American Journal of Managed Care最新文献

{"title":"The cost of implementing and sustaining the Massachusetts model.","authors":"Philip J Jeng, Ali Jalali, Kai Yeung, Casey Luce, Thanh Lu, Amy K Lee, Colleen T LaBelle, Katharine A Bradley, Sean M Murphy","doi":"10.37765/ajmc.2026.89923","DOIUrl":"https://doi.org/10.37765/ajmc.2026.89923","url":null,"abstract":"<p><strong>Objectives: </strong>To identify and value resources required to implement and sustain the Massachusetts model of office-based addiction treatment (MA Model) in the Primary Care Opioid Use Disorders Treatment trial (NCT03407638) using a nurse care manager (NCM) to support medication for opioid use disorder in primary care settings.</p><p><strong>Study design: </strong>A site-specific microcosting analysis was conducted via activity-based costing. Guided by a structured costing instrument, we conducted semistructured interviews with relevant personnel and assigned nationally representative costs.</p><p><strong>Methods: </strong>Data came from 6 health care systems. Costs were categorized as fixed start-up, time dependent, or variable and estimated as annual per-clinic and per-patient costs for implementation and sustainment phases.</p><p><strong>Results: </strong>Mean implementation cost (ie, year 1 fixed start-up, time-dependent, and variable) was $238,888 per clinic ($3185 per patient); each subsequent year cost $229,676 ($3062 per patient), assuming 75 patients per month and 29% new patient case mix. Mean onetime fixed start-up costs were $9212 per clinic and included supplies and training. Time-dependent costs were $70,446 per clinic and included rent and meetings. Variable costs were $159,229 per clinic and included NCMs' and prescribers' clinical duties. On average, NCMs spent 1967.6 hours on MA Model-related work per year (26.2 hours per patient). In sensitivity analyses, costs varied drastically with patient caseload, provider mix, and new patient case mix.</p><p><strong>Conclusions: </strong>Fixed start-up and time-dependent costs were minimal. Variable costs were 66.7% of implementation costs and 69.3% of costs annually afterward. The primary cost driver was NCM time conducting MA Model-related work. The additional value of the model will depend on associated downstream outcomes. These results may be helpful to health care systems considering implementing the MA Model.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 4","pages":"e110-e117"},"PeriodicalIF":2.1,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147788242","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":"Association of Medicare enrollment with increased inpatient coding intensity.","authors":"Michael I Ellenbogen, Daniel J Brotman","doi":"10.37765/ajmc.2026.89919","DOIUrl":"https://doi.org/10.37765/ajmc.2026.89919","url":null,"abstract":"<p><strong>Objectives: </strong>Significant variation in coding intensity exists across patients and institutions, with important implications for reimbursement and risk-adjusted quality metrics. The degree to which coding intensity for hospitalized patients may be a function of primary payer is not well understood. We sought to measure differences in coding intensity between commercially insured and Medicare, Medicaid and Medicare, and self-pay and Medicare inpatient encounters for the same cohort of patients.</p><p><strong>Study design: </strong>Regression discontinuity, leveraging the fact that patients typically enroll in Medicare at age 65 years.</p><p><strong>Methods: </strong>A multivariable linear regression was estimated to evaluate the relationship between the outcomes of interest and primary payer, controlling for age, age by payer interaction term, and inpatient visit count. Our analysis included Florida inpatients with at least 1 commercially insured, Medicaid, or self-pay inpatient hospitalization before age 65 years and at least 1 inpatient Medicare hospitalization at 65 years and older, with patients serving as their own controls. The outcome of interest was the number of hospital discharge diagnoses. Outcomes were measured separately for each group (commercial insurance to Medicare, Medicaid to Medicare, and self-pay to Medicare).</p><p><strong>Results: </strong>Medicare inpatient encounters were associated with 0.8 (95% CI, 0.4-1.2), 1.0 (95% CI, 0.5-1.5), and 2.0 (95% CI, 1.2-2.8) more discharge diagnoses than commercially insured, Medicaid, and self-pay inpatient encounters, respectively.</p><p><strong>Conclusions: </strong>Our findings suggest that Medicare inpatient encounters are associated with higher coding intensity than commercially insured, Medicaid, or self-pay inpatient encounters for those same individuals prior to age 65 years. This has important implications for the impact that insurance status may have on risk-adjusted quality measures.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 4","pages":"230-236"},"PeriodicalIF":2.1,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147788177","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":"Community response teams: extending the rapid response model to outpatient care.","authors":"Sanjay Basu, Scott Anders","doi":"10.37765/ajmc.2026.89921","DOIUrl":"https://doi.org/10.37765/ajmc.2026.89921","url":null,"abstract":"<p><strong>Objective: </strong>To propose community response teams (CRTs) as a systematic managed care approach that applies rapid response principles to prevent clinical deterioration and reduce costs in outpatient settings.</p><p><strong>Study design: </strong>Conceptual framework analysis with evidence review.</p><p><strong>Methods: </strong>We analyzed structural parallels between hospital rapid response teams and community-based systems, reviewed evidence on early intervention for rising-risk patients, and examined implementation models for managed care organizations.</p><p><strong>Results: </strong>CRTs can leverage existing care management infrastructure while focusing on rising-risk patients identified through predictive analytics rather than traditional high-cost populations. Multisite implementation demonstrates significant improvements in patient outcomes, chronic disease control, and reduced emergency department visits and hospitalizations, enabling shared savings models that fully fund proactive interventions.</p><p><strong>Conclusions: </strong>CRTs represent a paradigm shift in managed care population health management, providing a scalable, cost-effective approach to preventing avoidable clinical deterioration while generating measurable return on investment through reduced medical expenditures.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 4","pages":"e100-e102"},"PeriodicalIF":2.1,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147788180","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":"Biosimilar interchangeability and substitution in the US: what comes next?","authors":"Benjamin N Rome, Anushka Bhaskar, Aaron S Kesselheim","doi":"10.37765/ajmc.2026.89826","DOIUrl":"10.37765/ajmc.2026.89826","url":null,"abstract":"<p><p>In 2009, Congress created a regulatory pathway for biosimilars to encourage competition and address rising spending on biologic drugs. One barrier to adopting biosimilars in the US is that the FDA has traditionally required additional testing for biosimilars to be deemed interchangeable with the original biologic. This analysis reviews the history and current status of biosimilar regulation in the US, concluding that changing the FDA's interchangeability standards-as proposed by some policy makers-is a potentially useful but likely insufficient step to improve biosimilar competition in the US. Other policy options include more state laws allowing pharmacists to automatically substitute biosimilars, addressing strategies by payers and pharmacy benefit managers that inhibit biosimilar competition, and implementing more widespread education of clinicians and patients to build confidence about biosimilars. Other policies to ensure the affordability of biologic drugs include expanding Medicare's price negotiation to cover biologics with or without biosimilar competition.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":" ","pages":"198-201"},"PeriodicalIF":2.1,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147469975","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":"Integrated care for chronic conditions: a randomized care management trial.","authors":"Kelly Williams, Jane N Kogan, Sarah Markwardt, Chaeryon Kang, Doug Landsittel, Ellen Beckjord, Jordan F Karp, Dan Swayze","doi":"10.37765/ajmc.2026.89844","DOIUrl":"10.37765/ajmc.2026.89844","url":null,"abstract":"<p><strong>Objectives: </strong>Health care systems employ community-based solutions to help individuals manage multiple chronic conditions (MCC). Little knowledge exists on how to optimally translate evidence-based integrated care management models into widespread improvements in patient-centered outcomes. This study aimed to compare effectiveness and differential impact of 3 integrated care management delivery methods.</p><p><strong>Study design: </strong>Individual, stratified randomized trial with a 2:2:1 ratio for high-touch (in person), high-tech (remote monitoring), and optimal discharge planning (ODP; telephonic) delivery methods with 12-month follow-up.</p><p><strong>Methods: </strong>The UPMC Health Plan provided care management to adult Medicaid and Medicare-Medicaid beneficiaries with MCC who were recently discharged from an inpatient hospitalization. Primary (90-day readmission, health status, patient activation) and secondary (30-day readmission; functional status; quality of life; care satisfaction; emergent care use; engagement in primary, specialty, and mental health care; gaps in care) outcomes were assessed.</p><p><strong>Results: </strong>The analytic sample (n = 1387) included Medicaid (79.5%) or dually eligible (20.5%) beneficiaries with MCC (63.0% female, 73.0% White, and 21.6% Black). We found no evidence of a treatment effect on 90-day readmission rates (P = .669). There was a significant improvement over time for health status (P < .0001) but no significant difference by intervention (P = .866). Patient activation showed a significant time-by-treatment interaction (P = .021), with a significant difference (from baseline to 12 months) for the high-touch approach compared with ODP (adjusted difference of 2.69 points; SE = 1.22; P = .028). Participant subgroups (race, age, illness complexity, and comorbid behavioral health conditions) showed no statistically significant differences by interventions or over time on the primary outcomes.</p><p><strong>Conclusions: </strong>Results demonstrate how health care systems can leverage a variety of impactful, person-centered care management approaches without compromising patient outcomes.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":" ","pages":"202-210"},"PeriodicalIF":2.1,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147470042","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":"Utilization by high-cost, high-need Medicaid patients receiving social worker care coordination.","authors":"Nicolas M Oreskovic, Ann E Erwin, Zachary A Allon, Hang Lee, Marcela G Del Carmen","doi":"10.37765/ajmc.2026.89922","DOIUrl":"https://doi.org/10.37765/ajmc.2026.89922","url":null,"abstract":"<p><strong>Objectives: </strong>Office-based care coordination programs are increasingly utilizing social work-trained care coordinators to manage high-cost, high-need (HCHN) patients with increased psychosocial risk, including patients covered by Medicaid. Whether utilization of social worker care coordinators (SWCCs) with HCHN Medicaid patients impacts health care utilization is not clear, so we conducted a wait-list randomized controlled trial to test whether social worker care coordination decreases health care utilization and costs in HCHN Medicaid patients.</p><p><strong>Study design: </strong>Prospective enrollment with computer randomization 1:1 to an intervention group receiving SWCC office-based care coordination or to a control group.</p><p><strong>Methods: </strong>HCHN patients (N = 252) were randomly assigned to enrollment in an office-based care coordination program with SWCC engagement or to a wait-list control group. Total numbers of emergency department (ED) visits and hospitalizations and total medical expenditure (TME) within the preceding 12 months were collected at baseline and then again at 1 year and 2 years after study group assignment. Health care utilization and costs were compared using mixed-effects models.</p><p><strong>Results: </strong>Patients enrolled in an outpatient SWCC program had an increased number of hospitalizations compared with wait-listed control patients. There were no differences in the number of ED visits or in TME between groups.</p><p><strong>Conclusions: </strong>Enrollment for up to 2 years in an office-based social worker-led care coordination program did not reduce health care utilization or costs in HCHN Medicaid patients.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 4","pages":"e103-e109"},"PeriodicalIF":2.1,"publicationDate":"2026-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147788199","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":"Cost-effectiveness of integrated behavioral health for depression, anxiety, and chronic pain.","authors":"Dennis Xuan, Jeffrey Burton, Lizheng Shi, Eboni G Price-Haywood","doi":"10.37765/ajmc.2026.89913","DOIUrl":"10.37765/ajmc.2026.89913","url":null,"abstract":"<p><strong>Objective: </strong>To conduct a cost-effectiveness analysis comparing behavioral health integration (BHI) in primary care vs clinical decision support (usual care) for adult patients with depression and/or anxiety taking chronic opioid therapy for noncancer pain.</p><p><strong>Study design: </strong>Piggyback economic analysis of data collected for 632 adult patients during a pragmatic, stepped-wedge, type 2 effectiveness-implementation hybrid trial conducted in a health system in Louisiana between April 2019 and June 2022.</p><p><strong>Methods: </strong>The study used decision tree analysis. The base case modeled study patients and assessed costs associated with interventions, acute care, ambulatory utilization, and prescriptions. Efficacy measures were modeled using quality-adjusted life-years (QALYs) and morphine equivalent daily dose (MEDD). Sensitivity analyses included 1-way sensitivity analysis and probabilistic sensitivity analysis (PSA). A US-based willingness to pay threshold range of $100,000 to $150,000 per QALY was used.</p><p><strong>Results: </strong>In the base case, the BHI group incurred a cost of $10,489.19 per patient for 1 year compared with $5673.96 for usual care. BHI was associated with 0.0439 QALYs gained, which yielded an incremental cost-effectiveness ratio (ICER) of $108,784 per QALY. The BHI group had a MEDD reduction of 7.3 mg/d compared with an increase of 2.0 mg/d among usual care. This translates into an ICER of $513.51 per 1-mg/d reduction. One-way sensitivity analysis and PSA indicated that the cost of prescriptions for both study groups as well as the cost of primary care providers and licensed clinical social workers for the BHI group were the biggest drivers of cost-effectiveness.</p><p><strong>Conclusions: </strong>BHI was cost-effective from the health system perspective, with reductions in prescription drug expenses being the primary driver of savings.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":" ","pages":""},"PeriodicalIF":2.1,"publicationDate":"2026-03-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13127833/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147470115","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}

{"title":"Inflation Reduction Act impact on the hematology/oncology treatment landscape.","authors":"Mei Ka Fong, Grace Elsey, Allison Karabinos, Julia Lea Ziegengeist, Donald C Moore","doi":"10.37765/ajmc.2026.89891","DOIUrl":"https://doi.org/10.37765/ajmc.2026.89891","url":null,"abstract":"<p><p>The Inflation Reduction Act (IRA) represents a transformative shift in US health care policy by enabling Medicare to negotiate drug prices for high-expenditure medications, with significant implications for hematology and oncology treatment. This commentary explores the potential clinical impact of the IRA on selected cancer therapies and cancer-related supportive care agents, including apixaban (Eliquis), rivaroxaban (Xarelto), ibrutinib (Imbruvica), acalabrutinib (Calquence), enzalutamide (Xtandi), palbociclib (Ibrance), and pomalidomide (Pomalyst). These agents, used across various cancer types including chronic lymphocytic leukemia, prostate cancer, breast cancer, and multiple myeloma, are central to current treatment paradigms and have high utilization among the Medicare population. The IRA's negotiated pricing may improve drug affordability and access, influence prescribing patterns, and shift prescribing practice. However, clinical considerations, including efficacy, toxicity profiles, and overall survival benefits, remain critical in guiding therapeutic decisions. As cost-effectiveness analyses evolve in response to pricing changes, the IRA may ultimately reshape the oncology treatment landscape by aligning economic value with patient-centered care.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 3","pages":"133-137"},"PeriodicalIF":2.1,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147522601","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":"Neighborhood opportunities and pediatric health care utilization: implications for Medicaid managed care.","authors":"Shamly Austin, Abisola Olaniyan, Haiyan Qu","doi":"10.37765/ajmc.2026.89894","DOIUrl":"https://doi.org/10.37765/ajmc.2026.89894","url":null,"abstract":"<p><strong>Objectives: </strong>Disparities in health care utilization exist, particularly among children in socially disadvantaged neighborhoods. This study examined the relationship between neighborhood opportunity and health care utilization among pediatric Medicaid managed care beneficiaries, identifying key areas for interventions to address disparities and improve pediatric health outcomes.</p><p><strong>Study design: </strong>We conducted a retrospective cross-sectional analysis of a merged 2022 administrative claims data set with the Child Opportunity Index (COI) 3.0 database for Medicaid managed care beneficiaries younger than 21 years who were continuously enrolled for 12 months (N = 157,261).</p><p><strong>Methods: </strong>Generalized linear models (logistic regression and zero-inflated negative binomial regression) were used to examine the association between neighborhood opportunities and health care utilization (measured by primary care physician [PCP] visits, emergency department [ED] visits, and hospitalizations) while adjusting for confounders.</p><p><strong>Results: </strong>Compared with those in high-opportunity neighborhoods, pediatric beneficiaries in very low-, low-, and moderate-opportunity neighborhoods were 11.5 percentage points, 5.1 percentage points, and 2.2 percentage points less likely to have PCP visits, respectively, and 1.4 times, 1.2 times, and 1.1 times more likely to visit the ED. Hospitalizations were 0.5 percentage points more likely in very low-opportunity neighborhoods.</p><p><strong>Conclusions: </strong>The results corroborate that health care utilization varies by neighborhood opportunity levels. Managed care organizations can use the COI to address disparities in pediatric beneficiaries' health care utilization. Findings underscore the differences in health care utilization that may be a basis for researchers, policy analysts, and decision makers to further investigate underlying unmet needs that affect pediatric health care utilization in lower opportunity neighborhoods.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 3","pages":"154-161"},"PeriodicalIF":2.1,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147522592","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":"Exploring novel management options for alopecia areata.","authors":"Libbi Green, Emma Guttman, Mark Lebwohl, Benjamin Ungar","doi":"10.37765/ajmc.2026.89904","DOIUrl":"10.37765/ajmc.2026.89904","url":null,"abstract":"<p><p>Alopecia areata (AA) is a chronic autoimmune disease characterized by a breakdown of immune privilege, resulting in an inflammatory response to hair follicles that can cause hair loss. Beyond its visible manifestations, AA imposes a considerable psychosocial burden and substantial economic impact due to increased health care utilization. There is no cure for AA, and management may be challenging due to the heterogeneic and recurrent nature of the disease. Attenuating the autoimmune response to hair follicles and stimulating hair regrowth in affected areas are key goals of AA treatment. Given its central role in mediating AA-related inflammation, the JAK-STAT pathway is a common target of current pharmacological strategies. Three JAK inhibitors are currently FDA-approved for severe AA: baricitinib, ritlecitinib, and deuruxolitinib. The safety and efficacy of these agents have been demonstrated in phase 3 trials. To support optimal outcomes for patients, there is an opportunity to recognize AA as a complex, immune-mediated condition rather than just a cosmetic concern. Aligning managed care coverage criteria with this clinical perspective and facilitating timely access to therapy may help mitigate the long-term clinical and economic consequences of the disease.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 4 Suppl","pages":"S43-S52"},"PeriodicalIF":2.1,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147357564","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}