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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To (1) explore relationships among food insecurity, neighborhood disadvantage, and health care utilization in adults from a single health system and (2) determine whether food insecurity and neighborhood disadvantage predict acute health care utilization within 90 days of hospital discharge. ⋯ When considering social determinants of health for health system patients, food insecurity was a stronger predictor of acute health care utilization than was neighborhood disadvantage. Identifying patients with food insecurity and targeting appropriate interventions to high-risk populations may improve provider follow-up and acute health care utilization.
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Observational Study
Distinct health care use patterns of patients with chronic gastrointestinal diseases.
Patients with complex chronic conditions have varying multidisciplinary care needs and utilization patterns, which limit the effectiveness of initiatives designed to improve continuity of care (COC) and reduce utilization. Our objective was to categorize patients with complex chronic conditions into distinct groups by pattern of outpatient care use and COC to tailor interventions. ⋯ Patients at high risk for health care utilization with specialty care needs can be grouped by varying propensity for health care continuity patterns.
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Injuries are the leading cause of death among children and youth in the United States, representing a major concern to society and to the public and private health plans covering pediatric patients. Data from ALL Kids, Alabama's Children's Health Insurance Program, were used to evaluate the relationship between community-level social determinants of health (SDOH) and pediatric emergency department (ED) use and differences in these associations by age and race. ⋯ The environment in which children live influences their ED use; however, the impact varies by age, race, and Census tract factors. Further studies should focus on specific community factors to better understand the relationship among SDOH, individual characteristics, and ED utilization.
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National guidelines recommend that children with sickle cell anemia receive annual transcranial Doppler (TCD) screening to assess stroke risk. Our objectives were to estimate the rate of TCD screening among privately insured children with sickle cell anemia, estimate out-of-pocket spending for TCD screening, and evaluate the association between TCD screening and enrollment in high-deductible health plans (HDHPs). ⋯ Among privately insured children with sickle cell anemia, fewer than half received annual TCD screening. Out-of-pocket spending exceeded $100 for 27% of TCD screens. Although HDHP enrollment was not associated with TCD screening, additional studies are needed to assess whether cost sharing might deter this screening.