American Journal of Managed Care最新文献

{"title":"Blood Pressure Control Among Adherent vs Nonadherent Medicare Patients With Hypertension.","authors":"Kaitlyn T Haas, Joseph J Saseen, Oliver Titus, Nathan Lamberton, Lisa M Schilling, Keri N Hogan, Alison Marks, Sarah J Billups","doi":"10.37765/ajmc.2026.89987","DOIUrl":"https://doi.org/10.37765/ajmc.2026.89987","url":null,"abstract":"<p><strong>Objectives: </strong> Medication adherence measures for hypertension drive financial incentives and patient care strategies for many value-based health care programs. The association between medication adherence and hypertension control as a value-based quality measure is not well described. The objectives of this study were to compare blood pressure (BP) control among Medicare and Medicare Advantage patients who meet vs do not meet the medication adherence for hypertension (MAH) measure and compare patient and prescription factors associated with adherence vs disease control.</p><p><strong>Study design: </strong>Retrospective cohort study using linked payer and electronic health record data from a single health system.</p><p><strong>Methods: </strong> Medicare patients eligible for MAH in 2023 were categorized as adherent or nonadherent according to measure specifications, and hypertension control was defined as a primary care office BP less than 140/90 mm Hg or less than 130/80 mm Hg. Multivariable logistic regression was used to identify factors independently associated with adherence and disease control.</p><p><strong>Results: </strong> Of the 5206 patients evaluated, 77.9% were classified as adherent to the MAH measure. Of adherent patients, 77.2% achieved a BP less than 140/90 mm Hg vs 73.5% of nonadherent patients ( P  = .01), and 45.9% and 43.4%, respectively, achieved a BP of less than 130/80 mm Hg ( P  = .14). White race and younger age were positively associated with hypertension control, whereas extended days' supply and non-White race were associated with meeting the MAH measure.</p><p><strong>Conclusions: </strong> Patients classified as adherent were more likely to achieve a BP less than 140/90 mm Hg, but achievement of BP less than 130/80 mm Hg did not differ between groups. A sizeable proportion of patients who did not meet the adherence measure (73.5%) achieved a BP less than 140/90 mm Hg. Factors associated with adherence vs disease control differed. Emphasis on disease control over medication adherence measures may more meaningfully reflect high-value clinical care.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 7","pages":"e228-e233"},"PeriodicalIF":2.1,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148814706","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 Timing and Characteristics of Supplemental Indications for Medicines.","authors":"Yingying Zhu, Claire H Brennan, Haijun Tian, Josephine N Tran, Peter J Neumann, James D Chambers, Pei-Jung Lin, Meng Li","doi":"10.37765.ajmc.2026.89982","DOIUrl":"10.37765.ajmc.2026.89982","url":null,"abstract":"<p><strong>Objectives: </strong>We investigated the timing of supplemental indications and characteristics of those approved after 9 years (small molecules) or 13 years (biologics) post initial approval across all therapeutic areas.</p><p><strong>Study design: </strong>Using FDA databases, we identified small molecule drugs (n = 97) initially approved between 2004 and 2015 and biologics between 2004 and 2011 (n = 21), allowing for at least 9 and 13 years of follow-up, respectively.</p><p><strong>Methods: </strong>We reviewed drug labels as of 2024 to identify supplemental indications. We characterized supplemental indications approved at least 9 or 13 years post approval in several ways: by FDA expedited review pathway, whether they had orphan designation, whether they were approved for pediatric or geriatric populations, and their therapeutic class. We calculated the mean time between consecutive indications for small molecules and biologics.</p><p><strong>Results: </strong>Overall, 24.0% of small molecule supplemental indications were approved at least 9 years post approval, and 10.0% of biologic supplemental indications were approved at least 13 years post approval. Of the supplemental indications approved (whether for small molecules or biologics) at least 9 or 13 years after initial approval, 56.9% received at least 1 FDA expedited review, 39.2% had orphan status, 49.0% were approved for pediatric use, and 62.7% were approved for older adults. The mean time between consecutive indications was longer for small molecules than for biologics (4.0 vs 3.3 years).</p><p><strong>Conclusions: </strong>Additional drug indications approved after 9 years for small molecules and 13 years for large molecules are not uncommon. Many of these later-approved indications receive expedited or orphan designation and target populations with high unmet medical needs.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 7","pages":"380-382"},"PeriodicalIF":2.1,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148814944","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":"Aligning the stars: quality metrics must evolve from screening rates to diagnostic resolution.","authors":"Diana S M Buist, Robert A Smith, A Mark Fendrick","doi":"10.37765/ajmc.2026.89931","DOIUrl":"10.37765/ajmc.2026.89931","url":null,"abstract":"<p><p>Cancer screening in the US is at a critical juncture, facing an urgent need to shift from a focus on initial test uptake toward a mandate for complete diagnostic resolution. Historically, quality metrics have prioritized the singular event of a recommended test over the necessity of diagnostic resolution. Financial barriers, administrative blind spots in quality metrics, and the \"Medicare 5-star paradox\" have created a screening purgatory in which patients with abnormal findings are frequently left without a definitive diagnosis. Although the Affordable Care Act successfully increased access to initial screening tests by eliminating cost sharing for insured individuals, it historically left subsequent diagnostic pathways financially unprotected, contributing to late-stage diagnoses despite the availability of effective tools. This commentary explores the systemic failures of current Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare Star Ratings metrics that continue to reward test volume while neglecting the consequences for health equity, cancer prevention, and patient survival. We review key regulatory shifts, including new 2026 federal mandates for first-dollar coverage of diagnostic follow-up for breast and cervical cancers, while noting that significant gaps remain for lung cancer screening and clinical navigation. Additionally, we highlight the potential of the 2025 HEDIS measure for breast cancer follow-up after abnormal mammogram and the proposed 2027 HEDIS measure for colorectal cancer follow-up to serve as a nascent model for aligning quality with timely resolution. Finally, we emphasize the importance of physician leadership, advocacy, and universal diagnostic closure in ensuring that screening fulfills its lifesaving potential. Aligning quality metrics with the entire screening continuum is essential to moving beyond the \"easy screen\" toward a system that preserves patient-centered outcomes and reduces avoidable cancer mortality.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 7","pages":"376-379"},"PeriodicalIF":2.1,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148814664","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":"Potential Role for Assistant Physicians in Addressing the Physician Shortage.","authors":"David Schwartzman, A Mark Fendrick","doi":"10.37765/ajmc.2026.89916","DOIUrl":"10.37765/ajmc.2026.89916","url":null,"abstract":"<p><p>Given the fixed supply of residency training slots, pathways to increasing physician supply are limited. We assess use of the novel assistant physician (AP) status and the early impact of regulatory changes in Missouri. We find limited impacts of APs on supply, with a substantial majority (80.2%) of licensed APs not reporting a practice address and declining numbers of new licenses in recent years. We discuss implications and potential changes to increase health care supply through an AP pathway.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 7","pages":"414-416"},"PeriodicalIF":2.1,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148814736","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":"Changes in Semaglutide Fills Following Expanded FDA and Medicare Policies.","authors":"Christopher Scannell, John A Romley, Rebecca Myerson, Dana Goldman, Dima Mazen Qato","doi":"10.37765/ajmc.2026.89983","DOIUrl":"10.37765/ajmc.2026.89983","url":null,"abstract":"<p><strong>Objectives: </strong>The glucagon-like peptide-1 receptor agonist (GLP-1 RA) semaglutide has several branded versions, including Wegovy, which was initially approved for chronic weight management. In March 2024, the FDA expanded Wegovy's indications to include reducing cardiovascular events in patients with overweight or obesity and cardiovascular disease. That same month, Medicare Part D expanded coverage for this indication. Evidence is lacking on how these policy changes have affected the utilization of Wegovy and other semaglutide products.</p><p><strong>Study design: </strong>Retrospective analysis of monthly semaglutide fills in the US before and after expanded FDA indications and Medicare coverage.</p><p><strong>Methods: </strong>IQVIA National Prescription Audit PayerTrak data were used to assess temporal trends in semaglutide utilization by brand and payer between September 2023 and September 2024. Additionally, linear segmented regression was used to identify the number of additional fills associated with the FDA and Medicare policy changes.</p><p><strong>Results: </strong>Total semaglutide utilization increased during the study period, with Wegovy showing the largest relative increase compared with the prepolicy period (136.4%) among all semaglutide products. The greatest increase in relative utilization by payer was for Wegovy purchased through Medicare Part D (598.1%). Policy implementation was associated with an estimated 592,624 additional Wegovy fills by September 2024.</p><p><strong>Conclusions: </strong>Expanded FDA indications and Medicare coverage of semaglutide for cardiovascular risk prevention were associated with increased Wegovy utilization, most notably through Medicare Part D. These policies may serve as a template for improving access to semaglutide and other GLP-1 RAs as the clinical indications for these drugs continue to expand.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 7","pages":"392-395"},"PeriodicalIF":2.1,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148814723","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of Automated Insulin Delivery on Type 2 Diabetes Measures.","authors":"Thomas W Martens, Bimal V Patel, Sharon M Wang, Laurel H Messer, Jordan E Pinsker, Daniel C Malone, Miranda R Polin, Diana I Brixner, Diana Isaacs, Osagie Ebekozien","doi":"10.37765/ajmc.2026.89986","DOIUrl":"10.37765/ajmc.2026.89986","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate the effect of using the t:slim X2 insulin pump with Control-IQ technology (hereafter, Control-IQ ; Tandem Diabetes Care, Inc) on glycemic status in individuals with type 2 diabetes (T2D) who switched from multiple daily insulin injections.</p><p><strong>Study design: </strong>This 12-month retrospective analysis utilized data from the Tandem t:connect web application and customer relationship management database, encompassing individuals covered by commercial insurers, Medicaid, and Medicare.</p><p><strong>Methods: </strong>We assessed changes in glucose management indicator (GMI) values from baseline hemoglobin A 1c (HbA 1c ) at 12 months relative to Healthcare Effectiveness Data and Information Set (HEDIS) quality measures (HbA 1c or GMI: < 8.0% [in control] and > 9.0% [poor control]). The primary outcome was the proportion of individuals who met the recommended HEDIS measure. Achievement of a GMIof less than 7.0% was included as a secondary outcome. Changes in glycemic outcomes and the proportion of individuals meeting the national threshold were analyzed.</p><p><strong>Results: </strong>The analysis included 1737 individuals with T2D who had baseline HbA 1c data. Following initiation of Control-IQ, the number of individuals who met the HEDIS (GMI < 8.0%) measure increased from 755 (43.5%) at baseline to 1545 (88.9%) at 12 months (∆ = 104.6%). The number of individuals who achieved a GMI of less than 7% increased from 282 (16.2%) to 678 (39.0%) (∆ = 140.4%). The number of individuals with HbA 1c greater than 9.0% at baseline decreased from 514 (29.6%) at baseline to 10 (0.6%) (∆ = -98.1%) at 12 months.</p><p><strong>Conclusions: </strong>A greater proportion of individuals who transitioned to Control-IQ therapy achieved the HEDIS goal for in-control diabetes across all payer types, as measured by GMI.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 7","pages":"e222-e227"},"PeriodicalIF":2.1,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148814739","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":"Musculoskeletal Quality Collaborative improves value-based health care delivery across hospital system.","authors":"Hannah I Travers, Mikhail Kuznetsov, John Mazzocco, Nicholas Pagani, Tricia Ide, Brian L Hollenbeck, Eric L Smith","doi":"10.37765/ajmc.2026.89966","DOIUrl":"10.37765/ajmc.2026.89966","url":null,"abstract":"<p><strong>Objectives: </strong>Rising health care costs necessitate value-based health care (VBHC) initiatives. Large hospital systems offer a platform for surgeon collaboration in developing standardized, interdisciplinary orthopedic care. This study evaluates the formation, implementation, and outcomes of the Musculoskeletal Quality Collaborative (MSKQC) across a hospital system.</p><p><strong>Methods: </strong>Established in 2019, the MSKQC comprises physician, quality, and nursing leaders from 14 hospitals. Using the Delphi method, surgeons identified VBHC interventions, leading to protocols for antibiotic-infused bone cement (AIBC), povidone-iodine irrigation, and negative pressure wound therapy (NPWT) dressings, implemented in May 2023. Usage was tracked across hospitals and reviewed quarterly from June 2023 to June 2024. Total hip arthroplasty and total knee arthroplasty (TKA) standardized infection ratios (SIRs) were calculated using National Healthcare Safety Network (NHSN) baselines. Surgeons performing more than 30 cases annually with more than 30% utilization of a target consumable were deemed high utilizers.</p><p><strong>Results: </strong>The systemwide savings opportunity exceeded $800,000 annually. AIBC use dropped from 19.6% to 5.5%. Two high-use hospitals showed gradual improvement, and 7 high-use surgeons were identified. NPWT usage remained stable at less than 5%. Sterile iodine irrigation decreased by 51.6% to less than 10%. TKA infections occurred in 18 of 6592 (0.27%) surgeries in 2023, compared with 14 of 5955 (0.24%) in 2022. The NHSN SIR was 0.906.</p><p><strong>Conclusions: </strong>The MSKQC successfully reduced high-cost consumable use while maintaining low infection rates. Regular protocol distribution and surgeon-specific feedback proved effective in advancing VBHC initiatives. This model offers a scalable approach for orthopedic VBHC implementation in the absence of national guidelines.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 Spec. No. 6","pages":"SP269-SP275"},"PeriodicalIF":2.1,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148201040","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":"Under the magnifying glass: a wave of drug price transparency.","authors":"Mary Gens, Anna Kaltenboeck","doi":"10.37765/ajmc.2026.89930","DOIUrl":"10.37765/ajmc.2026.89930","url":null,"abstract":"<p><p>Federal pharmacy benefit manager transparency reforms must contend with concentrated pharmaceutical markets that lack competitive conditions. Learnings from transparency will shape future drug pricing reforms.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 Spec. No. 6","pages":"eSP6-eSP9"},"PeriodicalIF":2.1,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148201017","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 value of mental health partnerships in oncology practice.","authors":"Justin Dam, Ananya Vennam, Morvarid Rezaie","doi":"10.37765/ajmc.2026.89981","DOIUrl":"https://doi.org/10.37765/ajmc.2026.89981","url":null,"abstract":"<p><p>Why colocation of mental health in community oncology practice boosts adherence, eases distress, and thrives with payer-backed reimbursement.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 Spec. No. 7","pages":"SP322-SP323"},"PeriodicalIF":2.1,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148272919","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 societal costs of food insecurity: implications for managed care strategies.","authors":"Sungchul Park, Alexander N Ortega, Jie Chen, Karoline Mortensen, Arturo Vargas Bustamante","doi":"10.37765/ajmc.2026.89954","DOIUrl":"10.37765/ajmc.2026.89954","url":null,"abstract":"<p><strong>Objectives: </strong>To estimate the direct health care costs and indirect economic implications of food insecurity among working-age adults in the US from a societal perspective.</p><p><strong>Study design: </strong>We conducted a retrospective longitudinal cohort study using the 2016-2017 and 2021-2022 Medical Expenditure Panel Survey.</p><p><strong>Methods: </strong>Our sample included 17,524 working-age adults. Our outcomes included health care spending, employment status, and income. The primary independent variable was food insecurity. Lagged dependent variable models assessed the association between food insecurity in year 1 and outcomes in year 2, adjusting for baseline characteristics.</p><p><strong>Results: </strong>Our lagged dependent variable models showed that food insecurity was not associated with total health care spending in year 2, but it was associated with a $132 (95% CI, $25-$239) increase in emergency department spending. Although food insecurity was not associated with employment, it was associated with increased likelihood of having a seasonal job or a temporary job and missing work due to illness in year 2 by 2.4 (95% CI, 1.0-3.8), 3.7 (95% CI, 1.1-6.3), and 4.8 (95% CI, 1.9-7.7) percentage points, respectively. Furthermore, food insecurity was associated with a decrease of $2521 (95% CI, -$4129 to -$914) in annual individual-level income in year 2, which was primarily driven by a decline in wages of $2030 (95% CI, -$3438 to -$621).</p><p><strong>Conclusions: </strong>Food insecurity was associated with economic burdens beyond medical spending, particularly through lost income and employment instability. These findings suggest that food insecurity is linked to economic instability while placing targeted demands on the health system, underscoring the importance of addressing food insecurity as a policy and public health priority.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 6","pages":"342-347"},"PeriodicalIF":2.1,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148310272","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}