September Issue of The American Journal of Managed Care® Highlights Federal Healthcare Reform Efforts

Health policy experts writing in the current issue of The American Journal of Managed Care® illustrate efforts that are being tested or considered to improve care for elderly patients, veterans and others, as well as physician-led initiatives to improve stakeholder buy-in for value-based care.

CRANBURY, NJ — The latest issue of The American Journal of Managed Care® (AJMC®) spotlights several recent innovative examples that policymakers might consider as part of reform efforts to control rising costs in Medicare, Medicaid and the Veterans Health Administration without hurting the quality of care.

The papers discuss the promises and challenges of the various approaches, as these programs must cope with an aging population beset with chronic health problems while also balancing rising costs.

“Access to and affordability of high-quality health care are among the most important policy issues for many Americans,” said A. Mark Fendrick, MD, co-editor-in-chief of AJMC®. “We are pleased that The American Journal of Managed Care® continues to provide important research and commentary to inform how we can spend our health care dollars more efficiently and ultimately improve individual and population health.”

Studies featured in this issue found:

Physician-initiated payment reform offers a path toward value. This analysis of the first set of new payment models initiated by physicians and not payers to create more value in Medicare found that the models shared several important features, including acceptance of financial risk, case management and new technologies to support care delivery. These payment models were submitted to the Physician Focused Payment Model Technical Advisory Committee, which is a task force created by the Medicare Access and CHIP Reauthorization Act of 2015. Some providers, especially specialists, might support payment reform if it is done in a way that incorporates their views and priorities, write authors Suhas Gondi, BA; Timothy G. Ferris, MD, MPH; Kavita K. Patel, MD, MSHS; and Zirui Song, MD, PhD.

A more accurate way to predict patients at high risk for hospitalization. Health systems use predictive models to try and determine which patients may have a high risk of readmission but using a single risk score may lead to false results. An article using a large data set from the Veterans Health Administration found that few patients who were initially high-risk remained so two years after admission. Authors Evelyn T. Chang, MD, MSHS; Rebecca Piegari, MS; Edwin S. Wong, PhD; Ann-Marie Rosland, MD, MS; Stephan D. Fihn, MD, MPH; Sandeep Vijan, MD; and Jean Yoon, PhD, MHS, found that using a combination of characteristics—urban residence, chronic medical comorbidities, auditory and visual impairment, chronic pain, cancer and social instability—produces a more accurate prediction of risk.

Medicare Advantage payment cut did not hurt enrollment. Another study examined Medicare Advantage payment cuts to see if the reductions affected healthcare access and affordability for enrollees compared with beneficiaries in traditional Medicare fee-for-service plans. While some thought the payment cuts would deter both plans and enrollees from joining the privately managed plans, enrollment grew steadily from 2009 to 2017. The plans were able to reduce their costs for providing both Part A and Part B benefits, say Laura Skopec, MS; Joshua Aarons, BA; and Stephen Zuckerman, PhD.

Unmet needs among enrollees with serious mental illness in Medicaid managed care. Most states have moved their Medicaid programs to managed care models, but little information exists about how these models work for those with serious mental illness. This article, by Jean P. Hall, PhD; Tracey A. LaPierre, PhD; and Noelle K. Kurth, MS, examined the experiences of these Medicaid patients in Kansas, including successes and challenges, especially in regard to the unmet needs of this challenging population. Managed care organizations that are able to help patients navigate coverage and use more of their benefits can see outcomes improved as barriers to care fall.

For the full issue, click here.

About The American Journal of Managed Care®

The American Journal of Managed Care® (AJMC®) is a peer-reviewed, Medline-indexed journal that keeps readers on the forefront of health policy by publishing research relevant to industry decision makers as they work to promote the efficient delivery of high-quality care. is the essential website for managed care professionals, distributing industry updates daily to leading stakeholders. Other titles in the AJMC® family include The American Journal of Accountable Care® and two evidence-based series, Evidence-Based Oncology and Evidence-Based Diabetes Management. These comprehensive offerings bring together stakeholder views from payers, providers, policymakers and other industry leaders in managed care. To order reprints of articles appearing in AJMC® publications, please contact Gil Hernandez at 609-716-7777, ext. 139.

AJMC® Media Contacts

Alexandra Ventura, 609-716-7777, ext. 121

John Patricolo, 609-325-4630, ext. 133

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