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Over 70% of Medicaid beneficiaries are enrolled in Medicaid managed care (MMC). MMC provider networks therefore represent a critical determinant of access to the Medicaid program. Many MMC insurers also participate in commercial insurance markets where prices are high, and some insurers exercise considerable market power. In this paper, we examined the relationship between commercial insurer market power and MMC physician network breadth using linked national enrollment data and provider directory data. Insurers with more commercial market power had broader Medicaid physician networks. Insurers with over 30% market share had 37.3% broader Medicaid networks than insurers in the same county that had no commercial market share. These differences were driven by greater breadth among primary care providers, as well as other specialists including OB/GYNs, surgeons, neurologists, and cardiologists. Commercial insurance market power may have spillovers on access to care for MMC beneficiaries., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Importance: Dual Eligible Special Needs Plans (D-SNPs) are private managed care plans designed to promote Medicare and Medicaid integration for full-benefit, dually eligible beneficiaries. Currently, the highest level of D-SNP integration occurs in plans with exclusively aligned enrollment (EAE)., Objective: To compare patient experience of care, out-of-pocket spending, and satisfaction among dually enrolled Medicaid beneficiaries in D-SNPs with EAE, those in D-SNPs without EAE, and those with traditional Medicare., Design, Setting, and Participants: This cross-sectional study included respondents to a mail survey fielded to a stratified random sample of full-benefit, community-dwelling, dual-eligible Medicaid beneficiaries who qualified for receipt of home and community-based services in the Virginia Medicaid Commonwealth Coordinated Care Plus program between March and October 2022., Exposure: Enrollment in a D-SNP with EAE or a D-SNP without EAE vs traditional Medicare., Main Outcomes and Measures: The main outcomes were self-reported measures of access and delays in receiving plan approvals, out-of-pocket spending, and satisfaction with health plans' customer service and choice of primary care and specialist physicians., Results: Of 7200 surveys sent, 2226 were completed (response rate, 30.9%). The analytic sample consisted of 1913 Medicaid beneficiaries with nonmissing data on covariates (mean [SD] age, 70.8 [15.6] years; 1367 [71.5%] female). Of these, 583 (30.5%) were enrolled in D-SNPs with EAE, 757 (39.6%) in D-SNPs without EAE, and 573 (30.0%) in traditional Medicare. Compared with respondents enrolled in D-SNPs without EAE, those in D-SNPs with the highest level of integration (EAE) were 6.77 percentage points (95% CI, 8.81-12.66 percentage points) more likely to report being treated with courtesy and respect and 5.83 percentage points (95% CI, 0.21-11.46 percentage points) more likely to know who to call when they had a health problem. No statistically significant differences were found between members in either type of D-SNP and between those in D-SNPs and traditional Medicare in terms of their difficulty accessing care, delays in care, and satisfaction with care coordination and physician choice., Conclusions and Relevance: This cross-sectional study found some benefits of integrating administrative processes under Medicare and Medicaid but suggests that care coordination and access improvements under full integration require additional time and/or efforts to achieve.

Introduction: Medicaid managed care organizations (MCO) play a major role in addressing the nation's epidemic of drug overdose and mortality by administering substance use disorder (SUD) treatment benefits for over 50 million Americans. While it is known that some Medicaid MCO plans delegate responsibility for managing SUD treatment benefits to an outside "carve out" entity, the extent and structure of such carve out arrangements are unknown. This is an important gap in knowledge, given that carve outs have been linked to reductions in rates of SUD treatment receipt in several studies. To address this gap, we examined carve out arrangements used by Medicaid MCO plans to administer SUD treatment benefits in ten states., Methods: Data for this study was gleaned using a purposive sampling approach through content analysis of publicly available benefits information (e.g., member handbooks, provider manuals, prescription drug formularies) from 70 comprehensive Medicaid MCO plans in 10 selected states (FL, GA, IL, MD, MI, NH, OH, PA, UT, and WV) active in 2018. Each Medicaid MCO plan's documents were reviewed and coded to indicate whether a range of SUD treatment services (e.g., inpatient treatment, outpatient treatment, residential treatment) and medications were carved out, and if so, to what type of entity (e.g., behavioral health organization)., Results: A large majority of Medicaid MCO plans carved out at least some (28.6 %) or all (40.0 %) SUD treatment services, with nearly all plans carving out some (77.1 %) or all (14.3 %) medications, mainly due to the carving out of methadone treatment. Medicaid MCO plans most commonly carved out SUD treatment services to behavioral health organizations, while most medications were carved out to state Medicaid fee-for-service plans., Conclusions: Carve out arrangements for SUD treatment vary dramatically across states, across plans, and even within plans. Given that some studies have linked carve out arrangements to reductions in treatment access, their widespread use among Medicaid MCO plans is cause for further consideration by policymakers and other key interest groups. Moreover, reliance on such complex arrangements for administering care may create challenges for enrollees who seek to learn about and access plan benefits., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Several states are considering competitive procurement to help shape Medicaid managed care markets. In New York state, the focus of our study, regulators propose contracts that reward quality improvement and simplify state administration by rewarding plans that operate across several of the state's 62 counties. This case analysis uses novel regulatory data from New York state, obtained via public records request, to examine incentives underlying Medicaid markets and help inform contracting design. The data report plan enrollment by county and plan spending across administrative activities for all 16 Medicaid plans in New York state for 2018. We examine the counties in which plans operate, profitability, and administrative resource allocation. We compare outcomes by tertile of plan profitability, measured as net income per member-month. Plan profitability ranged widely, with the most profitable plan realizing nearly $30 per member-month while the least profitable 5 plans realized net negative earnings. Operational differences across plan profitability emerged most clearly in administrative spending. The most profitable plans reported greater spending on salaries overall and for executive management, and taxes, while the least profitable plans spent more on operational functions including utilization management/ quality improvement, claims processing, and informational systems. We observe modest differences in county rurality and little in geographic breadth. Procurement design that rewards capacity-building in key administrative functions might impact market evolution, given that on average, highly profitable firms spent less on these activities in New York's Medicaid managed care market in 2018., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services is a Medicaid benefit for children that addresses their health problems before they become advanced, debilitating, and expensive. We conducted a retrospective cross-sectional analysis of pediatric beneficiaries (newborn to younger than 21 years) enrolled in a Medicaid managed care organization to examine the factors associated with EPSDT screening services completion. We obtained 2018 administrative claims data for beneficiaries continuously enrolled for a minimum of 90 days (n=156,108). Completion of EPSDT screening services among our Medicaid managed care beneficiaries was low. Those having more emergency department visits and hospitalizations, having family medicine practitioners as primary care physicians, belonging to the racial/ethnic group Asian/Pacific Islander/Hawaiian/Alaskan Native/Native American, and 18 to younger than 21 years age group were less likely than others to complete EPSDT services. Our results provide information on segments of pediatric beneficiaries that can be targeted to increase EPSDT screening services completion.

In Spain, the compensation model for statutory health personnel is complex, heterogeneous, and more oriented to rewarding complementary functions and activities, than to paying for the actual performance in the position of employee. The various attempts to incorporate incentives have been distorted by a civil service egalitarianist culture, and weak systemic governance. External attractors (private practice, etc.) for healthcare professionals are becoming more important and neutralize many intramural incentives. There are few prospects of relevant or general changes, since the main actors involved are reforms-averse; but some environmental factors can lead to incremental improvements in employment contracts, in the information available to improve benchmarking, and in the creation of islands of good clinical governance and management. The economic scenario, increasingly concerned about inflationary trends and sustainability risks, may have a revitalizing effect of some governance and management reforms., (Copyright © 2024 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: To evaluate differences in access to behavioral health services for Medicaid enrollees covered by a Medicaid entity that integrated the financing of behavioral and physical health care ("carve-in group") versus a Medicaid entity that separated this financing ("carve-out group")., Data Sources/study Setting: Medicaid claims data from two Medicaid entities in the Portland, Oregon tri-county area in 2016., Study Design: In this cross-sectional study, we compared differences across enrollees in the carve-in versus carve-out group, using a machine learning approach to incorporate a large set of covariates and minimize potential selection bias. Our primary outcomes included behavioral health visits for a variety of different provider types. Secondary outcomes included inpatient, emergency department, and primary care visits., Data Collection: We used Medicaid claims, including adults with at least 9 months of enrollment., Principal Findings: The study population included 45,786 adults with mental health conditions. Relative to the carve-out group, individuals in the carve-in group were more likely to access outpatient behavioral health (2.39 percentage points, p < 0.0001, with a baseline rate of approximately 73%). The carve-in group was also more likely to access primary care physicians, psychologists, and social workers and less likely to access psychiatrists and behavioral health specialists. Access to outpatient behavioral health visits was more likely in the carve-in arrangement among individuals with mild or moderate mental health conditions (compared to individuals with severe mental illness) and among black enrollees (compared to white enrollees)., Conclusions: Financial integration of physical and behavioral health in Medicaid managed care was associated with greater access to behavioral health services, particularly for individuals with mild or moderate mental health conditions and for black enrollees. Recent changes to incentivize financial integration should be monitored to assess differential impacts by illness severity, race and ethnicity, provider types, and other factors., (© 2021 Health Research and Educational Trust.)

Importance: Although there is no pharmacological treatment for autism spectrum disorder (ASD) itself, behavioral and pharmacological therapies have been used to address its symptoms and common comorbidities. A better understanding of the medications used to manage comorbid conditions in this growing population is critical; however, most previous efforts have been limited in size, duration, and lack of broad representation., Objective: To use a nationally representative database to uncover trends in the prevalence of co-occurring conditions and medication use in the management of symptoms and comorbidities over time among US individuals with ASD., Design, Setting, and Participants: This retrospective, population-based cohort study mined a nationwide, managed health plan claims database containing more than 86 million unique members. Data from January 1, 2014, to December 31, 2019, were used to analyze prescription frequency and diagnoses of comorbidities. A total of 26 722 individuals with ASD who had been prescribed at least 1 of 24 medications most commonly prescribed to treat ASD symptoms or comorbidities during the 6-year study period were included in the analysis., Exposures: Diagnosis codes for ASD based on International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision., Main Outcomes and Measures: Quantitative estimates of prescription frequency for the 24 most commonly prescribed medications among the study cohort and the most common comorbidities associated with each medication in this population., Results: Among the 26 722 individuals with ASD included in the analysis (77.7% male; mean [SD] age, 14.45 [9.40] years), polypharmacy was common, ranging from 28.6% to 31.5%. Individuals' prescription regimens changed frequently within medication classes, rather than between classes. The prescription frequency of a specific medication varied considerably, depending on the coexisting diagnosis of a given comorbidity. Of the 24 medications assessed, 15 were associated with at least a 15% prevalence of a mood disorder, and 11 were associated with at least a 15% prevalence of attention-deficit/hyperactivity disorder. For patients taking antipsychotics, the 2 most common comorbidities were combined type attention-deficit/hyperactivity disorder (11.6%-17.8%) and anxiety disorder (13.1%-30.1%)., Conclusions and Relevance: This study demonstrated considerable variability and transiency in the use of prescription medications by US clinicians to manage symptoms and comorbidities associated with ASD. These findings support the importance of early and ongoing surveillance of patients with ASD and co-occurring conditions and offer clinicians insight on the targeted therapies most commonly used to manage co-occurring conditions. Future research and policy efforts are critical to assess the extent to which pharmacological management of comorbidities affects quality of life and functioning in patients with ASD while continuing to optimize clinical guidelines, to ensure effective care for this growing population.

Objective: To evaluate the impact of the Health and Recovery Plan (HARP), a capitated special needs Medicaid managed care product that fully integrates physical and behavioral health delivery systems in New York State., Data Sources: 2013-2019 claims and encounters data on continuously enrolled individuals from the New York State Medicaid data system., Study Design: We used a difference-in-difference approach with inverse probability of exposure weights to compare service use outcomes in individuals enrolled in the HARP versus HARP eligible comparison group in two regions, New York City (NYC) pre- (2013-2015) versus post- (2016-2018) intervention periods, and rest of the state (ROS) pre- (2014-2016) versus post- (2017-2019) intervention periods., Data Collection/extraction Methods: Not applicable., Principal Findings: HARPs were associated with a relative decrease in all-cause (RR = 0.78, 95% CI 0.68-0.90), behavioral health-related (RR = 0.76, 95% CI 0.60-0.96), and nonbehavioral-related (RR = 0.87, 95% CI 0.78-0.97) stays in the NYC region. In the ROS region, HARPs were associated with a relative decrease in all-cause (RR = 0.87, 95% CI 0.80-0.94) and behavioral health-related (RR = 0.80, 95% CI 0.70-0.91) stays. Regarding outpatient visits, the HARPs benefit package were associated with a relative increase in behavioral health (RR = 1.21, 95% CI 1.13-1.28) and nonbehavioral health (RR = 1.08, 95% CI 1.01-1.15) clinic visits in the NYC region. In the ROS region, the HARPs were associated with relative increases in behavioral health (RR = 1.47, 95% CI 1.32-1.64) and nonbehavioral health (RR = 1.17, 95% CI 1.11-1.25) clinic visits., Conclusions: Compared to patients with similar clinical needs, HARPs were associated with a relative increase in services used and led to a better engagement in the HARPs group regardless of the overall decline in services used pre- to postperiod., (© 2021 Health Research and Educational Trust.)

Objectives: To determine (1) factors linked to hospitalizations among managed care patients (MCPs), (2) outcome improvement with use of outpatient off-label treatment, and (3) outcome comparison between MCPs and a mirror group., Study Design: Retrospective cohort study comparing MCPs with an age- and gender-matched mirror group in Florida from April 1, 2020, to May 31, 2020., Methods: A total of 38,193 MCPs in a Florida primary care group were monitored for COVID-19 incidence, hospitalization, and mortality. The highest-risk patients were managed by the medical group's COVID-19 Task Force. As part of a population health program, the COVID-19 Task Force contacted patients, conducted medical encounters, and tracked data including comorbidities and medical outcomes. The MCPs enrolled in the medical group were compared with a mirror group from the state of Florida., Results: The mean (SD) age among the MCPs was 67.9 (15.2) years, and 60% were female. Older age and hypertension were the most important factors in predicting COVID-19. Obesity, chronic kidney disease (CKD), and congestive heart failure (CHF) were linked to higher rates of hospitalizations. Patients prescribed off-label outpatient medications had 73% lower likelihood of hospitalization (P < .05). Compared with the mirror group, MCPs had 60% lower COVID-19 mortality (P < .05)., Conclusions: MCPs have risk factors similar to the general population for COVID-19 incidence and progression, including older age, hypertension, obesity, CHF, and CKD. Outpatient treatment with off-label medicines decreased hospitalizations. A comprehensive population health program decreased COVID-19 mortality.

Despite the opportunity for large health gains, there are many challenges associated with rare disease therapies. Among these are striking the appropriate balance between the urgency to respond to patient needs with the uncertainty that is often inherent in rare disease therapy datasets leading to concerns with developing and interpreting clinical data; uncertainty around financial impact, value determination, and affordability; and variation in approach to coverage and potential effects on access. To discuss these challenges and opportunities to address them, AMCP held a virtual multidisciplinary stakeholder forum on September 8-10, 2020. Forum participants represented diverse sectors of the health care industry, including integrated delivery systems, health plans, pharmacy benefit managers, employer groups, biopharmaceutical companies, patient advocacy organizations, health policy researchers, and consulting firms; they evaluated strategies to plan for and manage rare disease therapies and recommended best practices and next steps. DISCLOSURES: This forum was sponsored by the following: AstraZeneca, Dicerna, Genentech, National Pharmaceutical Council, Novo Nordisk, Pfizer, Precision Value, Sanofi, Sarepta Therapeutics, Seattle Genetics, Spark Therapeutics, and Takeda. These proceedings were prepared as a summary of the forum to represent common themes; they are not necessarily endorsed by all attendees nor should they be construed as reflecting group consensus.

Objectives: To describe real-time changes in medical visits (MVs), visit mode, and patient-reported visit experience associated with rapidly deployed care reorganization during the coronavirus disease 2019 (COVID-19) pandemic., Study Design: Cross-sectional time series from September 29, 2019, through June 20, 2020., Methods: Responding to official public health and clinical guidance, team-based systematic structural changes were implemented in a large, integrated health system to reorganize and transition delivery of care from office-based to virtual care platforms. Overall and discipline-specific weekly MVs, visit mode (office-based, telephone, or video), and associated aggregate measures of patient-reported visit experience were reported. A 38-week time-series analysis with March 8, 2020, and May 3, 2020, as the interruption dates was performed., Results: After the first interruption, there was a decreased weekly visit trend for all visits (β3 = -388.94; P < .05), an immediate decrease in office-based visits (β2 = -25,175.16; P < .01), increase in telephone-based visits (β2 = 17,179.60; P < .01), and increased video-based visit trend (β3 = 282.02; P < .01). After the second interruption, there was an increased visit trend for all visits (β5 = 565.76; P < .01), immediate increase in video-based visits (β4 = 3523.79; P < .05), increased office-based visit trend (β5 = 998.13; P < .01), and decreased trend in video-based visits (β5 = -360.22; P < .01). After the second interruption, there were increased weekly long-term visit trends for the proportion of patients reporting "excellent" as to how well their visit needs were met for all visits (β5 = 0.17; P < .01), telephone-based visits (β5 = 0.34; P < .01), and video-based visits (β5 = 0.32; P < .01). Video-based visits had the highest proportion of respondents rating "excellent" as to how well their scheduling and visit needs were met., Conclusions: COVID-19 required prompt organizational transformation to optimize the patient experience.

Objectives: Prior to the coronavirus disease 2019 (COVID-19) pandemic, introductions between primary care physicians (PCPs) and specialists were conducted in person. These important meetings were integral to patient care, facilitated care coordination, and improved the managed care of the patient. During COVID-19 and beyond, these important relationships should be fostered via digital means. We aimed to identify opportunities of digital health integration for the optimization of physician integration., Study Design: Cross-sectional study., Methods: Prior to COVID-19, we conducted a survey of PCPs at a large multidisciplinary group with more than 1500 physicians that staffs multiple hospitals within a health system. The survey was sent via email with only 1 reminder., Results: Thirty-six PCPs responded to the survey; 25% (9/36) were very satisfied and 19.4% (7/36) were moderately satisfied with the current in-person introductions. The PCPs found introductions to specialists helpful; 83.7% (31/37) wanted to "put a name to the face," and 64.9% (24/37) wanted to "understand the range of service provided by the specialist." Fifty-one percent (19/37) and 54% (20/37) said "I can better manage patient care and know when to refer to a specialist" and "I learn more about a particular specialist," respectively, with specialist introductions. If made easy, 67.6% (25/37) of PCPs would be interested in TeleConnect to facilitate introductions to specialists., Conclusions: Referrals between PCPs and specialists have been an integral aspect of medical care within managed care organizations. With the advent of technology during COVID-19, and along with this brief survey, the need for digital means to introduce PCPs and specialists is underscored.

Objectives: The coronavirus disease 2019 (COVID-19) pandemic forced health systems to offer video and telephone visits as in-person visit alternatives. Although video visits offer some benefits compared with telephone visits, they require complex setup, which may disadvantage some patients due to the "digital divide." Our objective was to determine patient and neighborhood characteristics associated with visit modality., Study Design: This was a cross-sectional study across 1652 primary care and specialty care practices of adult patients at an integrated health system from April 23 to June 1, 2020., Methods: We used electronic health record and administrative data. Our primary outcome was visit modality (in-person, video, or telephone), which was captured using billing codes. We assessed predictors of using video vs telephone using multivariable logistic regression. We used hierarchical logistic regression to determine the contribution of patient-, physician-, and practice-level components of variance in the choice of video or telephone visits., Results: We analyzed 231,596 visits by 162,102 patients. Sixty-five percent of the visits were virtual (31.7% telephone, 33.5% video). Patients who were older than 65 years (adjusted odds ratio [AOR], 0.41; 95% CI, 0.40-0.43), Black (AOR, 0.60; 95% CI, 0.57-0.63), Hispanic (AOR, 0.76; 95% CI, 0.73-0.80), Spanish-speaking (AOR, 0.57; 95% CI, 0.52-0.61), and from areas with low broadband access (AOR, 0.93; 95% CI, 0.88-0.98) were less likely to use video visits. Practices (38%) and clinicians (26%) drove more of the variation in video visit use than patients (9%)., Conclusions: Telemedicine access differences may compound disparities in chronic disease and COVID-19 outcomes. Institutions should monitor video visit use across demographics and equip patients, clinicians, and practices to promote telemedicine equity.

The telehealth policy changes enacted for short-term control of the coronavirus disease 2019 (COVID-19) pandemic present an opportunity to address the fundamental gap in health care underutilization.

Importance: Teledermatology (TD) enables remote triage and management of dermatology patients. Previous analyses of TD systems have demonstrated improved access to care but an inconsistent fiscal impact., Objective: To compare the organizationwide cost of managing newly referred dermatology patients within a TD triage system vs a conventional dermatology care model at the Zuckerberg San Francisco General Hospital and Trauma Center (hereafter referred to as the ZSFG) in California., Design, Setting, and Participants: A retrospective cost minimization analysis was conducted of 2098 patients referred to the dermatology department at the ZSFG between June 1 and December 31, 2017., Intervention: Implementation of the TD triage system in January 2015., Main Outcomes and Measures: The main outcome was mean cost to the health care organization to manage newly referred dermatology patients with or without TD triage. To estimate costs, decision-tree models were constructed to characterize possible care paths with TD triage and within a conventional dermatology care model. Costs associated with primary care visits, dermatology visits, and TD visits were then applied to the decision-tree models to estimate the mean cost of managing patients following each care path for 6 months. The mean cost for each visit type incorporated personnel costs, with the mean cost per TD consultation also incorporating software implementation and maintenance costs. Finally, ZSFG patient data were applied within the models to evaluate branch probabilities, enabling calculation of mean cost per patient within each model., Results: The analysis captured 2098 patients (1154 men [55.0%]; mean [SD] age, 53.4 [16.8] years), with 1099 (52.4%) having Medi-Cal insurance and 879 (41.9%) identifying as non-White. In the decision-tree model with TD triage, the mean (SD) cost per patient to the health care organization was $559.84 ($319.29). In the decision-tree model for conventional dermatology care, the mean (SD) cost per patient was $699.96 ($390.24). Therefore, the TD model demonstrated a statistically significant mean (SE) cost savings of $140.12 ($11.01) per patient. Given an annual dermatology referral volume of 3150 patients, the analysis estimates an annual savings of $441 378., Conclusions and Relevance: Implementation of a TD triage system within the dermatology department at the ZSFG was associated with cost savings, suggesting that managed health care settings may experience significant cost savings from using TD to triage and manage patients.

The COVID-19 pandemic and the social unrest pervading U.S. cities in response to the killings of George Floyd and other Black citizens at the hands of police are historically significant. These events exemplify dismaying truths about race and equality in the United States. Racial health disparities are an inexcusable lesion on the U.S. health care system. Many health disparities involve medications, including antidepressants, anticoagulants, diabetes medications, drugs for dementia, and statins, to name a few. Managed care pharmacy has a role in perpetuating racial disparities in medication use. For example, pharmacy benefit designs are increasingly shifting costs of expensive medications to patients, creating affordability crises for lower income workers, who are disproportionally persons of color. In addition, the quest to maximize rebates serves to inflate list prices paid by the uninsured, among which Black and Hispanic people are overrepresented. While medication cost is a foremost barrier for many patients, other factors also propagate racial disparities in medication use. Even when cost sharing is minimal or zero, medication adherence rates have been documented to be lower among Blacks as compared with Whites. Deeper understandings are needed about how racial disparities in medication use are influenced by factors such as culture, provider bias, and patient trust in medical advice. Managed care pharmacy can address racial disparities in medication use in several ways. First, it should be acknowledged that racial disparities in medication use are pervasive and must be resolved urgently. We must not believe that entrenched health system, societal, and political structures are impermeable to change. Second, the voices of community members and their advocates must be amplified. Coverage policies, program designs, and quality initiatives should be developed in consultation with those directly affected by racial disparities. Third, the industry should commit to dramatically reducing patient cost sharing for essential medication therapies. Federal and state efforts to limit annual out-of-pocket pharmacy spending should be supported, even though increased premiums may be an undesirable (yet more equitable) consequence. Finally, information about race should be incorporated into all internal and external reporting and quality improvement activities. DISCLOSURES: No funding was received for the development of this manuscript. Kogut is partially supported by Institutional Development Award Numbers U54GM115677 and P20GM125507 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds Advance Clinical and Translational Research (Advance-CTR), and the RI Lifespan Center of Biomedical Research Excellence (COBRE) on Opioids and Overdose, respectively. The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health.

Objectives: The aim of this publication is to analyze the organizational units of mental healthcare for adults based on the data on the services reported to the National Health Fund in 2010-2016., Methods: The following organizational forms of care were analyzed: mental health outpatient clinics, general psychiatric wards, general day care psychiatric wards, community mental health teams, and psychiatric emergency rooms. These organizational units were analyzed in terms of their number, utilization and accessibility. In addition, a preliminary simulation of the expected Mental Health Centers was carried out., Results: In Poland, in 2010-2016, the number of mental health service providers under contracts with the National Health Fund increased by 5%. The most robust growth was observed for community mental health teams, whose number increased by 282%. However, this organizational form was used by a marginal (1.9%) percentage of patients. The highest rate of admission to general psychiatric wards was observed in districts where a general psychiatric ward and a mental health clinic were available with no day care psychiatric wards or community mental health teams. Asmall number of entities providing comprehensive care was in operation in 2016. The preliminary simulation has shown that in 2016 a total of 156 MentalHealth Centers should have been in operation, assuming that each of them would have provided care for 200,000 inhabitants., Conclusions: It would be advisable to analyze the exact geographic distribution of units, human resources in individual organizational units, and to take financial outlays for mental healthcare in their various forms into consideration.

Disclosures: No funding contributed to the writing of this commentary. The authors have nothing to disclose.

Objectives: To evaluate the impact of the Community-Based Care Management (CBCM) program on total costs of care and utilization among adult high-need, high-cost patients enrolled in a Medicaid managed care organization (MCO). CBCM was a Medicaid insurer-led care coordination and disease management program staffed by nurse care managers paired with community health workers., Study Design: Retrospective cohort analysis., Methods: We obtained deidentified health plan claims data, enrollment information, and the MCO's monthly registry of the top 10% of costliest patients. The analysis included 896 patients enrolled in CBCM over the course of 2 years (January 2016 to December 2017) and a propensity score-matched cohort of high-cost patients (n = 2152) who received primary care at sites that did not participate in CBCM during the same time period. The primary outcomes were total costs of care and utilization in the 12-month period after enrollment. Secondary outcomes included utilization by care setting: outpatient, inpatient, emergency department, pharmacy, postacute care, and all other remaining sites. We used zero-inflated gamma and Poisson regression models to estimate average differences in postperiod costs and utilization between CBCM enrollees versus non-CBCM enrollees., Results: We did not observe meaningful differences in total costs or visit frequency among CBCM enrollees relative to non-CBCM enrollees., Conclusions: Although our study found no association between the CBCM program and subsequent cost or utilization outcomes, understanding why these outcomes were not achieved will inform how future Medicaid programs are designed to achieve better patient outcomes and lower costs.

Disclosures: No funding supported the writing of this commentary. The author has nothing to disclose.

More and more states are addressing the long-term services and supports needs of Medicaid only and dually eligible persons by developing Managed Long-Term Services and Supports (MLTSS) programs. States are moving away from fee-for-service plans and coordinating care through these capitated programs. The goals of these programs include greater efficiency while maintaining quality and better coordination of care. For dually eligible persons, the expansion of MLTSS has been made possible through the creation of the Medicare-Medicaid Coordination Office at the Centers for Medicare & Medicaid Services by the Affordable Care Act to improve communication and coordination between state and federal programs. MLTSS invest heavily into home and community-based services and care coordination to increase the efficiency of their organizations and improve person-centered care. Nurses who engage with this vulnerable population are in a prime position to further innovate this model to improve person and family outcomes. [Journal of Gerontological Nursing, 46(6), 7-11.]., (Copyright 2020, SLACK Incorporated.)

Disclosures: No funding was required for this project. The authors are or have been members of the Format Executive Committee.

Diabetes prevalence has risen rapidly and has become a global health challenge. The Diabetes Prevention Program (DPP) has been shown to prevent or delay the development of diabetes among individuals with prediabetes. Yet, diabetes prevention studies within the Medicaid population are limited and results are mixed. This study aimed to evaluate the impact of different financial incentive strategies on the utilization of the DPP for Medicaid managed care adults in New York State. A four-arm randomized controlled trial was conducted among Medicaid managed care adult enrollees diagnosed with prediabetes and/or obesity. Study participants were offered a 16-week DPP with various incentive strategies based on class attendance and weight loss as follows: Attendance-Only, Weight-Loss Only, and both Attendance and Weight-Loss. A control group was offered DPP with no incentives for attendance or weight loss. We evaluated the impact of incentives on achievement of the program completion and weight-loss milestone. Participants who received incentives for the Attendance-Only class were least likely to be lost to follow-up, more likely to complete the program, and had two times higher percentage of meeting the weight-loss milestone compared to the control group. Results for the other incentive cohorts were mixed. A strong positive association was observed for participants who attended 9 or more classes and weight-loss regardless of incentive strategies. Providing monetary incentives for DPP class attendance had a positive impact on program completion and achieving the weight-loss milestone. However, the results from this study indicate that participant enrollment and retention remained challenges despite the incentives., (Published by Elsevier Inc.)

OBJECTIVE: To review the development and implementation of prescription formularies by managed care organizations, identify their current applications, and recognize future trends in the managed care pharmacy environment. DATA SOURCES: Current journal articles and texts regarding the use of formularies and the managed care environment. DATA SYNTHESIS: Not applicable. CONCLUSION: Formulary systems have proven to be a valuable means to control the pharmacy benefit and can be expected to expand in both scope and sophistication.

Research agendas play valuable roles in clearly identifying high-priority topics that reflect potential to improve health care quality. The purpose of this report is to present work completed by the Academy of Managed Care Pharmacy (AMCP) and AMCP Foundation Joint Research Committee. This committee set forth to develop a research agenda for our 2 organizations that focuses on critical evidence needs in managed care pharmacy. This document reviews results from 2 surveys that were conducted to better understand unmet research needs within managed care pharmacy and to inform professional efforts of managed care pharmacists. The first survey collected qualitative data from key opinion leaders (KOLs) regarding the top evidentiary gaps in managed care pharmacy and barriers to closing those gaps. The second survey was sent to AMCP members and AMCP Foundation stakeholders, used a mixed methods quantitative-qualitative design, and incorporated concepts from initial KOL responses. The key outcome from these proceedings is the research agenda, which identifies and prioritizes 4 evidentiary gaps in managed care pharmacy: (1) real-world evidence to inform managed care pharmacy decision making, (2) value-based models in managed care pharmacy to address total cost of care, (3) impact of benefit design or utilization management strategies on patient outcomes, and (4) impact of direct patient care services provided by managed care pharmacy on patient outcomes. The agenda was intended to be broad and will evolve over time. AMCP and the AMCP Foundation hope that this research agenda inspires the AMCP membership, researchers, and funding agencies to close these gaps in knowledge and understanding. DISCLOSURES: Chairs and members of the Joint Research Committee oversaw and conducted the work outlined in this report with the support of AMCP and the AMCP Foundation. No outside funding was received. Gembarski, Couto, Wilson, and Eichenbrenner declare no conflicts of interest, real or apparent, with any product or service mentioned in this report. Gembarski is employed by BCBS Michigan; Couto is employed by Cigna; Wilson is employed by HealthCore, a wholly owned subsidiary of Anthem; and Eichenbrenner is employed by the AMCP Foundation.

Disclosures: No funding was received for the writing of this reflection. Avey is a member of the AMCP Foundation and has recently retired from MedImpact Health Systems, where he served as Vice President of Specialty Clinical Solutions.

Objectives: In 2012, the Ohio Department of Medicaid introduced requirements for enhanced care management to be delivered by Medicaid managed care organizations (MCOs). This study evaluated the impact of care management on reducing infant mortality in the largest Medicaid MCO in Ohio., Study Design: Observational study using infant and maternal individual-level enrollment and claims data (2009-2015), which used a quasi-experimental research design built on a sibling-comparison approach that controls for within-family confounders., Methods: Using individual-level data from the largest MCO in Ohio, we estimated linear probability models to examine the effect of infant engagement in care management on infant mortality. We used a within-family fixed-effects research design to determine if care management reduced infant mortality and estimated models separately for healthy infants and nonhealthy infants., Results: Infant engagement in care management was associated with a reduction of 7.4 percentage points (95% CI, -10.7 to -4.1; P <.001) in infant mortality among the most vulnerable infants, those identified as not well at birth. This effect was larger in recent years and likely driven by new statewide enhanced care management requirements. Infant mortality was unchanged for healthy infants engaged in care management (coefficient = 0.03; 95% CI, -0.01 to 0.08)., Conclusions: This study provides evidence that care management can be effective in reducing infant mortality among Medicaid MCO enrollees, a population at high risk of mortality. Few infants were engaged in care management, suggesting to policy makers that there is room for many additional infants to benefit from this intervention.

This paper describes key findings of two states that sought to integrate physical and behavioral health services by delivering them through one Medicaid managed care contract. The purpose was to explore how managed care organizations (MCOs) could improve physical and behavioral health integration. Promising practices include leveraging data accumulated by MCOs about beneficiaries to support providers and enhanced case management, encouraging MCOs to pay providers for care coordination and care collocation, and offering protections to providers and beneficiaries. Finally, in the absence of a shared vision among key stakeholders regarding how to best promote integrated care, a state can make progress by promoting stakeholder innovation.

Managed care pharmacists apply real-world evidence (RWE) to support activities such as pipeline forecasting, clinical policy development, and contracting for pharmaceutical products. Managed care pharmacy researchers strive to produce studies that can be applied in practice. While asking the right research question is necessary, it is not sufficient. As with all studies, consumers of RWE look for internal and external validity, as well as sources of bias, to determine how the study findings can be applied in their work. To date, however, some of the safeguards that exist for clinical trials-such as public registration of study protocols-are lacking for RWE. Several leading professional organizations have initiatives dedicated to improving the credibility and reliability of such research. One component common to these initiatives is enhanced transparency and completeness of methodologic reporting. Graphical representations of study designs can improve the reporting and design of research conducted in health care databases, specifically by enhancing the transparency and clarity of often complex studies. As such, Schneeweiss et al. (2019) proposed a graphical framework for longitudinal study designs in health care databases. Herein, we apply this framework to 2 studies published in the Journal of Managed Care & Specialty Pharmacy that represent common research designs and report how application of the framework revealed deficiencies in reporting. We advocate for adoption of this framework in the effort to increase the usability of RWE studies using health care databases by managed care pharmacy. DISCLOSURES: No funding was provided for this work. Gatwood has received research funding from Merck & Co., AstraZeneca, and GlaxoSmithKline, unrelated to this work. Schneeweiss is a consultant to Aetion, of which he also owns equity. He is the principal investigator of investigator-initiated grants to the Brigham and Women's Hospital from Bayer, Genentech, Boehringer Ingelheim, and Vertex. Wang reports support from investigator-initiated grants from Novartis, Boehringer Ingelheim, and Johnson & Johnson to Brigham and Women's Hospital, unrelated to this work. Happe and Brown have nothing to disclose.

It has been nearly 20 years since the Academy of Managed Care Pharmacy (AMCP) and other stakeholders adopted the Principles for a Sound Formulary System. Since that time, best practices for pharmacy and therapeutics (P&T) committees have matured throughout the health care system. On March 28, 2019, AMCP convened a group of thought leaders representing clinicians, academia, patient advocacy, payer organizations, and the pharmaceutical industry to consider P&T committee best practices in today's evolving health care system. Specifically, the group provided perspectives on (a) P&T committee composition and relevant stakeholders, (b) evaluation of emerging evidence for formulary decisions and recommendations around training of P&T committee members, and (c) characteristics and best practices of successful committees. DISCLOSURES: This AMCP Partnership Forum and the development of the proceedings document were supported by Amgen, Genentech, Merck, National Pharmaceutical Council, Novo Nordisk, Pharmaceutical Research and Manufacturers of America, Precision for Value, and Takeda. This proceedings document presents common themes and comments from individuals participating in the forum and is not necessarily endorsed by all participants nor should it be construed to reflect group consensus. Eric Jen, PharmD, and Cynthia Reilly, MS, BSPharm, declare no conflicts of interest, real or apparent, with any product or service mentioned in this article. Jen is an employee of Precision for Value, a sponsor of the Partnership Forum. Development of these proceedings was done as an in-kind sponsorship. Reilly is an employee of AMCP.

Prior authorization (PA) and step therapy (ST) are utilization management tools that have been in use by managed care organizations for decades. These processes require that health care providers obtain advanced approval to qualify a specific product for coverage from a health plan before it is delivered to the patient. These tools are intended to ensure that patients have access to evidence-based medications while payers remain good stewards of limited health care resources. PA and ST are growing in use to support appropriate use of medications and manage associated costs but may pose challenges related to administrative burden and access to care. In June 2019, the Academy of Managed Care Pharmacy (AMCP) conducted a multistakeholder forum to identify processes for optimizing PA and ST utilization management programs. Health care leaders representing academia, health plans, integrated delivery systems, pharmacy benefit managers, employers, federal government agencies, national health care provider organizations, and patient advocacy organizations participated in the forum. Participants explored current operations of these programs, evaluated stakeholder perspectives on opportunities to improve these programs, and provided recommendations for next steps. They also reviewed current federal and state legislative and regulatory activities to reform PA and ST processes and offered guidance to support program improvements. The goal of the forum was to gather stakeholder input to inform the development of recommendations to improve efficiencies around PA and ST processes; provide recommendations to address administrative burdens; increase the visibility of the clinical and economic value of PA and ST utilization management programs; collect, review, and disseminate data-driven, real-world experiences of PA programs that support clinical and economic value; collect and disseminate best practices around PA appeals and denial processes; and improve channels of communications between health insurance providers, health care professionals, and patients to minimize care delays and improve clarity of coverage authorization requirements. DISCLOSURES: This AMCP Partnership Forum was sponsored by Mallinckrodt Pharmaceuticals, Merck, the National Pharmaceutical Council, and Takeda. These proceedings were prepared as a summary of what occurred at the forum to represent common themes; they are not necessarily endorsed by all attendees nor should they be construed as reflecting group consensus.

There is growing recognition that social determinants of health influence individual and population health. A well-designed population health management strategy can yield improved outcomes for a given community, while improving the financial health of health care systems and providers. This article provides an overview of aligned care delivery, community engagement, education, technology, and other key strategies required to address the needs of patients and communities. A holistic vision incorporating social factors can lead to a return on investment and improvement in the health of a community, at the same time decreasing health care costs for the population managed., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Hip fracture patients in the aging population frequently present with various comorbidities, whilst preservation of independency and activities of daily living can be challenging. Thus, an interdisciplinary orthogeriatric treatment of these patients has recognized a growing acceptance in the last years. As there is still limited data on the impact of this approach, the present study aimed to evaluate the long-term outcome in elderly hip fracture patients, by comparing the treatment of a hospital with integrated orthogeriatric care (OGC) with a conventional trauma care (CTC)., Methods: We conducted a retrospective, two-center, cohort study. In two maximum care hospitals all patients presenting with a hip fracture at the age of ≥ 70 years were consecutively assigned within a 1 year period and underwent follow-up examination 12 months after surgery. Patients treated in hospital site A were treated with an interdisciplinary orthogeriatric approach (co-managed care), patients treated in hospital B underwent conventional trauma care. Main outcome parameters were 1 year mortality, readmission rate, requirement of care (RC) and personal activities of daily living (ADL)., Results: A total of 436 patients were included (219 with OGC / 217 with CTC). The mean age was 83.55 (66-99) years for OGC and 83.50 (70-103) years for CTC (76.7 and 75.6% of the patients respectively were female). One year mortality rates were 22.8% (OGC) and 28.1% (CTC; p = 0.029), readmission rates were 25.7% for OGC compared to 39.7% for CTC (p = 0.014). Inconsistent data were found for activities of daily living. After 1 year, 7.8% (OGC) and 13.8% (CTC) of the patients were lost to follow-up., Conclusions: Interdisciplinary orthogeriatric management revealed encouraging impact on the long-term outcome of hip fracture patients in the aging population. The observed reduction of mortality, requirements of care and readmission rates to hospital clearly support the health-economic impact of an interdisciplinary orthogeriatric care on specialized wards., Trial Registration: The study was approved and registered by the bavarian medical council (BLAEK: 7/11192) and the local ethics committee of munich university (Reg. No. 234-16) and was conducted as a two-center, cohort study at a hospital with integrated orthogeriatric care and a hospital with conventional trauma care.

In 2016, The Professional Society for Health Economics and Outcomes Research (ISPOR) formed a special task force (STF) to review approaches and methods to support the definition and use of high-quality U.S. value frameworks. As the leadership group of that initiative, we present our perspective, focusing on implications for the managed care pharmacy community. Our reflections are organized by 9 key observations and conclude with a summary recommendation. We begin by emphasizing the importance of distinguishing among "perspectives" and "decision contexts." Possible perspectives include patient, payer, provider, health care sector, and societal. Decision contexts range from formulary inclusion to guideline development to clinical shared decision making, and multiple perspectives can be taken on each of these decisions. The STF focused on value in the context of including a new medicine in a formulary and, thus, health plan, using a health economics approach that compares marginal benefit (gross value) and marginal (opportunity) cost, yielding the net value. Health care is unique compared with other markets. While economists often use market purchases as indicators of value, they also recognize that this does not work well in health care, since most patent-protected drugs are covered by insurance. To assess the likely health and economic impact, health economists often employ cost-effectiveness analysis, using the quality-adjusted life-year (QALY), a metric that combines mortality and morbidity into a single preference-based index. We strongly endorse the STF's recommendation that payers should use the cost-per-QALY metric as a starting point. However, like the STF, and many of those stakeholders who provided input, we recognize that this metric has some limitations in theory and in practice. Nonetheless, the cost-per-QALY metric is a pragmatic tool that can be augmented to address some of its limitations by integrating other elements of value, particularly those related to uncertainty, such as financial risk protection, health risk protection, the value of hope, real option value, and the value of knowing. The resulting adjusted ratio can be compared with a willingness-to-pay threshold or combined in a measure of net monetary benefit. Alternatively, the array of elements can be valued using multi-criteria decision analysis. We end with the key recommendation that further development and testing of these promising approaches is needed to improve the deliberative process of health technology assessment. DISCLOSURES: No outside funding supported the writing of this article. The authors are leaders of the ISPOR Special Task Force on U.S. Value Frameworks. Willke is employed by ISPOR. Garrison and Neumann have nothing to disclose. The opinions expressed in this article should be considered as belonging only to the authors.

TRICARE is the military's health plan that provides coverage to 9.4 million active duty and retired uniformed services personnel and their family members. The TRICARE pharmacy benefit has undergone many changes in the last decade. These changes include assigning newly approved drugs to nonformulary status after regulatory approval, the addition of weight loss medications to the benefit, channel management point-of-service requirements for some medications, and copay increases. Several initiatives have resulted in significant cost avoidance to the Department of Defense (DoD). The purpose of this article is to discuss the changes to the TRICARE pharmacy benefit, describe the continual challenges, and estimate cost savings associated with implementation of these changes. DoD implemented its 3-tier Uniform Formulary in 2005. Since then, many changes have been enacted, including more extensive use of prior authorization, step therapy, and quantity limits; coverage of over-the-counter medications; the retail refund program; coverage of vaccines and smoking cessation agents; mandatory mail/military treatment facility requirements; rapid review and initial nonformulary status for newly approved innovator drugs; revisions to the compounded drug benefit; initial deployment of a new medical record system; coverage of weight loss medications; and the ability to exclude medications from the Uniform Formulary. Although the TRICARE pharmacy benefit has evolved significantly, the focus remains on the beneficiaries, with an overall goal of providing integrated, affordable, and high quality health services for the Military Health System. Challenges for the future include maximizing clinical effectiveness in the face of rising pharmaceutical costs and cost avoidance, while supporting the needs of TRICARE beneficiaries. DISCLOSURES: No outside funding supported this study. The authors declare no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. The information discussed here represents the views of the authors and does not necessarily reflect the views of the Defense Health Agency (DHA), the Department of Defense (DoD), or the Departments of the Army, Navy, and Air Force. The authors have nothing to disclose that presents a potential conflict of interest.

Many programs use care managers to improve care coordination for high-need, high-cost patient populations. However, little is known about how programs integrate care managers into care delivery or the attributes shared by successful programs. We used a case study approach to examine the common attributes of 10 programs for high-need, high-cost individuals utilizing a longitudinal care manager that had achieved success in reducing cost, improving quality, or increasing patient satisfaction. Through interviews with program leaders and document review, we identified 10 common attributes of successful care manager programs, offering insights for providers aiming to better serve the high-need, high-cost population.

In the United States, managed long-term care programs offer a noninstitutional approach to meeting the needs of increasing numbers of frail elders. Providing services that support both quality of life and quality of dying poses unique challenges. Using a qualitative descriptive design, we explored these challenges from the perspectives of care providers. Themes were identified using qualitative content analysis techniques applied to transcripts of 33 semistructured interviews. Professionals comprising an interdisciplinary care team and home health aide direct care providers described cues by which they identified movement into the end-of-life phase, their understandings of how care changed, and their concerns and recommendations for improvement. When the changing care needs could be met, a "good death" ensued, but that was not always possible. Managed long-term care programs are called upon to develop the capacity to integrate the phase of dying into the full story of each life for which they care.

North Carolina's transformation to Medicaid managed care is projected to improve health outcomes for the state's Medicaid population and elevate patient experience by integrating the social determinants of health into the state's care model and aligning state, provider, and health plan goals. This will increase access to timely, localized care services for members., (©2019 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

North Carolina's upcoming shift to Medicaid managed care will present the opportunity to build on the current quality of services in a system that is focused on whole-person treatment. WellCare of North Carolina, Inc. intends to use innovative approaches that combine aspects of successful programs in other states, tailored to fit North Carolina and improve the quality of care., (©2019 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Medicaid transformation in North Carolina marks the next step in a lengthy history of caring for individuals with behavioral health challenges. "Tailored" health plans will cover people with severe mental illness, substance use disorders, intellectual/developmental disabilities, and traumatic brain injury, a vulnerable population that North Carolina's LME/MCOs are uniquely qualified to serve., (©2019 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

North Carolina's move to Medicaid managed care is part of the larger move to value-based care nationally. Keys to value-based care guide how practices and health systems can navigate the new payment model. The experience of North Carolina's Area Health Education Centers with primary care practices that work on value-based care can serve as an important case study., (©2019 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

As North Carolina's Medicaid program transitions from fee-for-service to managed care, the Department of Health and Human Services is committed to building an innovative, whole-person-centered and well-coordinated system of care that addresses both medical and non-medical drivers of health. Delivering on that vision, and improving the health and well-being of North Carolinians, means shifting from thinking of payers as exclusively buying medical services to thinking of them as buying health for their beneficiaries. Operationalizing this complex work will require strong partnership from stakeholders across the state and will also provide North Carolina an opportunity to help drive a national agenda centered around how to buy good health., (©2019 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Federal managed care rules require that the services delivered through Medicaid prepaid health plans are available, accessible, and continually being evaluated for improvement. Working with stakeholders, NC Medicaid created a Quality Strategy that serves as a roadmap to measure and oversee performance. NC Medicaid will make a variety of quality reports available including network access, annual quality measures, and provider survey results., (©2019 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)