Although 21% of U.S. adults have a mental illness, access to behavioral healthcare remains out of reach for most. From 2008 to 2019, the number of adults with any mental illness increased nearly 30%. The pandemic further exacerbated mental health problems for adults and sparked an expanding youth mental health crisis. As the demand for behavioral healthcare continues to grow, Magellan Healthcare recognizes the need to increase access.

Increasing Access to Evidence-based Care

Magellan has collaborated with NeuroFlow, an award-winning behavioral health technology company, to increase access to our evidence-based digital cognitive behavioral therapy (DCBT) programs and enhance engagement. With a history of over 20 years of research and development and an endorsement from the Substance Abuse and Mental Health Services Administration (SAMHSA), Magellan’s DCBT programs are integral components of our Digital Emotional Wellbeing program, including FearFighter® for anxiety, panic and phobia and MoodCalmer for depression. Both programs, as well as RESTORE® for insomnia and other difficulties sleeping, are available online in Spanish, further increasing access to evidence-based programs.

Understanding Digital Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a short-term intervention that behavioral health clinicians use to help individuals overcome negative thoughts and behaviors. CBT is effective for depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders, and severe mental illness. CBT has been demonstrated to be as effective in certain conditions as other forms of therapy or psychiatric medications. Digital CBT (DCBT) is the implementation of CBT on a digital platform with the same core principles, language and exercises used in live practice that include:

• Learning to recognize thought distortions
• Evaluating distortions against reality
• Gaining a better understanding of others’ behavior and motivations
• Using problem-solving skills
• Developing a greater confidence in one’s own abilities
• Changing behavioral patterns
• Developing coping skills

True evidence-based DCBT follows the exact CBT process, differing from evidence-informed digital programs that use some CBT practices but are not built with fidelity to the intervention model. Learn more about evidence-based vs. evidence-informed behavioral health interventions here.

Impact of FearFighter and MoodCalmer on Mental Health

Our collaboration with NeuroFlow has yielded remarkable outcomes that underscore the power of innovative partnerships. In a recent study, members participating in the Digital Emotional Wellbeing program who completed 75% or more of FearFighter and MoodCalmer reported significant reductions in anxiety and depression symptoms within 90 days.

• FearFighter users experienced a 41% average reduction in Generalized Anxiety Disorder Assessment (GAD-7) scores, compared to other DCBT users who averaged an 11% reduction in GAD-7 scores.
• MoodCalmer users experienced a 24% average reduction in Patient Health Questionnaire (PHQ-9) scores, compared to an average 13% reduction among those who completed less of the program.

Beyond these impressive results, Magellan has seen a 124% increase in registrations after launching Digital Emotional Wellbeing over previous programs. Members also report high levels of satisfaction with the Digital Emotional Wellbeing program with 85% indicating they would recommend the program to someone else.

Visit Magellanhealthcare.com/digital-bh/ to learn more about the results and how our Digital Emotional Wellbeing program, including our award-winning DCBT programs improve anxiety, depression and more.

Sources:

• Exploring Barriers to Mental Health Care in the U.S. | AAMC
• What is Cognitive Behavioral Therapy? (apa.org)
• Satiani A, Niedermier J, Satiani B, Svendsen DP. Projected Workforce of Psychiatrists in the United States: A Population Analysis. Psychiatr Serv. 2018 Jun 1;69(6):710-713. doi: 10.1176/appi.ps.201700344. Epub 2018 Mar 15. PMID: 29540118.

FearFighter® and MoodCalmer are owned by CCBT Limited Corporation, United Kingdom. CCBT has granted Magellan exclusive rights to FearFighter® and MoodCalmer in the U.S.

While up to 80% of all primary care visits include a behavioral health component, primary care providers (PCPs) may feel overwhelmed and ill-equipped to meet their patients’ behavioral health needs. Collaborative care can help.

What is collaborative care?

Collaborative care is a specific type of integrated care that uses a team-based, patient-centered approach to address behavioral health in the primary care setting. Collaborative care links a patient’s PCP with a behavioral health care manager and psychiatric consultant to help meet their mental health goals. This approach has been studied in over 90 different randomized control trials and has shown to be highly effective in delivering a better patient experience, as well as improving patient outcomes and providing cost reduction.

Collaborative care gives PCPs the tools and support they need to manage ongoing mental healthcare and helps improve the quality of care provided.

• A patient registry allows PCPs to track patients and ensure that no one falls through the cracks. Patients who do not show improvement are outreached, and behavioral health specialists offer caseload-focused consultation.
• Screening tools, such as the Patient Health Questionnaire (PHQ)-9 for depression and the Generalized Anxiety Disorder (GAD)-7 for anxiety, help identify and direct patients to the appropriate levels of care for mental health conditions.
• A behavioral health care manager supports the PCP in myriad ways, including:
  • Ensuring effective communication among the team
  • Coordinating the team and mental health treatment
  • Providing progress updates and treatment recommendations to the provider
  • Alerting the PCP when the patient is not improving
  • Supporting medication management
  • Facilitating communication with the psychiatric consultant regarding treatment changes
  • Conducting brief interventions, such as motivational interviews with patients to guide their progress
• A psychiatric consultant reviews cases alongside behavioral health care managers and assists the care team with treatment planning, and diagnostic and treatment recommendations.

Collaborative care allows patients to get mental healthcare where they regularly seek physical healthcare, rather than having to go elsewhere.

 Throughout the U.S., individuals lack access to mental healthcare. In fact, over 26 million individuals experiencing a mental health condition are going untreated. Providing mental healthcare in the primary care setting allows patients to:

• Address mental health concerns with a provider they trust and see regularly for physical health concerns
• Receive mental health treatment at an earlier stage to help prevent more serious problems
• Have regular contact with a behavioral health care manager who can deliver brief interventions and individualized care planning
• Receive coordinated care for co-occurring mental and physical conditions
• Reduce the burden they carry in communicating treatment updates to multiple providers when they have comorbid physical and mental health concerns
• Feel comfortable that all of their health needs are being addressed
• Receive mental health treatment that is often less expensive

Magellan Healthcare’s collaborative care solution, powered by NeuroFlow

 Collaborative care has been proven to double the effectiveness of depression care, as well as improve physical function and reduce healthcare costs. Magellan Healthcare’s evidence-based Collaborative Care Management solution for health plans and healthcare delivery systems provides care management and psychiatric consults for primary care patients and augments physical health providers’ staff with Magellan staff to facilitate integrated physical and behavioral healthcare. Learn more here.

Sources:

• 2020 Adult Data | Mental Health America (mhanational.org)
• Benefits of Behavioral Health Integration for Primary Care Providers | Bipartisan Policy Center
• Collaborative Care | University of Washington AIMS Center (uw.edu)

Total cost of care is challenging to define. In general, we consider total cost of care to be the total cost of what it takes to treat a population. Is it direct provider fees and hospital fees? What about labs? Medications? Caregiver burden? Time away from work?

When I was in clinical practice—whether internal medicine or psychiatry out-patient clinics— I commonly saw what I called the Ziploc phenomenon—the arrival of a patient carrying a Ziploc bag of prescription drugs. We would spend time going through that bag to help me understand what the patient was actually taking. There would be medications from an ER visit, from an in-patient stay, and those that had been in the medicine cabinet at home. There would be brand names and generics of the same medication or different doses with different instructions. And despite all these medications, some patients invariably had ended up with higher total cost of care due to medication-related issues such as confusion, side-effects, falls, or just from not taking the medication at all because they did not feel better.

Typically, the total cost of care is the sum of in-patient, out-patient, clinic, ancillary, pharmacy, and all other types of direct care services and is defined as a per member per month expenditure. Members continuously enrolled in the health plan for at least a year make up the denominator. Groups who receive an intervention, like case management, are compared against a like-group that does not. The challenges really come when trying to attribute whether the intervention or some other occurrence made the difference in lowering the total cost of care. In order for comparisons to be statistically valid, techniques such as risk adjustment, case-matched controls, trend analyses, and regression analyses are used.

A couple of years ago, I took a role that focused on developing innovative clinical programs for Magellan Rx Management, a pharmacy benefits management company. The CEO challenged me with bringing forward clinical programs that looked different than what typical PBMs offered. I went back to my roots in med/psych and epidemiology. We drew on the interventions more commonly used in health plans. Surely, in the data, we could find the groups of people who needed support, whether in dealing with the Ziploc bag or in other areas at the intersection of medication and well-being. My teams focused on providing the right kinds of interventions to bring better clinical outcomes. As a side effect, we saw improvements in the total cost of care for those members.

Here are two innovative strategies to manage total cost of care

1. Having access to data is critical to address the total cost of care.

Unfortunately, it is often the case that PBMs don’t have access to medical claims or other data, including medical pharmacy spend. To hone in on the populations that could benefit from clinical programs, a combination of medical, behavioral, and pharmacy claims is necessary. My team works with a data science company, Arine, to support our work. Arine ingests all sorts of data, including the typical claims data and information from health risk assessments, social determinants factors, and remote monitoring data from devices such as blood pressure monitors. Arine’s technology includes hundreds of algorithms that can help identify individuals at risk for gaps in care, non-adherence, and even heightened suicide risk.

2. Identifying at-risk individuals and offering provider academic detailing services

Navigate Whole Health is one of our signature programs directed at improving quality and addressing spend. The original idea behind Navigate Whole Health was to find individuals who were prescribed potentially lethal combinations of opioids and other drugs, high doses of opioids, or poly-pharmacy with behavioral health medications. Using a set of algorithms running through pharmacy, behavioral and medical claims, we can identify individuals who fall into one of the target groups. With Arine’s support, we have expanded the number of algorithms we use to identify at-risk individuals and prescribers.

In fact, provider outreach with academic detailing is the salient intervention. The pharmacists providing the academic detailing have nearly universally found that the providers welcome our input. Our approach has never been threatening or punitive. Rather, the team approaches each case with an attitude of “How can I help you?” Many providers do not know all the medications an individual is taking, including prescriptions written by other providers, medications coming from an in-patient stay, an ER visit, or even the dentist. For one Medicaid client, the team’s work with providers resulted in significant reductions in combinations of opioids and benzodiazepines, reduction in the number of prescribers, and reduction in pharmacy spend, in-patient spend and emergency department utilization during the measurement period. This is one program that I unequivocally believe saves lives. And here is the thing, in doing the right thing, the positive outcome is that we also save total cost of care dollars.

I have a hard time supporting the logic that buckets cost in such a way that could adversely affect overall health outcomes. It is a privilege to bring forward clinical programs that save total cost of care dollars which in turn promote positive health outcomes. What is even better is knowing that these programs positively affect the well-being of those we serve.

It is midnight and I’m feeling anxious. I am hearing my daughter cough—she and I returned from New York City four days ago. I’m highly aware of what is known about the incubation and symptom development of the coronavirus. What if she, I, and all the others flying home from NYC last week became the latest vectors of this disease? I have a feeling of dread that I can’t shake, and it’s fueled by the fact that I can’t protect her from any illness, let alone coronavirus.

Anxiety is natural. It’s to be expected in times like these. The news cycle keeps us up to date on every change in the number of infected persons, or the number likely to die. There is a sense of foreboding about whether oneself will get sick, or whether our children or parents will fall ill. We rightly worry about what will happen to the economy and our financial well-being. And, it’s not as if anything else goes away—there is still work, financial obligations, an impending presidential election, countries at unease, and climate change. It is easy to reach the point of feeling on edge, irritable, anxious, or overwhelmed. I would be lying if I said I didn’t feel some of those feelings tonight.

Turning the Anxiety Around

Here are some helpful tips to consider as you grapple with the uneasy feelings associated with the coronavirus:

1. Accept It – It’s important to accept that this is happening; it’s real. Don’t pretend that it’s not. Look for the middle ground here—avoid the Armageddon predictions, as well as the pundits who say this will be over in a week. Accept that your partner, your children, your friends, your parents likely have some level of anxiety—some more than others. Be willing to share those feelings—sharing does not mean that one is weak. That honesty may make one feel less isolated in learning that others feel the same way. Talk to your kids to understand their feelings. My daughter asked me why I was buying extra groceries when I had told her that I wasn’t scared. Her question opened up a wonderful conversation; I am so glad she asked.
2.  Be Informed – Keep yourself informed, but, don’t fall for the endless news cycle and the counting of the numbers of people who have become infected, or what the politicians are saying. Use legitimate sources such as the World Health Organization or the Centers for Disease Control websites. Listen to the science. Know what your public health authorities are saying so that closures don’t come as a surprise, and you are aware of mitigation efforts.
3. Recognize our Burdened System – Try to understand that the healthcare system is under strain right now. The coronavirus is additive—none of the other needs for healthcare have gone away. This means that triaging is critically important and because for the vast majority of cases—those with mild and moderate symptoms—the care is symptomatic, there is no cure. Demanding to be seen because of cold or flu symptoms doesn’t serve anyone. Those with documented fevers, and with shortness of breath or labored breathing, need to be prioritized and seen first.
4. Take Advantage of the Time – If you are now working at home, embrace some of the time you’ve saved in not commuting. Use this time to go for an outdoor walk, or to do yoga in the house. Start journaling. Engage in self-care, and care for those who live with you. Read your child an extra story, cook a hot breakfast, watch something that will make you laugh. All of this will support your ability to focus while you are at working from home. And if you are still needed in the office, use this time to focus on the task at hand. Remember to engage in handwashing, and social distancing. Use your commute to focus on something other than the coronavirus. Listen to a book or find new music. While at work, think about starting a desk exercise routine.
5. Recognize the Challenges – Realize that working from home and social distancing can be hard, especially in our tech-enabled world. If you are someone who travels a great deal for work, and those travels have been placed on hold, understand that you might become antsy at being grounded for weeks on end. Your routine, and the routine of your family has been upset. Talk about it. Understand that while it may be hard for you to stay home, it may be hard for your family to change their usual routine that takes place in your absence. It will take time to adjust and that’s okay. That’s the reality.
6. Maintain a Routine – Do your best to keep your usual schedule, and keep your kids on their schedule, too. This isn’t a holiday. It’s a time to be productive at home during the usual work and school hours. It’s a time to get a full night’s sleep. Print worksheets for your kids. Read. Keep screen time limited to educational activities. If going outdoors is an option, stay active outside. If it’s not, access an exercise program online. Checkout online books from your local library. Play a game. Do a puzzle. Watch television or stream some of the content you’ve been wanting to watch—but not for endless hours. I have ordered a PSAT prep book, and downloaded DuoLingo for my daughter. While she’s not so happy about that, those unpopular choices are the right thing to do.
7. Seek Help – Finally, if the anxiety is affecting your ability to carry out your roles, seek counseling. While face-to-face visits may not be possible, look for telemedicine or tele-behavioral health providers. If these are not an option, seek support through app-based services. Apps that focus on cognitive behavioral therapy or problem-focused therapy may be helpful. Look for apps that support relaxation, medication, and techniques to deal with insomnia.

As our country engages in mitigation, and promotes self-isolation and quarantine, realize that none of this is easy. But it is necessary. You aren’t in it alone—the whole community, even most of the world’s population is adjusting to this new state of life. By participating in what is best for the community, you are taking control of the anxiety by doing something to fight the spread of coronavirus. It’s important to recognize the critical role you are playing in this fight. Thank you.

To learn more about what Magellan Healthcare is doing to support clients during the  COVID-19 pandemic, visit  MagellanHealthcare.com/COVID-19.

To learn more about Magellan Health’s corporate response to the COVID-19 pandemic and to view Magellan’s available resources click here: https://www.magellanhealth.com/news/covid-19/

When I was a child visiting my grandparent’s Iowa farm, I would often hear stories of how my mom and her eight brothers and sisters lived during the war efforts of the 1940’s. My grandma described a common purpose—that sense of pride that the family rationed and repurposed. Their singular focus was that the good of the individual was less important than the whole of the country, even the world.

Watching the coronavirus make its way across the world and rapidly grow in the United States, I can’t help but think of those stories. As the shelves of Costco and Sam’s Club stores emptied this weekend, and school closures were announced community by community, it made me realize that our time to step up is now. Our singular, collective focus needs to be mitigation and in order to be successful, mitigation efforts need to be embraced and enacted on by us as individuals.

What is Mitigation?

Mitigation is a strategy to reduce the seriousness or impact of a natural disaster, such as a pandemic. The goals of mitigation include minimizing morbidity and associated mortality, avoiding an epidemic peak that overwhelms healthcare services, keeping the effects on the economy within manageable levels, flattening the epidemic curve to wait for vaccine development and manufacturing to reach populations, and actively pursuing the development of antiviral drug therapies. Practically, mitigation relies on social distancing—measures that are taken to restrict when and where people can gather to stop or slow the spread of infectious diseases such as the coronavirus.  Social distancing measures include limiting large group gatherings, closing buildings and canceling events. However, for mitigation to be successful, individuals, even those who are asymptomatic, must be willing to self-isolate.

Self-Isolation Challenges

In a society as mobile as ours, and where high degrees of social contact is the norm, self-isolation is challenging. For instance, if one has become accustomed to eating meals outside the home, the transition to grocery buying and cooking may seem formidable. If one is used to getting together with friends to play cards, go running, have a beer after work, the loss of those types of activities will create holes in one’s social network.

We are fortunate to have an infrastructure in which many people can work from home and education can be delivered virtually. Workers who cannot isolate because the nature of their work cannot be done virtually, must take precautions. While in the workplace, distancing at least six feet, maintaining high levels of handwashing and the use of hand sanitizers is a must.   When returning home, it is best to avoid being in the presence of those most vulnerable to coronavirus—elders and persons with underlying comorbidities. It is also important to acknowledge that one may feel anxious and may not have all the answers that our members or clients are seeking. Maintain lines of communication with co-workers and supervisors. For those who are new to work at home, talk to coworkers for whom this has been the norm to get some advice on structuring the workplace and the day. And don’t forget that you can use technology to connect with friends. Facetime, Skype and other video conference capabilities are a great way foster your relationships during social isolation.

Mitigation is a critically important strategy to quell the spread of the virus. It has been beneficial in China as new cases are now falling. In areas where community spread is mild, targeted isolation of high-risk people, or those who may have come in contact with the virus, can be implemented. Even inside households, those with symptoms should keep distance from the healthy. And, even if you are asymptomatic, but have been in a high-risk area or where there is growing or wide community spread, it is important to maintain social distancing and self-isolation.

Social distancing and isolation are not easy—but I am trying to look at them as the Victory Gardens of my mother’s childhood. I hope that 50 years from now, my grandchildren will hear stories of how the United States and the world beat back the coronavirus, and I hope that my children who are on this journey with me now will reflect and recognize the importance of a global community, productively working together for the common good.

Primary care providers can be responsible for everything from first line dermatology to behavioral health to musculoskeletal injuries. In a world of rapidly changing technologies, and in which new therapies can cure or alter diseases that only a few years ago would have never been thought possible, the basics still matter. As a clinician, I’ve practiced internal medicine and psychiatry, and still have the opportunity to work with a FQHC in building integrated care. Those experiences and my national view of utilization and prescribing patterns highlight the need for provider support to care for persons with mental health conditions, including opioid use and abuse.

It is often challenging to translate new medical knowledge to the clinic setting. How does a provider care for the individual on a potentially lethal combination of opioids, benzodiazepines, and muscle relaxants? Or, how does one address the young child who has been placed on a combination of psychotropic medications.

In our current health system, primary care providers are in the best place to begin patient care journey or change the course of an already established treatment plan. An effective solution for supporting providers in delivering high quality care is in the form of provider support, especially through programs that involve data analytics, followed by one on one academic detailing. PBMs are in a unique position, having the ability to assist providers in working with patients on complex behavioral health or opioid regimens. PBMs have access to data that allows for identifying outlier member and provider behavior and finding patients who are at risk for adverse outcomes. While PBMs don’t have access to prescription drug monitoring programs, they can see what prescriptions are filled, where there is overlap, and where there are multiple providers interacting with a patient.

Magellan Rx developed the Live Vibrantly: Whole Health program to address those outlier providers and members, with the goal of achieving higher quality care. This program uses evidence-based algorithms to find members who may be at risk for adverse outcomes, and targets prescribers who may be over-prescribing. We become the provider’s go-to source for translating the evidence to the bedside through assistance with difficult issues, such as withdrawing an individual from high dose opioids. Through taking an approach to support providers in delivering high quality care, we’ve been able to truly partner in leading our members to leading more healthy vibrant lives.

With the number of opioid-related overdose deaths in the U.S. reaching a record high last year, it’s time for our nation to fully embrace evidence-based treatment options that best support our communities, loved ones, friends and families in their recovery efforts.

One growing approach—often considered as the gold standard of treatment—is medication-assisted treatment (MAT). MAT is the use of FDA-approved medications in combination with counseling and behavioral therapies to provide a holistic, person-centered approach to the treatment of substance use disorders (SUDs). The use of this treatment approach has grown to nearly 40 percent in residential facilities and is increasingly leveraged by primary care providers nationwide—but more still must be done for widespread adoption.

The most pervasive stigma surrounding MAT is that it merely enables patients to replace one addiction with another. It’s a belief held not only by some groups of doctors and clinicians, but also family members and peer support groups—those whose support is critical to successful recovery. When a patient’s core support system of family members and peers doubts the legitimacy of an evidence-based form of treatment, the likelihood that the patient will follow through long-term is diminished.

Pair that with a lack of understanding and comfort from the medical community around how to administer MAT, limited numbers of physicians who are certified to prescribe this treatment that actually do prescribe the treatment, as well as the number of residential facilities that offer MAT, and we get low adoption rates as a result of these barriers.

There’s a better way to treat opioid use disorder

Although abstinence-based therapy works for a small percentage of those suffering from OUD, MAT offers a successful way for people to fight their addictions in an outpatient environment, in the community in which they live, and avoid hospitalization or institutionalization. It helps those struggling with OUD and other SUDs address underlying conditions that may have contributed to substance abuse—significantly improving the chances of recovery. In one study, more than half of patients utilizing MAT reported opioid abstinence 18 months after beginning treatment.

Today, while 900,000 U.S. physicians prescribe opioids, fewer than 35,000 physicians are certified to prescribe buprenorphine, one of three medications approved to treat opioid addiction. And even fewer actually prescribe buprenorphine to patients. MAT prescribing is not limited to psychiatrists. In fact, primary care providers provide more access to MAT than any other type of provider.

The impact of limited access to MAT on health outcomes cannot be overlooked. One analysis found only one-third of individuals who experienced a nonfatal opioid overdose received access to MAT. Those who received methadone were linked to a 59 percent decrease in mortality rates after one year, according to the analysis. Additionally, individuals who were treated with buprenorphine were associated with a 38 percent decrease in mortality after a year.

Increasing Access to MAT

The SUPPORT for Patients and Communities Act, signed in October 2018, expands the ability to prescribe MAT by increasing clinician eligibility for certification. This provision is a solid and necessary step toward broadening access to treatment; however to make a true impact on the opioid epidemic, we must break the stigma surrounding MAT.

When it comes to recovery, the potential for relapse is high, especially in the early stages when resolve is fragile. It is important to note that for individuals with co-occurring mental health conditions, chronic pain or other addictions, MAT should be supplemented by treatment for those conditions, such as cognitive behavioral therapy. Building in care management support to assist in navigating the treatment process may reduce the possibility of relapse and/or readmission to a substance abuse inpatient or residential rehabilitation program. It also helps provide individuals with the tools needed to live addiction-free.

By taking the time to dispel the myths about non-traditional addiction treatment like MAT, we create an environment that more fully supports a return to complete health—physical, mental and emotional. Fighting the stigmas around MAT is an important step toward enabling those suffering from OUD to recover from their addiction and live healthy, vibrant lives.

The following is an excerpt from an article appearing in the American Journal of Managed Care (AJMC)

One out of four patients who receive long-term opioid therapy in primary care settings struggle with opioid use disorder (OUD), according to Centers for Disease Control and Prevention research. While conversations around opioid addiction are beginning to impact physician prescribing patterns, there is still much progress to be made around treatment and recovery solutions for those battling OUD.

One important option that requires greater attention: the need to leverage an integrated team approach in opioid treatment and recovery.

Recent research points to the value of a holistic approach to opioid recovery delivered in a community setting. Such an approach may include relapse prevention medications; group and individual counseling; physician visits for medication management; mental health therapy; and psychiatric treatment for cooccurring disorders. But there are barriers to accessing holistic opioid recovery treatment within the patient’s community. Such barriers can include lack of mental health resources, stigmas associated with certain treatment options, limited availability of specialized providers, difficulties navigating the complexities of substance abuse treatment, and insufficient capacity.

Overcoming the challenges to a holistic approach to opioid recovery is critical to engaging patients safely and comfortably and supporting sustained recovery. The following five elements contribute to a successful integrated approach.

You can read the rest of the article in the American Journal of Managed Care (AJMC).