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Moore M, Mongomery SR, Perez J, Savage-Elliott I, Sundaram V, Kaplan D, Youm T. Worker's compensation and no-fault insurance are associated with decreased patient reported outcomes and higher rates of revision at 2 and 5 years follow-up compared to patients with commercial insurance undergoing hip arthroscopy for femoroacetabular impingement. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05367-6. [PMID: 38940985 DOI: 10.1007/s00402-024-05367-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/05/2024] [Indexed: 06/29/2024]
Abstract
PURPOSE To investigate the patient reported outcomes (PROs) of patients undergoing hip arthroscopy (HA) for femeroacetabular impingement syndrome (FAIS), a condition where irregular bone growth in the hip joint leads to friction and pain during movement, who have worker's compensation (WC) or no-fault insurance (NF) versus commercial insurance (CI) at both 2 year and 5 year follow-up. METHODS This was a single center, single surgeon, retrospective analysis performed between August 2007 and May 2023 of consecutive patients that underwent HA, a minimally invasive surgical procedure used to diagnose and treat problems inside the hip joint through small incisions, for FAIS. Patients were divided into two cohorts-those with WC/NF and those with commercial insurance (CI). Patient reported outcomes (PROs), which included modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS), were collected preoperatively, as well as at least 2-year postoperatively. Additionally, other clinically relevant outcomes variables including prevalence of revision surgery and conversion to total hip arthroplasty were recorded. RESULTS Three hundred and forty three patients met inclusion criteria. There were 32 patients in the WC/NF cohort and 311 patients in the commercial cohort. When controlling for age, sex, and Body Mass Index (BMI), WC/NF status was associated with lower mHHS at both 2 year (β = - 8.190, p < 0.01, R2 = 0.092) and 5 year follow-up (β = - 16.60, p < 0.01, R2 = 0.179) and NAHS at 5 year follow up (β = - 13.462, p = 0.03, R2 = 0.148). The WC/NF cohort had a lower rate of achieving Substantial Clinical Benefit (SCB) for mHHS at 2-years follow-up (66.7% vs. 84.1%, p = 0.02).The rate of revision hip arthroscopy was significantly higher in the worker's compensation/no fault cohort than the commercial insurance cohort (15.6% vs. 3.5%, p < 0.01). The rate of conversion to total hip arthroplasty (THA) in the WC/NF cohort was not significantly different than the rate of conversion to THA in the commercial insurance cohort (0.0% vs. 3.2%, p = 0.30). CONCLUSION Patients with WC/NF insurance may expect a significant improvement from baseline mHHS and NAHS following HA for FAIS at short-term follow-up. However, this improvement may not be as durable as those experienced by patients with CI. Additionally, WC/NF patients should be counseled that they have a higher risk of undergoing revision hip arthroscopy than similar CI patients. LEVEL OF EVIDENCE III, Retrospective Comparative Prognostic Investigation.
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Affiliation(s)
- Michael Moore
- NYU Langone Orthopedics, 334 East 26th Street, New York, NY, 10003, USA.
| | | | - Jose Perez
- NYU Langone Orthopedics, 334 East 26th Street, New York, NY, 10003, USA
| | | | - Vishal Sundaram
- NYU Langone Orthopedics, 334 East 26th Street, New York, NY, 10003, USA
| | - Daniel Kaplan
- NYU Langone Orthopedics, 334 East 26th Street, New York, NY, 10003, USA
| | - Thomas Youm
- NYU Langone Orthopedics, 334 East 26th Street, New York, NY, 10003, USA
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McIntyre A, Sommers BD, Aboulafia G, Phelan J, Orav EJ, Epstein AM, Figueroa JF. Coverage and Access Changes During Medicaid Unwinding. JAMA HEALTH FORUM 2024; 5:e242193. [PMID: 38943683 PMCID: PMC11214671 DOI: 10.1001/jamahealthforum.2024.2193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 06/03/2024] [Indexed: 07/01/2024] Open
Abstract
Importance States resumed Medicaid eligibility redeterminations, which had been paused during the COVID-19 public health emergency, in 2023. This unwinding of the pandemic continuous coverage provision raised concerns about the extent to which beneficiaries would lose Medicaid coverage and how that would affect access to care. Objective To assess early changes in insurance and access to care during Medicaid unwinding among individuals with low incomes in 4 Southern states. Design, Setting, and Participants This multimodal survey was conducted in Arkansas, Kentucky, Louisiana, and Texas from September to November 2023, used random-digit dialing and probabilistic address-based sampling, and included US citizens aged 19 to 64 years reporting 2022 incomes at or less than 138% of the federal poverty level. Exposure Medicaid enrollment at any point since March 2020, when continuous coverage began. Main Outcomes and Measures Self-reported disenrollment from Medicaid, insurance at the time of interview, and self-reported access to care. Using multivariate logistic regression, factors associated with Medicaid loss were evaluated. Access and affordability of care among respondents who exited Medicaid vs those who remained enrolled were compared, after multivariate adjustment. Results The sample contained 2210 adults (1282 women [58.0%]; 505 Black non-Hispanic individuals [22.9%], 393 Hispanic individuals [17.8%], and 1133 White non-Hispanic individuals [51.3%]) with 2022 household incomes less than 138% of the federal poverty line. On a survey-weighted basis, 1564 (70.8%) reported that they and/or a dependent child of theirs had Medicaid at some point since March 2020. Among adult respondents who had Medicaid, 179 (12.5%) were no longer enrolled in Medicaid at the time of the survey, with state estimates ranging from 7.0% (n = 19) in Kentucky to 16.2% (n = 82) in Arkansas. Fewer children who had Medicaid lost coverage (42 [5.4%]). Among adult respondents who left Medicaid since 2020 and reported coverage status at time of interview, 47.8% (n = 80) were uninsured, 27.0% (n = 45) had employer-sponsored insurance, and the remainder had other coverage as of fall 2023. Disenrollment was higher among younger adults, employed individuals, and rural residents but lower among non-Hispanic Black respondents (compared with non-Hispanic White respondents) and among those receiving Supplemental Nutrition Assistance Program benefits. Losing Medicaid was significantly associated with delaying care due to cost and worsening affordability of care. Conclusions and Relevance The results of this survey study indicated that 6 months into unwinding, 1 in 8 Medicaid beneficiaries reported exiting the program, with wide state variation. Roughly half who lost Medicaid coverage became uninsured. Among those moving to new coverage, many experienced coverage gaps. Adults exiting Medicaid reported more challenges accessing care than respondents who remained enrolled.
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Affiliation(s)
- Adrianna McIntyre
- Harvard University T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, Massachusetts
| | - Benjamin D. Sommers
- Harvard University T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Gabriella Aboulafia
- Harvard University T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, Massachusetts
| | - Jessica Phelan
- Harvard University T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, Massachusetts
| | - E. John Orav
- Harvard University T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Department of Medicine, Boston, Massachusetts
| | - Arnold M. Epstein
- Harvard University T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Department of Medicine, Boston, Massachusetts
| | - Jose F. Figueroa
- Harvard University T.H. Chan School of Public Health, Department of Health Policy and Management, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women’s Hospital, Department of Medicine, Boston, Massachusetts
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Kopczynski K, Casamassimo P, Amini H, Peng J, Gorham T, Meyer BD. Evaluating the type of pediatric dental care use in the context of neighborhood opportunity. J Am Dent Assoc 2024; 155:294-303.e4. [PMID: 38340112 DOI: 10.1016/j.adaj.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/26/2023] [Accepted: 11/16/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND Increasing evidence supports the influence of neighborhood factors on health care use and outcomes. This study measured the association between area-level social determinants of health (SDH) and type of dental care use among Ohio pediatric Medicaid beneficiaries. METHODS A retrospective dental claims analysis was completed for children aged 1 through 5 years enrolled in Ohio Medicaid with a dental visit in 2017. Dental care use was measured from 2017 through 2021 as 1 of 4 visit types: (1) preventive, (2) caries treatment, (3) dental general anesthesia (GA), and (4) dental emergency department. The Ohio Children's Opportunity Index defined area-level SDH at the census tract level. Exploratory analysis included descriptive statistics of area-level SDH for each outcome. Poisson regression models were developed to examine the associations between the number of each dental care use outcome and Ohio Children's Opportunity Index quintiles. Visualizations were facilitated with geospatial mapping. RESULTS Fifty-six percent of children (10,008/17,675) had caries treatment visits. Overall area-level SDH were positively associated with preventive (fifth vs first quintile incidence rate ratio [IRR], 1.09; 95% CI, 1.07 to 1.12), caries treatment (fifth vs first quintile IRR, 1.16; 95% CI, 1.08 to 1.24), and dental GA visits (fifth vs first quintile IRR, 2.13; 95% CI, 1.13 to 4.01). CONCLUSIONS Children with preventive, caries treatment, and dental GA visits were more likely to live in neighborhoods with better SDH. Future efforts should investigate the mechanisms by which area-level factors influence dental access and use. PRACTICAL IMPLICATIONS Neighborhood factors influence pediatric dental care use. Patient home addresses might add value to caries risk assessment tools and efforts by care networks to optimize efficient care use.
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Meng YY, Yue D, Molitor J, Chen X, Su JG, Jerrett M. Reductions in NO 2 and emergency room visits associated with California's goods movement policies: A quasi-experimental study. ENVIRONMENTAL RESEARCH 2022; 213:113600. [PMID: 35660569 DOI: 10.1016/j.envres.2022.113600] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/07/2022] [Accepted: 05/30/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION This study examines whether the "Emission Reduction Plan for Ports and Goods Movement" in California reduced air pollution exposures and emergency room visits among California Medicaid enrollees with asthma and/or chronic obstructive pulmonary disease. METHOD We created a retrospective cohort of 5608 Medicaid enrollees from ten counties in California with data from 2004 to 2010. We grouped the patients into two groups: those living within 500 m of goods movement corridors (ports and truck-permitted freeways), and control areas (away from the busy truck or car permitted highways). We created annual air pollution surfaces for nitrogen dioxide and assigned them to enrollees' home addresses. We used a quasi-experimental design with a difference-in-differences method to examine changes before and after the policy for cohort beneficiaries in the two groups. RESULTS The reductions in nitrogen dioxide exposures and emergency room visits were greater for enrollees in goods movement corridors than those in control areas in post-policy years. We found that the goods movement actions were associated with 14.8% (95% CI, -24.0% to -4.4%; P = 0.006) and 11.8% (95% CI, -21.2% to -1.2%; P = 0.030) greater reduction in emergency room visits for the beneficiaries with asthma and chronic obstructive pulmonary disease, respectively, in the third year after California's emission reduction plan. CONCLUSION These findings indicate remarkable health benefits via reduced emergency room visits from the significantly improved air quality due to public policy interventions for disadvantaged and susceptible populations.
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Affiliation(s)
- Ying-Ying Meng
- UCLA Center for Health Policy Research, University of California at Los Angeles, 10960 Wilshire Boulevard, Suite 1550, Los Angeles, CA, 90024, USA.
| | - Dahai Yue
- Department of Health Policy and Management, University of Maryland, 4200 Valley Dr, College Park, MD, 20742, USA.
| | - John Molitor
- College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
| | - Xiao Chen
- UCLA Center for Health Policy Research, University of California at Los Angeles, 10960 Wilshire Boulevard, Suite 1550, Los Angeles, CA, 90024, USA
| | - Jason G Su
- School of Public Health, University of California, Berkeley, CA, United States
| | - Michael Jerrett
- Department of Environmental Health Science, University of California at Los Angeles, Los Angeles, CA, USA
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Fung V, Yang Z, Cook BL, Hsu J, Newhouse JP. Changes in Insurance Coverage Continuity After Affordable Care Act Expansion of Medicaid Eligibility for Young Adults With Low Income in Massachusetts. JAMA HEALTH FORUM 2022; 3:e221996. [PMID: 35977216 PMCID: PMC9287752 DOI: 10.1001/jamahealthforum.2022.1996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/17/2022] [Indexed: 11/14/2022] Open
Abstract
Question Did Medicaid expansion in Massachusetts change coverage continuity for child Medicaid enrollees entering young adulthood? Findings In this cohort study of 41 247 young adults, Medicaid enrollees who turned 19 after vs before Medicaid expansion were significantly less likely to have 3 or more months without insurance coverage at ages 18 to 19 and 19 to 20 years and more likely to have continuous Medicaid coverage for 24 or more months. Meaning Federal and state Medicaid expansions were associated with reductions in insurance disruptions and coverage gaps among child Medicaid enrollees entering young adulthood. Importance Young adults historically have had the highest uninsured rates among all age groups. In 2014, in addition to Medicaid expansion for adults with low income (≤133% of the federal poverty level [FPL]) through the Patient Protection and Affordable Care Act, Massachusetts also extended eligibility for children (≤150% FPL) to beneficiaries aged 19 to 20 years. Objective To examine changes in insurance coverage continuity for Medicaid enrollees who turned age 19 years before and after eligibility policy changes. Design, Setting, and Participants This cohort study used data from the Massachusetts All-Payer Claims Database (2012 to 2016) to compare coverage for Medicaid beneficiaries turning age 19 years before and after Medicaid expansion. Monthly coverage was examined for each cohort for 3 years as beneficiaries aged from 18 and 19 years to 19 and 20 years to 20 and 21 years. Analyses were performed between November 1, 2020, and May 12, 2022. Main Outcomes and Measures In each year, the likelihood of being uninsured or having Medicaid, employer-sponsored insurance, or individual commercial coverage for 3 or more months was examined along with the likelihood of having continuous Medicaid enrollment for 12 or more and 24 or more months. Multivariable linear probability models were used to compare the likelihood of these outcomes for those in the postexpansion vs preexpansion cohorts, adjusting for sex, comorbidity levels, neighborhood socioeconomic status, and neighborhood race and ethnicity. Results A total of 41 247 young adults turning age 18 to 19 years in the baseline year (20 876 [50.6%] men) were included in the study, with 20 777 in the preexpansion cohort and 20 470 in the postexpansion cohort. Enrollees who turned age 19 years after vs before the Medicaid eligibility expansion were less likely to have 3 or more uninsured months at ages 18 to 19 years (4.4% [n = 891] vs 22.9% [n = 4750]; adjusted difference, −18.4 [95% CI, −19.0 to −17.7] percentage points) and 19 to 20 years (13.2% [n = 2702] vs 35.8% [n = 7447]; adjusted difference, −22.4 [95% CI, −23.2 to −21.6] percentage points) and more likely to have continuous insurance coverage for 12 or more months (94.1% [n = 19 272] vs 63.7% [n = 13 234]; adjusted difference, 30.5 [95% CI, 29.7-31.2] percentage points) or 24 or more months (77.5% [n = 15 868] vs 44.4% [n = 9221]; adjusted difference, 33.0 [95% CI, 32.1-33.9] percentage points). Differences in the likelihood of having 3 or more uninsured months diminished at ages 20 to 21 years, when both groups had access to Medicaid (ie, in calendar years 2014 for the preexpansion cohort and 2016 for the postexpansion cohort). Conclusions and Relevance In this cohort study of young adults in Massachusetts, the combination of expanding Medicaid to lower-income adults and increasing the age threshold for child Medicaid eligibility was associated with reduced likelihood of becoming uninsured among Medicaid enrollees entering adulthood.
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Affiliation(s)
- Vicki Fung
- Mongan Institute, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Zhiyou Yang
- Mongan Institute, Massachusetts General Hospital, Boston
| | - Benjamin L. Cook
- Health Equity Research Lab, Cambridge Health Alliance, Cambridge, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - John Hsu
- Mongan Institute, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Joseph P. Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Kennedy School, Cambridge, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
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Abstract
Objectives To identify ICD-10-CM diagnostic codes associated with the social determinants of health (SDOH), determine frequency of use of the code for homelessness across time, and examine the frequency of interrupted periods of Medicaid eligibility (ie, Medicaid churn) for beneficiaries with and without this code. Design Retrospective data analyses of New York State (NYS) Medicaid claims data for years 2006-2017 to determine reliable indicators of SDOH hypothesized to affect Medicaid churn, and for years 2016-2017 to examine frequency of Medicaid churn among patients with and without an indicator for homelessness. Main Outcome Measures Any interruption in the eligibility for Medicaid insurance (Medicaid churn), assessed via client identification numbers (CIN) for continuity. Methods Analyses were conducted to assess the frequency of use and pattern of New York State Medicaid claims submission for SDOH codes. Analyses were conducted for Medicaid claims submitted for years 2016-2017 for Medicaid patients with and without a homeless code (ie, ICD-10-CM Z59.0) in 2017. Results ICD-9-CM / ICD-10-CM codes for lack of housing / homelessness demonstrated linear reliability over time (ie, for years 2006-2017) with increased usage. In 2016-2017, 22.9% of New York Medicaid patients with a homelessness code in 2017 experienced at least one interruption of Medicaid eligibility, while 18.8% of Medicaid patients without a homelessness code experienced Medicaid churn. Conclusions Medicaid policies would do well to take into consideration the barriers to continued enrollment for the Medicaid population. Measures ought to be enacted to reduce Medicaid churn, especially for individuals experiencing homelessness.
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Affiliation(s)
- Isaac Dapkins
- Family Health Centers at NYU Langone, Brooklyn, NY.,Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - Saul B Blecker
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
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Winestone LE, Hochman LL, Sharpe JE, Alvarez E, Becker L, Chow EJ, Reiter JG, Ginsberg JP, Silber JH. Impact of Dependent Coverage Provision of the Affordable Care Act on Insurance Continuity for Adolescents and Young Adults With Cancer. JCO Oncol Pract 2020; 17:e882-e890. [PMID: 33090897 DOI: 10.1200/op.20.00330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE The 2010 Dependent Coverage Provision (DCP) of the Affordable Care Act (ACA) allowed enrollees to remain on their parents' health insurance until 26 years of age. We compared rates of insurance disenrollment among patients with cancer who were DCP-eligible at age 19 to those who were not eligible at age 19. METHODS Using OptumLabs Data Warehouse, which contains longitudinal, real-world, de-identified administrative claims for commercial enrollees, we examined patients born between 1982 and 1993 and diagnosed with cancer between 2000 and 2015. In the recent cohort, patients who turned 19 in 2010-2012 (DCP-eligible to stay on parents' insurance) were matched to patients who turned 19 in 2007-2009 (not DCP-eligible when turning 19). In an earlier control cohort, patients who turned 19 between 2004 and 2006 (not DCP-eligible) were matched to patients who turned 19 between 2001 and 2003 (not DCP-eligible). Patients were matched on cancer type, diagnosis date, demographics, and treatment characteristics. The time to loss of coverage was estimated using Cox models. Difference-in-difference between the recent and earlier cohorts was also evaluated. RESULTS A total of 2,829 patients who turned 19 years of age in 2010-2012 were matched to patients who turned 19 in 2007-2009. Median time to disenrollment was 26 months for younger patients versus 22 months for older patients (hazard ratio [HR], 0.85; 95% CI, 0.80 to 0.90; P = .001). In 8,978 patients who turned 19 between 2001 and 2006, median time to disenrollment was 20 months among both younger and older patients (HR, 0.99; 95% CI, 0.94 to 1.03; P = .59). The difference between the recent cohort and the earlier control cohort was a 15% greater reduction in coverage loss (P < .0001), favoring those turning 19 after the DCP went into effect. CONCLUSION In the vulnerable population of adolescent and young adult cancer survivors, the ACA may have lowered the insurance dropout rate.
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Affiliation(s)
- Lena E Winestone
- Division of Allergy, Immunology, and Blood & Marrow Transplant, Department of Pediatrics, University of California San Francisco (UCSF) Benioff Children's Hospital; and UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | - Lauren L Hochman
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - James E Sharpe
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Elysia Alvarez
- Department of Pediatrics, University of California Davis, Sacramento, CA
| | | | - Eric J Chow
- Department of Pediatrics, University of Washington, Seattle Children's Hospital; and Fred Hutchinson Cancer Research Institute, Seattle, WA
| | - Joseph G Reiter
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jill P Ginsberg
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine; and Division of Pediatric Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA.,Cancer Survivorship Program, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jeffrey H Silber
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine; and Division of Pediatric Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Health Care Management, The Wharton School; and Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA
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Burns ME, Dague L, Saloner B, Voskuil K, Kim NH, Serna Borrero N, Look K. Implementing parity for mental health and substance use treatment in Medicaid. Health Serv Res 2020; 55:604-614. [PMID: 32578233 DOI: 10.1111/1475-6773.13309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To estimate the association between the implementation of parity in coverage for mental health and substance use disorder (MHSUD) services within the Medicaid program and MHSUD service use. DATA SOURCES/STUDY SETTING Wisconsin Medicaid enrollment and claims data from 2013 to 2015. In April 2014, Wisconsin Medicaid transitioned childless adult beneficiaries from coverage with limited MHSUD services to parity-consistent coverage. Preparity, they only had Medicaid coverage for MHSUD visits to psychiatrists and the emergency department, while parent beneficiaries had parity-consistent coverage. STUDY DESIGN The study uses a difference-in-differences design to compare outcome changes for childless adult and parent beneficiaries. DATA COLLECTION/EXTRACTION METHODS We identified 76, 569 childless adult and parent beneficiaries aged 18-64 who were continuously enrolled for the 2-year study period. PRINCIPAL FINDINGS Introducing parity-consistent coverage within Medicaid was associated with increased utilization of Medicaid-reimbursed MHSUD services: outpatient, prescription medication, ED, and inpatient. Increased MHSUD outpatient visits were driven by increased visits to nonpsychiatrists. CONCLUSIONS Parity's effects on MHSUD service use have been studied in the context of private insurance, but its impact among Medicaid beneficiaries has not. Our findings suggest that parity implementation in Medicaid could increase access to effective MHSUD services in a high-need population.
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Affiliation(s)
- Marguerite E Burns
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Laura Dague
- Texas A&M University, College Station, Texas
| | - Brendan Saloner
- Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kristen Voskuil
- Institute for Research on Poverty, University of Wisconsin-Madison, Madison, Wisconsin
| | - Nam Hyo Kim
- School of Pharmacy, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Kevin Look
- Social & Administrative Sciences, School of Pharmacy, University of Wisconsin-Madison, Madison, Wisconsin
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Where Do Oregon Medicaid Enrollees Seek Outpatient Care Post-affordable Care Act Medicaid Expansion? Med Care 2020; 57:788-794. [PMID: 31513138 DOI: 10.1097/mlr.0000000000001189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous studies suggest the newly Medicaid insured are more likely to use the emergency department (ED) however they did not differentiate between patients established or not established with primary care. OBJECTIVES To understand where Oregon Medicaid beneficiaries sought care after the Patient Protection and Affordable Care Act (PPACA) Medicaid expansion (ED, primary care, or specialist) and the interaction between primary care establishment and outpatient care utilization. RESEARCH DESIGN A retrospective cohort study. SUBJECTS Adults continuously insured from 2014 through 2015 who were either newly, returning, or continuously insured post-PPACA. MEASURES Site of first and last outpatient visit, established with primary care status, and outpatient care utilization. RESULTS The odds of being established with primary care at their first visit were lower among newly [odds ratio (OR), 0.18; 95% confidence interval (CI), 0.18-0.19] and returning insured (OR, 0.22; 95% CI, 0.22-0.23) than the continuously insured. Continuously insured, new patients with primary care had higher odds of visiting the ED (OR, 2.15; 95% CI, 2.01-2.30) at their first visit than newly or returning insured. Patients established with a single primary care provider in all insurance groups had lower rates of ED visit, whereas those established with multiple primary care providers had the highest ED visit rates. CONCLUSIONS Most newly and returning insured Medicaid enrollees sought primary care rather than ED services and most became established with primary care. Our findings suggest that both insurance and primary care continuity play a role in where patients seek health care services.
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Keohane LM, Trivedi A, Mor V. States With Medically Needy Pathways: Differences in Long-Term and Temporary Medicaid Entry for Low-Income Medicare Beneficiaries. Med Care Res Rev 2019; 76:711-735. [PMID: 29073847 PMCID: PMC5878973 DOI: 10.1177/1077558717737152] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Medically needy pathways may provide temporary catastrophic coverage for low-income Medicare beneficiaries who do not otherwise qualify for full Medicaid benefits. Between January 2009 and June 2010, states with medically needy pathways had a higher percentage of low-income beneficiaries join Medicaid than states without such programs (7.5% vs. 4.1%, p < .01). However, among new full Medicaid participants, living in a state with a medically needy pathway was associated with a 3.8 percentage point (adjusted 95% confidence interval [1.8, 5.8]) increase in the probability of switching to partial Medicaid and a 4.5 percentage point (adjusted 95% confidence interval [2.9, 6.2]) increase in the probability of exiting Medicaid within 12 months. The predicted risk of leaving Medicaid was greatest when new Medicaid participants used only hospital services, rather than nursing home services, in their first month of Medicaid benefits. Alternative strategies for protecting low-income Medicare beneficiaries' access to care could provide more stable coverage.
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Affiliation(s)
| | - Amal Trivedi
- Brown University, Providence, RI, USA
- Providence VA Medical Center, Providence, RI, USA
| | - Vincent Mor
- Brown University, Providence, RI, USA
- Providence VA Medical Center, Providence, RI, USA
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Heflin C, Hodges L, Ojinnaka C. Administrative Churn in SNAP and Health Care Utilization Patterns. Med Care 2019; 58:33-37. [PMID: 31688555 DOI: 10.1097/mlr.0000000000001235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Administrative churn occurs when a household exits the Supplemental Nutrition Assistance Program (SNAP) and then returns to the program within 4 months. Although a number of studies have examined health care utilization patterns related to Medicaid administrative churn less is known about health care utilization patterns among Medicaid-insured SNAP enrollees. OBJECTIVES To investigate the characteristics and health care utilization patterns of Medicaid insured SNAP participants who experience SNAP administrative churn. RESEARCH DESIGN Retrospective cohort study using 2010-2013 SNAP benefit data from the state of Missouri linked to Medicaid claims data for the same time period. Individual fixed effect regression analysis was used to investigate differences in health care claims for churners and nonchurners across various health care settings. SUBJECTS Missouri residents ages 18-64 who were Medicaid-insured SNAP enrollees. MEASURES Inpatient, outpatient, emergency department (ED), and pharmacy claims, and churn status. RESULTS Half of our sample (49.63%) experienced administrative churn. In the descriptive analyses, churners had fewer claims for prescription drugs than nonchurners (25.42% vs. 30.47%), but more claims for ED visits (3.79% vs. 2.74%). Adjusting for individual fixed characteristics, inpatient claims occurred with more frequency during periods of churn than while on SNAP, whereas ED, outpatient, and pharmacy claims occurred with less frequency during periods of churn than while on SNAP. CONCLUSIONS SNAP administrative churn was very common among our study sample. Given that health care utilization patterns varied for churners compared with nonchurners, it is important that researchers and public health professionals not assume stable SNAP receipt among participants.
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Affiliation(s)
- Colleen Heflin
- Maxwell School of Public Affairs and Citizenship, Syracuse University, Syracuse, NY
| | - Leslie Hodges
- Institute for Research on Poverty, University of Wisconsin, Madison, WI
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Wolf RA, Haw JS, Paul S, Spezia Faulkner M, Cha E, Findley MK, Khan F, Markley Webster S, Alexopoulos AS, Mehta K, Alfa DA, Ali MK. Hospital admissions for hyperglycemic emergencies in young adults at an inner-city hospital. Diabetes Res Clin Pract 2019; 157:107869. [PMID: 31560962 PMCID: PMC6914263 DOI: 10.1016/j.diabres.2019.107869] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/18/2019] [Accepted: 09/23/2019] [Indexed: 12/16/2022]
Abstract
AIMS There is limited information characterizing young adults (18-35 years) (YA) with diabetes, especially those admitted for hyperglycemic emergencies. The study aims were to examine associations of patient-level characteristics with hyperglycemic emergency hospitalization and to identify variations based on diabetes type and glycemic control. METHODS We conducted retrospective analysis of 273 YA admitted to an inner-city hospital with diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic nonketotic syndrome (HHS). T-tests, Chi-Square tests, and ANOVA identified differences in demographics, diabetes history, clinical indicators, complications/comorbidities, and hospital admission stratified separately by diabetes type (1 vs 2) and admission HbA1c < 9% (75 mmol/mol), ≥9% to 12% (108 mmol/mol), ≥12%). RESULTS Mean admission HbA1c was 12.4% (112 mmol/ml). HbA1c was ≥9.0% for 90.5%. The main DKA/HHS trigger was medication nonadherence (57.9%), with 35.6% presenting with new-onset type 2 diabetes. Only 3.7% utilized outpatient diabetes clinics, 38.8% were re-hospitalized within the year, and 69% lacked insurance. Diabetes complications (44.7%) and psychiatric co-morbidities (35.5%) were common. Significantly more YA with type 1 diabetes had insurance, whereas YA with type 2 diabetes had higher admission HbA1c. YA with HbA1c ≥12% were more likely to be Black and lack insurance. CONCLUSIONS YA hospitalized for DKA/HHS in an inner-city hospital tended to have severely uncontrolled diabetes. Many already had comorbidities and diabetes complications, high use of acute care services and low use of diabetes specialty services. YA characteristics varied by diabetes type and HbA1c. Overall, a substantial percentage lacked insurance, potentially impacting healthcare utilization patterns and medication adherence, and leading to DKA/HHS admissions.
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Affiliation(s)
- Rachel A Wolf
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States.
| | - J Sonya Haw
- School of Medicine, Emory University, Atlanta, GA, United States
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States
| | - Melissa Spezia Faulkner
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States; School of Nursing, Georgia State University, Atlanta, GA, United States
| | - EunSeok Cha
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States; Chungnam National University, College of Nursing, Daejeon, South Korea
| | - M K Findley
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States
| | - Farah Khan
- School of Medicine, Emory University, Atlanta, GA, United States; Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, United States
| | | | | | - Komal Mehta
- School of Medicine, Emory University, Atlanta, GA, United States
| | - David A Alfa
- School of Medicine, Emory University, Atlanta, GA, United States
| | - Mohammed K Ali
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States; Rollins School of Public Health, Emory University, Atlanta, GA, United States
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Rogers MAM, Lee JM, Tipirneni R, Banerjee T, Kim C. Interruptions In Private Health Insurance And Outcomes In Adults With Type 1 Diabetes: A Longitudinal Study. Health Aff (Millwood) 2019; 37:1024-1032. [PMID: 29985705 DOI: 10.1377/hlthaff.2018.0204] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Type 1 diabetes mellitus, which often originates during childhood, is a lifelong disease that requires intensive daily medical management. Because health care services are critical to patients with this disease, we investigated the frequency of interruptions in private health insurance, and the outcomes associated with them, for working-age adults with type 1 diabetes in the United States in the period 2001-15. We designed a longitudinal study with a nested self-controlled case series, using the Clinformatics Data Mart Database. The study sample consisted of 168,612 adults ages 19-64 with type 1 diabetes who had 2.6 mean years of insurance coverage overall. Of these adults, 24.3 percent experienced an interruption in coverage. For each interruption, there was a 3.6 percent relative increase in glycated hemoglobin. The use of acute care services was fivefold greater after an interruption in health insurance compared to before the interruption and remained elevated when stratified by age, sex, or diabetic complications. An interruption was associated with lower perceived health status and lower satisfaction with life. We conclude that interruptions in private health insurance are common among adults with type 1 diabetes and have serious consequences for their well-being.
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Affiliation(s)
- Mary A M Rogers
- Mary A. M. Rogers ( ) is a research associate professor of internal medicine at the University of Michigan, in Ann Arbor
| | - Joyce M Lee
- Joyce M. Lee is a professor of pediatrics and communicable diseases at the University of Michigan
| | - Renuka Tipirneni
- Renuka Tipirneni is a clinical lecturer in internal medicine at the University of Michigan
| | - Tanima Banerjee
- Tanima Banerjee is a statistician senior at the Institute of Healthcare Policy and Innovation, University of Michigan
| | - Catherine Kim
- Catherine Kim is an associate professor of internal medicine at the University of Michigan
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Ferdinand AO, Akinlotan MA, Callaghan T, Towne SD, Bolin J. Diabetes-related hospital mortality in the U.S.: A pooled cross-sectional study of the National Inpatient Sample. J Diabetes Complications 2019; 33:350-355. [PMID: 30910276 DOI: 10.1016/j.jdiacomp.2019.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/29/2019] [Accepted: 01/31/2019] [Indexed: 01/22/2023]
Abstract
AIMS Despite advancements in the diagnosis and treatment of diabetes in the U.S., place-based disparities still exist. The purpose of this study is to determine place-based and other individual-level variations in diabetes-related hospital deaths. METHODS A pooled cross-sectional study of the 2009-2015 National Inpatient Sample was conducted to examine the odds of a diabetes-related hospital death. The main predictors were rurality and census region. Individual-level socio-demographic factors were also examined. RESULTS Approximately 1.5% (n = 147,069) of diabetes-related hospitalizations resulted in death. In multivariable analysis, the odds of diabetes-related hospital deaths increased across the urban-rural continuum, except for large fringe metropolitan areas, with the highest odds of such deaths occurring among residents of micropolitan (OR = 1.16, 95% C.I. = 1.14, 1.18) and noncore areas (OR = 1.21, 95% C.I. = 1.19, 1.24). Compared to residents of the Northeast, residents in the South, West and Midwest regions were significantly more likely to experience a diabetes-related hospital death. Asian or Pacific Islanders, Medicaid-covered patients and the uninsured were also more likely to die during a diabetes-related hospitalization. CONCLUSIONS Place-based disparities in diabetes-related hospital deaths exist. Targeted focus should be placed on the control of diabetic complications in the South, West and Midwest census regions, and among rural residents.
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Affiliation(s)
- Alva O Ferdinand
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, United States of America; Southwest Rural Health Research Center, School of Public Health, Texas A&M University, College Station, TX, United States of America.
| | - Marvellous A Akinlotan
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, United States of America; Southwest Rural Health Research Center, School of Public Health, Texas A&M University, College Station, TX, United States of America
| | - Timothy Callaghan
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, United States of America; Southwest Rural Health Research Center, School of Public Health, Texas A&M University, College Station, TX, United States of America
| | - Samuel D Towne
- Southwest Rural Health Research Center, School of Public Health, Texas A&M University, College Station, TX, United States of America; Department of Health Management and Informatics, University of Central Florida, Orlando, FL, United States of America; Disability, Aging, and Technology Cluster, University of Central Florida, Orlando, FL, United States of America
| | - Jane Bolin
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, United States of America; Southwest Rural Health Research Center, School of Public Health, Texas A&M University, College Station, TX, United States of America
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15
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Gordon SH, Lee Y, Ndumele CD, Vivier PM, Gutman R, Swaminathan S, Gadbois EA, Shield RR, Kind AJH, Trivedi AN. The Impact of Medicaid Managed Care Plan Type on Continuous Medicaid Enrollment: A Natural Experiment. Health Serv Res 2018; 53:3770-3789. [PMID: 29952062 DOI: 10.1111/1475-6773.13000] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess the impact of assignment to a Medicaid-focused versus mixed managed care plan on continuity of Medicaid coverage. DATA SOURCES 2011-2016 Medicaid claims from a Northeastern state. STUDY DESIGN Following the exit of a Medicaid managed care insurer, Medicaid administrators prioritized provider networks in reassigning enrollees, but randomly assigned beneficiaries whose providers were equally represented in the two plans. We leveraged the natural experiment created by random plan assignment and conducted an instrumental variable analysis. DATA COLLECTION We analyzed Medicaid claims for 12,083 beneficiaries who were members of the exiting Blue Cross Blue Shield plan prior to January 1, 2011. PRINCIPAL FINDINGS Managed care plan type did not significantly impact continuous enrollment in the Medicaid program. Greater outpatient utilization and the presence of a special need among children were associated with longer enrollment in Medicaid. CONCLUSIONS Managed care plans did not differ in their capacity to keep Medicaid beneficiaries continuously enrolled in coverage, despite differences in plan features.
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Affiliation(s)
- Sarah H Gordon
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Yoojin Lee
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI
| | | | - Patrick M Vivier
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI.,Hassenfeld Child Health Innovation Institute at Brown University, Providence, RI
| | - Roee Gutman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Shailender Swaminathan
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI.,Public Health Foundation of India, New Delhi, India
| | - Emily A Gadbois
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI
| | - Renee R Shield
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI
| | - Amy Jo Haavisto Kind
- Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, William S. Middleton VA Hospital-GRECC, Madison, WI
| | - Amal N Trivedi
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI.,Providence VA Medical Center, Providence, RI
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Discontinuity of Medicaid Coverage: Impact on Cost and Utilization Among Adult Medicaid Beneficiaries With Major Depression. Med Care 2017; 55:735-743. [PMID: 28700457 DOI: 10.1097/mlr.0000000000000751] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Gaps in Medicaid coverage may disrupt access to and continuity of care. This can be detrimental for beneficiaries with chronic conditions, such as major depression, for whom disruptions in access to outpatient care may lead to increased use of acute care. However, little is known about how Medicaid coverage discontinuities impact acute care utilization among adults with depression. OBJECTIVE Examine the relationship between Medicaid discontinuities and service utilization among adults with major depression. SUBJECTS A total of 139,164 adults (18-64) with major depression was identified using the 2003-2004 Medicaid Analytic eXtract Files. METHODS We used generalized linear and two-part models to examine the effect of Medicaid discontinuity on service utilization. To establish causality in this relationship, we used instrumental variables analysis, relying on exogenous variation in a state-level policy for identification. OUTCOME MEASURES Emergency department (ED) visits, inpatient episodes, inpatient days, and Medicaid-reimbursed costs. RESULTS Approximately 29.4% of beneficiaries experienced coverage disruptions. In instrumental variables models, those with coverage disruptions incurred an increase of $650 in acute care costs per-person per Medicaid-covered month compared with those with continuous coverage, evidenced by an increase in ED use (0.1 more ED visits per-person-month) and inpatient days (0.6 more days per-person-month). The increase in acute costs contributed to an overall increase in all-cause costs by $310 per-person-month (all P-values<0.001). CONCLUSIONS Among depressed adults, those experiencing coverage disruptions have, on average, significantly greater use of costly ED/inpatient services than those with continuous coverage. Maintenance of continuous Medicaid coverage may help prevent acute episodes requiring high-cost interventions.
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Hoffman DJ, Campos-Ponce M, Taddei CR, Doak CM. Microbiome, growth retardation and metabolism: are they related? Ann Hum Biol 2017; 44:201-207. [PMID: 27927018 DOI: 10.1080/03014460.2016.1267261] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
CONTEXT Despite an improvement in food security and the delivery of nutritional supplements to children living in impoverished parts of the world, poor growth is still highly prevalent. Given that the microbiome is related to both nutrient absorption, as well as overweight/obesity, it may play a central role in limiting or modifying normal growth processes while contributing to chronic disease risks. OBJECTIVE The objective of this paper is to describe normal growth processes, the role of the microbiome in supporting or disrupting normal growth processes, and its potential impact on long-term health. METHODS A literature search of relevant human and laboratory research on growth, microbiome and the relationship between poor growth and chronic diseases was conducted. This review focuses on potential mechanisms that implicate the microbiome as a mediator of poor growth and later metabolic outcomes. In this relationship, attention was given to the potential for gastrointestinal infections to disrupt the microbiome. RESULTS Based on the studies reviewed, it is clear that exposure to infections disturbs both intestinal functioning as well as normal growth and changes in the microbiome may influence micronutrient availability and metabolic processes. CONCLUSIONS The microbiome may play a significant role in limiting human growth, but little is known about changes in the microbiome during periods of undernutrition. Thus, it is of great scientific and public health importance to improve the understanding of how the microbiome changes during nutrient deprivation. To best address the issue of the double burden and poor growth in low-income countries, research is warranted to advance the knowledge of the long-term role of the microbiome in the health of children exposed to undernutrition.
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Affiliation(s)
- Daniel J Hoffman
- a Department of Nutritional Sciences and the New Jersey Institute for Food, Nutrition, and Health , Rutgers, the State University of New Jersey , New Brunswick , NJ , USA
| | - Maiza Campos-Ponce
- b Department of Health Sciences , VU University , Amsterdam , The Netherlands
| | - Carla R Taddei
- c Department of Clinical and Toxicological Analyses, School of Pharmaceutical Sciences , University of São Paulo , São Paulo, SP , Brazil.,d School of Arts, Science and Humanities , University of São Paulo , São Paulo, SP , Brazil
| | - Colleen M Doak
- b Department of Health Sciences , VU University , Amsterdam , The Netherlands
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Swartz K, Short PF, Graefe DR, Uberoi N. Reducing Medicaid Churning: Extending Eligibility For Twelve Months Or To End Of Calendar Year Is Most Effective. Health Aff (Millwood) 2016; 34:1180-7. [PMID: 26153313 DOI: 10.1377/hlthaff.2014.1204] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicaid churning--the constant exit and reentry of beneficiaries as their eligibility changes--has long been a problem for both Medicaid administrators and recipients. Churning will continue under the Affordable Care Act because, despite new federal rules, Medicaid eligibility will continue to be based on current monthly income. We developed a longitudinal simulation model to evaluate four policy options for modifying or extending Medicaid eligibility to reduce churning. The simulations suggest that two options--extending eligibility either to the end of a calendar year or for twelve months after enrollment--would be the most effective methods for reducing churning. The other options--a three-month extension or eligibility based on projected annual income--would reduce churning to a lesser extent. States should consider implementation of the option that best balances costs while improving access to coverage and, thereby, the health of Medicaid enrollees.
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Affiliation(s)
- Katherine Swartz
- Katherine Swartz is a professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health, in Boston, Massachusetts
| | - Pamela Farley Short
- Pamela Farley Short is a professor in the Department of Health Policy and Administration at Pennsylvania State University, in University Park
| | - Deborah Roempke Graefe
- Deborah Roempke Graefe is a research associate at the Population Research Institute at Pennsylvania State University
| | - Namrata Uberoi
- Namrata Uberoi is an analyst in health care financing at the Congressional Research Service, in Washington, D.C
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Abstract
BACKGROUND Transitions into and out of Medicaid, termed churning, may disrupt access to and continuity of care. Low-income, working adults who became eligible for Medicaid under the Affordable Care Act are particularly susceptible to income and employment changes that lead to churning. OBJECTIVE To compare health care use among adults who do and do not churn into and out of Medicaid. DATA Longitudinal data from 6 panels of the Medical Expenditure Panel Survey. METHODS We used differences-in-differences regression to compare health care use when adults reenrolled in Medicaid following a loss of coverage, to utilization in a control group of continuously enrolled adults. OUTCOME MEASURES Emergency department (ED) visits, ED visits resulting in an inpatient admission, and visits to office-based providers. RESULTS During the study period, 264 adults churned into and out of Medicaid and 627 had continuous coverage. Churning adults had an average of approximately 0.05 Medicaid-covered office-based visits per month 4 months before reenrolling in Medicaid, significantly below the rate of approximately 0.20 visits in the control group. Visits to office-based providers did not reach the control group rate until several months after churning adults had resumed Medicaid coverage. Our comparisons found no evidence of significantly elevated ED and inpatient admission rates in the churning group following reenrollment. CONCLUSIONS Adults who lose Medicaid tend to defer their use of office-based care to periods when they are insured. Although this suggests that enrollment disruptions lead to suboptimal timing of care, we do not find evidence that adults reenroll in Medicaid with elevated acute care needs.
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20
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Ratanawongsa N, Karter AJ, Quan J, Parker MM, Handley M, Sarkar U, Schmittdiel JA, Schillinger D. Reach and Validity of an Objective Medication Adherence Measure Among Safety Net Health Plan Members with Diabetes: A Cross-Sectional Study. J Manag Care Spec Pharm 2015; 21:688-98. [PMID: 26233541 PMCID: PMC4553246 DOI: 10.18553/jmcp.2015.21.8.688] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND With the expansion of Medicaid and low-cost health insurance plans among diverse patient populations, objective measures of medication adherence using pharmacy claims could advance clinical care and translational research for safety net care. However, safety net patients may experience fluctuating prescription drug coverage, affecting the performance of adherence measures. OBJECTIVE To evaluate the performance of continuous medication gap (CMG) for diverse, low-income managed care members with diabetes. METHODS We conducted this cross-sectional analysis using administrative and clinical data for 680 members eligible for a self-management support trial at a nonprofit, government-sponsored managed care plan. We applied CMG methodology to cardiometabolic medication claims for English- , Cantonese- , or Spanish-speaking members with diabetes. We examined inclusiveness (the proportion with calculable CMG) and selectivity (sociodemographic and medical differences from members without CMG). For validity, we examined unadjusted associations of suboptimal adherence (CMG > 20%) with suboptimal cardiometabolic control. RESULTS 429 members (63%) had calculable CMG. Compared with members without CMG, members with CMG were younger, more likely employed, and had poorer glycemic control but had better blood pressure and lipid control. Suboptimal adherence occurred more frequently among members with poor cardiometabolic control than among members with optimal control (28% vs. 12%, P = 0.02). CONCLUSIONS CMG demonstrated acceptable inclusiveness and validity in a diverse, low-income safety net population, comparable with its performance in studies among other insured populations. CMG may provide a useful tool to measure adherence among increasingly diverse Medicaid populations, complemented by other strategies to reach those not captured by CMG.
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Affiliation(s)
- Neda Ratanawongsa
- UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center, 1001 Potrero Ave., Box 1364, San Francisco CA 94110.
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Pruitt Z, Robst J, Langland-Orban B, Brooks RG. Healthcare costs associated with antiretroviral adherence among medicaid patients. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2015; 13:69-80. [PMID: 25403718 DOI: 10.1007/s40258-014-0138-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND The relationship of antiretroviral therapy (ART) adherence to total healthcare expenditures for Medicaid-insured people living with HIV or AIDS (PLWHA) is not well understood, especially among asymptomatic HIV-positive patients. OBJECTIVE This study examined Medicaid-insured HIV-positive and AIDS-diagnosed patient groups to determine the association of ART adherence to mean monthly total healthcare expenditures in the 24-month measurement period, controlling for demographic, geographic, insurance, and clinical factors. The present study extends the existing literature by analyzing the relationship of ART adherence to total healthcare costs for asymptomatic HIV-positive patients separately from those patients with AIDS-defining conditions. METHODS This retrospective study utilized claims data from Florida Medicaid claims from July 2006 through June 2011. All patients (n = 502) were HIV-positive, aged 18-64 years, non-pregnant, and ART naïve for at least 12 months prior to the measurement period. Each patient was categorized, based on medication possession ratios, as adherent (≥90 %) or non-adherent (<90 %), and were divided into two groups: HIV positive (n = 232) and AIDS diagnosed (n = 270). Generalized linear models predicted the mean monthly total expenditures for the non-adherence group versus the adherence group. RESULTS For the HIV-positive group, the adjusted mean monthly expenditures for the non-adherent group were US$1,291; the adherent group adjusted mean monthly expenditures were US$1,926. The HIV-positive non-adherent group adjusted mean monthly expenditures were significantly less than the adherent group (-40 %, p < 0.001). However, for the AIDS-diagnosed group, there was not a statistically significant association of ART adherence to total healthcare expenditures (p = 0.29). CONCLUSION The results show that the relationship of ART adherence to healthcare costs is more complex than previously reported.
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Affiliation(s)
- Zachary Pruitt
- College of Public Health, Health Policy and Management, University of South Florida, 13201 Bruce B. Downs Blvd., MDC 56, Tampa, FL, 33612-3805, USA,
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Dague L. The effect of Medicaid premiums on enrollment: a regression discontinuity approach. JOURNAL OF HEALTH ECONOMICS 2014; 37:1-12. [PMID: 24879608 DOI: 10.1016/j.jhealeco.2014.05.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 04/29/2014] [Accepted: 05/09/2014] [Indexed: 06/03/2023]
Abstract
This paper estimates the effect that premiums in Medicaid have on the length of enrollment of program beneficiaries. Whether and how low income-families will participate in the exchanges and in states' Medicaid programs depends crucially on the structure and amounts of the premiums they will face. I take advantage of discontinuities in the structure of Wisconsin's Medicaid program to identify the effects of premiums on enrollment for low-income families. I use a 3-year administrative panel of enrollment data to estimate these effects. I find an increase in the premium from 0 to 10 dollars per month results in 1.4 fewer months enrolled and reduces the probability of remaining enrolled for a full year by 12 percentage points, but other discrete changes in premium amounts do not affect enrollment or have a much smaller effect. I find no evidence of program enrollees intentionally decreasing labor supply in order to avoid the premiums.
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Ku L, Steinmetz E, Bruen BK. Continuous-eligibility policies stabilize Medicaid coverage for children and could be extended to adults with similar results. Health Aff (Millwood) 2014; 32:1576-82. [PMID: 24019362 DOI: 10.1377/hlthaff.2013.0362] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A key method of stabilizing Medicaid coverage is to provide beneficiaries with twelve months of continuous eligibility. Following the passage of the Children's Health Insurance Program Reauthorization Act in 2009, seven states adopted the continuous-eligibility option for children. That policy change led to a 1.8-percentage-point increase in the average length of child enrollment during fiscal year 2010 and increased annual costs for children by about 2.2 percent. The Medicaid and CHIP Payment and Access Commission has recommended offering states the option of giving adults twelve-month continuous eligibility for Medicaid. Our findings suggest that continuous eligibility could promote more stable coverage for adults enrolled in Medicaid at a modest cost.
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Burns ME, O'Hara BJ, Huskamp HA, Soumerai SB. Uninsurance and its correlates among poor adults with disabilities. J Health Care Poor Underserved 2012; 23:1630-46. [PMID: 23698677 DOI: 10.1353/hpu.2012.0197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
States must offer Medicaid coverage to low-income adults with disabilities; however, they have discretion in the design of eligibility criteria and enrollment processes. Using the American Community Survey, we examined the health insurance status of adults enrolled in the Supplemental Security Income (SSI) disability program including (1) the national rate of health insurance coverage; (2) state rates of uninsurance and Medicaid; and (3) the correlates of uninsurance. Uninsurance and Medicaid rates varied across states from 1% to 12% and from 63% to 91%, respectively. Nationally, 5% of the SSI population was uninsured; 77% was enrolled in Medicaid. Limited English proficiency, Black race, lack of U.S. citizenship, and residence in a state that used an enrollment process and/or eligibility criteria distinct from the SSI program were associated with uninsurance. As states streamline Medicaid enrollment processes to meet requirements of the Affordable Care Act, they should consider the needs of this vulnerable population.
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Affiliation(s)
- Marguerite E Burns
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, 133 Brookline Ave., 6th Floor, Boston, MA 02215, USA.
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