American Journal of Managed Care最新文献

{"title":"Effects of Maryland's All-Payer Model on elective joint replacement surgery.","authors":"Meiling Ying, Addison Shay, John M Hollingsworth, Vahakn B Shahinian, Richard A Hirth, Brent K Hollenbeck","doi":"10.37765/ajmc.2025.89735","DOIUrl":"10.37765/ajmc.2025.89735","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate the Maryland All-Payer Model's impact on the rate of elective major joint replacement surgery.</p><p><strong>Study design: </strong>A retrospective cohort study of patients in Maryland undergoing elective major joint replacement between 2011 and 2018 was performed using a 20% fee-for-service Medicare sample in a difference-in-difference framework with patients undergoing hip fracture repair serving as controls.</p><p><strong>Methods: </strong>Among Maryland residents, there were 7147 Medicare fee-for-service patients undergoing elective major joint replacement and 1008 Medicare fee-for-service beneficiaries undergoing hip fracture repair. We used patient-level generalized linear models with a negative binomial family function and a log link function to estimate the association of the All-Payer Model with the rate of elective major joint replacement surgery.</p><p><strong>Results: </strong>Under the All-Payer Model, the rate of elective major joint replacement surgery increased more than that of hip fracture repair (adjusted relative risk, 1.31; 95% CI, 1.15-1.51). Compared with hospitals without affiliates in adjacent states (Maryland-only hospitals), those with affiliates (Maryland hospitals with affiliates) saw rates of elective major joint replacement grow more slowly (adjusted relative risk, 0.87; 95% CI, 0.80-0.95) after the All-Payer Model. Furthermore, major joint replacement rates for Maryland residents at affiliated hospitals in adjacent states increased from 4.26 per 10,000 in the preintervention period to 5.23 per 10,000 in the postintervention period.</p><p><strong>Conclusions: </strong>Under the All-Payer Model, population-based rates of elective major joint replacement surgery increased more rapidly than did rates of hip fracture repair. Although rates of major joint replacement at Maryland hospitals with affiliates grew more slowly than for Maryland-only hospitals, rates among Maryland residents increased at the affiliates in adjacent states.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"e120-e124"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12092050/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095715","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":"Organizational factors associated with variation in primary care providers in ACOs.","authors":"Mariétou H Ouayogodé, Xiaodan Liang, Sancia K Ferguson","doi":"10.37765/ajmc.2025.89723","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89723","url":null,"abstract":"<p><strong>Objective: </strong> To assess the association between the organizational structure of accountable care organizations (ACOs) and provider workforce composition. Quantifying these relationships may improve understanding of factors contributing to changes in the health care workforce in ACOs and improve clinician recruitment and retention across ACOs to help them succeed in the program.</p><p><strong>Study design: </strong>Cross-sectional study of 409 ACOs from the National Survey of Accountable Care Organizations Wave 4 (2017-2018; response rate, 48%).</p><p><strong>Methods: </strong>We evaluated ACO provider workforce composition. In multivariable linear regression models, we examined the relationship among ACO provider workforce composition, contract type, structure, and financial risk level. For Medicare Shared Savings Program participants, we also assessed the role of the market environment.</p><p><strong>Results: </strong> We found that provider workforce composition varied across organizations by ACO contract payer. The percentage of primary care providers-physicians and nonphysician providers-was higher in smaller organizations with ACO contracts from a single public payer (77.7% for those with Medicaid-only contracts; 59.5% with Medicare-only contracts) relative to larger organizations with contracts from a single commercial payer (52.4% primary care providers) or multiple payers (54.8%-55.7%). A higher percentage of primary care providers in the ACO was associated with physician leadership, upside financial risk, and financial compensation of physicians being tied to performance measures.</p><p><strong>Conclusions: </strong>With payers' recent interest in more capitated payment models, larger ACOs should consider extending more population-based payments, provider engagement, and compensation strategies to engage aligned providers toward high quality and low costs, mitigate overall provider turnover, and make participation in ACOs sustainable.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 4","pages":"e87-e94"},"PeriodicalIF":2.5,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144057716","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":"Insurance payer is associated with length of stay after traumatic brain injury.","authors":"John K Yue, Nishanth Krishnan, Christopher Toretsky, Renee Y Hsia, Geoffrey T Manley, W John Boscardin, Anil N Makam, Anthony M DiGiorgio","doi":"10.37765/ajmc.2025.89688","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89688","url":null,"abstract":"<p><strong>Objectives: </strong>Timely provision of postacute care (PAC) rehabilitation is critical for achieving functional recovery after traumatic brain injury (TBI). Medicaid coverage is a predictor of prolonged hospital length of stay (LOS) after TBI, a proxy for decreased PAC access. Among Medicaid patients with TBI, it is unknown whether coverage under a managed care organization (MCO) or fee-for-service (FFS) model predicts differences in LOS.</p><p><strong>Study design: </strong>Discharge data for patients with TBI from 318 California hospitals between 2017 and 2019 were obtained. We used multivariable regression models, treating mortality/hospice disposition as competing risks, to evaluate associations between insurance type and LOS, adjusting for sociodemographic factors and illness severity. Sensitivity analysis was conducted in patients with severe TBI identified by receipt of intracranial pressure monitoring or trauma craniotomy/craniectomy. Adjusted HRs (aHRs) were reported.</p><p><strong>Methods: </strong>The California Department of Health Care Access and Information Patient Discharge Dataset was queried for patients with TBI using International Classification of Diseases, Tenth Revision, Clinical Modification codes. Exclusion criteria were younger than 18 years or older than 65 years, payer other than private insurance (PI) or Medicaid, death or hospice discharge within 5 days of hospitalization, presence of a do-not-resuscitate order, and nonemergency admission.</p><p><strong>Results: </strong>A total of 39,834 patients were analyzed (FFS, 24.2%; MCO, 33.2%; PI, 42.6%). Competing risk regressions showed that Medicaid models were associated with longer LOS compared with PI (FFS: aHR, 0.80; 95% CI, 0.80-0.83; MCO: aHR, 0.92; 95% CI, 0.87-0.96). Compared with MCOs, FFS was associated with longer LOS in the overall cohort (aHR, 0.88; 95% CI, 0.85-0.91) and in the severe TBI subgroup (aHR, 0.90; 95% CI, 0.82-0.99).</p><p><strong>Conclusions: </strong>Medicaid FFS is associated with increased LOS in hospitalized patients with TBI compared with Medicaid MCOs, suggesting decreased PAC access.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 4","pages":"173-181"},"PeriodicalIF":2.5,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144055765","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":"Combined effect of continuous glucose monitoring and semaglutide: analysis of administrative claims.","authors":"Poorva M Nemlekar, Katia L Hannah, Courtney R Green, Thomas Grace, Peter M Lynch, Jessica R Castle, Gregory J Norman","doi":"10.37765/ajmc.2025.89719","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89719","url":null,"abstract":"<p><strong>Objectives: </strong>This study evaluated whether the combined use of continuous glucose monitoring (CGM) and semaglutide, a glucagon-like peptide-1 receptor agonist, was associated with larger hemoglobin A1c (HbA1c) improvements compared with use of semaglutide alone.</p><p><strong>Study design: </strong>Using US health care claims data from the Optum Clinformatics database, this retrospective analysis identified adults with type 2 diabetes (T2D) using semaglutide.</p><p><strong>Methods: </strong>The CGM cohort had at least 1 CGM-related claim between January 1, 2019, and September 30, 2022. Random index dates were used in the control (non-CGM) cohort. At least 1 laboratory HbA1c value was required during baseline and follow-up periods. Outcomes included change in HbA1c and the proportion of people who reached American Diabetes Association (ADA) or Healthcare Effectiveness Data and Information Set (HEDIS) HbA1c targets of less than 7.0% or less than 8.0%, respectively.</p><p><strong>Results: </strong>A total of 21,247 people with T2D were identified, with 18,488 in the control group and 2759 using CGM. Overall, a significantly greater reduction in HbA1c was observed in the CGM cohort compared with the control group (difference-in-differences, -0.55%; 95% CI, -0.64% to -0.47%; P < .0001). Among CGM users, the proportion meeting the ADA target of HbA1c less than 7.0% nearly doubled, and the proportion achieving the HEDIS target of HbA1c less than 8.0% increased by more than 50%.</p><p><strong>Conclusions: </strong>The results suggest that CGM provides an additive benefit to semaglutide, leading to greater decreases in HbA1c. Expanded use of these complementary therapies in the primary care setting could enable more people with T2D to achieve their glycemic goals.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 4","pages":"183-188"},"PeriodicalIF":2.5,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144049675","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":"Making PIN and telehealth work together-it can be done.","authors":"Grace Showalter","doi":"10.37765/ajmc.2025.89728","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89728","url":null,"abstract":"","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 Spec. No. 4","pages":"SP238-SP239"},"PeriodicalIF":2.5,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144051352","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 Hoangmai H. Pham, MD, MPH.","authors":"Hoangmai H Pham, Christina Mattina","doi":"10.37765/ajmc.2025.89716","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89716","url":null,"abstract":"<p><p>To mark the 30th anniversary of The American Journal of Managed Care® (AJMC®), each issue in 2025 will include 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 April issue features a conversation with Hoangmai H. Pham, MD, MPH, a member of AJMC's editorial board and the president and CEO of the Institute for Exceptional Care (IEC).</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 4","pages":"159-160"},"PeriodicalIF":2.5,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144048188","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":"The role of advanced technologies in improving diabetes outcomes.","authors":"David G Marrero, Christopher G Parkin, Grazia Aleppo, Irl B Hirsch, Janet McGill, Rodolfo J Galindo, Davida F Kruger, Carol J Levy, Anders L Carlson, Guillermo E Umpierrez","doi":"10.37765/ajmc.2025.89725","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89725","url":null,"abstract":"<p><strong>Objectives: </strong>To discuss the current state of diabetes care in America, the value and utility of innovative diabetes technologies, barriers to access to quality diabetes care and technologies, and how a value-based model of diabetes care can improve outcomes and reduce costs.</p><p><strong>Study design: </strong>Narrative review of the current state of diabetes care in America and use of diabetes technologies such as continuous glucose monitoring (CGM) and automated insulin delivery (AID) systems.</p><p><strong>Methods: </strong>An internet search of relevant studies and government reports was conducted.</p><p><strong>Results: </strong>Numerous studies have shown that use of CGM and AID improves glycemia, diabetes-related events, and health care resource utilization and lowers overall health care costs. Despite these demonstrated benefits, the majority of individuals with diabetes are not achieving their glycemic goals. Although many of these individuals have limited access to these technologies due to restrictive coverage eligibility criteria, significant disparities exist in technology use within racial/ethnic minority populations and communities of lower socioeconomic status. Transitioning to a value-based approach to diabetes care supports the Quintuple Aim framework.</p><p><strong>Conclusions: </strong>Shifting our current health care delivery paradigm from the traditional volume-based, fee-for-service model to a value-based model that takes a proactive approach could improve patient outcomes and overall quality of life while helping to reduce the long-term costs of diabetes care.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 4","pages":"e102-e112"},"PeriodicalIF":2.5,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144046651","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":"Comparing breast cancer treatment outcomes between fee-for-service and Medicare Advantage.","authors":"Galen Shearn-Nance, Rishi R Sachdev, Long Vu, Weichuan Dong, Alberto J Montero, Siran M Koroukian, Johnie Rose","doi":"10.37765/ajmc.2025.89720","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89720","url":null,"abstract":"<p><strong>Objectives: </strong>Medicare Advantage (MA) enrollment has increased over the past 2 decades. We compare receipt of standard treatment, time to treatment initiation (TTI), and overall survival (OS) between fee-for-service (FFS) Medicare and MA for women in Ohio with breast cancer.</p><p><strong>Study design: </strong>Retrospective cohort.</p><p><strong>Methods: </strong>We used Ohio cancer registry data linked with Medicare enrollment files to identify women diagnosed between 2011 and 2016 with local- or regional-stage breast cancer. We evaluated the association between FFS or MA and each outcome, adjusting for age, race, marital status, county type, neighborhood poverty level, stage, hormone receptor status, and dual Medicare-Medicaid enrollment. Standard treatment was mastectomy or breast-conserving surgery plus radiotherapy; chemotherapy for regional disease; and hormone therapy if hormone receptor positive.</p><p><strong>Results: </strong>A total of 12,349 patients met inclusion criteria (6801 FFS; 5548 MA). No difference was found in receipt of standard treatment between FFS and MA patients (adjusted OR [AOR], 0.99; 95% CI, 0.91-1.08) or between Black and White patients (AOR, 1.14; 95% CI, 0.94-1.40); however, Black patients with FFS had lower odds of standard treatment (AOR for interaction, 0.75; 95% CI, 0.57-0.99). We detected no difference in TTI (adjusted HR [AHR], 0.98; 95% CI, 0.94-1.01) or OS (AHR, 1.03; 95% CI, 0.92-1.15) between FFS and MA patients, and we found no significant interaction between MA status and race for OS or TTI.</p><p><strong>Conclusions: </strong>MA enrollment was not independently associated with standard treatment, TTI, or OS after cancer diagnosis. Further work is needed to understand why Black patients with FFS Medicare were less likely to receive standard treatment.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 4","pages":"190-196"},"PeriodicalIF":2.5,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144040193","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 the MiniMed 780G system for type 1 diabetes.","authors":"Mallika Kommareddi, Kael Wherry","doi":"10.37765/ajmc.2025.89722","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89722","url":null,"abstract":"<p><strong>Objectives: </strong>Advances in diabetes technology have led to improved glycemic control. However, no study has evaluated the economic impact of advanced hybrid closed-loop (AHCL) technology in the US compared with older and less expensive treatments. We assessed the cost-effectiveness of the MiniMed 780G system (MM780G) with AHCL technology vs multiple daily injections of insulin (MDI) with intermittently scanned continuous glucose monitoring (isCGM) among patients with type 1 diabetes (T1D) in the US.</p><p><strong>Study design: </strong>A 6-month randomized controlled trial compared MM780G against MDI with isCGM among patients with T1D. Outcomes included changes in hemoglobin A 1c and quality of life.</p><p><strong>Methods: </strong>We used the IQVIA Core Diabetes Model to simulate direct costs and quality of life separately over a 4-year horizon and a lifetime horizon. Treatment effects were sourced from the randomized controlled trial, and utilities and disutilities for diabetes-related complications came from the literature. We generated incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves for the base case and 5 one-way sensitivity analyses.</p><p><strong>Results: </strong>At a willingness-to-pay threshold of $100,000, MM780G is cost-effective in the base case, with an ICER of $68,402 per quality-adjusted life-year over a 4-year horizon and $38,842 per quality-adjusted life-year over a lifetime horizon. Sensitivity analyses varying the rates of short-term complications, pricing, and assumptions about treatment-related utilities show cost-effectiveness at a threshold of $100,000 in all but 1 case.</p><p><strong>Conclusions: </strong>MM780G is likely to be cost-effective vs MDI with isCGM in patients with T1D in the US at a willingness-to-pay threshold of $100,000.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 4","pages":"e79-e86"},"PeriodicalIF":2.5,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143993482","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":"Prior authorizations and the adverse impact on continuity of care.","authors":"Jay S Pickern","doi":"10.37765/ajmc.2025.89721","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89721","url":null,"abstract":"<p><p>This commentary discusses the current prior authorization (PA) process and the negative impacts it can have on patient care. According to the American Medical Association, 94% of patients experience delays in care and 78% abandon treatment altogether. These delays in care are often for lifesaving treatments and can result in adverse events. Additionally, PAs place an extensive administrative and financial burden on both patients and providers, often requiring several hours of seeking approval from insurance companies or requiring patients to try one or more other therapeutic avenues before an insurance company will approve the original course of treatment. This is all while insurance companies are making record profits each year. Frustrations with this system are leading to a rise in the number of physician practices switching to a cash-only business model, which increases autonomy, enables price transparency, and benefits both physicians and patients.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 4","pages":"163-165"},"PeriodicalIF":2.5,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144007422","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}