Utilization management criteria influence patients' access to specialty drugs, yet the processes used by health plans to establish these criteria are not well understood. This study examined the alignment between clinical practice guidelines and plans' utilization management criteria. Using the Tufts Medicine Specialty Drug Evidence and Coverage Database (December 2023), we reviewed US-based guidelines for 389 drug-indication pairs, excluding oncology and biosimilar treatments. We categorized guidelines as recommending or not recommending utilization management, based on alignment with each drug's Food and Drug Administration label-specifically, line of therapy and clinical requirements (for example, disease severity). We analyzed 5,699 coverage policies from eighteen large commercial health plans. When guidelines recommended utilization management, 67 percent of plans' coverage decisions aligned with the recommendation; when guidelines did not recommend utilization management, only 37 percent of decisions were consistent. Most plans imposed utilization management criteria (61 percent of all decisions), and plans were more likely to be consistent with guideline recommendations when utilization management was recommended, indicating a weak alignment with guideline recommendations.

Medicare enrollment increases provider visits among older adults; however, it remains unclear whether this increase is uniform across all types of providers. Using data from the 2014-21 Medical Expenditure Panel Surveys, we examined the effect of Medicare enrollment on office and outpatient visits across providers, using a regression discontinuity design. We found that Medicare enrollment at age sixty-five led to a 14 percent increase in visits to primary care providers and a 31 percent increase in visits to other providers, with the former more prominent among Medicare Advantage enrollees. In contrast, there was no change in visits to mental health care providers. Our study highlights the heterogenous effects of Medicare enrollment on health care use across different types of providers. Strengthening partnerships across providers, especially between primary care and mental health care providers, could be one way to improve mental health care use among new Medicare enrollees.

For nearly a half-century, Congress has created various legal authorities from among which states may select to provide Medicaid beneficiaries with long-term services and supports (LTSS) in home and community-based settings, instead of in institutions. This article describes these legal authorities and their genesis and contends that a simpler architecture would better serve program goals. In theory, state-level variation could shine a light on how Medicaid can best meet beneficiaries’ needs. Instead, a maze of federal legal authorities has resulted in inconsistent and inequitable access to care among beneficiaries and across geographies. The many programs are difficult to understand, even for researchers and regulators trying to measure outcomes. This opacity obscures the most effective paths forward as the demand for Medicaid LTSS grows. Simplifying Medicaid LTSS legal authorities could ease burdens for states and better serve beneficiaries.

The Medicare Care Choices Model (MCCM) tested a new option for eligible Medicare beneficiaries to receive conventional treatment for terminal conditions along with supportive and palliative care from participating hospice providers. Using claims data, we estimated differences in average outcomes from enrollment to death between deceased MCCM enrollees and matched comparison beneficiaries who received usual services covered by original Medicare. Enrollees were 15percentage points less likely to receive an aggressive life-prolonging treatment at the end of life and spent more than five more days at home. MCCM also reduced net Medicare expenditures by 13percent, decreased inpatient admissions by 26percent, reduced outpatient emergency department visits by 12percent, and increased hospice use by 18percentage points. Although the Centers for Medicare and Medicaid Services did not expand the model, given concerns about generalizability, these results provide evidence that MCCM is a promising approach to transforming care delivery at the end of life.

Hospital equity officers have become critical leaders in the effort to address the determinants of health care disparities, including structural racism. In this mixed-methods study, we surveyed a national sample of equity officers and interviewed a subset of respondents to provide additional perspective. About one-half of survey respondents reported at least some obstacles to achieving their health equity objectives, including racist beliefs among people working in their hospitals and health care systems, policies that perpetuate racism, and a lack of staff diversity. To address these challenges, some hospitals are collecting information about instances of racism, reviewing clinical algorithms for evidence of bias, or forming community partnerships. However, in interviews, equity officers pointed out that racism is a public health issue that cannot be adequately addressed solely within the health care system. Given the relative newness of most hospital equity officer positions, our research may be viewed as an early glimpse into the challenges and opportunities of this evolving work.

Among US adults in 2013-18, we found high-deductible health plan enrollment to be the lowest among heterosexual and gay/lesbian adults in families with incomes below 200percent of the federal poverty level and the highest among bisexual adults in families with incomes at or above 400percent of poverty. Gay/lesbian and bisexual adults in these plans experienced greater financial barriers to health care than heterosexual adults.

Systemic racism has imposed stark health inequities on marginalized communities. Now, some are beginning to shift the balance of power to improve their health.

Authorized generics are approved brand-name drugs that are sold by brand-name manufacturers or licensees without brands on their labeling. Despite their prevalence in prescription drug markets in the US, little is known about trends in their launches, their timing relative to traditional generics, and the characteristics of their respective brand-name drugs. We linked Food and Drug Administration and IQVIA data to investigate newly launched authorized generics during the period 2010-19. We found 854 launches over this period, with launches peaking in 2014. Marketing appears strategic: In markets with traditional generics, three-fourths of authorized generics launched after the respective generic competition started. When we focused on markets where generics were eligible for the 180-day exclusivity, about 70percent of authorized generics launched before or during the exclusivity period. These findings provide insights for future research on the effect of authorized generics on competition, prices, and access to generics.

Previous research has demonstrated that the introduction of a new brand-name pharmaceutical competitor does not lower list prices for existing competitive therapies. However, no study has systematically evaluated the impact of new therapeutic competition on net prices of pharmaceutical products. We identified new therapies approved during the period 2013-17 that were competitors for existing treatments. We used a novel peer-reviewed algorithm to estimate the net prices of existing therapies. We implemented regression models to estimate changes in these net prices after the approval of the new therapeutic competition during the period 2011-19. Across twelve therapeutic classes with new drug entrants in 2013-17, the introduction of new therapeutic competition was associated with a 4.2percent decrease in annual net price growth. The introduction of new brand-name therapies in twelve therapeutic classes reduced net commercial spending on existing therapies by $10.4 billion-an 18.5percent reduction in projected spending absent therapeutic competition. Our findings demonstrate that new therapeutic competition allows pharmacy benefit managers to use formulary management to decrease net prices and reduce drug spending, contrary to observed trends in list price increases.