American Journal of Managed Care最新文献

{"title":"Unmet health care and health-related social needs of laundromat users.","authors":"Lindsey Jeanne Leininger, Courtney Bragg, Allister Chang, Andrea Palm","doi":"10.37765/ajmc.2025.89733","DOIUrl":"10.37765/ajmc.2025.89733","url":null,"abstract":"<p><strong>Objectives: </strong>To estimate the prevalence of unmet health care and health-related social needs (HRSNs) among laundromat users and examine differences by health insurance coverage.</p><p><strong>Study design: </strong>Cross-sectional observational study.</p><p><strong>Methods: </strong>We collected a survey from participants in a pilot intervention conducted in 14 Pennsylvania laundromats between September and December 2023. The measures included health insurance coverage, unmet health care needs, and unmet HRSNs. Descriptive analyses and linear probability regression models with laundromat fixed effects were used to estimate the overall prevalence of unmet needs and explore subgroup differences.</p><p><strong>Results: </strong>Among the 1995 sample members, approximately half (52.9%) had Medicaid coverage, 21.7% had private coverage, 14.5% were uninsured, 5.4% had Medicare, and 5.5% were dually enrolled in Medicare and Medicaid. The prevalence of having any unmet HRSN was higher than having any unmet health care need (54.3% vs 12.3%). Across unmet need measures, Medicaid sample members had 1.5 to 5 times higher levels relative to the privately insured. Differences by insurance coverage remained in fixed-effects analyses that limited comparisons to laundromat users at the same location.</p><p><strong>Conclusions: </strong>Laundromat-based outreach is likely most promising for Medicaid-serving stakeholders because Medicaid enrollees are disproportionately represented among laundromat users and have disproportionately high levels of unmet needs.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"233-239"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095777","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":"Longitudinal, relationship-based case management: a prospective cohort trial.","authors":"Patrick Runnels, Ryan Muskin, Mark Votruba, Peter J Pronovost, Afua Ansah, James Penman","doi":"10.37765/ajmc.2025.89731","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89731","url":null,"abstract":"<p><strong>Objectives: </strong>This study addresses the challenge of improving outcomes for the 5% of individuals with complex chronic diseases who utilize 50% of health care resources. Previous interventions targeting this population have shown limited impact, often due to transactional and time-limited approaches. This study proposes a longitudinal, relationship-based case management framework as an alternative solution.</p><p><strong>Study design: </strong>A nonrandomized, prospective cohort study was conducted among Medicaid enrollees with complex medical and social needs.</p><p><strong>Methods: </strong>The intervention involved case managers building strong interpersonal relationships over a minimum of 1 year, addressing barriers to care and facilitating solutions. Primary outcomes were total health care expenditures and patient-rated quality of life.</p><p><strong>Results: </strong>The intervention group exhibited a significant reduction in total health care costs over 1 year ($8568 per patient), with greater savings observed for patients with higher preintervention costs. Additionally, an estimated annual savings net of program costs of $248,121 was observed. Patient-rated quality of life showed substantial improvement, evident at both 6 months and 1 year post enrollment.</p><p><strong>Conclusions: </strong>This study demonstrates the effectiveness of a longitudinal, relationship-based case management approach in improving outcomes for individuals with complex medical, social, and behavioral needs. Unlike transactional interventions, this approach emphasizes partnership and customization, yielding substantial cost reductions and enhanced quality of life. Although limitations exist, including nonrandomization and staff diversity, this study provides a foundation for future research and scalability of similar interventions.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"216-221"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095759","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":"Using data exchange to improve quality reporting, target outreach, and reduce cost.","authors":"Barbara Rubino, Chelsea Hart-Connor, Todd A May","doi":"10.37765/ajmc.2025.89738","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89738","url":null,"abstract":"<p><p>The burden of collecting data and reporting on quality measures is a strain on both providers and payers, exacerbated by the multitude of required metrics and disparate data systems. Covered California, the California health benefits exchange that supports more than 1.9 million Californians receiving insurance through the Affordable Care Act, and insurance carrier Health Net, serving approximately 138,000 members on the exchange, implemented a novel approach to data exchange using Covered California's all-payer claims database (APCD). This initiative used historical cancer screening data for Health Net enrollees who had been insured under different Covered California plans in the prior 5 years and analyzed the impact of historical data sharing on screening rates, cost, and efficiency. Historical data exchange led to improved accuracy of quality measure reporting by up to 14% in breast cancer screening quality scores. Additionally, through reduced administrative costs and the elimination of duplicative testing, Health Net saw more than $640,000 in estimated potential cost savings. The success of the pilot between Covered California and Health Net has led to an expansion across all carriers, highlighting the potential of APCDs to facilitate more targeted quality improvement strategies and improve efficiency in health care. This initiative underscores the importance of innovative data exchange strategies to advance health care quality, efficiency, and equity.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"e138-e140"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095778","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":"Evaluating access to care for Medicare beneficiaries younger than 65 Years.","authors":"Emma M Achola, Shelley A Jazowski, Lauren Hersch Nicholas, Laura M Keohane, William A Wood, Christopher R Friese, Stacie B Dusetzina","doi":"10.37765/ajmc.2025.89732","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89732","url":null,"abstract":"<p><strong>Objectives: </strong>Individuals younger than 65 years can qualify for Medicare if they have long-term disabilities or certain qualifying conditions. These beneficiaries-particularly the non-dual-eligible population-may experience cost and access barriers to medical care. We examined the association between Medicare coverage type and reported barriers to care.</p><p><strong>Study design: </strong>Multivariable linear probability models assessed the association between self-reported Medicare coverage and patient-reported outcomes by dual-eligibility status.</p><p><strong>Methods: </strong>Using 2012-2020 data from the Health and Retirement Study, we compared self-reported sociodemographic and health-related characteristics of non-dual-eligible and dual-eligible beneficiaries aged 50 to 64 years by Medicare coverage type at their baseline interview. We then examined the following self-reported outcomes: experiencing cost-related medication nonadherence, delaying care due to cost, not having a usual source of care, and having trouble finding a doctor.</p><p><strong>Results: </strong>Among non-dual-eligible beneficiaries, enrollment in traditional Medicare (TM) plus supplemental coverage vs TM with no supplemental coverage was associated with lower reported rates of experiencing cost-related medication nonadherence (-7.5 percentage point [PP] change; 95% CI, -12.1 to -3.0), delaying care due to cost (-9.8 PP; 95% CI, -13.3 to -6.3), and having no usual source of care (-5.5 PP; 95% CI, -8.9 to -2.1). Compared with TM with no supplement, Medicare Advantage enrollment was associated with lower rates of delaying care due to cost (-4.2 PP; 95% CI, -7.6 to -0.7) and having no usual source of care (-5.2 PP; 95% CI, -8.2 to -2.3). Among dual-eligible beneficiaries, outcomes largely did not differ by coverage type. Switching from traditional Medicare to Medicare Advantage was associated with trouble finding a doctor for dual-eligible beneficiaries.</p><p><strong>Conclusions: </strong>Enrollment in less generous Medicare coverage was associated with greater cost and access barriers to care for beneficiaries younger than 65 years.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"222-229"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095717","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":"Quantifying the altruism value for a rare pediatric disease: Duchenne muscular dystrophy.","authors":"Jason Shafrin, Suhail Thahir, Alexa C Klimchak, Ivana Audhya, Lauren E Sedita, John A Romley","doi":"10.37765/ajmc.2025.89673","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89673","url":null,"abstract":"<p><strong>Objectives: </strong>To quantify the magnitude of altruism value as applied to a hypothetical new treatment for a rare, severe pediatric disease: Duchenne muscular dystrophy (DMD).</p><p><strong>Study design: </strong>Prospective survey of individuals not planning to have children in the future.</p><p><strong>Methods: </strong>A survey was administered to US adults (aged ≥ 21 years) not intending to have a child in the future to elicit willingness to pay (WTP) for government insurance coverage for a new hypothetical DMD treatment that improves mortality and morbidity relative to the current standard of care. A multiple random staircase design was used to identify an indifference point between status quo government insurance coverage and coverage with additional cost in taxes that would cover the treatment if unrelated individuals had a child with DMD. Altruism value was calculated as respondents' mean WTP.</p><p><strong>Results: </strong>Among 215 respondents, 54.9% (n = 118) were aged 25 to 44 years and 80.0% (n = 172) were women. Mean WTP for insurance coverage of the hypothetical DMD treatment for others was $80.01 (95% CI, $41.64-$118.37) annually, or $6.67 monthly, after adjustment to account for disease probability overestimation. The adjusted altruism value was higher than the ex ante per-person value using traditional cost-effectiveness approaches ($45.30/year). Without adjusting, individuals were willing to pay $799.11 annually ($66.59 monthly).</p><p><strong>Conclusions: </strong>Despite no possibility of accruing health benefits directly for themselves or their children, individuals had a high WTP for government insurance coverage of a novel treatment for this rare, severe pediatric disease.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"240-244"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095776","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":"Digital health implementation among older adults: health technology navigators' perspectives.","authors":"Katarina Wang, Ann Marie Hernandez, Veronica Penate, Anshu Abhat, Alejandra Casillas","doi":"10.37765/ajmc.2025.89736","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89736","url":null,"abstract":"<p><strong>Objectives: </strong>Despite the rise in health technology, a persistent digital divide affects underserved groups, including low-income, uninsured or underinsured, and limited English proficient (LEP) patients. This study highlights lessons learned from a unique stakeholder-health technology navigators-about factors affecting digital health use among older and linguistically diverse patients in one of the largest US safety-net health systems.</p><p><strong>Study design: </strong>We conducted in-depth interviews with Los Angeles County Department of Health Services (LAC DHS) navigators from June to December 2023. Discussions focused on their job role, identity, experiences supporting older patients (≥ 50 years) to register and use the patient portal, and linguistically diverse patients (primary language other than English or LEP) in this safety net.</p><p><strong>Methods: </strong>We used the Theoretical Domains Framework to create an interview guide. We interviewed 9 female and 2 male navigators across 9 LAC DHS clinics who were bilingual (English and Spanish). Interviews were transcribed and analyzed for major themes.</p><p><strong>Results: </strong>Three primary themes emerged from the qualitative analysis: characteristics of a successful navigator, patients' prior experiences with digital health, and barriers in the clinic.</p><p><strong>Conclusions: </strong>Navigators highlighted older patients' interest in learning to use digital tools and the need for support in digital health engagement. In describing their work with patients, navigators drew on their lived experiences with family and community to connect with these older patients in the Los Angeles safety-net health system. The lessons learned from these navigators can inform digital health engagement in other safety-net health settings so that they are more inclusive for older patients.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"e125-e131"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095729","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 John Michael O'Brien, PharmD, MPH.","authors":"John Michael O'Brien, Christina Mattina","doi":"10.37765/ajmc.2025.89729","DOIUrl":"10.37765/ajmc.2025.89729","url":null,"abstract":"<p><p>To mark the 30th anniversary of The American Journal of Managed Care (AJMC), each issue in 2025 includes reflections from a thought leader on what has changed over the past 3 decades and what's next for managed care. The May issue features a conversation with John Michael O'Brien, PharmD, MPH, a member of AJMC's editorial board and the president and CEO of the National Pharmaceutical Council.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"209-211"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095773","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":"Predicting mortality risk using the PREVENT equation across diverse racial groups.","authors":"Ofer Kobo, Martin K Rutter, Shivani Misra, Erin D Michos, Phyo K Myint, Ariel Roguin, Louise Y Sun, Mamas A Mamas","doi":"10.37765/ajmc.2025.89734","DOIUrl":"10.37765/ajmc.2025.89734","url":null,"abstract":"<p><strong>Objectives: </strong>The Predicting Risk of CVD Events (PREVENT) score offers a contemporary tool for assessing cardiovascular risk without incorporating race, which has raised concerns about its performance across diverse racial and ethnic groups. We aimed to validate the performance of the PREVENT cardiovascular risk equation across diverse racial and ethnic groups and assess its association with long-term all-cause and cardiovascular mortality.</p><p><strong>Study design: </strong>Observational cohort study using nationally representative data from the National Health and Nutrition Examination Survey (NHANES) linked with mortality data.</p><p><strong>Methods: </strong>Using 10-year data from the NHANES (2009-2018), we analyzed a cohort of more than 177 million adults in the US to evaluate the association between baseline cardiovascular risk, as determined by the PREVENT overall cardiovascular disease risk equation, and long-term all-cause and cardiovascular mortality across racial and ethnic groups. The cohort was stratified by race and ethnicity. We employed Cox proportional hazards models to assess the relationship between cardiovascular risk and mortality.</p><p><strong>Results: </strong>Our analysis revealed significant variations in baseline cardiovascular risk across racial and ethnic groups. Across all groups, there was a consistent incremental increase in both cardiovascular and all-cause mortality rates with higher estimated cardiovascular risk. During up to a decade of follow-up, we found that individuals at high risk had a 6-fold higher risk of all-cause mortality and a 9-fold higher risk of cardiovascular mortality compared with individuals at low cardiovascular risk. The association between cardiovascular risk and mortality remained consistent across all racial and ethnic groups, albeit with very different risk estimates. For every 5% increase in estimated 10-year cardiovascular risk, there was a 54% increase in all-cause mortality and a 57% increase in cardiovascular mortality.</p><p><strong>Conclusions: </strong>These study findings validate PREVENT scores across diverse racial and ethnic populations, highlighting the tool's effectiveness in predicting cardiovascular risk and mortality regardless of race or ethnicity.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"e113-e119"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095774","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":"How employers can fight the price crisis.","authors":"Torie Nugent-Peterson, Ryan Olmstead","doi":"10.37765/ajmc.2025.89730","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89730","url":null,"abstract":"<p><p>The US is in a health care price crisis that significantly impacts employees, employers, and public purchasers. With employer-sponsored health insurance covering 60% of Americans as of 2024, plan sponsors must consider policy advocacy as a part of their long-term cost containment strategy. Plan sponsors can leverage membership in national and regional health care business coalitions, such as The ERISA Industry Committee and the Employers' Forum of Indiana, for policy advocacy and education at federal and state levels. Coalition successes include Texas House Bill 711, which combats anticompetitive contracting practices, and Indiana's House Enrolled Act 1259, which enhances pricing transparency. Although navigating policy advocacy may seem daunting, Catalyst for Payment Reform emphasizes the importance of aligning public policy strategies with procurement/purchasing strategies. By engaging in tailored advocacy efforts, plan sponsors can help lower health care costs, improve access, and ensure sustainable benefits for their plan members.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"212-214"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095735","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":"Predictive models for low birth weight: a comparative analysis of algorithmic fairness-improving approaches.","authors":"Clare C Brown, Horacio Gomez-Acevedo, Benjamin C Amick, J Mick Tilford, Keneshia Bryant-Moore, Michael Thomsen","doi":"10.37765/ajmc.2025.89737","DOIUrl":"10.37765/ajmc.2025.89737","url":null,"abstract":"<p><strong>Objective: </strong>Evaluating whether common algorithmic fairness-improving approaches can improve low-birth-weight predictive model performance can provide important implications for population health management and health equity. This study aimed to evaluate alternative approaches for improving algorithmic fairness for low-birth-weight predictive models.</p><p><strong>Study design: </strong>Retrospective, cross-sectional study of birth certificates linked with medical insurance claims.</p><p><strong>Methods: </strong>Birth certificates (n = 191,943; 2014-2022) were linked with insurance claims (2013-2021) from the Arkansas All-Payer Claims Database to assess alternative approaches for algorithmic fairness in predictive models for low birth weight (< 2500 g). We fit an original model and compared 6 fairness-improving approaches using elastic net models trained and tested with 70/30 balanced random split samples and 10-fold cross validation.</p><p><strong>Results: </strong>The original model had lower accuracy (percent predicted correctly) in predicting low birth weight among Black, Native Hawaiian/Other Pacific Islander, Asian, and unknown racial/ethnic populations relative to White individuals. For Black individuals, accuracy increased with all 6 fairness-improving approaches relative to the original model; however, sensitivity (true-positives correctly predicted as low birth weight) significantly declined, as much as 31% (from 0.824 to 0.565), in 5 of 6 approaches.</p><p><strong>Conclusions: </strong>When developing and implementing decision-making algorithms, it is critical that model performance metrics align with management goals for the predictive tool. In our study, fairness-improving models improved accuracy and area under the curve scores for Black individuals but decreased sensitivity and negative predictive value, suggesting that the original model, although unfair, was not improved. Implementation of unfair models for allocating preventive services could perpetuate racial/ethnic inequities by failing to identify individuals most at risk for a low-birth-weight delivery.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"e132-e137"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12109546/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095775","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}