The American journal of managed care
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Patients with rare diseases such as Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL), a hematologic malignancy affecting approximately 1500 new patients per year, experience barriers to care involving both clinical and administrative factors. Optimal patient outcomes depend on timely identification, diagnosis of disease, and treatment initiation. For patients living with Ph+ ALL, the process can be delayed by limited treatment options approved by the US Food and Drug Administration and administrative hurdles that often delay treatment initiation. ⋯ Panelists at the roundtable discussed approaches including the use of guideline-concordant electronic PAs and other digital solutions, expedited approval pathways for use in specific conditions, use of real-world evidence in decision-making, issuance of PA "Gold Cards" to select providers, and a shift to value-based care agreements. Roundtable attendees agreed that, regardless of the strategy for PA-process improvement, there is a need for improved communication between providers and payers to ensure that the decision-making system meets the essential need for timely patient access to optimal care. This article reviews utilization management and guideline-concordant care through the lens of rare diseases and then presents solutions to utilization.
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Commercial accountable care organization (ACO) contracts attempt to mitigate spending growth, but past evaluations have been limited to continuously enrolled ACO members in health maintenance organization (HMO) plans, excluding many members. The objective of this study was to examine the magnitude of turnover and leakage within a commercial ACO. ⋯ Both turnover and leakage hamper the ability of ACOs to manage spending. Modifications that address potentially intrinsic vs avoidable sources of population turnover and increase patient incentives for care within vs outside of ACOs could help address medical spending growth within commercial ACO programs.
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Observational Study
Mental health diagnoses and services utilization vary by wage level.
The relationship between employee wage status and mental health care utilization has not been characterized in large-scale analyses. This study assessed health care utilization and cost patterns for mental health diagnoses according to wage category among employees with health insurance. ⋯ Lower mental health condition prevalence and greater use of high-intensity health care resources highlight the need to more effectively identify and manage mental health conditions among lower-wage workers.
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Private managed care plans in the Medicare Advantage (MA) program have been gaining market share relative to traditional fee-for-service Medicare (TM), yet there are no obvious structural changes to Medicare that would explain this growth. Our goal is to explain the growth in MA market share during a period when it increased dramatically. ⋯ Overall, we find that MA is becoming more appealing to more educated and nonminority beneficiaries than in the past, although minority and lower-income beneficiaries are still more likely to pick the program. Over time, if preferences continue to shift, the nature of the MA program will change as it moves more toward the middle of the Medicare distribution.
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Home care that maintains continuity of health care services after cardiac surgery is considered a complementary component of clinical care. We estimated that effective home care given with a multidisciplinary approach would contribute to decreasing symptoms and readmissions to the hospital after cardiac surgery. ⋯ This study's findings suggest that home care, with a focus on continuity of care, decreases symptoms and readmissions to the hospital and improves the self-efficacy of patients after cardiac surgery.