American Journal of Managed Care最新文献

{"title":"Health outcomes under full-risk Medicare Advantage vs traditional Medicare.","authors":"Kenneth Cohen, Boris Vabson, Jennifer Podulka, Omid Ameli, Kierstin Catlett, Nathan Smith, Megan S Jarvis, Jane Sullivan, Caroline Goldzweig, Susan Dentzer","doi":"10.37765/ajmc.2025.89740","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89740","url":null,"abstract":"<p><strong>Objectives: </strong> To compare quality and health resource utilization among beneficiaries under 2-sided risk Medicare Advantage (MA) payment arrangements (at-risk MA) vs traditional Medicare (TM).</p><p><strong>Study design: </strong>Retrospective cross-sectional regression analyses of claims and enrollment data from 2016 to 2019 examining 20 performance measures. All patients were cared for by the same 17 physician groups and 15,488 physicians across 35 health insurers.</p><p><strong>Methods: </strong>Logistic regressions adjusted for demographics, geography, and comorbidities for 20 quality and utilization measures across 4 domains of care. Estimates were reported using marginal risk and marginal risk difference per 1000 across the study period.</p><p><strong>Results: </strong> The sample comprised 6,564,538 person-years (30.3% at-risk MA and 69.7% TM). Sixteen of the 20 measures favored at-risk MA, including lower acute inpatient admissions, lower 30-day readmissions, avoidance of emergency department utilization across 4 measures, avoidance of disease-specific inpatient admissions in 7 of 9 measures, lower high-risk medication use and office visits, and higher medication adherence to renin-angiotensin system drugs. The other 4 measures were statistically equivalent.</p><p><strong>Conclusions: </strong>Given the CMS goal of moving all beneficiaries to fully accountable care arrangements by 2030, it is critical to understand the differences in quality and health resource utilization between at-risk MA and fee-for-service TM to inform policies on payment and service delivery. Although the associations are not causal, in this cross-sectional study, at-risk MA relative to TM was associated with 11.3% to 54.0% higher quality and efficiency in 16 of 20 measures after adjusting for differences in demographics, comorbidities, and other health characteristics.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":" ","pages":""},"PeriodicalIF":2.1,"publicationDate":"2025-05-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144977593","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":"An assessment of nurse practitioner low-value care use in primary care.","authors":"Sara B Nugent, Roberta P Lavin, Jongwon Lee, Brady P Horn, Barbara I Holmes Damron","doi":"10.37765/ajmc.2025.89741","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89741","url":null,"abstract":"<p><strong>Objectives: </strong>To establish baseline prevalence rates associated with nurse practitioner (NP) use of 3 of the most commonly observed primary care low-value-care (LVC) services and to examine whether practice location and patient characteristics impact NP LVC use.</p><p><strong>Study design: </strong>Cross-sectional, secondary analysis.</p><p><strong>Methods: </strong>Data for 14,579 adult beneficiaries in the 2021 Merative MarketScan Commercial and Medicare databases in Arizona, Nevada, and New Mexico were analyzed. Outpatient claims associated with NP care were used to examine the use of low-value lumbar x-ray, antibiotics for acute upper respiratory infection (aURI), and routine electrocardiogram (ECG) as described by the Choosing Wisely initiative. International Statistical Classification of Diseases, Tenth Revision and Current Procedural Terminology codes were used to apply inclusion and exclusion criteria. Relationships between LVC use and the state where a beneficiary received care, rural-urban practice location, and beneficiary sex and age were examined.</p><p><strong>Results: </strong>Prevalence rates of NP use of low-value lumbar x-ray (13%), aURI antibiotic (42%), and ECG (6%) were lower or relatively similar to those found in other studies. Older beneficiary age was significantly associated with more low-value ECGs used (P < .001), but when adults 45 years and older were examined, age no longer remained significantly related. No significant relationships between NP LVC use and practice location or beneficiary sex were found.</p><p><strong>Conclusions: </strong>NP LVC use in primary care was lower or relatively similar compared with the general clinician population. MarketScan may underrepresent rural care, and the relationship between NP LVC use and rural-urban location should be reexamined using an alternative classification system. To deimplement NP LVC use, other factors, such as NP characteristics, must be explored.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":" ","pages":""},"PeriodicalIF":2.1,"publicationDate":"2025-05-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144977451","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":"Effect of remote patient monitoring on stage 2 hypertension.","authors":"Lyle Dennis, Irina Koyfman","doi":"10.37765/ajmc.2025.89742","DOIUrl":"10.37765/ajmc.2025.89742","url":null,"abstract":"<p><strong>Objectives: </strong>Remote patient monitoring (RPM) is increasingly being utilized in clinical practice to reduce blood pressure in patients with hypertension. RPM depends on home readings by patients electronically transmitted to clinicians and includes automated alerts for excessive abnormal readings. Data demonstrating the efficacy of RPM are limited; moreover, no study has specifically addressed patients with stage 2 hypertension. The current study aimed to address this gap.</p><p><strong>Study design: </strong>Quasi-experimental retrospective cohort study.</p><p><strong>Methods: </strong>A cohort of community-dwelling Medicare patients in a large outpatient primary care practice was enrolled in an RPM program if they were diagnosed with hypertension. Patients were followed for 1 year. Each patient was also assigned a nurse to function as a care coach, who communicated with the patients monthly and provided at least 20 minutes of care management.</p><p><strong>Results: </strong>Of the 3403 Medicare beneficiaries who consented to participate, 1594 actively engaged in the program for 1 year. Of these, 652 had stage 2 hypertension (systolic blood pressure [SBP] ≥ 140 mm Hg and/or diastolic BP [DBP] ≥ 90 mm Hg). The initial mean SBP/DBP ratio for those with stage 2 hypertension was 152/85 mm Hg, which decreased to 132/74 mm Hg by month 12. At baseline, 100% of these 652 patients met the criteria for stage 2 hypertension, but by month 12, this percentage decreased to 25%. In the 163 patients who remained in stage 2 hypertension, a notable decrease in BP was also achieved, with the mean BP dropping from 155/87 mm Hg to 146/77 mm Hg (P < .05).</p><p><strong>Conclusions: </strong>Deployment of an RPM program in Medicare patients with concomitant care coaching was associated with statistically significant reductions in both elevated BP readings and the presence of stage 2 hypertension.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":" ","pages":"e244-e248"},"PeriodicalIF":2.1,"publicationDate":"2025-05-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144977577","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":"Unmet health care and health-related social needs of laundromat users.","authors":"Lindsey Jeanne Leininger, Courtney Bragg, Allister Chang, Andrea Palm","doi":"10.37765/ajmc.2025.89733","DOIUrl":"10.37765/ajmc.2025.89733","url":null,"abstract":"<p><strong>Objectives: </strong>To estimate the prevalence of unmet health care and health-related social needs (HRSNs) among laundromat users and examine differences by health insurance coverage.</p><p><strong>Study design: </strong>Cross-sectional observational study.</p><p><strong>Methods: </strong>We collected a survey from participants in a pilot intervention conducted in 14 Pennsylvania laundromats between September and December 2023. The measures included health insurance coverage, unmet health care needs, and unmet HRSNs. Descriptive analyses and linear probability regression models with laundromat fixed effects were used to estimate the overall prevalence of unmet needs and explore subgroup differences.</p><p><strong>Results: </strong>Among the 1995 sample members, approximately half (52.9%) had Medicaid coverage, 21.7% had private coverage, 14.5% were uninsured, 5.4% had Medicare, and 5.5% were dually enrolled in Medicare and Medicaid. The prevalence of having any unmet HRSN was higher than having any unmet health care need (54.3% vs 12.3%). Across unmet need measures, Medicaid sample members had 1.5 to 5 times higher levels relative to the privately insured. Differences by insurance coverage remained in fixed-effects analyses that limited comparisons to laundromat users at the same location.</p><p><strong>Conclusions: </strong>Laundromat-based outreach is likely most promising for Medicaid-serving stakeholders because Medicaid enrollees are disproportionately represented among laundromat users and have disproportionately high levels of unmet needs.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"233-239"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095777","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":"Longitudinal, relationship-based case management: a prospective cohort trial.","authors":"Patrick Runnels, Ryan Muskin, Mark Votruba, Peter J Pronovost, Afua Ansah, James Penman","doi":"10.37765/ajmc.2025.89731","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89731","url":null,"abstract":"<p><strong>Objectives: </strong>This study addresses the challenge of improving outcomes for the 5% of individuals with complex chronic diseases who utilize 50% of health care resources. Previous interventions targeting this population have shown limited impact, often due to transactional and time-limited approaches. This study proposes a longitudinal, relationship-based case management framework as an alternative solution.</p><p><strong>Study design: </strong>A nonrandomized, prospective cohort study was conducted among Medicaid enrollees with complex medical and social needs.</p><p><strong>Methods: </strong>The intervention involved case managers building strong interpersonal relationships over a minimum of 1 year, addressing barriers to care and facilitating solutions. Primary outcomes were total health care expenditures and patient-rated quality of life.</p><p><strong>Results: </strong>The intervention group exhibited a significant reduction in total health care costs over 1 year ($8568 per patient), with greater savings observed for patients with higher preintervention costs. Additionally, an estimated annual savings net of program costs of $248,121 was observed. Patient-rated quality of life showed substantial improvement, evident at both 6 months and 1 year post enrollment.</p><p><strong>Conclusions: </strong>This study demonstrates the effectiveness of a longitudinal, relationship-based case management approach in improving outcomes for individuals with complex medical, social, and behavioral needs. Unlike transactional interventions, this approach emphasizes partnership and customization, yielding substantial cost reductions and enhanced quality of life. Although limitations exist, including nonrandomization and staff diversity, this study provides a foundation for future research and scalability of similar interventions.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"216-221"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095759","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":"Evaluating access to care for Medicare beneficiaries younger than 65 Years.","authors":"Emma M Achola, Shelley A Jazowski, Lauren Hersch Nicholas, Laura M Keohane, William A Wood, Christopher R Friese, Stacie B Dusetzina","doi":"10.37765/ajmc.2025.89732","DOIUrl":"10.37765/ajmc.2025.89732","url":null,"abstract":"<p><strong>Objectives: </strong>Individuals younger than 65 years can qualify for Medicare if they have long-term disabilities or certain qualifying conditions. These beneficiaries-particularly the non-dual-eligible population-may experience cost and access barriers to medical care. We examined the association between Medicare coverage type and reported barriers to care.</p><p><strong>Study design: </strong>Multivariable linear probability models assessed the association between self-reported Medicare coverage and patient-reported outcomes by dual-eligibility status.</p><p><strong>Methods: </strong>Using 2012-2020 data from the Health and Retirement Study, we compared self-reported sociodemographic and health-related characteristics of non-dual-eligible and dual-eligible beneficiaries aged 50 to 64 years by Medicare coverage type at their baseline interview. We then examined the following self-reported outcomes: experiencing cost-related medication nonadherence, delaying care due to cost, not having a usual source of care, and having trouble finding a doctor.</p><p><strong>Results: </strong>Among non-dual-eligible beneficiaries, enrollment in traditional Medicare (TM) plus supplemental coverage vs TM with no supplemental coverage was associated with lower reported rates of experiencing cost-related medication nonadherence (-7.5 percentage point [PP] change; 95% CI, -12.1 to -3.0), delaying care due to cost (-9.8 PP; 95% CI, -13.3 to -6.3), and having no usual source of care (-5.5 PP; 95% CI, -8.9 to -2.1). Compared with TM with no supplement, Medicare Advantage enrollment was associated with lower rates of delaying care due to cost (-4.2 PP; 95% CI, -7.6 to -0.7) and having no usual source of care (-5.2 PP; 95% CI, -8.2 to -2.3). Among dual-eligible beneficiaries, outcomes largely did not differ by coverage type. Switching from traditional Medicare to Medicare Advantage was associated with trouble finding a doctor for dual-eligible beneficiaries.</p><p><strong>Conclusions: </strong>Enrollment in less generous Medicare coverage was associated with greater cost and access barriers to care for beneficiaries younger than 65 years.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"222-229"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12231181/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095717","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":"Using data exchange to improve quality reporting, target outreach, and reduce cost.","authors":"Barbara Rubino, Chelsea Hart-Connor, Todd A May","doi":"10.37765/ajmc.2025.89738","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89738","url":null,"abstract":"<p><p>The burden of collecting data and reporting on quality measures is a strain on both providers and payers, exacerbated by the multitude of required metrics and disparate data systems. Covered California, the California health benefits exchange that supports more than 1.9 million Californians receiving insurance through the Affordable Care Act, and insurance carrier Health Net, serving approximately 138,000 members on the exchange, implemented a novel approach to data exchange using Covered California's all-payer claims database (APCD). This initiative used historical cancer screening data for Health Net enrollees who had been insured under different Covered California plans in the prior 5 years and analyzed the impact of historical data sharing on screening rates, cost, and efficiency. Historical data exchange led to improved accuracy of quality measure reporting by up to 14% in breast cancer screening quality scores. Additionally, through reduced administrative costs and the elimination of duplicative testing, Health Net saw more than $640,000 in estimated potential cost savings. The success of the pilot between Covered California and Health Net has led to an expansion across all carriers, highlighting the potential of APCDs to facilitate more targeted quality improvement strategies and improve efficiency in health care. This initiative underscores the importance of innovative data exchange strategies to advance health care quality, efficiency, and equity.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"e138-e140"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095778","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":"Quantifying the altruism value for a rare pediatric disease: Duchenne muscular dystrophy.","authors":"Jason Shafrin, Suhail Thahir, Alexa C Klimchak, Ivana Audhya, Lauren E Sedita, John A Romley","doi":"10.37765/ajmc.2025.89673","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89673","url":null,"abstract":"<p><strong>Objectives: </strong>To quantify the magnitude of altruism value as applied to a hypothetical new treatment for a rare, severe pediatric disease: Duchenne muscular dystrophy (DMD).</p><p><strong>Study design: </strong>Prospective survey of individuals not planning to have children in the future.</p><p><strong>Methods: </strong>A survey was administered to US adults (aged ≥ 21 years) not intending to have a child in the future to elicit willingness to pay (WTP) for government insurance coverage for a new hypothetical DMD treatment that improves mortality and morbidity relative to the current standard of care. A multiple random staircase design was used to identify an indifference point between status quo government insurance coverage and coverage with additional cost in taxes that would cover the treatment if unrelated individuals had a child with DMD. Altruism value was calculated as respondents' mean WTP.</p><p><strong>Results: </strong>Among 215 respondents, 54.9% (n = 118) were aged 25 to 44 years and 80.0% (n = 172) were women. Mean WTP for insurance coverage of the hypothetical DMD treatment for others was $80.01 (95% CI, $41.64-$118.37) annually, or $6.67 monthly, after adjustment to account for disease probability overestimation. The adjusted altruism value was higher than the ex ante per-person value using traditional cost-effectiveness approaches ($45.30/year). Without adjusting, individuals were willing to pay $799.11 annually ($66.59 monthly).</p><p><strong>Conclusions: </strong>Despite no possibility of accruing health benefits directly for themselves or their children, individuals had a high WTP for government insurance coverage of a novel treatment for this rare, severe pediatric disease.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"240-244"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095776","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":"Digital health implementation among older adults: health technology navigators' perspectives.","authors":"Katarina Wang, Ann Marie Hernandez, Veronica Penate, Anshu Abhat, Alejandra Casillas","doi":"10.37765/ajmc.2025.89736","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89736","url":null,"abstract":"<p><strong>Objectives: </strong>Despite the rise in health technology, a persistent digital divide affects underserved groups, including low-income, uninsured or underinsured, and limited English proficient (LEP) patients. This study highlights lessons learned from a unique stakeholder-health technology navigators-about factors affecting digital health use among older and linguistically diverse patients in one of the largest US safety-net health systems.</p><p><strong>Study design: </strong>We conducted in-depth interviews with Los Angeles County Department of Health Services (LAC DHS) navigators from June to December 2023. Discussions focused on their job role, identity, experiences supporting older patients (≥ 50 years) to register and use the patient portal, and linguistically diverse patients (primary language other than English or LEP) in this safety net.</p><p><strong>Methods: </strong>We used the Theoretical Domains Framework to create an interview guide. We interviewed 9 female and 2 male navigators across 9 LAC DHS clinics who were bilingual (English and Spanish). Interviews were transcribed and analyzed for major themes.</p><p><strong>Results: </strong>Three primary themes emerged from the qualitative analysis: characteristics of a successful navigator, patients' prior experiences with digital health, and barriers in the clinic.</p><p><strong>Conclusions: </strong>Navigators highlighted older patients' interest in learning to use digital tools and the need for support in digital health engagement. In describing their work with patients, navigators drew on their lived experiences with family and community to connect with these older patients in the Los Angeles safety-net health system. The lessons learned from these navigators can inform digital health engagement in other safety-net health settings so that they are more inclusive for older patients.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"e125-e131"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095729","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 John Michael O'Brien, PharmD, MPH.","authors":"John Michael O'Brien, Christina Mattina","doi":"10.37765/ajmc.2025.89729","DOIUrl":"10.37765/ajmc.2025.89729","url":null,"abstract":"<p><p>To mark the 30th anniversary of The American Journal of Managed Care (AJMC), each issue in 2025 includes reflections from a thought leader on what has changed over the past 3 decades and what's next for managed care. The May issue features a conversation with John Michael O'Brien, PharmD, MPH, a member of AJMC's editorial board and the president and CEO of the National Pharmaceutical Council.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 5","pages":"209-211"},"PeriodicalIF":2.5,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144095773","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}