American Journal of Managed Care最新文献

{"title":"Disparities in physician access for rheumatology, dermatology, and gastroenterology: a systematic review.","authors":"Grace C Wright, Ginette A Okoye, Adam C Ehrlich, D J Lorimier, Shahnaz Khan, Jessica Costello, Catherine Copley-Merriman, Kateryna Onishchenko, Osayi Ovbiosa, Manish Mittal","doi":"10.37765/ajmc.2025.89792","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89792","url":null,"abstract":"<p><strong>Objectives: </strong>Substantial disparities in access to health care, including to physician specialists, hinder diagnosis, treatment, and outcomes for patients with immunological diseases; thus, more studies are needed to understand and address these disparities. This study aimed to evaluate factors associated with disparities in rheumatology, dermatology, and gastroenterology specialist access for patients with immunological conditions and the consequences of such disparities.</p><p><strong>Study design: </strong>Systematic literature review.</p><p><strong>Methods: </strong>Studies published between 2017 and 2023 examining US adults (≥ 18 years) with key immunological conditions receiving care by rheumatologists, dermatologists, and gastroenterologists were systematically reviewed. Thematic analyses of qualitatively synthesized data were used to evaluate disparities in specialist access (defined under \"5 A's\": affordability, availability, accessibility, accommodation, and acceptability) and the associated clinical/economic outcomes.</p><p><strong>Results: </strong>Specialist access disparities and related outcomes were inconsistently evaluated across the 46 included studies, with limited evidence in gastroenterology. Common factors associated with specialist access disparities in rheumatology and dermatology included rural residence, insurance type (primarily Medicaid), Black or Hispanic race and ethnicity, and low regional specialist density. Frequent outcomes of this low access included higher disease severity, higher hospital admission and readmission rates, and higher numbers of emergency department visits. Importantly, studies described ways to improve specialist access across the 5 A's (eg, minimize structural barriers, use a multidisciplinary approach, promote telemedicine, increase health literacy, improve community partnerships).</p><p><strong>Conclusions: </strong>Specialist access disparities were identified in rheumatology and dermatology. Conclusions in gastroenterology could not be inferred due to limited evidence. Evidence-based solutions are provided to address identified gaps in US health care.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 9","pages":"e270-e277"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145087864","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":"Integrating research, health care, and community at scale to address the population health question.","authors":"Sanne J Magnan, Paul Hughes-Cromwick, David Kindig","doi":"10.37765/ajmc.2025.89798","DOIUrl":"10.37765/ajmc.2025.89798","url":null,"abstract":"<p><p>The authors discuss the need to repair a house divided among research, health care, and the multisector health community.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 Spec. No. 10","pages":"SP721-SP723"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145056114","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":"ACA dependent coverage extension and young adults' substance-associated ED visits.","authors":"Refat Rasul Srejon, Timothy Grigsby, Chris Cochran, Jay J Shen","doi":"10.37765/ajmc.2025.89790","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89790","url":null,"abstract":"<p><strong>Objectives: </strong>The Affordable Care Act (ACA), enacted in 2010, aimed to improve health insurance coverage and access to care, notably through a provision extending dependent coverage up to age 26 years. This study investigates the ACA's impact on substance use disorder (SUD)-associated emergency department (ED) visits among young adults aged 23 to 29 years.</p><p><strong>Study design: </strong>A quasi-experimental study analyzed opioid- and alcohol-associated ED visits and inpatient admissions among young adults (aged 23-25 [treatment] vs 27-29 [comparison] years) using 2007-2019 Nationwide Emergency Department Sample data.</p><p><strong>Methods: </strong>A difference-in-differences approach assessed the ACA's impact, adjusting for covariates including sex, comorbidities, payer source, income, residence, and hospital region. Generalized linear models estimated adjusted ORs with 95% CIs, ensuring robust analysis of the ACA's effects on substance-related health care utilization.</p><p><strong>Results: </strong>Opioid-associated ED visits had no change between the treatment and comparison groups, whereas alcohol- associated ED visits declined more for the treatment group after the ACA (OR, 0.841; 95% CI, 0.828-0.855). No changes in inpatient admissions among opioid- or alcohol-associated visits, respectively, were seen between the 2 groups.</p><p><strong>Conclusions: </strong>Our findings indicate that the ACA's implementation led to mixed effects on substance-associated health care utilization among young adults, with reduced alcohol-associated visits in the treatment group but unchanged discrepancies in opioid-associated ED visits and inpatient admissions between the 2 groups. Further research is warranted to explore state-level variations and population-level substance use trends along with continuous monitoring to inform interventions addressing substance-associated public health challenges.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 9","pages":"e258-e264"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145087845","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":"ACA network regulatory filings are inaccurate, poorly match provider directories.","authors":"Simon F Haeder, Jane M Zhu","doi":"10.37765/ajmc.2025.89791","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89791","url":null,"abstract":"<p><strong>Objectives: </strong>Access to mental health services has been shown to be particularly inadequate, with limited understanding of the efficacy of existing network adequacy regulations. State and federal regulations mandate insurance carriers to submit regulatory filings to help maintain network adequacy compliance, but the accuracy of these data remains unassessed.</p><p><strong>Study design: </strong>We employed a secret shopper survey to verify regulatory filings and assess the congruence between the filings and provider directory listings as well as appointment availability and wait time for 8306 mental health counselors submitted by all carriers participating in Pennsylvania's Affordable Care Act (ACA) Marketplace for plan year 2024.</p><p><strong>Methods: </strong>Descriptive analyses, with tests of proportion and t tests to assess differences between carriers and between adult and pediatric provider specialties.</p><p><strong>Results: </strong>A total of 19.9% of filed regulatory listings (n = 1649) were not present in consumer-facing provider directories, and only 35.3% of filed listings (n = 2928) fully matched provider directory entries. Of the 2152 provider listings we were able to verify fully via secret shopper calls, 65.2% (n = 1404) exhibited at least 1 inaccuracy. Inaccurate phone number was the most common issue (56.6%; n = 1219). Appointments were available for only 321 of the 2152 providers (14.9%), with a mean of 33.2 days lapsed between call and scheduled appointment time. Although we identified substantial differences in appointment wait times by carrier, we found no difference between adult and pediatric providers.</p><p><strong>Conclusions: </strong>ACA network adequacy assessments that rely on carrier regulatory filings and/or consumer-facing directories substantially overestimated provider availability and access to mental health services.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 9","pages":"e265-e269"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145087850","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":"Patient and physician perceptions of a hypercholesterolemia safety-net program.","authors":"Teresa N Harrison, Matt Zhou, Hui Zhou, Hananeh Derakhshan, Mona Zia, Michael H Kanter, Ronald D Scott, Tracy M Imley, Mark A Sanders, Royann Timmins, Kristi Reynolds, Matthew T Mefford","doi":"10.37765/ajmc.2025.89794","DOIUrl":"10.37765/ajmc.2025.89794","url":null,"abstract":"<p><strong>Objectives: </strong>To understand the perceptions of patients and primary care physicians as well as barriers to and facilitators of engaging with a safety-net program for patients with hypercholesterolemia.</p><p><strong>Study design: </strong>A cross-sectional telephone survey of patients and qualitative interviews with PCPs.</p><p><strong>Methods: </strong>Patients' reasons for adherence or nonadherence to statins and completion of laboratory tests and their perceptions of the safety-net program were ascertained. PCPs were asked to describe their familiarity with the safety-net program and perceived patient barriers to filling a new statin prescription and completing laboratory tests.</p><p><strong>Results: </strong>Among 59 participating patients, 86% did and 14% did not fill their statin. Patients reported statin adherence because their doctor prescribed it (100%), to lower cholesterol (94%), and to prevent a heart attack/stroke (51%). Reasons for nonadherence included wanting to try lifestyle modification (63%), general medication concerns (50%), and fear of adverse events (38%). Among patients filling their prescription, 94% completed a follow-up lipid panel. Among 14 PCPs interviewed, 8 were aware of the safety-net program. PCPs cited in-basket volume and lack of an automated reminder system as common barriers to following up with patients with high low-density lipoprotein cholesterol levels. PCPs perceived (1) patients' fear of statins and (2) forgetfulness as the main reasons for not filling their prescriptions and not completing lipid panels, respectively. PCPs suggested that more frequent patient and provider reminders could improve prescription fills and laboratory test completions.</p><p><strong>Conclusions: </strong>Interventions focused on improving patients' knowledge of statins and educating PCPs about outreach programs may facilitate patient-provider communication and improve statin adherence.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 Spec. No. 10","pages":"SP680-SP690"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145056129","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":"Navigating compounded semaglutide: what health care providers need to know.","authors":"Grace Liu, Marissa Jarema, Millie Mo, Trish Stievater","doi":"10.37765/ajmc.2025.89787","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89787","url":null,"abstract":"<p><p>Semaglutide, a glucagon-like peptide-1 receptor agonist, is FDA approved under the brand names Ozempic for treatment of type 2 diabetes and Wegovy for the treatment of overweight or obesity. The soaring popularity of these drugs, driven by social media and their overall efficacy, has resulted in nationwide shortages. The high costs associated with the FDA-approved products for both insurers and patients have also led to additional restrictions in access. In response to the unmet growing demand for semaglutide, suppliers have started to sell compounded versions of these products, both legally and illegally. This narrative review examines the implications of these compounded products on our health care system, highlighting concerns regarding their safety, efficacy, and regulatory status. Compounding, when done following federal and state regulations, can fill an important need in our health care marketplace. However, the compounded semaglutide products currently available to patients may lack the quality controls historically seen with compounded formulations, resulting in risks for dosing errors and adverse health outcomes. In addition, the compounded semaglutide market worldwide has seen batches of fraudulent products. Pharmacists and other health care providers have a unique opportunity to help guide patients in navigating this compounded semaglutide market, including directing them to lawful sources of compounded semaglutide, providing counseling on dosage and administration, and minimizing safety concerns.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 9","pages":"480-484"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145087801","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":"Hospital participation in Medicare ACOs: no change in admission practices and spending.","authors":"Amber K Sabbatini, David B Muhlestein, Canada Parrish, Laura G Burke, Kathleen Y Li, Michelle P Lin","doi":"10.37765/ajmc.2025.89783","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89783","url":null,"abstract":"<p><strong>Objectives: </strong>Hospital participation in accountable care organizations (ACOs)-Medicare's signature alternative payment model-continues to grow despite mixed evidence on spending and quality. This study examines whether hospital ACO participation is associated with changes in emergency department (ED) admission practices, hospital length of stay (LOS), and spending for unplanned admissions.</p><p><strong>Study design: </strong>A difference-in-differences analysis of Medicare fee-for-service ED visits and hospitalizations (2008-2019).</p><p><strong>Methods: </strong>Medicare claims were linked to ACO tracking data from Torch Insight to identify hospitals that joined an ACO between 2012 and 2017 (6 cohorts, followed for a maximum of 5 years), the start date of their initial contract, and ACO characteristics. Key outcomes included ED admission and observation stay rates, hospital LOS for emergent admissions, and total costs for an index ED event.</p><p><strong>Results: </strong>Among the 995 hospitals (27.6% of the short-term hospitals in our study) that joined a Medicare ACO during the study period, program participation up to 5 years was not associated with changes in the rate of hospitalization from the ED, hospital LOS, or total costs of the index event. Findings remained consistent across ACO program, contract risk levels, year of program entry, and overall ACO performance (eg, whether the ACO generated shared savings).</p><p><strong>Conclusions: </strong>Hospitals did not significantly alter care delivery for unplanned hospitalizations after joining an ACO. These findings suggest that hospital-led ACOs may have limited impact on reducing costs for emergent admissions, raising concerns about their ability to drive meaningful care transformation.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":" ","pages":""},"PeriodicalIF":2.1,"publicationDate":"2025-08-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144977634","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":"Assessment of variation in ambulatory cardiac monitoring among commercially insured patients.","authors":"Pierantonio Russo, Henriette Coetzer, Erik M Hendrickson, Kenneth Boyle, Brent Wright","doi":"10.37765/ajmc.2026.89782","DOIUrl":"https://doi.org/10.37765/ajmc.2026.89782","url":null,"abstract":"<p><strong>Objectives: </strong>Ambulatory cardiac monitors (ACMs) enable heart rhythm monitoring for various durations, including Holter monitors (0-48 hours), long-term continuous monitors (LTCMs; 3-14 days), and external ambulatory event monitors (AEMs; up to 30 days). These devices detect intermittent or asymptomatic arrhythmias that might go unnoticed with a standard electrocardiogram. Previous research has explored variations in ACM use among Medicare beneficiaries. This study assessed the incidence of clinical and economic outcomes among commercially insured patients who had never had an arrhythmia diagnosis and received their first ACM.</p><p><strong>Study design: </strong>Retrospective cohort study using a large commercial claims database focused on patients without prior arrhythmia diagnoses who received their first ACM between 2016 and 2023.</p><p><strong>Methods: </strong>Outcomes included new arrhythmia diagnoses, repeat ACM testing, cardiovascular (CV) events, and health care resource use and costs. Results were stratified by major ACM manufacturers using National Provider Identifiers. To minimize confounding, inverse probability of treatment weighting was used to balance covariates, and adjusted regression models were used to evaluate outcomes during follow-up.</p><p><strong>Results: </strong>Of 428,707 patients meeting inclusion criteria, 36% used LTCMs, 36% used Holter monitors, and 27% used external AEMs. Adjusted analyses showed that a certain LTCM brand was associated with higher odds of a new arrhythmia diagnosis, fewer retests (except vs AEMs), lower odds of CV events, and less follow-up health care resource use and costs than other ACM types and manufacturers.</p><p><strong>Conclusions: </strong>Clinical and economic outcomes can vary by ACM type among commercially insured patients. A specific LTCM manufacturer demonstrated superior performance, with greater diagnoses of arrhythmia, fewer repeat tests, and fewer CV events compared with other ACM types and manufacturers.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":" ","pages":""},"PeriodicalIF":2.1,"publicationDate":"2025-08-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144977517","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":"Care quality metrics in Medicare during COVID-19 pandemic.","authors":"Jeanette Thornton, Mark Hamelburg, Lynn Nonnemaker, Sherzod Abdukadirov, German Veselovskiy, Sari Siegel","doi":"10.37765/ajmc.2025.89781","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89781","url":null,"abstract":"<p><strong>Objective: </strong>To examine the impact on quality of care for individuals enrolled in Medicare Advantage (MA) plans or traditional Medicare (TM) during the COVID-19 pandemic.</p><p><strong>Study design: </strong>Retrospective cohort study.</p><p><strong>Methods: </strong>The study examined beneficiaries enrolled in Medicare from 2017 through 2021. Beneficiaries were divided into 4 cohorts based on their enrollment in TM or MA and the year of enrollment in 2019, the year before the COVID-19 pandemic, or 2021, during the COVID-19 pandemic. For each cohort, 12 clinical quality measures were constructed, including 4 screening measures requiring in-person visits and 8 medication management and adherence measures.</p><p><strong>Results: </strong>A total of 3,190,208 Medicare beneficiaries were included (58.4% female; mean age, 73.0 years). In both 2019 and 2021, the MA program performed significantly better than TM across the 12 clinical quality measures. Compared with the year before the pandemic, both programs experienced a decrease in screening measures that required in-person visits during the pandemic, with a slightly higher decrease for the MA plans. In contrast, measures of medication management and adherence improved for both programs, but especially for MA plans.</p><p><strong>Conclusions: </strong>MA plans continued to outperform TM on clinical quality measures during the COVID-19 pandemic.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":" ","pages":""},"PeriodicalIF":2.1,"publicationDate":"2025-08-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144977604","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 Charles N. (Chip) Kahn III, MPH.","authors":"Charles N Kahn, Christina Mattina","doi":"10.37765/ajmc.2025.89771","DOIUrl":"10.37765/ajmc.2025.89771","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 August issue features a conversation with Charles N. (Chip) Kahn III, MPH, the president and CEO of the Federation of American Hospitals and a longtime member of the AJMC editorial board.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 8","pages":"374-377"},"PeriodicalIF":2.1,"publicationDate":"2025-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144884243","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}