American Journal of Managed Care最新文献

{"title":"How employers can fight the price crisis.","authors":"Torie Nugent-Peterson, Ryan Olmstead","doi":"10.37765/ajmc.2025.89730","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89730","url":null,"abstract":"<p><p>The US is in a health care price crisis that significantly impacts employees, employers, and public purchasers. With employer-sponsored health insurance covering 60% of Americans as of 2024, plan sponsors must consider policy advocacy as a part of their long-term cost containment strategy. Plan sponsors can leverage membership in national and regional health care business coalitions, such as The ERISA Industry Committee and the Employers' Forum of Indiana, for policy advocacy and education at federal and state levels. Coalition successes include Texas House Bill 711, which combats anticompetitive contracting practices, and Indiana's House Enrolled Act 1259, which enhances pricing transparency. Although navigating policy advocacy may seem daunting, Catalyst for Payment Reform emphasizes the importance of aligning public policy strategies with procurement/purchasing strategies. By engaging in tailored advocacy efforts, plan sponsors can help lower health care costs, improve access, and ensure sustainable benefits for their plan members.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"212-214"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095735","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Predictive models for low birth weight: a comparative analysis of algorithmic fairness-improving approaches.","authors":"Clare C Brown, Horacio Gomez-Acevedo, Benjamin C Amick, J Mick Tilford, Keneshia Bryant-Moore, Michael Thomsen","doi":"10.37765/ajmc.2025.89737","DOIUrl":"10.37765/ajmc.2025.89737","url":null,"abstract":"<p><strong>Objective: </strong>Evaluating whether common algorithmic fairness-improving approaches can improve low-birth-weight predictive model performance can provide important implications for population health management and health equity. This study aimed to evaluate alternative approaches for improving algorithmic fairness for low-birth-weight predictive models.</p><p><strong>Study design: </strong>Retrospective, cross-sectional study of birth certificates linked with medical insurance claims.</p><p><strong>Methods: </strong>Birth certificates (n = 191,943; 2014-2022) were linked with insurance claims (2013-2021) from the Arkansas All-Payer Claims Database to assess alternative approaches for algorithmic fairness in predictive models for low birth weight (< 2500 g). We fit an original model and compared 6 fairness-improving approaches using elastic net models trained and tested with 70/30 balanced random split samples and 10-fold cross validation.</p><p><strong>Results: </strong>The original model had lower accuracy (percent predicted correctly) in predicting low birth weight among Black, Native Hawaiian/Other Pacific Islander, Asian, and unknown racial/ethnic populations relative to White individuals. For Black individuals, accuracy increased with all 6 fairness-improving approaches relative to the original model; however, sensitivity (true-positives correctly predicted as low birth weight) significantly declined, as much as 31% (from 0.824 to 0.565), in 5 of 6 approaches.</p><p><strong>Conclusions: </strong>When developing and implementing decision-making algorithms, it is critical that model performance metrics align with management goals for the predictive tool. In our study, fairness-improving models improved accuracy and area under the curve scores for Black individuals but decreased sensitivity and negative predictive value, suggesting that the original model, although unfair, was not improved. Implementation of unfair models for allocating preventive services could perpetuate racial/ethnic inequities by failing to identify individuals most at risk for a low-birth-weight delivery.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"e132-e137"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12109546/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095775","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"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":"Impact of telemedicine use on outpatient-related CO2 emissions: estimate from a national cohort.","authors":"Benjo Delarmente, Artem Romanov, Manying Cui, Chi-Hong Tseng, Melody Craff, Dale Skinner, Michael Hadfield, Catherine A Sarkisian, Cheryl L Damberg, A Mark Fendrick, John N Mafi","doi":"10.37765/ajmc.2025.89714","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89714","url":null,"abstract":"<p><strong>Objective: </strong>The US health care system contributes to approximately 9% of domestic US greenhouse gas emissions, exacerbating climate change and threatening human health. By substituting for in-person visits, telemedicine may represent a means of emission avoidance.</p><p><strong>Study design: </strong>Leveraging multipayer claims data, we developed models based on various assumptions to estimate ranges of emissions from travel averted by telemedicine utilization between April 1, 2023, and June 30, 2023.</p><p><strong>Methods: </strong>We estimated the carbon dioxide (CO2) emissions averted from the avoidance of travel by patients using telemedicine as a substitute for their usual source of in-person care at post-public health emergency rates through a modeling analysis of nationwide multipayer claims data representing 19% of US insured adults; findings were extrapolated to the entire US insured adult population.</p><p><strong>Results: </strong>We quantified a monthly average of 1,481,530 US telemedicine visits (65,733 rural) during the study period. Between 740,765 and 1,348,192 of these were estimated to have substituted for in-person visits. Using inputs of 2021 electric vehicle (EV) production share and emissions per mile, we estimated that between 4,075,065 and 7,489,486 kg of CO2 are averted due to telemedicine use each month. Estimates accounting for different assumptions including EV and public transportation use produce a range of 4 million (most conservative) to 8.9 million (least conservative) kg of CO2 averted per month. Extrapolating to the entire US adult population, we estimate that monthly emissions averted range from 21.4 to 47.6 million kg of CO2-roughly equivalent to the monthly emissions of 61,255 to 130,076 gasoline-powered passenger vehicles.</p><p><strong>Conclusion: </strong>Our results suggest that telemedicine use at 2023 rates modestly decreases the carbon footprint of US health care delivery.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":" ","pages":""},"PeriodicalIF":2.1,"publicationDate":"2025-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144977552","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":"Coverage with evidence development study shows benefits in patients with migraine treated with remote electrical neuromodulation.","authors":"Andrea Synowiec, Alit Stark-Inbar, Dolores Dominguez Santamaria, Matthew Fickie, Stephen Ross","doi":"10.37765/ajmc.2025.89726","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89726","url":null,"abstract":"<p><strong>Objective: </strong>Migraine affects millions of individuals in the US, resulting in high health care costs and productivity loss. Traditional medications are often limited in effectiveness and tolerability, creating a need for accessible nonpharmacologic options. This coverage with evidence development (CED) study assessed the necessity of the remote electrical neuromodulation (REN) wearable device for migraine treatment as a standard payer-covered treatment.</p><p><strong>Study design: </strong>Real-world postmarketing CED study in 2 clinics for 14 months.</p><p><strong>Methods: </strong>Members (aged 12-75 years) of a major US health insurer (Highmark Inc) diagnosed with migraine were prescribed REN as part of their clinical care. Effectiveness was evaluated by change in Migraine Disability Assessment (MIDAS) score from baseline to 3 months of treatment and by prospective pain and disability reports 2 hours post treatment. Utilization was measured through prescription fulfillment and safety via adverse event reports.</p><p><strong>Results: </strong>A total of 381 patients (mean [SD] age, 40.5 [13.2] years; 91.1% female) participated. Change in MIDAS score was calculated from all participants who answered the questionnaire twice (n = 116), showing a significant and clinically meaningful mean (SD) improvement of -12.1 (51.8) points (P = .014), from 58.3 (59.0) to 46.2 (44.1). Of the participants, 77.8% reported pain relief and 33.3% reported pain freedom; 70.6% and 50.0% reported relief and freedom from functional disability, respectively. Patients used a mean (SD) of 4.0 (3.1) devices annually (extrapolated). Three minor adverse events were reported. These positive outcomes led to the inclusion of REN as a standard treatment for migraine under Highmark policy.</p><p><strong>Conclusions: </strong>REN leads to significant clinical and functional benefits in patients with migraine. Additional health insurers are encouraged to consider REN as a standard covered treatment.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":" ","pages":""},"PeriodicalIF":2.1,"publicationDate":"2025-04-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144977626","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":"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}