American Journal of Managed Care最新文献

{"title":"Medical policy determinations for pharmacogenetic tests among US health plans.","authors":"Jai N Patel, Lena Chaihorsky, Olivia M Dong, Christine Y Lu, Chad Moretz, Emily Reese, Wrenda Teeple, Benjamin Brown, Sara Rogers","doi":"10.37765/ajmc.2025.89683","DOIUrl":"10.37765/ajmc.2025.89683","url":null,"abstract":"<p><strong>Objectives: </strong>To evaluate medical policy determinations for pharmacogenetic (PGx) testing for 65 clinically relevant drug-gene pairs and evidence cited to support determinations across major US health plans and laboratory benefit managers (LBMs).</p><p><strong>Study design: </strong>Landscape analysis of available PGx medical policies to determine coverage status of certain drug-gene pairs.</p><p><strong>Methods: </strong>PGx medical policies as of February 1, 2024, were ascertained through Policy Reporter for top national insurers, LBMs, and the Palmetto GBA Molecular Diagnostic Services (MolDX) Program, which determines whether a molecular diagnostic test is covered by Medicare. Data elements included date of last policy update, coverage status for each drug-gene pair, and evidence cited for or against coverage. A drug-gene pair was considered covered if the policy indicated that a PGx test was deemed medically necessary and/or meets coverage criteria.</p><p><strong>Results: </strong>Policies from 8 insurers, 3 LBMs, and MolDX were available and reviewed. MolDX covered all 65 individual drug-gene pairs, followed by Avalon Healthcare Solutions (n = 50) and UnitedHealthcare (n = 45); these 3 also covered multigene panels. Eight policies covered 10 or fewer drug-gene pairs. HLA-B*57:01 testing prior to abacavir initiation and HLA-B*15:02 testing prior to carbamazepine initiation were covered across all policies. Drug-gene pairs with Clinical Pharmacogenetics Implementation Consortium guidelines and/or included in the FDA's Table of Pharmacogenetic Associations Section 1 were more commonly covered. Society guidelines were the most frequently cited evidence (413 times), and cost-effectiveness studies were infrequently cited (43 times).</p><p><strong>Conclusions: </strong>We found significant variability in medical policy determinations and evidence cited for clinically relevant PGx tests among major US health insurers and LBMs. A collaborative effort between payers and the PGx community to standardize evidence evaluation may lead to more consistent coverage and improve patient access to PGx tests meeting evidence requirements.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 2","pages":"e47-e55"},"PeriodicalIF":2.5,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143469993","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":"Veterans Health Administration benefit value has little effect on reliance.","authors":"Yevgeniy Feyman, Allison Dorneo, Steven D Pizer, Christine Yee","doi":"10.37765/ajmc.2025.89684","DOIUrl":"10.37765/ajmc.2025.89684","url":null,"abstract":"<p><strong>Objectives: </strong>US military veterans have multiple options for health insurance coverage, including the Veterans Health Administration (VHA) and Medicare programs, which can lead to strategic selection of coverage and potentially inefficient budgetary allocations. Because coverage choices are likely to be a function of coverage availability and benefit value, understanding the relationship between benefit value and reliance on coverage is critical.</p><p><strong>Study design: </strong>Analysis of cross-sectional, nationally representative survey data.</p><p><strong>Methods: </strong>This analysis relied on a novel measure of benefit value for the VHA and Medicare Advantage (MA) programs and nationally representative survey data of veterans and their health care use for 2016 through 2019. Linear regressions controlling for beneficiary and market characteristics with state and year fixed effects were used to first estimate the effect of VHA benefit value relative to MA benefit value on MA enrollment, and then on veteran reliance on VHA-paid care conditional on MA enrollment.</p><p><strong>Results: </strong>We found that a $1 increase in relative VHA benefit value leads to at most a 0.2% (SE = 0.04) reduction in the probability of MA enrollment and a 0.3-percentage point (SE = 0.1) increase in reliance on VHA-paid care. Results were consistent across subgroups of enrollees, with slightly larger effects for enrollees with less generous benefits.</p><p><strong>Conclusions: </strong>For most veterans, benefit value has a small, often nonsignificant, effect on reliance. These results imply that changes in VHA benefit value are unlikely to have major effects on veteran reliance on the VHA.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 2","pages":"e56-e61"},"PeriodicalIF":2.5,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12171973/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143469243","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":"Health disparities in HIV care and strategies for improving equitable access to care.","authors":"Omar Daoud, Jay E Gladstein, Diana Brixner, Stuart O'Brochta, Sarjita Naik","doi":"10.37765/ajmc.2025.89687","DOIUrl":"10.37765/ajmc.2025.89687","url":null,"abstract":"<p><p>The US HIV/AIDS Strategy and Ending the HIV Epidemic (EHE) initiatives aim to reduce HIV transmission by 90% by 2030 through targeted care and prevention initiatives such as the Undetectable = Untransmittable strategy. Effective HIV management involves implementation of widely available testing to ensure early diagnosis, immediate or early initiation of antiretroviral therapy (ART), patient adherence to medication, and retention in care to achieve viral suppression and improve clinical outcomes. A disproportionate burden of HIV incidence is experienced by certain populations that include Black/African American and Hispanic/Latinx people, transgender individuals, those who inject drugs, older adults, and people living in the southeastern US. People with HIV (PWH) in vulnerable and underserved populations are more likely to be affected by the negative impacts of structural and social determinants of health-such as experiencing HIV-related stigma, poverty, and homelessness-resulting in barriers to accessing HIV care and achieving favorable treatment outcomes. Suboptimal HIV care negatively impacts outcomes for both individuals and society. Overall and comorbidity-free life expectancies are lower for individuals who start ART late than for the overall PWH population, and a lack of viral suppression increases community transmission rates. These poor outcomes increase costs for both patients and health care systems. Maintaining access to high-quality care by optimizing ART regimens, decreasing delays in ART initiation, and engaging patients in care by building trust and empowering patient choice will improve individual and population-level outcomes and support the EHE initiative. This manuscript examines strategies to improve HIV care access and outcomes for underserved populations, focusing on social determinants of health, stigma, geographic disparities, and treatment adherence, while highlighting the role of national initiatives and managed care programs in advancing health equity.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 1 Suppl","pages":"S3-S12"},"PeriodicalIF":2.5,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143124049","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":"Financial navigation: lessons from a program in practice.","authors":"Natalie R Dickson, Samyukta Mullangi","doi":"10.37765/ajmc.2025.89689","DOIUrl":"https://doi.org/10.37765/ajmc.2025.89689","url":null,"abstract":"","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 Spec. No. 2","pages":"SP105-SP106"},"PeriodicalIF":2.5,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143460508","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":"Development of multipayer claims-based emergency department episodes of care.","authors":"Kristen P Hassett, Keith E Kocher, Alexander Janke, Chelsea A Pizzo, Michael P Thompson","doi":"10.37765/ajmc.2025.89679","DOIUrl":"10.37765/ajmc.2025.89679","url":null,"abstract":"<p><strong>Objectives: </strong>To describe the design of multipayer claims-based episodes of care initialized by visits to the emergency department (ED) and to demonstrate the utility of this framework for health care quality improvement work.</p><p><strong>Study design: </strong>A retrospective analysis of paid medical insurance claims organized into 30-day episodes of care initialized by ED visits for Michigan adult residents with private insurance, Medicare, and Medicaid.</p><p><strong>Methods: </strong>Thirty-day claims-based episodes of care initialized by ED visits at Michigan hospitals were constructed for 15 medical conditions. Mean episode payments were price standardized and risk adjusted. Analyses described episode payments and postacute care utilization primarily across 6 conditions: abdominal pain, cellulitis, chronic obstructive pulmonary disease, congestive heart failure, nonspecific chest pain, and urinary tract infection.</p><p><strong>Results: </strong>A total of 2,657,818 ED-based episodes of care for 15 conditions were identified for commercially and government-insured adult patients receiving ED care at 105 Michigan hospitals. Total payments across a 30-day episode of care and utilization of postacute care services varied substantially by condition and across the state, with mean risk-adjusted, price-standardized 30-day total payments for a given episode ranging from $3262 for abdominal pain to $17,941 for congestive heart failure.</p><p><strong>Conclusions: </strong>Episodes of care created from multipayer claims data can be used to provide insight into opportunities for collaboration and improvement of patients' care continuum following an ED visit.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 2","pages":"90-96"},"PeriodicalIF":2.5,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143469973","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":"KAP regarding ChatGPT among health care professionals: correspondence.","authors":"Hinpetch Daungsupawong, Viroj Wiwanitkit","doi":"10.37765/ajmc.2025.89680","DOIUrl":"10.37765/ajmc.2025.89680","url":null,"abstract":"<p><p>This letter discusses previously published research that paves the way for deeper exploration of the ethical and human aspects of artificial intelligence in health care.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 2","pages":"e31"},"PeriodicalIF":2.5,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143469985","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":"Telephone follow-up on Medicare patient surveys remains critical.","authors":"Ann Haas, Denise D Quigley, Amelia M Haviland, Nate Orr, Julie Brown, Sarah Gaillot, Marc N Elliott","doi":"10.37765/ajmc.2025.89668","DOIUrl":"10.37765/ajmc.2025.89668","url":null,"abstract":"<p><strong>Objectives: </strong>Patient experience surveys are essential to measuring patient-centered care, a key component of health care quality. Low response rates in underserved groups may limit their representation in overall measure performance and hamper efforts to assess health equity. Telephone follow-up improves response rates in many health care settings, yet little recent work has examined this for surveys of Medicare enrollees, including those with Medicare Advantage. Our objective was to describe response rates to the 2022 Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) surveys and the completion mode (mail or telephone), overall and by person-level characteristics.</p><p><strong>Study design: </strong>Cross-sectional survey.</p><p><strong>Methods: </strong>Participants were 1,092,434 individuals with Medicare who were selected to receive the 2022 MCAHPS survey in the 50 states and the District of Columbia and who were representative of the Medicare population. Study measures were survey response and completion mode.</p><p><strong>Results: </strong>The overall response rate was 33.7% (31.3% by mail and 2.3% by telephone), with 6.9% of responses by telephone. Despite the low overall telephone response rate, the phone was used at markedly higher rates by respondents in some groups with lower overall response rates who are thus underrepresented among respondents, including those who were younger than 65 years (eligible for Medicare due to disability: 16.5% of responses by telephone), Black (16.1%), or Hispanic (14.1%) or had limited income and assets (14.6%).</p><p><strong>Conclusions: </strong>Including a telephone component in the administration of the MCAHPS survey continues to have value because several groups still show a relative preference for survey completion by telephone. Steps should be taken to improve response rates by telephone.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 1","pages":"e26-e30"},"PeriodicalIF":2.5,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143030057","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":"Overcoming challenges to optimize the clinical and financial benefits of in-home rehabilitation services.","authors":"Michael P Thompson, A Mark Fendrick","doi":"10.37765/ajmc.2025.89659","DOIUrl":"10.37765/ajmc.2025.89659","url":null,"abstract":"<p><p>The authors advocate for the implementation of value-based principles to address the underutilization and limited supply of home care and rehabilitation services.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 1","pages":"10-11"},"PeriodicalIF":2.5,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12035738/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143029971","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":"Association between screening for suspected COVID-19 cases and outcomes of patients revisiting the emergency department.","authors":"Chung-Ting Chen, Yu-Hsiang Meng, Meng-Chen Lin, Chorng-Kuang How, Yu-Chi Tung","doi":"10.37765/ajmc.2025.89667","DOIUrl":"10.37765/ajmc.2025.89667","url":null,"abstract":"<p><strong>Objectives: </strong>Patients who revisit the emergency department (ED) shortly after discharge are a high-risk group for complications and death, and these revisits may have been seriously affected by the COVID-19 pandemic. Detecting suspected COVID-19 cases in EDs is resource intensive. We examined the associations of screening workload for suspected COVID-19 cases with in-hospital mortality and intensive care unit (ICU) admission during short-term ED revisits.</p><p><strong>Study design: </strong>We conducted a retrospective cohort study using electronic health record data from a tertiary teaching hospital.</p><p><strong>Methods: </strong>We analyzed all 72-hour ED-revisiting patients at the Taipei Veterans General Hospital ED in Taiwan between January 27, 2020, and December 31, 2020. Screening workload for suspected COVID-19 cases was measured with the daily number of suspected COVID-19 cases. Multivariate logistic regression models were used after adjustment for patient characteristics to examine the associations of screening workload with in-hospital mortality and ICU admission.</p><p><strong>Results: </strong>A total of 1107 patients were included. The mean number of daily suspected COVID-19 cases was 9.4. The rates of subsequent in-hospital mortality and ICU admission were 2.1% and 3.2%, respectively. The volume of daily suspected COVID-19 cases was significantly associated with increased subsequent in-hospital mortality (adjusted OR, 1.073 with each additional daily suspected COVID-19 case; P  = .005).</p><p><strong>Conclusions: </strong>This is the first study to our knowledge to identify that screening for suspected COVID-19 cases in EDs can adversely affect patient outcomes during short ED revisits. Identifying this association could enable ED providers and policy makers to optimize emergency service delivery during an epidemic and help patients.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 1","pages":"e20-e25"},"PeriodicalIF":2.5,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143029748","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 Jan E. Berger, MD, MJ.","authors":"Jan E Berger, Christina Mattina","doi":"10.37765/ajmc.2025.89658","DOIUrl":"10.37765/ajmc.2025.89658","url":null,"abstract":"<p><p>To mark the 30th anniversary of The American Journal of Managed Care (AJMC), each issue in 2025 includes 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 January issue features a conversation with longtime editorial board member Jan E. Berger, MD, MJ, the CEO of Health Intelligence Partners.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":"31 1","pages":"8-9"},"PeriodicalIF":2.5,"publicationDate":"2025-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143029753","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}