Insurance

Laxmi Patel discusses proposed Medicaid reforms in HR 1, including work rules, coverage limits, and state-level risks for vulnerable populations.

Refat Rasul Srejon, MPH, found that Affordable Care Act (ACA) dependent coverage had mixed effects on young adults’ substance-related emergency department (ED) visits.

A secret shopper survey (N = 8306) in Pennsylvania’s Affordable Care Act (ACA) Marketplace found inconsistencies between carrier regulatory filings and provider directories, frequent inaccuracies in regulatory filings, and challenges in securing timely appointments.

This study of community health workers as clinical extenders demonstrates significant cost savings in managing chronic conditions among Medicaid beneficiaries.

Pulse of the Purchaser 2025 survey results showed the use of transparent PBMs more than doubled in just 1 year, from 12% to 31%.

Extended hospital stays among Medicare Advantage beneficiaries translated to an estimated 1.8 million additional hospital bed days in 2022.

Many states are enacting restrictions on insurers’ prior authorization policies, but these laws may increase costs and lead to other undesirable consequences.

To mark the 30th anniversary of The American Journal of Managed Care, each issue in 2025 includes a special feature: reflections from a thought leader on what has changed—and what has not—over the past 3 decades and what’s next for managed care. The September issue features a conversation with Dora Hughes, MD, MPH, chief medical officer and director of the Center for Clinical Standards and Quality at CMS.

Why is health care so staggeringly difficult to use? How do we fix it? To move forward, we first must look back, because the system we have today was not really designed, it evolved, notes Ariela Simerman, Turquoise Health.

Patients with acute respiratory failure who’ve been placed on a mechanical ventilator are less likely to be transferred to high-volume centers if they are uninsured, thus increasing their odds of mortality.

Hospital accountable care organization (ACO) participation did not impact emergency department admission rates, length of stay, or costs, suggesting limited effectiveness in reducing spending for unplanned admissions and challenging hospital-led ACO cost-saving strategies.

More large employers with high-deductible health plans with health savings accounts offer preventive drug list benefits over time.

Laxmi Patel, chief strategy officer at Savista, outlines major impacts of the “One Big Beautiful Bill” Act on Medicaid and what hospitals can do to prepare for these changes.

Proposed Affordable Care Act (ACA) premium hikes threaten health care access, with potential increases of over 75% for enrollees.

Medicare Advantage outperformed traditional Medicare on clinical quality measures before and during the COVID-19 pandemic; mid-pandemic, however, traditional Medicare narrowed the gap on some in-person screenings.

This retrospective analysis explored the impact of infertility health benefit design on the use of infertility medications and procedures and pregnancy outcomes.

This study examined the impact of price transparency and prosocial messaging on patient engagement of price-protected consumers in seeking value-based care.

Key legal, ethical, and compliance considerations for managed care professionals navigating the evolving landscape of psychedelic-assisted therapy include regulatory risks, data privacy challenges, reimbursement limitations, and the need for culturally informed care models.

To mark the 30th anniversary of The American Journal of Managed Care (AJMC), each issue in 2025 includes a special feature: reflections from a thought leader on what has changed—and what has not—over the past 3 decades and what’s next for managed care. The August issue features a conversation with Charles N. (Chip) Kahn III, MPH, the president and CEO of the Federation of American Hospitals and a longtime member of the AJMC editorial board.

This Managed Care Cast episode explores how high costs and inconsistent insurance coverage for incretin mimetics impact obesity management and patient care.

Patients who experienced a formulary-related rejection of cariprazine for adjunctive treatment of major depressive disorder had significantly higher hospitalization rates than those with approved claims.

Mental health, care of acute and chronic conditions, primary care access and prevention, and maternal and perinatal health were identified as key focus areas among a majority of states.

There is a great need to streamline the process from the tissue sample to the diagnostic lab, whether it's genomic or immunohistochemistry, Robert Kratzke, MD, says.

According to the American Medical Association, blame for the ongoing physician shortage may lie with overly burdensome administrative processes, an antiquated Medicare payment system, and lack of education for residents in primary care and psychiatry.

Apixaban would still cost patients 9 times more through the Eliquis 360 Support program than with commercial insurance.