The American journal of managed care
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New direct-acting antivirals (DAAs), introduced in late 2013, are effective for treating chronic hepatitis C virus (HCV) infection but may pose substantial financial burden on patients and health insurers. We examined HCV medication use and costs in a commercially insured population. ⋯ The proportion of a commercially insured population with HCV infection who were treated with HCV medications doubled within 2 years following availability of new DAAs. Member OOP spending was kept low while the health plan bore 99% of the cost of HCV medications. During our 2-year follow-up, we did not observe financial benefits to the health plan of the cure of HCV infection by new DAAs.
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Providers who do not contract with insurance plans are considered out-of-network (OON) providers. There were 2 objectives in this study: (1) to examine the variations of OON cost sharing, both at the state level and by care settings, and (2) to investigate the pattern of OON care use and cost sharing associated with OON care over time. ⋯ Cost-sharing payments for OON care represent a growing financial burden for some enrollees. Consumers should be held harmless from higher cost sharing for OON care when it occurs without their knowledge or consent. Further, health plan network adequacy may also merit closer scrutiny. Leveraging provider participation in narrow networks must be balanced with broader consumer protections.
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To refine a payer algorithm identifying patients with schizophrenia at high risk of relapse within a managed Medicaid population and evaluate its effectiveness in a case management (CM) program. ⋯ Although not all of these differences were statistically significant, they suggest that the algorithm may be an effective case-finding tool for plans attempting to mitigate hospitalizations among high-risk patients with schizophrenia.
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Banner Health, a large delivery system in Maricopa County, Arizona, entered into both Medicare and commercial insurance contracts that varied the amount of financial risk that Banner assumed. Rates of utilization and spending under these various contracts were investigated. ⋯ The results are consistent with CMS' efforts to shift reimbursement away from pure fee-for-service reimbursement.