The American journal of managed care
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To evaluate hospital performance and behaviors in the first 2 years of a statewide commercial insurance episode-based incentive pay-for-performance (P4P) program. ⋯ There was little evidence for overall reductions in spending associated with the program, but the performance of the hospitals that achieved greatest savings and incentives provides insights into the ongoing design of hospital P4P metrics.
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Unplanned "crash" dialysis starts are associated with worse outcomes and higher costs, a challenging problem for health systems participating in value-based care (VBC). We examined expenditures and utilization associated with these events in a large health system. ⋯ In a major health system, crash starts demonstrated the highest cost and hospital utilization, a pattern that persisted after dialysis initiation. Developing strategies to promote optimal starts will improve VBC contract performance.
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Readmission is common and costly for hospitalized Medicaid patients with diabetes. We aimed to develop a model predicting risk of 30-day readmission in Medicaid patients with diabetes hospitalized for any cause. ⋯ Our model has moderate power for identifying hospitalized Medicaid patients with diabetes who are at high risk of readmission. It is a template for identifying patients at risk of readmission and for adjusting comparisons of 30-day readmission rates among sites or over time.
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To evaluate the appropriateness of the medication management for anyone who might have been affected by the Horizon New Jersey Health Medicaid Health Maintenance Organization (HNJH Medicaid HMO) formulary update from empagliflozin to ertugliflozin and to then optimize drug selection and monitoring. ⋯ Following the HNJH Medicaid HMO's coverage update from empagliflozin to ertugliflozin, some patients received inappropriate therapy and providers accepted clinical pharmacists' recommendations to optimize therapy.
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In 2015, CMS implemented reimbursement for non-face-to-face chronic care management (NFFCCM) for beneficiaries with multiple chronic conditions, including diabetes. This analysis estimated the association between NFFCCM and utilization of inpatient, outpatient, and emergency services. ⋯ CMS implementation of reimbursement codes for NFFCCM, and subsequent utilization of that reimbursement by health systems, was associated with a shift in patient utilization from high-cost settings (inpatient and emergency department) to a lower-cost setting (outpatient office).