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Dindinger-Hill K, Horns J, Ambrose J, Vehawn J, Choudry M, Hunt TC, Chipman J, Haaland B, Li J, Hanson HA, O'Neil B. Effect of Health Service Area on Primary Care Physician Provision of Low-Value Cancer Screening. Ann Intern Med 2024; 177:583-591. [PMID: 38648640 DOI: 10.7326/m23-1456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Using a health systems approach to investigate low-value care (LVC) may provide insights into structural drivers of this pervasive problem. OBJECTIVE To evaluate the influence of service area practice patterns on low-value mammography and prostate-specific antigen (PSA) testing. DESIGN Retrospective study analyzing LVC rates between 2008 and 2018, leveraging physician relocation in 3-year intervals of matched physician and patient groups. SETTING U.S. Medicare claims data. PARTICIPANTS 8254 physicians and 56 467 patients aged 75 years or older. MEASUREMENTS LVC rates for physicians staying in their original service area and those relocating to new areas. RESULTS Physicians relocating from higher-LVC areas to low-LVC areas were more likely to provide lower rates of LVC. For mammography, physicians staying in high-LVC areas (LVC rate, 10.1% [95% CI, 8.8% to 12.2%]) or medium-LVC areas (LVC rate, 10.3% [CI, 9.0% to 12.4%]) provided LVC at a higher rate than physicians relocating from those areas to low-LVC areas (LVC rates, 6.0% [CI, 4.4% to 7.5%] [difference, -4.1 percentage points {CI, -6.7 to -2.3 percentage points}] and 5.9% [CI, 4.6% to 7.8%] [difference, -4.4 percentage points {CI, -6.7 to -2.4 percentage points}], respectively). For PSA testing, physicians staying in high- or moderate-LVC service areas provided LVC at a rate of 17.5% (CI, 14.9% to 20.7%) or 10.6% (CI, 9.6% to 13.2%), respectively, compared with those relocating from those areas to low-LVC areas (LVC rates, 9.9% [CI, 7.5% to 13.2%] [difference, -7.6 percentage points {CI, -10.9 to -3.8 percentage points}] and 6.2% [CI, 3.5% to 9.8%] [difference, -4.4 percentage points {CI, -7.6 to -2.2 percentage points}], respectively). Physicians relocating from lower- to higher-LVC service areas were not more likely to provide LVC at a higher rate. LIMITATION Use of retrospective observational data, possible unmeasured confounding, and potential for relocating physicians to practice differently from those who stay. CONCLUSION Physicians relocating to service areas with lower rates of LVC provided less LVC than physicians who stayed in areas with higher rates of LVC. Systemic structures may contribute to LVC. Understanding which factors are contributing may present opportunities for policy and interventions to broadly improve care. PRIMARY FUNDING SOURCE National Cancer Institute of the National Institutes of Health.
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Affiliation(s)
- Kassandra Dindinger-Hill
- Division of Urology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah (K.D., J.V., B.O.)
| | - Joshua Horns
- Departments of Surgery and Population Sciences, University of Utah, Salt Lake City, Utah (J.H., J.A., J.C., B.H., J.L.)
| | - Jacob Ambrose
- Departments of Surgery and Population Sciences, University of Utah, Salt Lake City, Utah (J.H., J.A., J.C., B.H., J.L.)
| | - Jeffrey Vehawn
- Division of Urology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah (K.D., J.V., B.O.)
| | | | - Trevor C Hunt
- Department of Urology, University of Rochester Medical Center, Rochester, New York (T.C.H.)
| | - Jonathan Chipman
- Departments of Surgery and Population Sciences, University of Utah, Salt Lake City, Utah (J.H., J.A., J.C., B.H., J.L.)
| | - Benjamin Haaland
- Departments of Surgery and Population Sciences, University of Utah, Salt Lake City, Utah (J.H., J.A., J.C., B.H., J.L.)
| | - Jiaming Li
- Departments of Surgery and Population Sciences, University of Utah, Salt Lake City, Utah (J.H., J.A., J.C., B.H., J.L.)
| | - Heidi A Hanson
- Departments of Surgery and Population Sciences, University of Utah, Salt Lake City, Utah, and Computational Sciences and Engineering Division, Oak Ridge National Laboratory, Oak Ridge, Tennessee (H.A.H.)
| | - Brock O'Neil
- Division of Urology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah (K.D., J.V., B.O.)
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Nelson DB, Schwarz R, Dar M. Primary Care Sub-capitation in Medicaid: Improving Care Delivery in the Safety Net. J Gen Intern Med 2023; 38:1288-1290. [PMID: 36750508 PMCID: PMC9904520 DOI: 10.1007/s11606-023-08063-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/27/2023] [Indexed: 02/09/2023]
Affiliation(s)
- Daniel B Nelson
- Department of Population Medicine, Harvard Medical School, Boston, MA, USA.
| | - Ryan Schwarz
- Massachusetts Medicaid (MassHealth), Boston, MA, USA
| | - Mohammad Dar
- Massachusetts Medicaid (MassHealth), Boston, MA, USA
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Bell N, Lòpez-De Fede A, Cai B, Brooks J. Geographic proximity to primary care providers as a risk-assessment criterion for quality performance measures. PLoS One 2022; 17:e0273805. [PMID: 36067180 PMCID: PMC9447909 DOI: 10.1371/journal.pone.0273805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 08/15/2022] [Indexed: 11/18/2022] Open
Abstract
Importance Previous studies have found a mixed association between Patient-Centered Medical Home (PCMH) designation and improvements in primary care quality indicators, including avoidable pediatric emergency department (ED) encounters. Whether these associations persist after accounting for the geographic locations of providers relative to where patients reside is unknown. Objective To examine the association between geographic proximity to primary care providers versus hospitals and risk of avoidable and potentially avoidable ED visits among children with pre-existing diagnosis of attention-deficit/hyperactivity disorder or asthma. Methods Retrospective cohort study of a panel of pediatric Medicaid claims data from the South Carolina from 2016–2018 for 2,959 beneficiaries having a pre-existing diagnosis of attention-deficit/hyperactivity disorder (ADD, ages 6–12) and 6,390 beneficiaries with asthma (MMA, ages 5–18), as defined using Healthcare Effectiveness Data and Information Set (HEDIS) performance measures. We calculated differences in avoidable and potentially avoidable ED visits by the beneficiary’s PCMH attribution type and in relation to differences in proximity to their primary care providers versus hospitals. Outcomes were defined using the New York University Emergency Department Algorithm (NYU-EDA). Differences in ED visit risk were assessed using generalized estimation equations and compared using marginal effects models. Results The 2.4 percentage point reduction in risk of avoidable ED visits among children in the ADD cohort who attended a PCMH versus those who did not increased to 3.9 to 7.2 percentage points as relative proximity to primary care providers versus hospitals improved (p < 0.01). Children in the ADD and MMA cohorts that were enrolled in a medical home, but did not attend one for primary care services exhibited a 5.4 and 3.0 percentage point increase in avoidable ED visit compared to children who were unenrolled and did not attend medical homes (p < 0.05), but these differences were only observed when geographic proximity to hospitals was more convenient than primary care providers. Mixed findings were observed for potentially avoidable visits. Conclusions In several health care performance evaluations, patient-centered medical homes have not been found to reduce differences in hospital utilization for conditions that are treatable in primary care settings among children with chronic illnesses. Analytical approaches that also consider geographic proximity to health care services can identify performance benefits of medical homes. Expanding risk-adjustment models to also include geographic data would benefit ongoing quality improvement initiatives.
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Affiliation(s)
- Nathaniel Bell
- College of Nursing, University of South Carolina, Columbia, South Carolina, United States of America
- * E-mail:
| | - Ana Lòpez-De Fede
- Institute for Families in Society, University of South Carolina, Columbia, South Carolina, United States of America
| | - Bo Cai
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States of America
| | - John Brooks
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States of America
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TOBEY RACHEL, MAXWELL JAMES, TURER ERIC, SINGER ERIN, LINDENFELD ZOE, NOCON ROBERTS, COLEMAN ALLISON, BOLTON JOSHUA, HOANG HANK, SRIPIPATANA ALEK, HUANG ELBERTS. Health Centers and Value-Based Payment: A Framework for Health Center Payment Reform and Early Experiences in Medicaid Value-Based Payment in Seven States. Milbank Q 2022; 100:879-917. [PMID: 36252089 PMCID: PMC9576231 DOI: 10.1111/1468-0009.12580] [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: 11/11/2022] Open
Abstract
Policy Points As essential access points to primary care for almost 29 million US patients, of whom 47% are Medicaid enrollees, health centers are positioned to implement the population health management necessary in value-based payment (VBP) contracts. Primary care payment reform requires multiple payment methodologies used together to provide flexibility to care providers, encourage investments in infrastructure and new services, and offer incentives for achieving better health outcomes. State policy and significant financial incentives from Medicaid agencies and Medicaid managed care plans will likely be required to increase health center participation in VBP, which is consistent with broader state efforts to expand investment in primary care. CONTEXT Efforts are ongoing to advance value-based payment (VBP), and health centers serve as essential access points to comprehensive primary care services for almost 29 million people in the United States. Therefore, it is important to assess the levels of health center participation in VBP, types of VBP contracts, characteristics of health centers participating in VBP, and variations in state policy environments that influence VBP participation. METHODS This mixed methods study combined qualitative research on state policy environments and health center participation in VBP with quantitative analysis of Uniform Data System and health center financial data in seven vanguard states: Oregon, Washington, California, Colorado, New York, Hawaii, and Kentucky. VBP contracts were classified into three layers: base payments being transformed from visit-based to population-based (Layer 1), infrastructure and care coordination payments (Layer 2), and performance incentive payments (Layer 3). FINDINGS Health centers in all seven states participated in Layer 2 and Layer 3 VBP, with VBP participation growing from 35% to 58% of all health centers in these states from 2013 to 2017. Among participating health centers, the average percentage of Medicaid revenue received as Layer 2 and Layer 3 VBP rose from 6.4% in 2013 to 9.1% in 2017. Oregon and Washington health centers participating in Layer 1 payment reforms received most of their Medicaid revenue in VBP. In 2017, VBP participation was associated with larger health center size in four states (P <.05), and higher average number of days cash on hand (P <.05) in three states. CONCLUSIONS A multilayer payment model is useful for implementing and monitoring VBP adoption among health centers. State policy, financial incentives from Medicaid agencies and Medicaid managed plans, and health center-Medicaid collaboration under strong primary care association and health center leadership will likely be required to increase health center participation in VBP.
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Affiliation(s)
| | | | | | | | | | | | | | - JOSHUA BOLTON
- US Health Resources and Services Administration
- Author affiliation at time research was conducted
| | - HANK HOANG
- US Health Resources and Services Administration
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Rodriguez MI, Martinez Acevedo A, Swartz JJ, Caughey AB, Valent A, McConnell KJ. Association of Prenatal Care Expansion With Use of Antidiabetic Agents During Pregnancies Among Latina Emergency Medicaid Recipients With Gestational Diabetes. JAMA Netw Open 2022; 5:e229562. [PMID: 35486400 PMCID: PMC9055460 DOI: 10.1001/jamanetworkopen.2022.9562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Access to necessary prenatal care is not guaranteed through Medicaid for some people with low income based on their immigration status. Although states have the option to extend emergency Medicaid coverage for prenatal care, many states have not expanded coverage. OBJECTIVE To evaluate whether the receipt of prenatal care services through the extension of emergency Medicaid coverage is associated with an increase in antidiabetic medication use among Latina patients with gestational diabetes. DESIGN, SETTING, AND PARTICIPANTS This cohort study used linked Medicaid claims and birth certificate data on live births to 4869 Latina patients from October 1, 2010, to December 31, 2019, with a difference-in-differences design to compare the rollout of prenatal care and services in Oregon in 2013 with a comparison state, South Carolina, that did not cover prenatal or postpartum care. EXPOSURE Medicaid coverage of prenatal care. MAIN OUTCOMES AND MEASURES The main outcome was the receipt of antidiabetic agents. Secondary outcomes included hypertensive disorders, cesarean delivery, postpartum contraception, and a newborn morbidity composite outcome (large size for gestational age, neonatal intensive care unit admission, and preterm birth). RESULTS The study sample included live births to 4869 Latina patients (mean [SD] age, 32.7 [5.5] years [range, 12-44 years]) enrolled in emergency Medicaid who were mainly aged 25 to 34 years (1499 of 2907 [51.6%]), multiparous (2626 of 2907 [90.3%]), and living in urban areas (2299 of 2907 [79.1%]). After Oregon's policy change to offer prenatal coverage to individuals receiving emergency Medicaid, there was a large and significant increase in the receipt of antidiabetic agents among all people with diabetes during pregnancy (gestational diabetes). Prior to the policy, only 0.3% of all Latina emergency Medicaid recipients with gestational diabetes (2 of 617) received any medication (oral agents or insulin) to manage their blood glucose level. After the policy change, 28.8% of all patients with gestational diabetes (295 of 1023) received medication to manage their blood glucose level, translating to a 27.9-percentage-point increase (95% CI, 24.5-31.2 percentage points) in the receipt of antidiabetic agents in the adjusted model. The policy was also associated with a 10.4-percentage-point (95% CI, 5.3-15.5 percentage points) increase in insulin use during pregnancy among all patients with gestational diabetes. We observed an increase in postpartum contraceptive use (21.2 percentage points; 95% CI, 14.9-27.5 percentage points), the majority of which was due to postpartum sterilization (increase of 16.1 percentage points; 95% CI, 10.4-21.8 percentage points). We did not observe a significant association with gestational hypertension, cesarean births, or newborn health. CONCLUSIONS AND RELEVANCE This retrospective cohort study suggests that expanded emergency Medicaid benefits that included prenatal care were associated with an increased use of antidiabetic medications and postpartum contraception during pregnancy.
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Affiliation(s)
- Maria I. Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Ann Martinez Acevedo
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Jonas J. Swartz
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Aaron B. Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Amy Valent
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - K. John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
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Rodriguez MI, Kaufman M, Lindner S, Caughey AB, DeFede AL, McConnell KJ. Association of Expanded Prenatal Care Coverage for Immigrant Women With Postpartum Contraception and Short Interpregnancy Interval Births. JAMA Netw Open 2021; 4:e2118912. [PMID: 34338791 PMCID: PMC8329738 DOI: 10.1001/jamanetworkopen.2021.18912] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
IMPORTANCE Access to prenatal and postpartum care is restricted among women with low income who are recent or undocumented immigrants enrolled in Emergency Medicaid. OBJECTIVE To examine the association of extending prenatal care coverage to Emergency Medicaid enrollees with postpartum contraception and short interpregnancy interval births. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a difference-in-differences design to compare the staggered rollout of prenatal care in Oregon with South Carolina, a state that does not cover prenatal or postpartum care. Linked Medicaid claims and birth certificate data from 2010 to 2016 were examined for an association between prenatal care coverage for women whose births were covered by Emergency Medicaid and subsequent short IPI births. Additional maternal and infant health outcomes were also examined, including postpartum contraceptive use, preterm birth, and neonatal intensive care unit admission. The association between the policy change and measures of policy implementation (number of prenatal visits) and quality of care (receipt of 8 guideline-based screenings) was also analyzed. Statistical analysis was performed from August 2020 to March 2021. EXPOSURES Medicaid coverage of prenatal care. MAIN OUTCOMES AND MEASURES Postpartum contraceptive use, defined as receipt of any contraceptive method within 60 days of delivery; short IPI births, defined as occurring within 18 months of a previous pregnancy. RESULTS The study population consisted of 26 586 births to women enrolled in Emergency Medicaid in Oregon and South Carolina. Among these women, 14 749 (55.5%) were aged 25 to 35 years, 25 894 (97.4%) were Black, Hispanic, Native American, Alaskan, Pacific Islander, or Asian women or women with unknown race/ethnicity, and 17 905 (67.3%) lived in areas with urban zip codes. Coverage of prenatal care for women in Emergency Medicaid was associated with significant increases in mean (SD) prenatal visits (increase of 10.3 [0.9] prenatal visits) and prenatal quality. Prenatal care screenings (eg, anemia screening: increase of 65.7 percentage points [95% CI, 54.2 to 77.1 percentage points]) and vaccinations (eg, influenza vaccination: increase of 31.9 percentage points [95% CI, 27.4 to 36.3 percentage points]) increased significantly following the policy change. Although postpartum contraceptive use increased following prenatal care expansion (increase of 1.5 percentage points [95% CI, 0.4 to 2.6 percentage points]), the policy change was not associated with a reduction in short IPI births (-4.5 percentage points [95% CI, -9.5 to 0.5 percentage points), preterm births (-0.6 percentage points [95% CI, -3.2 to 2.0 percentage points]), or neonatal intensive care unit admissions (increase of 0.8 percentage points [95% CI, -2.0 to 3.6 percentage points]). CONCLUSIONS AND RELEVANCE This study found that expanding Emergency Medicaid benefits to include prenatal care significantly improved receipt of guideline-concordant prenatal care. Prenatal care coverage alone was not associated with a meaningful increase in postpartum contraception or a reduction in subsequent short IPI births.
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Affiliation(s)
- Maria I. Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Menolly Kaufman
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Stephan Lindner
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Aaron B. Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Ana Lopez DeFede
- Institute for Families in Society, University of South Carolina, Columbia
| | - K. John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
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Lindner S, McConnell KJ. Heterogeneous treatment effects and bias in the analysis of the stepped wedge design. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2021. [DOI: 10.1007/s10742-021-00244-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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