1
|
Holm J, Pagán JA, Silver D. The Impact of Medicaid Accountable Care Organizations on Health Care Utilization, Quality Measures, Health Outcomes and Costs from 2012 to 2023: A Scoping Review. Med Care Res Rev 2024; 81:355-369. [PMID: 38618890 DOI: 10.1177/10775587241241984] [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] [Indexed: 04/16/2024]
Abstract
Most of the evidence regarding the success of ACOs is from the Medicare program. This review evaluates the impacts of ACOs within the Medicaid population. We identified 32 relevant studies published between 2012 and 2023 which analyzed the association of Medicaid ACOs and health care utilization (n = 21), quality measures (n = 18), health outcomes (n = 10), and cost reduction (n = 3). The results of our review regarding the effectiveness of Medicaid ACOs are mixed. Significant improvements included increased primary care visits, reduced admissions, and reduced inpatient stays. Cost reductions were reported in a few studies, and savings were largely dependent on length of attribution and years elapsed after ACO implementation. Adopting the ACO model for the Medicaid population brings some different challenges from those with the Medicare population, which may limit its success, particularly given differences in state Medicaid programs.
Collapse
|
2
|
Adekoya N, Chang MH, Wortham J, Truman BI. Disparities in Rates of Death From HIV or Tuberculosis Before Age 65 Years, by Race, Ethnicity, and Sex, United States, 2011-2020. Public Health Rep 2024; 139:557-565. [PMID: 38111105 PMCID: PMC11324802 DOI: 10.1177/00333549231213328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVE Death from tuberculosis or HIV among people from racial and ethnic minority groups who are aged <65 years is a public health concern. We describe age-adjusted, absolute, and relative death rates from HIV or tuberculosis from 2011 through 2020 by sex, race, and ethnicity among US residents. METHODS We used mortality data from the Centers for Disease Control and Prevention online data system on deaths from multiple causes from 2011 through 2020 to calculate age-adjusted death rates and absolute and relative disparities in rates of death by sex, race, and ethnicity. We calculated corresponding 95% CIs for all rates and determined significance at P < .05 by using z tests. RESULTS For tuberculosis, when compared with non-Hispanic White residents, non-Hispanic American Indian or Alaska Native residents had the highest level of disparity in rate of death (666.7%). Similarly, as compared with non-Hispanic White female residents, American Indian or Alaska Native female residents had a high relative disparity in death from tuberculosis (620.0%). For HIV, the age-adjusted death rate was more than 8 times higher among non-Hispanic Black residents than among non-Hispanic White residents, and the relative disparity was 735.1%. When compared with non-Hispanic White female residents, Black female residents had a high relative disparity in death from HIV (1529.2%). CONCLUSION Large disparities in rates of death from tuberculosis or HIV among US residents aged <65 years based on sex, race, and ethnicity indicate an ongoing unmet need for effective interventions. Intervention strategies are needed to address disparities in rates of death and infection among racial and ethnic minority populations.
Collapse
Affiliation(s)
- Nelson Adekoya
- National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Man-Huei Chang
- National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jonathan Wortham
- National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Benedict I. Truman
- National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| |
Collapse
|
3
|
Jarlenski M, Cole E, McClure C, Sanders S, Smalls M, Méndez DD. Implementation and early effects of medicaid policy interventions to promote racial equity in pregnancy and early childhood outcomes in Pennsylvania: protocol for a mixed methods study. BMC Health Serv Res 2024; 24:498. [PMID: 38649983 PMCID: PMC11036682 DOI: 10.1186/s12913-024-10982-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/10/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND There are large racial inequities in pregnancy and early childhood health within state Medicaid programs in the United States. To date, few Medicaid policy interventions have explicitly focused on improving health in Black populations. Pennsylvania Medicaid has adopted two policy interventions to incentivize racial health equity in managed care (equity payment program) and obstetric service delivery (equity focused obstetric bundle). Our research team will conduct a mixed-methods study to investigate the implementation and early effects of these two policy interventions on pregnancy and infant health equity. METHODS Qualitative interviews will be conducted with Medicaid managed care administrators and obstetric and pediatric providers, and focus groups will be conducted among Medicaid beneficiaries. Quantitative data on healthcare utilization, healthcare quality, and health outcomes among pregnant and parenting people will be extracted from administrative Medicaid healthcare data. Primary outcomes are stakeholder perspectives on policy intervention implementation (qualitative) and timely prenatal care, pregnancy and birth outcomes, and well-child visits (quantitative). Template analysis methods will be applied to qualitative data. Quantitative analyses will use an interrupted time series design to examine changes over time in outcomes among Black people, relative to people of other races, before and after adoption of the Pennsylvania Medicaid equity-focused policy interventions. DISCUSSION Findings from this study are expected to advance knowledge about how Medicaid programs can best implement policy interventions to promote racial equity in pregnancy and early childhood health.
Collapse
Affiliation(s)
- Marian Jarlenski
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, 130 DeSoto St, A619, 15261, Pittsburgh, PA, USA.
| | - Evan Cole
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, 130 DeSoto St, A619, 15261, Pittsburgh, PA, USA
| | - Christine McClure
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, 130 DeSoto St, A619, 15261, Pittsburgh, PA, USA
| | - Sarah Sanders
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Marquita Smalls
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Dara D Méndez
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| |
Collapse
|
4
|
Gallifant J, Griffin M, Pierce RL, Celi LA. From quality improvement to equality improvement projects: A scoping review and framework. iScience 2023; 26:107924. [PMID: 37817930 PMCID: PMC10561034 DOI: 10.1016/j.isci.2023.107924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023] Open
Abstract
Increasing awareness of health disparities has led to proposals for a pay-for-equity scheme. Implementing such proposals requires systematic methods of collecting and reporting health outcomes for targeted demographics over time. This lays the foundation for a shift from quality improvement projects (QIPs) to equality improvement projects (EQIPs) that could evaluate adherence to standards and progress toward health equity. We performed a scoping review on EQIPs to inform a new framework for quality improvement through a health equity lens. Forty studies implemented an intervention after identifying a disparity compared to 149 others which merely identified group differences. Most evaluated race-based differences and were conducted at the institutional level, with representation in both the inpatient and outpatient settings. EQIPs that improved equity leveraged multidisciplinary expertise, healthcare staff education, and developed tools to track health outcomes continuously. EQIPs can help bridge the inequality gap and form part of an incentivized systematic equality improvement framework.
Collapse
Affiliation(s)
- Jack Gallifant
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Molly Griffin
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Robin L. Pierce
- The Law School, School of Social Sciences and International Studies, University of Exeter, Exeter, UK
| | - Leo Anthony Celi
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
5
|
Frimpong EY, Ferdousi W, Rowan GA, Chaudhry S, Swetnam H, Compton MT, Smith TE, Radigan M. Racial and Ethnic Disparities in Health Care Access and Utilization among Medicaid Managed Care Beneficiaries. J Behav Health Serv Res 2023; 50:194-213. [PMID: 35945481 DOI: 10.1007/s11414-022-09811-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 11/27/2022]
Abstract
This quasi-experimental study examined the impact of a statewide integrated special needs program Health and Recovery Plan (HARP) for individuals with serious mental illness and identified racial and ethnic disparities in access to Medicaid services. Generalized estimating equation negative binomial models were used to estimate changes in service use, difference-in-differences, and difference-in-difference-in-differences in the pre- to post-HARP periods. Implementation of the special needs plan contributed to reductions in racial/ethnic disparities in access and utilization. Notable among those enrolled in the special needs plan was the declining Black-White disparities in emergency room (ER) visits and inpatient stays, but the disparity in non-behavioral health clinic visits remains. Also, the decline of Hispanic-White disparities in ER, inpatient, and clinic use was more evident for HARP-enrolled patients. Health equity policies are needed in the delivery of care to linguistically and culturally disadvantaged Medicaid beneficiaries.
Collapse
Affiliation(s)
| | | | - Grace A Rowan
- New York State Office of Mental Health, New York, NY, USA
| | - Sahil Chaudhry
- New York State Office of Mental Health, New York, NY, USA
| | - Hannah Swetnam
- New York State Office of Mental Health, New York, NY, USA
| | - Michael T Compton
- Department of Psychiatry, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA.,New York State Psychiatric Institute, New York, NY, USA
| | - Thomas E Smith
- New York State Office of Mental Health, New York, NY, USA.,Department of Psychiatry, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA
| | | |
Collapse
|
6
|
Yee K, Hoopes M, Giebultowicz S, Elliott MN, McConnell KJ. Implications of missingness in self-reported data for estimating racial and ethnic disparities in Medicaid quality measures. Health Serv Res 2022; 57:1370-1378. [PMID: 35802064 PMCID: PMC9643085 DOI: 10.1111/1475-6773.14025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To assess the feasibility and implications of imputing race and ethnicity for quality and utilization measurement in Medicaid. DATA SOURCES AND STUDY SETTING 2017 Oregon Medicaid claims from the Oregon Health Authority and electronic health records (EHR) from OCHIN, a clinical data research network, were used. STUDY DESIGN We cross-sectionally assessed Hispanic-White, Black-White, and Asian-White disparities in 22 quality and utilization measures, comparing self-reported race and ethnicity to imputed values from the Bayesian Improved Surname Geocoding (BISG) algorithm. DATA COLLECTION Race and ethnicity were obtained from self-reported data and imputed using BISG. PRINCIPAL FINDINGS 42.5%/4.9% of claims/EHR were missing self-reported data; BISG estimates were available for >99% of each and had good concordance (0.87-0.95) with Asian, Black, Hispanic, and White self-report. All estimated racial and ethnic disparities were statistically similar in self-reported and imputed EHR-based measures. However, within claims, BISG estimates and incomplete self-reported data yielded substantially different disparities in almost half of the measures, with BISG-based Black-White disparities generally larger than self-reported race and ethnicity data. CONCLUSIONS BISG imputation methods are feasible for Medicaid claims data and reduced missingness to <1%. Disparities may be larger than what is estimated using self-reported data with high rates of missingness.
Collapse
Affiliation(s)
- Kimberly Yee
- Oregon Health & Science University‐Portland State University School of Public HealthPortlandOregonUSA
| | | | | | | | - K. John McConnell
- Center for Health Systems Effectiveness at Oregon Health & Science UniversityPortlandOregonUSA
| |
Collapse
|
7
|
Donohue JM, Cole ES, James CV, Jarlenski M, Michener JD, Roberts ET. The US Medicaid Program: Coverage, Financing, Reforms, and Implications for Health Equity. JAMA 2022; 328:1085-1099. [PMID: 36125468 DOI: 10.1001/jama.2022.14791] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Medicaid is the largest health insurance program by enrollment in the US and has an important role in financing care for eligible low-income adults, children, pregnant persons, older adults, people with disabilities, and people from racial and ethnic minority groups. Medicaid has evolved with policy reform and expansion under the Affordable Care Act and is at a crossroads in balancing its role in addressing health disparities and health inequities against fiscal and political pressures to limit spending. OBJECTIVE To describe Medicaid eligibility, enrollment, and spending and to examine areas of Medicaid policy, including managed care, payment, and delivery system reforms; Medicaid expansion; racial and ethnic health disparities; and the potential to achieve health equity. EVIDENCE REVIEW Analyses of publicly available data reported from 2010 to 2022 on Medicaid enrollment and program expenditures were performed to describe the structure and financing of Medicaid and characteristics of Medicaid enrollees. A search of PubMed for peer-reviewed literature and online reports from nonprofit and government organizations was conducted between August 1, 2021, and February 1, 2022, to review evidence on Medicaid managed care, delivery system reforms, expansion, and health disparities. Peer-reviewed articles and reports published between January 2003 and February 2022 were included. FINDINGS Medicaid covered approximately 80.6 million people (mean per month) in 2022 (24.2% of the US population) and accounted for an estimated $671.2 billion in health spending in 2020, representing 16.3% of US health spending. Medicaid accounted for an estimated 27.2% of total state spending and 7.6% of total federal expenditures in 2021. States enrolled 69.5% of Medicaid beneficiaries in managed care plans in 2019 and adopted 139 delivery system reforms from 2003 to 2019. The 38 states (and Washington, DC) that expanded Medicaid under the Affordable Care Act experienced gains in coverage, increased federal revenues, and improvements in health care access and some health outcomes. Approximately 56.4% of Medicaid beneficiaries were from racial and ethnic minority groups in 2019, and disparities in access, quality, and outcomes are common among these groups within Medicaid. Expanding Medicaid, addressing disparities within Medicaid, and having an explicit focus on equity in managed care and delivery system reforms may represent opportunities for Medicaid to advance health equity. CONCLUSIONS AND RELEVANCE Medicaid insures a substantial portion of the US population, accounts for a significant amount of total health spending and state expenditures, and has evolved with delivery system reforms, increased managed care enrollment, and state expansions. Additional Medicaid policy reforms are needed to reduce health disparities by race and ethnicity and to help achieve equity in access, quality, and outcomes.
Collapse
Affiliation(s)
- Julie M Donohue
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Evan S Cole
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | | | - Marian Jarlenski
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Jamila D Michener
- Department of Government and School of Public Policy, Cornell University, Ithaca, New York
| | - Eric T Roberts
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| |
Collapse
|
8
|
Yoon J, Harvey SM, Luck J. Improved depression screening and treatment among low-income pregnant and postpartum women following Medicaid expansion in the U.S. FRONTIERS IN HEALTH SERVICES 2022; 2:942476. [PMID: 36925770 PMCID: PMC10012772 DOI: 10.3389/frhs.2022.942476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/26/2022] [Indexed: 11/13/2022]
Abstract
Objective This study examined the effect of Medicaid expansion in Oregon under the Affordable Care Act on depression screening and treatment among pregnant and postpartum women who gave Medicaid-financed births. Methods Oregon birth certificates were linked to Medicaid enrollment and claims records for 2011-2016. The sample included a policy group of 1,368 women (n = 2,831) who gave births covered by pregnancy-only Medicaid in the pre-expansion period (before 2014) and full-scope Medicaid in the post-expansion period, and the comparison group of 2,229 women (n = 4,580) who gave births covered by full-scope Medicaid in both pre- and post-expansion periods. Outcomes included indicators for depression screening, psychotherapy, pharmacotherapy, and combined psychotherapy-pharmacotherapy, separately for the first, second, and third trimesters, and 2 and 6 months postpartum. This study utilized a difference-in-differences approach that compared pre-post change in an outcome for the policy group to a counterfactual pre-post change from the comparison group. Results Medicaid expansion led to a 3.64%-point increase in the rate of depression screening 6 months postpartum, 3.28%-point increase in the rate of psychotherapy 6 months postpartum, and 2.3 and 1%-point increases in the rates of pharmacotherapy and combined treatment in the first trimester, respectively. The relationships were driven by disproportionate gains among non-Hispanic whites and urban residents. Conclusions Expanding Medicaid eligibility may improve depression screening and treatment among low-income women early in pregnancy and/or beyond the usual two-month postpartum period. However, it does not necessarily reduce racial/ethnic and regional gaps in depression screening and treatment.
Collapse
Affiliation(s)
- Jangho Yoon
- Department of Preventive Medicine and Biostatistics, F. Edward Hebert School of Medicine, The Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - S Marie Harvey
- School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, United States
| | - Jeff Luck
- School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, United States
| |
Collapse
|
9
|
George R, Gunn R, Wiggins N, Rowland R, Davis MM, Maes K, Kuzma A, McConnell KJ. Early Lessons and Strategies from Statewide Efforts to Integrate Community Health Workers into Medicaid. J Health Care Poor Underserved 2021; 31:845-858. [PMID: 33410811 DOI: 10.1353/hpu.2020.0064] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The 2010 Affordable Care Act provided new impetus and funding opportunities for state Medicaid agencies to integrate community health workers (CHWs) into their health systems. Community health workers are trusted community members who participate in training so they can promote health in their own communities. This qualitative study shares lessons and strategies from Oregon's early efforts to integrate CHWs into Medicaid with concomitant financing, policy, and infrastructure issues. Key informant interviews were conducted with 16 Coordinated care organizations (CCO) and analyzed using an iterative, immersion-crystallization approach. Coordinated care organizations found CHW integration a supportive factor for Medicaid-enrolled members navigating health and social services, educating members about disease conditions, and facilitating member engagement in primary care. Barriers to CHW integration included a lack of understanding about CHW roles and their benefits to health systems, as well as a need for more intensive guidance and support on financing and integrating CHW services.
Collapse
|
10
|
Charlesworth CJ, Zhu JM, Horvitz-Lennon M, McConnell KJ. Use of behavioral health care in Medicaid managed care carve-out versus carve-in arrangements. Health Serv Res 2021; 56:805-816. [PMID: 34312839 DOI: 10.1111/1475-6773.13703] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 04/01/2021] [Accepted: 04/14/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To evaluate differences in access to behavioral health services for Medicaid enrollees covered by a Medicaid entity that integrated the financing of behavioral and physical health care ("carve-in group") versus a Medicaid entity that separated this financing ("carve-out group"). DATA SOURCES/STUDY SETTING Medicaid claims data from two Medicaid entities in the Portland, Oregon tri-county area in 2016. STUDY DESIGN In this cross-sectional study, we compared differences across enrollees in the carve-in versus carve-out group, using a machine learning approach to incorporate a large set of covariates and minimize potential selection bias. Our primary outcomes included behavioral health visits for a variety of different provider types. Secondary outcomes included inpatient, emergency department, and primary care visits. DATA COLLECTION We used Medicaid claims, including adults with at least 9 months of enrollment. PRINCIPAL FINDINGS The study population included 45,786 adults with mental health conditions. Relative to the carve-out group, individuals in the carve-in group were more likely to access outpatient behavioral health (2.39 percentage points, p < 0.0001, with a baseline rate of approximately 73%). The carve-in group was also more likely to access primary care physicians, psychologists, and social workers and less likely to access psychiatrists and behavioral health specialists. Access to outpatient behavioral health visits was more likely in the carve-in arrangement among individuals with mild or moderate mental health conditions (compared to individuals with severe mental illness) and among black enrollees (compared to white enrollees). CONCLUSIONS Financial integration of physical and behavioral health in Medicaid managed care was associated with greater access to behavioral health services, particularly for individuals with mild or moderate mental health conditions and for black enrollees. Recent changes to incentivize financial integration should be monitored to assess differential impacts by illness severity, race and ethnicity, provider types, and other factors.
Collapse
Affiliation(s)
- Christina J Charlesworth
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon, USA
| | - Jane M Zhu
- Division of General Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Marcela Horvitz-Lennon
- RAND Corporation, Cambridge Heath Alliance and Harvard Medical School, Boston, Massachusetts, USA
| | - K John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon, USA
| |
Collapse
|
11
|
Kushner J, Byers J, Petchel S, Cohen DJ, Jensen K, Bittinger K, McConnell KJ. Washington's Medicaid Transformation Project: Engaging the health care and social service sectors to improve health care delivery and address the social determinants of health. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 9:100560. [PMID: 34252708 DOI: 10.1016/j.hjdsi.2021.100560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 03/27/2021] [Accepted: 05/20/2021] [Indexed: 11/28/2022]
Abstract
Across the US, states have initiated reforms to improve population health by coordinating efforts among health care stakeholders and addressing health-related social needs. Washington State's Medicaid Transformation Project (MTP), launched in 2017, seeks to achieve these goals by supporting the state's Accountable Communities of Health, independent organizations that convene and coordinate the health care and social service sectors in nine regions of the state. MTP places Medicaid funds in the hands of ACHs for the purpose of building health system capacity and carrying out health improvement projects. It includes new supports for aging, housing and employment, and substance use disorder treatment. Early lessons from MTP are emerging that can inform health system transformation efforts in other states. MTP demonstrates the advantages of creating new organizations to serve as regional conveners and coordinators. However, the introduction of new entities will require states to clearly articulate the varying roles of these entities and existing managed care organizations and state agencies. States will need to balance the tradeoffs of local control versus centralization. For example, it may be optimal to standardize electronic health information exchanges but allow organizations flexibility to adopt other interventions that match their local context. In addition, states should build treatment and comparison groups into their program designs in order to generate high-quality evidence about the impact of new health care delivery and payment models.
Collapse
Affiliation(s)
| | - Jordan Byers
- Department of Family Medicine, Oregon Health & Science University, United States
| | - Shauna Petchel
- Center for Health Systems Effectiveness, Oregon Health & Science University, United States
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, United States
| | - Karen Jensen
- Policy Division, Washington State Health Care Authority, United States
| | - Katie Bittinger
- Office of Research and Data Analysis, Washington State Department of Social and Health Services, United States
| | - K John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, United States
| |
Collapse
|
12
|
Lindner S, Kaufman MR, Marino M, O'Malley J, Angier H, Cottrell EK, McConnell KJ, DeVoe JE, Heintzman JR. A Medicaid Alternative Payment Model Program In Oregon Led To Reduced Volume Of Imaging Services. Health Aff (Millwood) 2021; 39:1194-1201. [PMID: 32634361 DOI: 10.1377/hlthaff.2019.01656] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The patient-centered medical home model aspires to fundamentally restructure care processes, but a volume-based payment system may hinder such transformations. In 2013 Oregon's Medicaid program changed its reimbursement of traditional primary care services for selected community health centers (CHCs) from a per visit to a per patient rate. Using Oregon claims data, we analyzed the price-weighted volume of care for five service areas: traditional primary care services, including imaging, tests, and procedures; other services provided by CHCs that were carved out from the payment reform; emergency department visits; inpatient services; and other services of non-CHC providers. We further subdivided traditional primary care services using Berenson-Eggers Type of Service categories of care. We compared participating and nonparticipating CHCs in Oregon before and after the payment model was implemented. The payment reform was associated with a 42.4 percent relative reduction in price-weighted traditional primary care services, driven fully by decreased use of imaging services. Other outcomes remained unaffected. Oregon's initiative could provide lessons for other states interested in using payment reform to advance the patient-centered medical home model for the Medicaid population.
Collapse
Affiliation(s)
- Stephan Lindner
- Stephan Lindner is an assistant professor in the Center for Health Systems Effectiveness and in the Department of Emergency Medicine, both at Oregon Health & Science University, in Portland, Oregon
| | - Menolly R Kaufman
- Menolly R. Kaufman is a research associate in the Center for Health Systems Effectiveness, Oregon Health & Science University
| | - Miguel Marino
- Miguel Marino is an associate professor of biostatistics in the Department of Family Medicine, Oregon Health & Science University, and at the OHSU-Portland State University School of Public Health, in Portland
| | - Jean O'Malley
- Jean O'Malley is a biostatistician in the Research Department at Ochin, Inc., in Portland
| | - Heather Angier
- Heather Angier is an assistant professor in the Department of Family Medicine, Oregon Health & Science University
| | - Erika K Cottrell
- Erika K. Cottrell is an assistant professor in the Department of Family Medicine, Oregon Health & Science University, and an investigator at OCHIN, Inc
| | - K John McConnell
- K. John McConnell is director of the Center for Health Systems Effectiveness and a professor in the Department of Emergency Medicine, both at Oregon Health & Science University
| | - Jennifer E DeVoe
- Jennifer E. DeVoe is professor and chair in the Department of Family Medicine, Oregon Health & Science University
| | - John R Heintzman
- John R. Heintzman is an associate professor in the Department of Family Medicine, Oregon Health & Science University
| |
Collapse
|
13
|
Increased Use of Complementary and Alternative Therapies for Back Pain Following Statewide Medicaid Coverage Changes in Oregon. J Gen Intern Med 2021; 36:676-682. [PMID: 33443692 PMCID: PMC7947103 DOI: 10.1007/s11606-020-06352-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 11/17/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND In 2016, Oregon introduced a policy to improve back pain treatment among Medicaid enrollees by expanding benefits for evidence-based complementary and alternative medical (CAM) services and establishing opioid prescribing restrictions. OBJECTIVE To examine changes in CAM utilization following the policy and variations in utilization across patient populations. DESIGN A retrospective study of Oregon Medicaid claims data, examining CAM therapy utilization by back pain patients pre- vs post-policy. We used an interrupted time series analysis to evaluate changes in CAM use and examined the association between patient characteristics and CAM use post-policy using linear regression models. PARTICIPANTS Adult Medicaid patients with back pain. INTERVENTION The Oregon Medicaid back pain policy, administered through Coordinated Care Organizations (CCOs). MAIN MEASURES Use of CAM services. KEY RESULTS Use of any CAM service increased from 7.9% (95% CI 7.6-8.2%) prior to the policy to 30.9% (95% CI 30.4-31.3%) after the policy. Acupuncture increased from 0.3 to 5.6%, chiropractic from 0.3 to 11.1%, massage from 1.6 to 14.8%, PT/OT from 6.0 to 17.7%, and osteopathic from 1.4 to 1.9%. Interrupted time series showed an overall increase in proportion of back pain patients who used CAM service following the policy. Among those who accessed CAM, the policy did not appear to increase the number of services used. In the post period, CAM services were accessed more often by female and older enrollees and urban populations. Black, American Indian/Alaska Native, and Hispanic enrollees were less likely to access CAM services; for Black enrollees, this was true for all types of services. CONCLUSIONS CAM service utilization increased among back pain patients following implementation of Oregon's policy. There was significant heterogeneity in uptake across service types, CCOs, and patient subgroups. Policymakers should consider implementation factors that might limit impact and perpetuate health disparities.
Collapse
|
14
|
Lindner S, Levy A, Horner-Johnson W. The Medicaid expansion did not crowd out access for medicaid recipients with disabilities in Oregon. Disabil Health J 2020; 14:101010. [PMID: 33419718 DOI: 10.1016/j.dhjo.2020.101010] [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] [Received: 02/29/2020] [Revised: 08/02/2020] [Accepted: 08/31/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) substantially increased the number of Medicaid enrollees, which could have reduced access to health care services for those already on Medicaid before the expansion. OBJECTIVE To examine the association of the ACA expansion on health care access and utilization for adults ages 18-64 years who have qualified for Supplemental Security Income (SSI) in Oregon. METHODS We used Oregon Medicaid claims and enrollment data from 2012 to 2015 and information from the American Community Survey and the Local Area Unemployment Statistics. Multivariate regressions compared changes in health care access and utilization before and after the expansion among Medicaid recipients who qualified for SSI across counties in Oregon with higher and lower Medicaid enrollment increases due to the expansion. Health care access and utilization outcome measures included: primary care visits, non-behavioral health outpatient visits, behavioral health outpatient visits, emergency department (ED) visits and potentially avoidable ED visits. RESULTS The Medicaid expansion led to an uneven increase in Medicaid enrollment across Oregon's counties (mean increase from the first quarter of 2012 to the third quarter of 2015: 12.4% points; range: 7.3 to 18.6% points). Access and utilization outcomes for SSI Medicaid recipients were mostly unaffected by differential enrollment increases. ED visits increased more in counties with a larger Medicaid enrollment increase (estimate: 1.8, p < 0.05), but adjusting for pre-expansion trends eliminated this association. CONCLUSIONS We did not find evidence that an increase in Medicaid enrollment due to the ACA negatively impacted access and utilization for adult Medicaid recipients on SSI, who were eligible for Medicaid prior to expansion.
Collapse
Affiliation(s)
- Stephan Lindner
- OHSU Center for Health System Effectiveness (CHSE), Department of Emergency Medicine, School of Medicine, 3030 SW Moody Ave, Portland, 97201, OR, USA; OHSU-PSU School of Public Health, Portland 97239, OR, USA.
| | - Anna Levy
- OHSU Center for Health System Effectiveness (CHSE), Department of Emergency Medicine, School of Medicine, 3030 SW Moody Ave, Portland, 97201, OR, USA
| | - Willi Horner-Johnson
- OHSU-PSU School of Public Health, Portland 97239, OR, USA; OHSU Institute on Development and Disability, Department of Pediatrics, School of Medicine, Portland, 97239, OR, USA
| |
Collapse
|
15
|
O’Leary MC, Lich KH, Gu Y, Wheeler SB, Coronado GD, Bartelmann SE, Lind BK, Mayorga ME, Davis MM. Colorectal cancer screening in newly insured Medicaid members: a review of concurrent federal and state policies. BMC Health Serv Res 2019; 19:298. [PMID: 31072316 PMCID: PMC6509857 DOI: 10.1186/s12913-019-4113-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/22/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Colorectal cancer (CRC) screening is underutilized by Medicaid enrollees and the uninsured. Multiple national and state policies were enacted from 2010 to 2014 to increase access to Medicaid and to promote CRC screening among Medicaid enrollees. We aimed to determine the impact of these policies on screening initiation among newly enrolled Oregon Medicaid beneficiaries age-eligible for CRC screening. METHODS We identified national and state policies affecting Medicaid coverage and preventive services in Oregon during 2010-2014. We used Oregon Medicaid claims data from 2010 to 2015 to conduct a cohort analysis of enrollees who turned 50 and became age-eligible for CRC screening (a prevention milestone, and an age at which guideline-concordant screening can be assessed within a single year) during each year from 2010 to 2014. We calculated risk ratios to assess whether first year of Medicaid enrollment and/or year turned 50 was associated with CRC screening initiation. RESULTS We identified 14,576 Oregon Medicaid enrollees who turned 50 during 2010-2014; 2429 (17%) completed CRC screening within 12 months after turning 50. Individuals newly enrolled in Medicaid in 2013 or 2014 were 1.58 and 1.31 times more likely, respectively, to initiate CRC screening than those enrolled by 2010. A primary care visit in the calendar year, having one or more chronic conditions, and being Hispanic was also associated with CRC screening initiation. DISCUSSION The increased uptake of CRC screening in 2013 and 2014 is associated with the timing of policies such as Medicaid expansion, enhanced federal matching for preventive services offered to Medicaid enrollees without cost sharing, and formation of Medicaid accountable care organizations, which included CRC screening as an incentivized quality metric.
Collapse
Affiliation(s)
- Meghan C. O’Leary
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1105E McGavran-Greenberg Hall, Chapel Hill, NC 27599 USA
| | - Kristen Hassmiller Lich
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1105E McGavran-Greenberg Hall, Chapel Hill, NC 27599 USA
| | - Yifan Gu
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR USA
| | - Stephanie B. Wheeler
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1105E McGavran-Greenberg Hall, Chapel Hill, NC 27599 USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
- Center for Health Promotion & Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | | | | | - Bonnie K. Lind
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR USA
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR USA
| | - Maria E. Mayorga
- Edward P. Fitts Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC USA
| | - Melinda M. Davis
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR USA
- Department of Family Medicine, Oregon Health & Science University, Portland, OR USA
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR USA
| |
Collapse
|
16
|
King CJ, Moreno J, Coleman SV, Williams JF. Diabetes mortality rates among African Americans: A descriptive analysis pre and post Medicaid expansion. Prev Med Rep 2018; 12:20-24. [PMID: 30128267 PMCID: PMC6097282 DOI: 10.1016/j.pmedr.2018.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 07/31/2018] [Accepted: 08/01/2018] [Indexed: 11/28/2022] Open
Abstract
Background Compared with other racial and ethnic groups, African Americans are disproportionately burdened by high rates of deaths due to diabetes. Insurance coverage and access to primary care are critical for prevention and chronic disease management. Purpose To examine the difference in age-adjusted diabetes mortality rates in African Americans before and after Medicaid expansion. Methods Using ICD-10 Cause List E10–E14, age-adjusted diabetes mortality rates among African Americans were extracted from the Centers for Disease Control and Prevention's Compressed Mortality File. Sufficient and reliable data were available for 36 states and the District of Columbia. With a 95% confidence interval, two periods were analyzed: pre-Medicaid expansion - years 2008, 2009, 2010 and post-Medicaid expansion - years 2014, 2015, 2016. Three-year means for both periods were calculated for each state. Differences for each state are presented and contextualized as a state that opted in or out of expanding Medicaid coverage. Results There was a slight reduction in diabetes mortality in African Americans (41.14/100,000 pre-expansion and 38.94/100,000 post-expansion). We found variability across states – regardless of expansion status. Differences in rates ranged from a decrease of 15.43/100,000 to an increase of 9.53/100,000. Out of all states that met our criteria, 24 states expanded coverage; age-adjusted diabetes death rates declined in 16 of those states. There were also reductions in eight states that did not expand coverage. Conclusion Future research is needed to explore if Medicaid expansion is associated with reductions in diabetes mortality in the African American community. There was a reduction in mean age-adjusted diabetes mortality rates in 24 states after Medicaid expansion. Mean mortality reductions were observed in regions of the country with a high prevalence of diabetes. Mixed findings suggest age-adjusted diabetes mortality reductions in states regardless of Medicaid expansion.
Collapse
Affiliation(s)
- Christopher J King
- Georgetown University, Department of Health Systems Administration, United States of America
| | - Jonathan Moreno
- Georgetown University, Department of Health Systems Administration, United States of America
| | - Susan V Coleman
- Georgetown University, Department of Professional Nurse Practice, United States of America
| | - John F Williams
- Georgetown University, Department of Health Systems Administration, United States of America
| |
Collapse
|