Health Network, was instrumental in convening major stakeholders, including Medicaid, health plan, and safety-net provider representatives. Stakeholders reached consensus and developed and implemented common guidelines for reimbursement of health coaching services focused on cardiovascular health in the context of team-based primary care.</p><p><strong>Conclusions: </strong>Tennessee's experience suggests that statewide multistakeholder health care extension cooperatives can facilitate Medicaid and Medicare payment policy alignment and delivery system improvement. they have potential to yield important benefits in state-based efforts to improve access and quality of care.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 Spec. No. 10","pages":"SP709-SP720"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145056098","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":"Workforce innovation reduces Medicaid costs in chronic care.","authors":"Manmeet Kaur, Brett Ives, Tod Mijanovich, Prabhjot Singh, Jamillah Hoy-Rosas, Kevin Francis, Binoy Bhansali, Linda Green","doi":"10.37765/ajmc.2025.89796","DOIUrl":"10.37765/ajmc.2025.89796","url":null,"abstract":"<p><p>Effective chronic disease management must extend beyond clinical visits into the daily lives of patients, particularly in low-income communities with a disproportionate burden of illness. This study examines City Health Works' intervention model, which deploys highly trained nonclinical health coaches as tightly integrated extensions of primary care teams to support patient self-management. In a 12-month evaluation of Medicaid patients with poorly controlled diabetes and hypertension at a NYC Health + Hospitals outpatient site, the intervention achieved significant reductions in health care costs compared with a matched comparison group. These findings suggest that a technology-enabled, community-based workforce model can cost-effectively improve chronic disease management when closely linked to primary care delivery.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 Spec. No. 10","pages":"SP698-SP708"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145056155","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":"Health care utilization and cost of diagnostic testing for respiratory infections.","authors":"Azia Evans, Riddhi Doshi, Jason Yeaw, Katharine Coyle, Steven E Goldberg, Elizabeth J Wang, Maren S Fragala, Jairus Reddy","doi":"10.37765/ajmc.2025.89789","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89789","url":null,"abstract":"<p><strong>Objectives: </strong>This study compared all-cause health care resource use (HCRU) and costs between patients with acute oropharyngeal infections and respiratory tract infections (RTIs) receiving targeted syndromic real-time polymerase chain reaction (RT-PCR) tests with next-day results vs matched patients receiving other/no diagnostic tests.</p><p><strong>Study design: </strong>Propensity-matched, retrospective study.</p><p><strong>Methods: </strong>Two cohorts with International Classification of Diseases, Tenth Revision, Clinical Modification codes for diagnosis or symptom(s) of oropharyngeal infection or RTI (first diagnosis = index) on an outpatient claim were identified in the IQVIA PharMetrics Plus database (July 2020-October 2023). HCRU and costs were examined over 6 months post index across 5 subcohorts: patients receiving syndromic RT-PCR and 4 matched subcohorts (other PCR, point-of-care [POC] only, culture, or no test).</p><p><strong>Results: </strong>The mean (SD) costs for postindex total outpatient services ($2598 [$7564] vs $2970 [$8417]; P < .0001), physician office visit ($624 [$1150] vs $689 [$1082]; P = .0002), emergency department (ED) ($290 [$1145] vs $397 [$1630]; P = .0192), and other medical services ($1684 [$6799] vs $1883 [$7568]; P < .0001) were significantly lower for the oropharyngeal RT-PCR subcohort than the matched culture subcohort. The mean (SD) postindex costs for any outpatient medical services ($2796 [$11,453] vs $3221 [$7873]; P < .0001), physician office visits ($525 [$974] vs $703 [$2635]; P = .0057), ED visits ($253 [$1036] vs $355 [$1300]; P = .0011), and other medical services ($2018 [$10,986] vs $2163 [$6458]; P < .0001) were significantly lower for the RTI RT-PCR subcohort than the matched culture subcohort. Patients in both RT-PCR subcohorts had lower utilization of other medical services and any outpatient services compared with all matched comparator subcohorts.</p><p><strong>Conclusions: </strong>This propensity-matched study provides evidence on the economic impact of syndromic RT-PCR tests for respiratory infections, highlighting their advantages over traditional diagnostic methods.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 9","pages":"e249-e257"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145087782","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":"Overcoming weight bias in health care systems.","authors":"Theodore K Kyle, W Timothy Garvey, Julia P Dunn, Ximena Ramos Salas, Fatima Cody Stanford","doi":"10.37765/ajmc.2025.89788","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89788","url":null,"abstract":"<p><p>This commentary calls for health care systems to deliver equitable care for people living with obesity by addressing weight bias and updating standards in obesity care.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 9","pages":"e241-e243"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145087895","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}