American Journal of Managed Care最新文献

{"title":"Cost sharing for oral lenvatinib among commercially insured patients.","authors":"Margaret I Liang, Ling Chen, Emeline M Aviki, Jason D Wright","doi":"10.37765/ajmc.2024.89512","DOIUrl":"10.37765/ajmc.2024.89512","url":null,"abstract":"<p><strong>Objective: </strong>To use a nationwide pharmaceutical claims database to evaluate cost-sharing trends for commercially insured patients with cancer who were prescribed lenvatinib (Lenvima).</p><p><strong>Study design: </strong>IBM MarketScan databases were used to evaluate lenvatinib costs for patients with employer-based commercial insurance, and for patients 65 years and older, Medicare claims for fee-for-service plans.</p><p><strong>Methods: </strong>Patients were included if they had least 1 outpatient pharmaceutical claim for lenvatinib paid on a noncapitated basis from 2015 to 2019. Median and IQR costs were estimated and inflation adjusted to 2019 US$ for 30-day supplies and reported as total, insurance liability, coordination of benefits, and out-of-pocket costs.</p><p><strong>Results: </strong>A total of 685 patients had at least 1 pharmaceutical claim for lenvatinib, which included patients with thyroid (n = 251; 36.6%), renal cell (n = 202; 29.5%), hepatocellular (n = 160; 23.4%), and endometrial (n = 48; 7.0%) cancer. The median (IQR) number of prescriptions per patient was 3 (2-7), and the median (IQR) total days of supply was 90 (45-210) days. The median (IQR) 30-day cost of lenvatinib was $17,253 ($15,597-$18,120). Median (IQR) 30-day insurance liability was $16,847 ($15,000-$17,981). Median (IQR) 30-day coordination of benefits was $0 ($0-$0). Median (IQR) 30-day patient out-of-pocket cost was $32 ($0-$100). However, the maximum 30-day out-of-pocket cost in our patient cohort was $12,538.</p><p><strong>Conclusions: </strong>In this cohort, insurance was liable for the majority of total lenvatinib drug costs, and 75% of patients paid $100 or less per month out of pocket. This information can be used by care teams to counsel insured patients. Health systems and drug manufacturers must identify patients with high out-of-pocket costs and provide convenient access to financial assistance programs so that patients are not forced to forgo the benefits of these drugs due to financial barriers. Value-based payment models and drug pricing reform are also needed to address underlying drivers of high drug costs.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":null,"pages":null},"PeriodicalIF":2.5,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140066190","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":"Improving glycemic control in diabetes through virtual interdisciplinary rounds.","authors":"Abby F Hoffman, Cindy Leslie Roberson, Pamela Cohen, Victoria Lee Jackson, John Yeatts, Patrick Gregory, Samantha Wong, Susan E Spratt","doi":"10.37765/ajmc.2024.89518","DOIUrl":"10.37765/ajmc.2024.89518","url":null,"abstract":"<p><strong>Objective: </strong>A team-based disease management approach that considers comorbid conditions, social drivers of health, and clinical guidelines improves diabetes care but can be costly and complex. Developing innovative models of care is crucial to improving diabetes outcomes. The objective of this analysis was to evaluate the efficacy of virtual interdisciplinary diabetes rounds in improving glycemic control.</p><p><strong>Study design: </strong>Retrospective cohort study using observational data from July 2018 to December 2021.</p><p><strong>Methods: </strong>This study employed difference-in-differences analysis to compare change in hemoglobin A1c (HbA1c) in a group of patients whose providers received advice as part of virtual interdisciplinary rounds and a group of patients whose providers did not receive rounds advice. Patients with diabetes were identified for rounding (1) based on attribution to an accountable care organization along with an upcoming primary care appointment and an HbA1c between 8% and 9% or (2) via provider referral.</p><p><strong>Results: </strong>The rounded group consisted of 481 patients and the comparison group included 1806 patients. There was a 0.3-point reduction in HbA1c (95% CI, 0.1-0.4) associated with rounds overall. In a subanalysis comparing provider adoption of recommendations among those rounded, provider adoption was associated with an HbA1c reduction of 0.5 points (95% CI, 0.1-0.9) at 6 months post rounds, although there was no significant difference in the full year post rounds.</p><p><strong>Conclusions: </strong>Interdisciplinary rounds can be an effective approach to proactively provide diabetes-focused recommendations. This modality allows for efficient, low-cost, and timely access to an endocrinologist and team to support primary care providers in diabetes management.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":null,"pages":null},"PeriodicalIF":2.5,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140066192","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":"Insurer costs of COVID-19 by disease severity and duration.","authors":"Chantal E Holy, Brandon J Patterson, Jill W Ruppenkamp, Fayolah Richards, Ronita Debnath, Antoine C El Khoury, Jessica K DeMartino, Brahim Bookhart, Paul M Coplan","doi":"10.37765/ajmc.2024.89513","DOIUrl":"10.37765/ajmc.2024.89513","url":null,"abstract":"<p><strong>Objectives: </strong>To analyze US commercial insurance payments associated with COVID-19 as a function of severity and duration of disease.</p><p><strong>Study design: </strong>Retrospective database analysis.</p><p><strong>Methods: </strong>Patients with COVID-19 between April 1, 2020, and June 30, 2021, in the Merative MarketScan Commercial database were identified and stratified as having asymptomatic, mild, moderate (with and without lower respiratory disease), or severe/critical (S/C) disease based on the severity of the acute COVID-19 infection. Duration of disease (DOD) was estimated for all patients. Patients with DOD longer than 12 weeks were defined as having post-COVID-19 condition (PCC). Outcomes were all-cause payments (ACP) and disease-specific payments (DSP) for the entire DOD. Variables included demographic and comorbidities at the time of acute disease. Adjusted payments by disease severity were estimated using generalized linear models (γ distribution with log link).</p><p><strong>Results: </strong>A total of 738,339 patients were included (374,401 asymptomatic, 156,220 mild, 180,213 moderate, and 27,505 S/C cases). DSP increased from $217 (95% CI, $214-221) for asymptomatic cases to $2744 (95% CI, $2678-$2811) for moderate cases with lower respiratory disease and $28,250 (95% CI, $26,963-$29,538) for S/C cases. ACP increased from $505 (95% CI, $497-$512) for asymptomatic cases to $46,538 (95% CI, $44,096-$48,979) for S/C cases. The DSP and ACP further increased by $50,736 (95% CI, $45,337-$56,136) and $94,839 (95% CI, $88,029-$101,649), respectively, in S/C cases with PCC vs a DOD of fewer than 4 weeks.</p><p><strong>Conclusions: </strong>COVID-19 payments for S/C cases were more than 10-fold greater than those of moderate cases and further increased by nearly $95,000 in S/C cases with PCC vs a DOD of fewer than 4 weeks.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":null,"pages":null},"PeriodicalIF":2.5,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140066195","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":"Nurse practitioner low-value care ordering practices: an integrative review.","authors":"Sara B Nugent, Roberta P Lavin, Barbara I Holmes Damron","doi":"10.37765/ajmc.2024.89520","DOIUrl":"10.37765/ajmc.2024.89520","url":null,"abstract":"<p><strong>Objectives: </strong>Low-value care (LVC) health services are unsupported by current evidence, are associated with harmful patient outcomes, and equate to more than $100 billion in wasteful spending annually. Nurse practitioner (NP) LVC ordering practices among adult patients in outpatient settings are described and compared with those of other health care clinicians. Factors impacting NP ordering practices are also explored.</p><p><strong>Study design: </strong>Integrative review.</p><p><strong>Methods: </strong>Electronic databases, including MEDLINE's PubMed, CINAHL, Web of Science, and Business Source Complete, and Google Scholar were searched for original studies published prior to April 2023. Search terms included relevant keywords pertaining to LVC and NPs. Results were supplemented by a search of the reference lists of included studies.</p><p><strong>Results: </strong>Of the 20 included studies, 7 were of low quality, which limited findings. Results comparing NP LVC ordering practices with those of other health care clinicians were conflicting. When compared with physicians, NPs ordered equal rates of antibiotics in 4 studies and lumbar imaging in 6 studies; they ordered less imaging in 2 studies but more imaging in 1 study. In 1 study, NPs ordered fewer lumbar imaging studies than physician assistants. NPs reported following protocols for prescribing and found that patient education and reassurance were successful in minimizing LVC ordering when managing patient expectations. NP specialization appeared to influence LVC ordering, whereas scope of practice laws had no effect.</p><p><strong>Conclusions: </strong>The full extent to which NPs order LVC services, as well as a comprehensive understanding of the factors influencing their decisions, remains unknown. It is unclear whether NPs order fewer or equal LVC services compared with other health care clinicians. More research on NPs and LVC is indicated.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":null,"pages":null},"PeriodicalIF":2.5,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140066196","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":"Addressing patients' unmet social needs: checklists are a means, trust is foundational.","authors":"Bruce W Sherman, A Mark Fendrick","doi":"10.37765/ajmc.2024.89511","DOIUrl":"10.37765/ajmc.2024.89511","url":null,"abstract":"<p><p>Identifying and addressing unmet social needs without attention to other contributors to health inequities-such as medical mistrust-is unlikely to yield desired outcomes.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":null,"pages":null},"PeriodicalIF":2.5,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140066173","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":"Increased Medicare payments for homeless patients provide new opportunities for care.","authors":"Jack Tsai","doi":"10.37765/ajmc.2024.89516","DOIUrl":"10.37765/ajmc.2024.89516","url":null,"abstract":"<p><p>A final rule has been issued that increases Medicare fee-for-service payment rates for individuals experiencing homelessness. This rule provides new, incentivized opportunities to better screen for and document homelessness among patients in acute inpatient settings. With greater identification of homeless patients, there may be increased needs to develop comprehensive discharge plans that involve coordination with housing providers and social service agencies to prevent the high repeated use of acute care found among many homeless patients.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":null,"pages":null},"PeriodicalIF":2.5,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140066194","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The extent and growth of prior authorization in Medicare Advantage.","authors":"Hannah T Neprash, John F Mulcahy, Ezra Golberstein","doi":"10.37765/ajmc.2024.89519","DOIUrl":"10.37765/ajmc.2024.89519","url":null,"abstract":"<p><strong>Objectives: </strong>To assess trends in the use of prior authorization requirements among Medicare Advantage (MA) plans.</p><p><strong>Study design: </strong>Descriptive quantitative analysis.</p><p><strong>Methods: </strong>Data were from the CMS MA benefit and enrollment files for 2009-2019, supplemented with area-level data on demographic and provider market characteristics. For each service category, we calculated the annual share of MA enrollees in plans requiring at least some prior authorization and plotted trends over time. We mapped the county-level share of MA enrollees exposed to prior authorization in 2009 vs 2019. We quantified the association between local share of MA enrollees exposed to prior authorization and characteristics of that county in the same year. Finally, we plotted the share of MA enrollees exposed to prior authorization requirements over time for the 6 largest MA carriers.</p><p><strong>Results: </strong>From 2009 to 2019, the share of MA enrollees in plans requiring prior authorization for any service remained stable. By service category, the share of MA enrollees exposed to prior authorization ranged from 30.7% (physician specialist services) to 72.2% (durable medical equipment) in 2019, with most service categories requiring prior authorization more often over time. Several area-level demographic and provider market characteristics were associated with prior authorization requirements, but these associations weakened over time. The use of prior authorization varied widely across plans.</p><p><strong>Conclusions: </strong>In 2019, roughly 3 in 4 MA enrollees were in a plan requiring prior authorization. Service-level, area-level, and carrier-level patterns suggest a wide range of approaches to prior authorization requirements.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":null,"pages":null},"PeriodicalIF":2.5,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140066198","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":"Challenges of fracture risk assessment in Asian and Black women.","authors":"Joan C Lo, Malini Chandra, Wei Yang, Nailah Thompson, Catherine Lee, Mohan Ramaswamy, Mehreen Khan, Amber Wheeler","doi":"10.37765/ajmc.2024.89515","DOIUrl":"10.37765/ajmc.2024.89515","url":null,"abstract":"<p><strong>Objectives: </strong>Bone mineral density (BMD) and fracture risk calculators (eg, the Fracture Risk Assessment Tool [FRAX]) guide primary prevention care in postmenopausal women. BMD scores use non-Hispanic White (NHW) reference data for T-score classification, whereas FRAX incorporates BMD, clinical risk factors, and population differences when calculating risk. This study compares findings among Asian, Black, and NHW women who underwent osteoporosis screening in a US health care system.</p><p><strong>Study design: </strong>Retrospective cross-sectional study.</p><p><strong>Methods: </strong>Asian, Black, and NHW women aged 65 to 75 years who underwent BMD testing (with no recent fracture, osteoporosis therapy, metastatic cancer, multiple myeloma, metabolic bone disorders, or kidney replacement therapy) were compared across the following measures: femoral neck BMD (FN-BMD) T-score (normal ≥ -1, osteoporosis ≤ -2.5), high FRAX 10-year hip fracture risk (FRAX-Hip ≥ 3%), FRAX risk factors, and diabetes status.</p><p><strong>Results: </strong>Among 3640 Asian women, 23.8% had osteoporosis and 8.7% had FRAX-Hip scores of at least 3% (34.5% among those with osteoporosis). Among 11,711 NHW women, 12.3% had osteoporosis and 17.2% had FRAX-Hip scores of at least 3% (84.8% among those with osteoporosis). Among 1711 Black women, 68.1% had normal FN-BMD, 4.1% had BMD-defined osteoporosis, and 1.8% had FRAX-Hip scores of at least 3% (32.4% among those with osteoporosis). Fracture risk factors differed by group. Diabetes was 2-fold more prevalent in Black and Asian (35% and 36%, respectively) vs NHW (16%) women.</p><p><strong>Conclusions: </strong>A large subset of Asian women have discordant BMD and FRAX scores, presenting challenges in osteoporosis management. Furthermore, FN-BMD and especially FRAX scores identified few Black women at high fracture risk warranting treatment. Studies should examine whether fracture risk assessment can be optimized in understudied racial minority populations, particularly when findings are discordant.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":null,"pages":null},"PeriodicalIF":2.5,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11034894/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140066189","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":"Unintended consequences of the Inflation Reduction Act: clinical development toward subsequent indications.","authors":"Julie Patterson, James Motyka, John Michael O'Brien","doi":"10.37765/ajmc.2024.89495","DOIUrl":"10.37765/ajmc.2024.89495","url":null,"abstract":"<p><strong>Objectives: </strong>To describe the clinical development landscape for high-spend Medicare Part D small molecule drugs and illustrate the potential impact of the Inflation Reduction Act of 2022 (IRA) on research and development investments toward subsequent indications.</p><p><strong>Study design: </strong>Descriptive analysis of research and development time lines of small molecule drugs in the top 50 of 2020 Medicare Part D spending using publicly available dates when pivotal clinical trials were first posted to ClinicalTrials.gov and FDA approval dates for initial and subsequent indications.</p><p><strong>Methods: </strong>We summarize the drugs, indications, and time lines using descriptive statistics.</p><p><strong>Results: </strong>Thirty of the 50 drugs with highest gross spending by Medicare Part D in 2020 were small molecule drugs with subsequent indications. Subsequent indications based on preapproval research (n = 34) were often approved within 2 years of initial approval (n = 15) and, on average, 2.9 years after a drug's first approval. Additional indications based on postapproval clinical trials or real-world evidence (n = 42) received FDA approval, on average, 7.5 years after a drug was first approved, with the majority (55.8%) receiving FDA approval more than 7 years after the initial approval.</p><p><strong>Conclusions: </strong>Our analysis of clinical development for new indications reveals aspects of innovation in small molecule drugs that are at risk under the IRA. Specifically, the time lines described in this research demonstrate how the IRA may reduce economic incentives to develop multiple indications, including single-indication launches and investments in postapproval research for additional indications.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":null,"pages":null},"PeriodicalIF":2.5,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139934039","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The relationship between preventive dental care and overall medical expenditures.","authors":"Heather L Taylor, Ann M Holmes, Nir Menachemi, Titus Schleyer, Bisakha Sen, Justin Blackburn","doi":"10.37765/ajmc.2024.89499","DOIUrl":"10.37765/ajmc.2024.89499","url":null,"abstract":"<p><strong>Objectives: </strong>To examine the relationship between preventive dental visits (PDVs) and medical expenditures while mitigating bias from unobserved confounding factors.</p><p><strong>Study design: </strong>Retrospective data analysis of Indiana Medicaid enrollment and claims data (2015-2018) and the Area Health Resources Files.</p><p><strong>Methods: </strong>An instrumental variable (IV) approach was used to estimate the relationship between PDVs and medical and pharmacy expenditures among Medicaid enrollees. The instrument was defined as the number of adult enrollees with at least 1 nonpreventive dental claim per total Medicaid enrollees within a Census tract per year.</p><p><strong>Results: </strong>In naive analyses, enrollees had on average greater medical expenditures if they had a prior-year PDV (β = $397.21; 95% CI, $184.23-$610.18) and a PDV in the same year as expenditures were measured (β = $344.81; 95% CI, $193.06-$496.56). No significant differences in pharmacy expenditures were observed in naive analyses. Using the IV approach, point estimates of overall medical expenditures for the marginal enrollee who had a prior-year PDV (β = $325.17; 95% CI, -$708.03 to $1358.37) or same-year PDV (β = $170.31; 95% CI, -$598.89 to $939.52) were similar to naive results, although not significant. Our IV approach indicated that PDV was not endogenous in some specifications.</p><p><strong>Conclusions: </strong>This is the first study to present estimates with causal inference from a quasi-experimental study of the effect of PDVs on overall medical expenditures. We observed that prior- or same-year PDVs were not related to overall medical or pharmacy expenditures.</p>","PeriodicalId":50808,"journal":{"name":"American Journal of Managed Care","volume":null,"pages":null},"PeriodicalIF":2.5,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11302381/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139934038","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}