American Journal of Managed Care最新文献

{"title":"Prescription drug prior authorization: costs to pharmacies and physicians.","authors":"Norman V Carroll, Nathan W Carroll, Erica R Brody","doi":"10.37765/ajmc.2026.89956","DOIUrl":"10.37765/ajmc.2026.89956","url":null,"abstract":"<p><strong>Objective: </strong>To determine the costs of prior authorization (PA) for prescription drugs in outpatient settings in the US and Canada.</p><p><strong>Study design: </strong>Systematic literature review.</p><p><strong>Methods: </strong>We systematically searched PubMed, CINAHL, and Embase using keywords and controlled vocabulary to obtain English-language articles addressing PA and costs. Two authors reviewed each article to determine eligibility for the study.</p><p><strong>Results: </strong>The search identified 14 articles that met inclusion criteria. Four examined the time and costs of PA to pharmacies. All were conducted at hospital clinics. Mean times to complete PA varied from 15 minutes to 24 minutes. Labor costs varied from $15 to $63. One study estimated the mean time to complete a PA appeal to be 74 minutes. Eleven studies measured the time and/or costs of PA in physician practices. Four understated and 1 may have overstated time spent on PA. Mean estimates from the remaining studies varied from 25 to 64 minutes. Six studies also measured labor-related costs. The studies that misstated time also misstated labor costs. The 3 remaining mean estimates varied from $21 to $49.</p><p><strong>Conclusions: </strong>Providers incur substantial costs when completing PAs. However, not enough studies have been done to accurately estimate the magnitude of these costs or identify key sources of cost variation. Further, there is no research on the costs of PA to community, mail-order, or specialty pharmacies.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 6","pages":"359-364"},"PeriodicalIF":2.1,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148310297","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":"Stella Ko, David Tabano, Mona Kilany, Kimberly Jinnett, Victor Kirksey, Reg Ledesma, Sarah Mossburg, Charlene Nguyen, Bryan A Wilson","doi":"10.37765/ajmc.2026.90017","DOIUrl":"https://doi.org/10.37765/ajmc.2026.90017","url":null,"abstract":"<p><strong>Objectives: </strong>Underserved populations often have difficulty accessing care for diabetic eye disease, including screening, referral, and treatment. Although barriers to diabetes care management have been well documented, less is understood about barriers specific to rural and underserved populations. In this study, we interviewed health care professionals to identify barriers to and facilitators of screening for diabetic eye disease and specialty care among underserved patients in Alabama.</p><p><strong>Methods: </strong>We conducted 12 semistructured interviews with experts in ophthalmology, diabetes care management, and primary care in Alabama between November 2023 and January 2024. We used the Health Equity Implementation Framework to code interviews and identify key themes related to access barriers and other obstacles to care, as well as opportunities to improve access to screening and treatment.</p><p><strong>Results: </strong>Factors associated with access barriers for underserved populations include limited services in rural areas, insufficient referrals, cost, transportation, limited patient knowledge about diabetes and eye health, inadequate information provided during clinical encounters, and mistrust of clinicians. Several innovative approaches were identified to improve access to eye care services at the health system level and during clinical encounters.</p><p><strong>Conclusions: </strong>Experts have suggested groundbreaking ways to improve access to care across several domains, including clinic mobility, teleophthalmology, and improved information dissemination to patients on disease. Further research is needed to establish an evidence base for additional innovations aimed at improving access to diabetic eye care and expanding their scope through quantitative research efforts, both in Alabama and nationwide.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 Spec. No. 6","pages":""},"PeriodicalIF":2.1,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149129050","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 of behavioral messaging interventions for cardiovascular medication adherence.","authors":"Dana R Fletcher, Lisa M Sandy, Joy Waughtal, Cole Hoffman, Sylvie Novins-Montague, Patrick Hosokawa, Pamela N Peterson, Larry A Allen, Sheana Bull, P Michael Ho","doi":"10.37765/ajmc.2026.89962","DOIUrl":"10.37765/ajmc.2026.89962","url":null,"abstract":"<p><strong>Objectives: </strong>Mobile health (mHealth) interventions have promise as low-cost tools promoting behavioral change. We evaluated the implementation and maintenance costs of 3 text messaging strategies aimed at improving cardiovascular medication adherence.</p><p><strong>Study design: </strong>The Nudge Study (NCT03973931) was a randomized pragmatic trial that evaluated prescription refill adherence across 3 health systems. We estimated costs over the 4-year study period.</p><p><strong>Methods: </strong>After adjusting for inflation to 2023 US$, we calculated net non-research-related labor and materials costs in total and by The Nudge Study arm, assigning usual care a $0 cost. We calculated incremental cost-effectiveness ratios (ICERs) using observed cost; payoffs of the median reduction in number of gap days without medications; and the study's published rates of death, hospitalization, and emergency visits.</p><p><strong>Results: </strong>Program start-up costs were similar across the 3 health care systems (mean [SD], $2954 [$352]). Across the 53 months of the study and comprising start-up, implementation, and program delivery phases, the mean monthly cost to deliver all messaging strategies was $3949 and 1430 unique patients on average received any type of message monthly, resulting in an estimated cost of $2.76 per patient per month. ICER values were low, and there were no significant differences across treatment strategy or outcome.</p><p><strong>Conclusions: </strong>Providing medication adherence support via mobile messaging may be a low-cost solution for some hospital systems.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 6","pages":"e205-e211"},"PeriodicalIF":2.1,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13660525/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148310252","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":"Building a system to ensure awareness of nirogacestat, a treatment for desmoid tumors.","authors":"Kyle Kitchen","doi":"10.37765/ajmc.2026.89980","DOIUrl":"https://doi.org/10.37765/ajmc.2026.89980","url":null,"abstract":"","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 Spec. No. 7","pages":"SP320"},"PeriodicalIF":2.1,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148273882","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":"From transparency to action: turning price data into lower costs.","authors":"David B Muhlestein","doi":"10.37765/ajmc.2026.89928","DOIUrl":"10.37765/ajmc.2026.89928","url":null,"abstract":"<p><p>Using price transparency data to select high-value providers will require improving the quality of the data, presenting the data intuitively, and making it easier to act on the information.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 Spec. No. 6","pages":"eSP1-eSP4"},"PeriodicalIF":2.1,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148201028","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":"Socioeconomic and racial disparities in Guillain-Barré syndrome.","authors":"Yagiz M Altun, Edward R Bader, Siyu Yan, Lauren Gluck","doi":"10.37765/ajmc.2026.89974","DOIUrl":"10.37765/ajmc.2026.89974","url":null,"abstract":"<p><strong>Objectives: </strong>Guillain-Barré syndrome (GBS) is a rapidly progressive neuromuscular disorder that often requires intensive care and immunomodulatory therapy. Despite standardized treatment approaches, access to care and outcomes may be influenced by social determinants of health. We evaluated associations between socioeconomic and racial factors and inpatient interventions and outcomes in GBS in the US.</p><p><strong>Study design: </strong>Retrospective cohort study.</p><p><strong>Methods: </strong>This retrospective cohort study used data from the National Inpatient Sample (2016-2021) to identify hospitalizations with a primary diagnosis of GBS ( International Statistical Classification of Diseases, Tenth Revision code G61.0). Multivariable logistic regression models assessed associations between demographic and socioeconomic variables and 5 prespecified outcomes: in-hospital mortality, nonroutine discharge, prolonged hospitalization, receipt of intravenous immunoglobulin (IVIG), and receipt of plasmapheresis.</p><p><strong>Results: </strong>We analyzed 45,515 GBS-related hospitalizations (patients' mean age, 50.7 years; 46.0% female). After adjusting for covariates, higher zip code income was associated with reduced inpatient mortality (OR per quartile, 0.80; 95% CI, 0.66-0.98). Admission to private investor-owned hospitals was associated with lower IVIG or plasmapheresis use, an effect not seen when analyzing only privately insured patients. Black patients were less likely to receive plasmapheresis (OR, 0.75; 95% CI, 0.59-0.95). Black and Native American patients had higher odds of nonroutine discharge (Black: OR, 1.26; 95% CI, 1.06-1.51; Native American: OR, 2.16; 95% CI, 1.20-3.88). Medicare coverage was associated with higher odds of nonroutine discharge (OR, 1.90; 95% CI, 1.62-2.23), and Medicaid coverage was associated with prolonged hospitalization (OR, 1.73; 95% CI, 1.48-2.02). Self-pay was linked to reduced odds of nonroutine discharge but longer hospitalization (OR, 0.53; 95% CI, 0.43-0.66).</p><p><strong>Conclusions: </strong>This study reveals socioeconomic, racial, and institutional disparities in GBS hospitalization outcomes despite standardized treatment guidelines. These findings highlight the need for equity-focused strategies to ensure timely and consistent care for patients with acute neurologic conditions.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 Spec. No. 6","pages":"eSP12-eSP21"},"PeriodicalIF":2.1,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148201062","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":"Health care utilization in veterans with Alzheimer disease.","authors":"Ying Wang, Byron J Aguilar, Mingfei Li, Peter Morin, Joel Reisman, Wen Hu, Jong Soo Lee, Dan Berlowitz, Qinqing Li, Raymond Zhang, Amir Abbas Tahami Monfared, Quanwu Zhang, Weiming Xia","doi":"10.37765/ajmc.2026.89959","DOIUrl":"https://doi.org/10.37765/ajmc.2026.89959","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate health care utilization in veterans with Alzheimer disease (AD) in the Veterans Affairs health system (VAHS).</p><p><strong>Study design: </strong>This retrospective analysis identified veterans with AD using clinical notes extracted from the VAHS electronic health record from fiscal years 2010 to 2019.</p><p><strong>Methods: </strong>The first note identifying AD was the index date. Health care utilization in veterans with AD and a 1:1 matched comparison group without AD was evaluated at 2 years preindex, 1 year preindex, 1 year post index, and 2 years post index.</p><p><strong>Results: </strong>From clinical notes, we identified 571,671 veterans with AD and 571,671 for the comparison group (overall: mean age, 74 years; 96% male; 75% White). In those with AD, outpatient visits per patient per year peaked 1 year post index at 67 and remained elevated 2 years post index at 57; without AD, the rate was approximately 19 at all time points. Hospitalization rates peaked at 1 year post index with AD but were lower and generally stable without AD. Nursing home utilization was relatively low overall. Veterans meeting the 2-code criteria (n = 56,305), defined as having 2 diagnostic codes for AD recorded at least 30 days apart, had consistently higher utilization than veterans without AD (especially post index).</p><p><strong>Conclusion: </strong>Veterans with AD have higher health care utilization than veterans without AD, especially around the time of AD diagnosis.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 6","pages":"e185-e191"},"PeriodicalIF":2.1,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148310316","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":"Health outcomes of socially vulnerable populations in different Medicare payment arrangements.","authors":"Kenneth Cohen, Kierstin Catlett, Jennifer Podulka, Omid Ameli, Chris Freyder, Megan S Jarvis, Binh Nguyen, Susan Dentzer","doi":"10.37765/ajmc.2026.89964","DOIUrl":"10.37765/ajmc.2026.89964","url":null,"abstract":"<p><strong>Objectives: </strong>Two-sided risk Medicare Advantage (MA) arrangements (at-risk MA) outperform Medicare fee-for-service (FFS) arrangements in quality and efficiency. The influence of social determinants of health (SDOH) remains unclear. Using the Social Vulnerability Index (SVI) as a proxy for SDOH, we compared outcomes for beneficiaries with varying levels of social vulnerability across at-risk MA, FFS MA, and FFS Medicare (traditional Medicare [TM]) arrangements.</p><p><strong>Study design: </strong>Retrospective cohort study.</p><p><strong>Methods: </strong>We analyzed TM claims from 2019 and MA encounter data for 1,703,060 beneficiaries attributed to 16 physician groups in at-risk MA. Two models were estimated: (1) adjusting for SVI and (2) modeling SVI as interactions. We used multivariable logistic regression to analyze outcomes.</p><p><strong>Results: </strong>At-risk MA outperformed FFS in all 8 outcomes regardless of SVI. We found that at-risk MA outperformed FFS TM in 5 of 8 outcomes for beneficiaries with higher social vulnerabilities. Compared with TM, at-risk MA beneficiaries had 13.5% to 16.6% fewer acute admissions, 2.0% to 3.6% fewer emergency department (ED) visits, 10.9% to 14.4% fewer inpatient admissions through the ED, less than 1% fewer office visits, and 23.4% to 30.0% fewer instances of high-risk medication use, with the greatest differences observed in beneficiaries living in high SVI areas. At-risk MA also exhibited better quality metrics than FFS MA, but to a lesser extent than FFS TM.</p><p><strong>Conclusions: </strong>This observational study found that beneficiaries in at-risk MA received higher-quality, more efficient care-especially in groups with elevated social vulnerability-suggesting that these populations benefit from value-based care (VBC) arrangements. Additional research is required to identify the specific VBC components driving quality and efficiency differences.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 Spec. No. 6","pages":"SP258-SP266"},"PeriodicalIF":2.1,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148201075","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":"Availability of hospital financial assistance documents in non-English languages.","authors":"Nina Linh Nguyen, Samantha Randall, Ella Cho, Erin Trish, Erin L Duffy","doi":"10.37765/ajmc.2026.89953","DOIUrl":"10.37765/ajmc.2026.89953","url":null,"abstract":"<p><strong>Objectives: </strong>Millions of people struggle to afford hospital care in the US, and individuals who speak languages other than English (LOTE) are particularly vulnerable due to language barriers in understanding and accessing hospital financial assistance policies (FAPs). Nonprofit hospitals are required under Internal Revenue Service (IRS) rules to provide translated financial documents in any language spoken by at least 1000 individuals or 5% of the population in their service area. However, adherence to these requirements is unknown, and to our knowledge, no study has evaluated whether for-profit or government hospitals voluntarily offer translations of FAP documents to aid individuals who speak LOTE.</p><p><strong>Study design: </strong>Cross-sectional study.</p><p><strong>Methods: </strong>We reviewed the websites of all 426 nonfederal hospitals in the 10 most linguistically diverse US core-based statistical areas (CBSAs), focusing on the availability of 4 financial documents in multiple languages: financial assistance policies, plain language summaries, financial assistance applications, and billing/collections policies. We assessed the association between the number of languages served and hospitals' system and ownership status (nonprofit, for-profit, government) using multivariate regression, adjusting for CBSA.</p><p><strong>Results: </strong>The study findings demonstrate that system-affiliated and nonprofit hospitals provide more translated documents than their for-profit, governmental, and unaffiliated counterparts. Nonprofit hospitals provided significantly more language options across all document types, suggesting compliance with IRS requirements. System-affiliated hospitals also performed better, possibly due to greater administrative resources.</p><p><strong>Conclusions: </strong>The study highlights a gap in multilingual access among for-profit, governmental, and unaffiliated hospitals, raising concerns that individuals who speak LOTE may face greater challenges navigating financial assistance and medical billing at these hospitals.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 6","pages":"334-337"},"PeriodicalIF":2.1,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148310122","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 pharmacotherapy and psychotherapy impact on opioid use disorder treatment.","authors":"Daniel Maeng, Cory A Crane, Hugh Crean, Patrick Walsh, Suiyue Cui, Lisham Ashrafioun","doi":"10.37765/ajmc.2026.89955","DOIUrl":"10.37765/ajmc.2026.89955","url":null,"abstract":"<p><strong>Objective: </strong>To examine whether patients with opioid use disorder (OUD) who receive both medications for OUD (MOUD) and psychotherapy experience lower rates of acute care utilization and total cost of care relative to periods when they receive either MOUD or psychotherapy alone.</p><p><strong>Study design: </strong>Retrospective claims data analysis of commercially insured adults in the US with a diagnosis of OUD between 2019 and 2022.</p><p><strong>Methods: </strong>Multivariate linear regression models were estimated using rates of all-cause emergency department (ED) visits, inpatient admissions, and total cost of care as the outcome variables. Subsample analyses of urban and rural residents were also performed to examine whether the impacts differ by rurality.</p><p><strong>Results: </strong>The sample included 18,316 patients representing 450,437 member-month observations. During the months when patients received both MOUD and psychotherapy, their per-member per-month rates of all-cause ED visits and inpatient admissions were lower by 33.5% (P < .001) and 47.6% (P < .001), respectively, relative to months when they received either MOUD or psychotherapy alone. This translated to a 38.3% lower total cost of care (P < .001). Similar magnitudes were noted among both rural and urban residents.</p><p><strong>Conclusions: </strong>Receipt of both MOUD and psychotherapy is associated with reductions in the rates of ED visits and inpatient admissions along with lower total cost of care relative to receipt of either MOUD or psychotherapy alone. The results suggest that such a combined and complementary approach to OUD treatment may be justified due to its improved patient health outcomes and potential economic value.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"32 6","pages":"353-358"},"PeriodicalIF":2.1,"publicationDate":"2026-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148310106","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}