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Cartwright AF, Wallace M, Su J, Curtis S, Angeles G, Speizer IS. Neighborhood-level racialized socioeconomic deprivation and contraceptive use in the United States, 2011-2019. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2024. [PMID: 38853371 DOI: 10.1111/psrh.12269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
INTRODUCTION The social and structural environments where people live are understudied in contraceptive research. We assessed if neighborhood measures of racialized socioeconomic deprivation are associated with contraceptive use in the United States. METHODS We used restricted geographic data from four waves of the National Survey of Family Growth (2011-2019) limited to non-pregnant women ages 15-44 who had sex in the last 12 months. We characterized respondent neighborhoods (census tracts) with the Index of Concentration at the Extremes (ICE), a measure of spatial social polarization, into areas of concentrated privilege (predominantly white residents living on high incomes) and deprivation (predominantly people of color living on low incomes). We used multivariable binary and multinomial logistic regression with year fixed effects to estimate adjusted associations between ICE tertile and contraceptive use and method type. We also assessed for an interactive effect of ICE and health insurance type. RESULTS Of the 14,396 respondents, 88.4% in neighborhoods of concentrated deprivation used any contraception, compared to 92.7% in the most privileged neighborhoods. In adjusted models, the predicted probability of using any contraception in neighborhoods of concentrated deprivation was 2.8 percentage points lower than in neighborhoods of concentrated privilege, 5.0 percentage points higher for barrier/coital dependent methods, and 4.3 percentage points lower for short-acting methods. Those with Medicaid were less likely to use any contraception than those with private insurance irrespective of neighborhood classification. CONCLUSIONS This study highlights the salience of structural factors for contraceptive use and the need for continued examination of structural oppressions to inform health policy.
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Affiliation(s)
- Alice F Cartwright
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Maeve Wallace
- Mary Amelia Center for Women's Health Equity Research, Department of Social, Behavioral, and Population Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Jessica Su
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Sociology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Siân Curtis
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Gustavo Angeles
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ilene S Speizer
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Torabi SJ, Nguyen TV, Du AT, Birkenbeuel JL, Manes RP, Kuan EC. Medicaid Acceptance Varies by Physician Seniority and Specialty in California. Popul Health Manag 2024; 27:185-191. [PMID: 38629631 DOI: 10.1089/pop.2024.0006] [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: 06/21/2024] Open
Abstract
Given varied insurance acceptances and differing pay between insurances, our objective was to examine the number of California physicians enrolled in Medicare and Medicaid (Medi-Cal), stratified by specialty and graduation year. Medi-Cal and Medicare providers were extracted from publicly available databases (Centers for Medicare & Medicaid Services and California Health and Human Services) and were subsequently merged into one dataset using National Provider Identifier. From there, we stratified physicians by specialty and graduation year. We found that emergency medicine, radiology, pathology, anesthesiology, general surgery, and internal medicine had the highest percent of Medi-Cal-accepting physicians, whereas dermatology, psychiatry, physical medicine & rehabilitation, and plastic & reconstructive surgery physicians had the lowest. There also appears to be an inverse relationship between acceptance of Medi-Cal and earlier year of graduation (P < 0.05). This study demonstrated striking variability in Medi-Cal acceptance based upon physician years in practice and specialty. Older, experienced physicians, as well as physicians of certain specialties, are less likely to accept Medi-Cal.
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Affiliation(s)
- Sina J Torabi
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Theodore V Nguyen
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Amy T Du
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, Orange, California, USA
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| | - Jack L Birkenbeuel
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
| | - R Peter Manes
- Department of Surgery (Division of Otolaryngology), Yale University School of Medicine, New Haven, Connecticut, USA
| | - Edward C Kuan
- Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine, Orange, California, USA
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Faiz J, Blegen M, Nuñez V, Gonzalez D, Stokes DC, Truong K, Ryan G, Briggs-Malonson M, Kahn KL. Frontline perspectives on barriers to care for patients with California Medicaid: a qualitative study. Int J Equity Health 2024; 23:102. [PMID: 38778347 PMCID: PMC11110184 DOI: 10.1186/s12939-024-02174-8] [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: 12/22/2023] [Accepted: 04/05/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND While insurance is integral for accessing healthcare in the US, coverage alone may not ensure access, especially for those publicly insured. Access barriers for Medicaid-insured patients are rooted in social drivers of health, insurance complexities in the setting of managed care plans, and federal- and state-level policies. Elucidating barriers at the health system level may reveal opportunities for sustainable solutions. METHODS To understand barriers to ambulatory care access for patients with Medi-Cal (California's Medicaid program) and identify improvement opportunities, we performed a qualitative study using semi-structured interviews of a referred sample of clinicians and administrative staff members experienced with clinical patient encounters and/or completion of referral processes for patients with Medi-Cal (n = 19) at a large academic medical center. The interview guide covered the four process steps to accessing care within the health system: (1) scheduling, (2) referral and authorization, (3) contracting, and (4) the clinical encounter. We transcribed and inductively coded the interviews, then organized themes across the four steps to identify perceptions of barriers to access and improvement opportunities for ambulatory care for patients with Medi-Cal. RESULTS Clinicians and administrative staff members at a large academic medical center revealed barriers to ambulatory care access for Medi-Cal insured patients, including lack of awareness of system-level policy, complexities surrounding insurance contracting, limited resources for social support, and poor dissemination of information to patients. Particularly, interviews revealed how managed Medi-Cal impacts academic health systems through additional time and effort by frontline staff to facilitate patient access compared to fee-for-service Medi-Cal. Interviewees reported that this resulted in patient care delays, suboptimal care coordination, and care fragmentation. CONCLUSIONS Our findings highlight gaps in system-level policy, inconsistencies in pursuing insurance authorizations, limited resources for scheduling and social work support, and poor dissemination of information to and between providers and patients, which limit access to care at an academic medical center for Medi-Cal insured patients. Many interviewees additionally shared the moral injury that they experienced as they witnessed patient care delays in the absence of system-level structures to address these barriers. Reform at the state, insurance organization, and institutional levels is necessary to form solutions within Medi-Cal innovation efforts.
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Affiliation(s)
- Jessica Faiz
- National Clinician Scholars Program, VA Greater Los Angeles Healthcare System and UCLA, 1100 Glendon Ave., Ste. 1100, 90024, Los Angeles, CA, USA.
- Department of Emergency Medicine, David Geffen School of Medicine, UCLA, 757 Westwood Plaza, Ste. 1320, 90024, Los Angeles, CA, USA.
| | - Mariah Blegen
- National Clinician Scholars Program, VA Greater Los Angeles Healthcare System and UCLA, 1100 Glendon Ave., Ste. 1100, 90024, Los Angeles, CA, USA
- Department of Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave., 72-227 CHS, 90025, Los Angeles, CA, USA
| | - Vanessa Nuñez
- David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Ste. 7419, 90095, Los Angeles, CA, USA
| | - Daniel Gonzalez
- Department of Medicine, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Ste. 7419, 90095, Los Angeles, CA, USA
| | - Daniel C Stokes
- Department of Medicine, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Ste. 7419, 90095, Los Angeles, CA, USA
| | - Kevin Truong
- Department of Medicine, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Ste. 7419, 90095, Los Angeles, CA, USA
| | - Gery Ryan
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, 100 S Los Robles Ave, Ste. 300, 91101, Pasadena, CA, USA
| | - Medell Briggs-Malonson
- Department of Emergency Medicine, David Geffen School of Medicine, UCLA, 757 Westwood Plaza, Ste. 1320, 90024, Los Angeles, CA, USA
| | - Katherine L Kahn
- Department of Medicine, David Geffen School of Medicine at UCLA, 757 Westwood Plaza, Ste. 7419, 90095, Los Angeles, CA, USA
- RAND Health, RAND Corporation, 1776 Main St., 90401, Santa Monica, CA, USA
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Marr J, Polsky D, Meiselbach MK. Commercial Insurer Market Power and Medicaid Managed Care Networks. Med Care Res Rev 2024:10775587241241975. [PMID: 38577807 DOI: 10.1177/10775587241241975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Over 70% of Medicaid beneficiaries are enrolled in Medicaid managed care (MMC). MMC provider networks therefore represent a critical determinant of access to the Medicaid program. Many MMC insurers also participate in commercial insurance markets where prices are high, and some insurers exercise considerable market power. In this paper, we examined the relationship between commercial insurer market power and MMC physician network breadth using linked national enrollment data and provider directory data. Insurers with more commercial market power had broader Medicaid physician networks. Insurers with over 30% market share had 37.3% broader Medicaid networks than insurers in the same county that had no commercial market share. These differences were driven by greater breadth among primary care providers, as well as other specialists including OB/GYNs, surgeons, neurologists, and cardiologists. Commercial insurance market power may have spillovers on access to care for MMC beneficiaries.
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Affiliation(s)
- Jeffrey Marr
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Daniel Polsky
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins Carey School of Business, Baltimore, MD, USA
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Busch SH, Kyanko K. Patients' Reasons for Using Out-of-Network Mental and General Medical Health Providers. Psychiatr Serv 2024:appips20230212. [PMID: 38444357 DOI: 10.1176/appi.ps.20230212] [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] [Indexed: 03/07/2024]
Abstract
OBJECTIVE The authors sought to assess why patients use out-of-network health care providers and whether patients' reasons differ for mental and general medical health providers. METHODS In a national Internet survey of commercial plan enrollees (N=713) who used an out-of-network provider, participants indicated whether 12 reasons were "important" (vs. "not applicable" or "not important") in their decision to see an out-of-network provider. RESULTS Reasons for using out-of-network care were multifactorial. Six reasons were similarly important, including the three most-cited reasons: convenient location (66% vs. 69% for mental vs. general medical health, respectively), higher quality (65% vs. 69%), and affordability (70% vs. 71%). Reasons more commonly cited for using out-of-network mental health care were that in-network providers were not taking new patients (34% vs. 24%), confidentiality (33% vs. 19%), cultural competence (33% vs. 23%), and inaccurate in-network provider directories (30% vs. 22%). CONCLUSIONS The most common reasons for using out-of-network care were cited with similar frequency for both mental health and general medical health providers.
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Affiliation(s)
- Susan H Busch
- Department of Health Policy and Management, Yale School of Public Health, New Haven (Busch); Department of Population Health, New York University School of Medicine, New York City (Kyanko)
| | - Kelly Kyanko
- Department of Health Policy and Management, Yale School of Public Health, New Haven (Busch); Department of Population Health, New York University School of Medicine, New York City (Kyanko)
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Adams EK, Kramer MR, Joski PJ, Coloske M, Dunlop AL. Examination of the Black-White racial disparity in severe maternal morbidity among Georgia deliveries, 2016 to 2020. AJOG GLOBAL REPORTS 2024; 4:100303. [PMID: 38283324 PMCID: PMC10811457 DOI: 10.1016/j.xagr.2023.100303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Studies find that delivery hospital explains a significant portion of the Black-White gap in severe maternal morbidity. No such studies have focused on the US Southeast, where racial disparities are widest, and few have examined the relative contribution of hospital, residential, and maternal factors. OBJECTIVE This study aimed to estimate the portion of Georgia's Black-White gap in severe maternal morbidity during delivery through 42 days postpartum explained by hospital, residential, and maternal factors. STUDY DESIGN Using linked Georgia hospital discharge, birth, and fetal death records for 2016 through 2020, we identified 413,124 deliveries to non-Hispanic White (229,357; 56%) or Black (183,767; 44%) individuals. We linked hospital data from the American Hospital Association and Center for Medicare and Medicaid Services, and area data from the Area Resource File and American Community Survey. We identified severe maternal morbidity indicator conditions during delivery or subsequent hospitalizations through 42 days postpartum. Using race-specific logistic models followed by a decomposition technique, we estimated the portion of the Black-White severe maternal morbidity gap explained by the following: (1) sociodemographic factors (age, education, marital status, and nativity), (2) medical conditions (diabetes mellitus, gestational diabetes, chronic hypertension, gestational hypertension or preeclampsia, and smoking), (3) obstetrical factors (singleton or multiple, and birth order); (4) access to care (no or third trimester care, and payer), (5) hospital factors that are time-varying (delivery volume, deliveries per full-time equivalent nurse, doctor communication, patient safety, and adverse event composite score) or measured time-invariant characteristics (ownership, profit status, religious affiliation, teaching status, and perinatal level), and (6) residential factors (county urban/rural classification, percent uninsured women of reproductive age, obstetrician-gynecologists per women of reproductive age, number of federally-qualified and community health centers, medically-underserved area [yes/no], and census tract neighborhood deprivation index). We estimated models with and without hospital fixed-effects, which account for unobserved time-invariant hospital characteristics such as within-hospital care processes or unmeasured hospital-specific factors. RESULTS There was 1.8 times the rate of severe maternal morbidity per 100 discharges among non-Hispanic Black (3.15) than among White (1.73) individuals, with an explained proportion of 30.4% in models without and 49.8% in models with hospital fixed-effects. In the latter, hospital fixed-effects explained the largest portion of the Black-White severe maternal morbidity gap (15.1%) followed by access to care (14.9%) and sociodemographic factors (14.4%), with residential factors being protective for Black individuals (-7.5%). Smaller proportions were explained by medical (5.6%), obstetrical (4.0%), and time-varying hospital factors (3.2%). Within each category, the largest explanatory portion was payer type (13.3%) for access to care, marital status (10.3%) for sociodemographic, gestational hypertension (3.3%) for medical, birth order (3.6%) for obstetrical, and patient safety indicator (3.1%) for time-varying hospital factors. CONCLUSION Models with hospital fixed-effects explain a greater proportion of Georgia's Black-White severe maternal morbidity gap than models without them, thereby supporting the point that differences in care processes or other unmeasured factors within the same hospital translate into racial differences in severe maternal morbidity during delivery through 42 days postpartum. Research is needed to discern and ameliorate sources of within-hospital differences in care. The substantial proportion of the gap attributable to racial differences in access to care and sociodemographic factors points to other needed policy interventions.
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Affiliation(s)
- E. Kathleen Adams
- Department of Health Policy and Management, Rollins School of Public Health Emory University, Atlanta, GA (Dr Adams, Mr Joski, and Ms Coloske)
| | - Michael R. Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University Atlanta, GA (Dr Kramer)
| | - Peter J. Joski
- Department of Health Policy and Management, Rollins School of Public Health Emory University, Atlanta, GA (Dr Adams, Mr Joski, and Ms Coloske)
| | - Marissa Coloske
- Department of Health Policy and Management, Rollins School of Public Health Emory University, Atlanta, GA (Dr Adams, Mr Joski, and Ms Coloske)
| | - Anne L. Dunlop
- Department of Gynecology and Obstetrics, School of Medicine, Emory University Atlanta, GA (Dr Dunlop)
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Eck CS, Ho V, Jiang C, Petersen LA. Determinants of referral network size for screening colonoscopies in the Veterans Health Administration after the implementation of the MISSION Act. Health Serv Res 2024; 59:e14239. [PMID: 37750017 PMCID: PMC10771900 DOI: 10.1111/1475-6773.14239] [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: 09/27/2023] Open
Abstract
OBJECTIVE To measure key characteristics of the Veterans Health Administration's (VHA) Community Care (CC) referral network for screening colonoscopy and identify market and institutional factors associated with network size. DATA SOURCES VHA electronic health records, CC claim data, and National Plan and Provider Enumeration System. STUDY DESIGN In this retrospective cross-sectional study, we measure the size of the VHA's CC referral networks over time and by VHA parent facility (n = 137). We used a multivariable linear regression to identify factors associated with network size at the market-year level. Network size was measured as the number of physicians who performed at least one VHA-purchased screening colonoscopy per 1000 enrollees at baseline. DATA EXTRACTION Data were extracted for all Veterans (n = 102,119) who underwent a screening colonoscopy purchased by the VHA from a non-VHA physician from 2018 to 2021. PRINCIPAL FINDINGS From 2018 to 2021, median network volume of screening colonoscopies per 1000 enrollees grew from 1.6 (IQR: 0.6, 4.6) to 3.6 (IQR: 1.6, 6.6). The median network size grew from 0.63 (IQR: 0.30, 1.26) to 0.92 (IQR: 0.57, 1.63). Finally, the median procedures per physician increased from 2.5 (IQR: 1.6, 4.2) to 3.2 (IQR: 2.4, 4.7). After adjusting for baseline market characteristics, volume of screening colonoscopies was positively related to network size (β = 0.15, 95% CI: [0.10, 0.20]), negatively related to procedures per physician (β = -0.12, 95% CI: [-0.18, -0.05]), and positively associated with the percent of rural enrollees (β = 0.01, 95% CI: [0.00, 0.01]). CONCLUSIONS VHA facilities with a higher volume of VHA-purchased screening colonoscopies and more rural enrollees had more non-VHA physicians providing care. Geographic variation in referral networks may also explain differences in the effects of the MISSION Act on access to care and patient outcomes.
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Affiliation(s)
- Chase S. Eck
- Michael E. DeBakey VA Medical CenterHoustonTexasUSA
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt)HoustonTexasUSA
- Section of Health Services Research, Department of MedicineBaylor College of MedicineHoustonTexasUSA
| | - Vivian Ho
- Section of Health Services Research, Department of MedicineBaylor College of MedicineHoustonTexasUSA
- Department of EconomicsRice UniversityHoustonTexasUSA
- Baker Institute for Public PolicyRice UniversityHoustonTexasUSA
| | - Cheng Jiang
- Michael E. DeBakey VA Medical CenterHoustonTexasUSA
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt)HoustonTexasUSA
- Section of Health Services Research, Department of MedicineBaylor College of MedicineHoustonTexasUSA
| | - Laura A. Petersen
- Michael E. DeBakey VA Medical CenterHoustonTexasUSA
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt)HoustonTexasUSA
- Section of Health Services Research, Department of MedicineBaylor College of MedicineHoustonTexasUSA
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Feyman Y, Pizer SD, Shafer PR, Frakt AB, Garrido MM. Measuring restrictiveness of Medicare Advantage networks: A claims-based approach. Health Serv Res 2024; 59:e14255. [PMID: 37953067 PMCID: PMC10771910 DOI: 10.1111/1475-6773.14255] [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: 11/14/2023] Open
Abstract
OBJECTIVE To develop and validate a measure of provider network restrictiveness in the Medicare Advantage (MA) population. DATA SOURCES Prescription drug event data and beneficiary information for Part D enrollees from the Center for Medicare and Medicaid Services, along with prescriber identifiers; geographic variables from the Area Health Resources Files. STUDY DESIGN A prediction model was used to predict the unique number of primary care providers that would have been seen by MA beneficiaries absent network restrictions. The model was trained and validated on Traditional Medicare (TM) beneficiaries. A pseudo-Poisson and a random forest model were evaluated. An observed-to-expected (O/E) ratio was calculated as the number of unique providers seen by MA beneficiaries divided by the number expected based the TM prediction model. Multivariable linear models were used to assess the relationship between network restrictiveness and plan and market factors. DATA COLLECTION/EXTRACTION METHODS Prescription drug event data were obtained for a 20% random sample of beneficiaries enrolled in prescription drug coverage from 2011 to 2017. PRINCIPAL FINDINGS Health Maintenance Organization plans were more restrictive (O/E = 55.5%; 95% CI 55.3%-55.7%) than Health Maintenance Organization-Point of Service plans (67.2%; 95% CI 66.7%-67.8%) or Preferred Provider Organization plans (74.7%; 95% CI 74.3%-75.1%), and rural areas had more restrictive networks (31.6%; 95% CI 29.0%-34.2%) than metropolitan areas (61.5%; 95% CI 61.3%-61.7%). Multivariable results confirmed these findings, and also indicated that increased provider supply was associated with less restrictive networks. CONCLUSIONS We developed a means of estimating provider network restrictiveness in MA from claims data. Our results validate the approach, providing confidence for wider application (e.g., for other markets and specialties) and use for regulation.
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Affiliation(s)
- Yevgeniy Feyman
- Department of Health Law, Policy and ManagementBoston University School of Public HealthBostonMassachusettsUSA
- Partnered Evidence‐Based Policy Resource Center, Boston VA Healthcare SystemBostonMassachusettsUSA
| | - Steven D. Pizer
- Department of Health Law, Policy and ManagementBoston University School of Public HealthBostonMassachusettsUSA
- Partnered Evidence‐Based Policy Resource Center, Boston VA Healthcare SystemBostonMassachusettsUSA
| | - Paul R. Shafer
- Department of Health Law, Policy and ManagementBoston University School of Public HealthBostonMassachusettsUSA
- Partnered Evidence‐Based Policy Resource Center, Boston VA Healthcare SystemBostonMassachusettsUSA
| | - Austin B. Frakt
- Department of Health Law, Policy and ManagementBoston University School of Public HealthBostonMassachusettsUSA
- Partnered Evidence‐Based Policy Resource Center, Boston VA Healthcare SystemBostonMassachusettsUSA
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Melissa M. Garrido
- Department of Health Law, Policy and ManagementBoston University School of Public HealthBostonMassachusettsUSA
- Partnered Evidence‐Based Policy Resource Center, Boston VA Healthcare SystemBostonMassachusettsUSA
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Charlesworth CJ, Nagy D, Drake C, Manibusan B, Zhu JM. Rural and frontier access to mental health prescribers and nonprescribers: A geospatial analysis in Oregon Medicaid. J Rural Health 2024; 40:16-25. [PMID: 37088967 PMCID: PMC10590824 DOI: 10.1111/jrh.12761] [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: 04/25/2023]
Abstract
OBJECTIVE Medicaid enrollees in rural and frontier areas face inadequate access to mental health services, but the extent to which access varies for different provider types is unknown. We assessed access to Medicaid-participating prescribing and nonprescribing mental health clinicians, focusing on Oregon, which has a substantial rural population. METHODS Using 2018 Medicaid claims data, we identified enrollees aged 18-64 with psychiatric diagnoses and specialty mental health providers who billed Medicaid at least once during the study period. We measured both 30- and 60-minute drive time to a mental health provider, and a spatial access score derived from the enhanced 2-step floating catchment area (E2SFCA) approach at the level of Zip Code Tabulation Areas (ZCTAs). Results were stratified for prescribers and nonprescribers, across urban, rural, and frontier areas. RESULTS Overall, a majority of ZCTAs (68.6%) had at least 1 mental health prescriber and nonprescriber within a 30-minute drive. E2SFCA measures demonstrated that while frontier ZCTAs had the lowest access to prescribers (84.3% in the lowest quintile of access) compared to other regions, some frontier ZCTAs had relatively high access to nonprescribers (34.3% in the third and fourth quartiles of access). CONCLUSIONS Some frontier areas with relatively poor access to Medicaid-participating mental health prescribers demonstrated relatively high access to nonprescribers, suggesting reliance on nonprescribing clinicians for mental health care delivery amid rural workforce constraints. Efforts to monitor network adequacy should consider differential access to different provider types, and incorporate methods, such as E2SFCA, to better account for service demand and supply.
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Affiliation(s)
| | - Dylan Nagy
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Coleman Drake
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Brynna Manibusan
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon, USA
| | - Jane M. Zhu
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon, USA
- Division of General Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Denham A, Hill EL, Raven M, Mendoza M, Raz M, Veazie PJ. Is the emergency department used as a substitute or a complement to primary care in Medicaid? HEALTH ECONOMICS, POLICY, AND LAW 2024; 19:73-91. [PMID: 37870129 DOI: 10.1017/s1744133123000270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Policies to decrease low-acuity emergency department (ED) use have traditionally assumed that EDs are a substitute for unavailable primary care (PC). However, such policies can exacerbate ED overcrowding, rather than ameliorate it, if patients use EDs to complement, rather than substitute, their PC use. We tested whether Medicaid managed care enrolees visit the ED for nonemergent and PC treatable conditions to substitute for or to complement PC. Based on consumer choice theory, we modelled county-level monthly ED visit rate as a function of PC supply and used 2012-2015 New York Statewide Planning and Research Cooperative System (SPARCS) outpatient data and non-linear least squares method to test substitution vs complementarity. In the post-Medicaid expansion period (2014-2015), ED and PC are substitutes state-wide, but are complements in highly urban and poorer counties during nights and weekends. There is no evidence of complementarity before the expansion (2012-2013). Analyses by PC provider demonstrate that the relationship between ED and PC differs depending on whether PC is provided by physicians or advanced practice providers. Policies to reduce low-acuity ED use via improved PC access in Medicaid are likely to be most effective if they focus on increasing actual appointment availability, ideally by physicians, in areas with low PC provider supply. Different aspects of PC access may be differently related to low-acuity ED use.
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Affiliation(s)
- Alina Denham
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115, USA
| | - Elaine L Hill
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, USA
| | - Maria Raven
- Department of Emergency Medicine, School of Medicine, University of California, San Francisco, USA
| | - Michael Mendoza
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, USA
- Department of Family Medicine, School of Medicine and Dentistry, University of Rochester, Rochester, USA
| | - Mical Raz
- Department of History, University of Rochester, Rochester, USA
- Department of Medicine, School of Medicine and Dentistry, University of Rochester, Rochester, USA
| | - Peter J Veazie
- Department of Public Health Sciences, School of Medicine and Dentistry, University of Rochester, Rochester, USA
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Vasan A, Kyle MA, Venkataramani AS, Kenyon CC, Fiks AG. Inequities in Time Spent Coordinating Care for Children and Youth With Special Health Care Needs. Acad Pediatr 2023; 23:1526-1534. [PMID: 36918094 PMCID: PMC10495536 DOI: 10.1016/j.acap.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE In the United States, caregivers of children and youth with special health care needs (CYSHCN) must navigate complex, inefficient health care and insurance systems to access medical care. We assessed for sociodemographic inequities in time spent coordinating care for CYSHCN and examined the association between time spent coordinating care and forgone medical care. METHODS This cross-sectional study used data from the 2018-2020 National Survey of Children's Health, which included 102,740 children across all 50 states. We described the time spent coordinating care for children with less complex special health care needs (SHCN) (managed through medications) and more complex SHCN (resulting in functional limitations or requiring specialized therapies). We examined race-, ethnicity-, income-, and insurance-based differences in time spent coordinating care among CYSHCN and used multivariable logistic regression to examine the association between time spent coordinating care and forgone medical care. RESULTS Over 40% of caregivers of children with more complex SHCN reported spending time coordinating their children's care each week. CYSHCN whose caregivers spent ≥ 5 h/wk on care coordination were disproportionately Hispanic, low-income, and publicly insured or uninsured. Increased time spent coordinating care was associated with an increasing probability of forgone medical care: 6.7% for children whose caregivers spent no weekly time coordinating care versus 9.4% for< 1 hour; 11.4% for 1 to 4 hours; and 15.8% for ≥ 5 hours. CONCLUSIONS Reducing time spent coordinating care and providing additional support to low-income and minoritized caregivers may be beneficial for pediatric payers, policymakers, and health systems aiming to promote equitable access to health care for CYSHCN.
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Affiliation(s)
- Aditi Vasan
- Department of Pediatrics (A Vasan, CC Kenyon, and AG Fiks), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; PolicyLab and Center for Pediatric Clinical Effectiveness (A Vasan, CC Kenyon, and AG Fiks), Children's Hospital of Philadelphia, Pa; Leonard Davis Institute of Health Economics (A Vasan, AS Venkataramani, CC Kenyon, and AG Fiks), University of Pennsylvania, Philadelphia, Pa.
| | - Michael Anne Kyle
- Department of Health Care Policy (MA Kyle), Harvard Medical School and Dana Farber Cancer Institute, Boston, Mass.
| | - Atheendar S Venkataramani
- Leonard Davis Institute of Health Economics (A Vasan, AS Venkataramani, CC Kenyon, and AG Fiks), University of Pennsylvania, Philadelphia, Pa; Department of Medical Ethics and Health Policy (AS Venkataramani), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Calif.
| | - Chén C Kenyon
- Department of Pediatrics (A Vasan, CC Kenyon, and AG Fiks), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; PolicyLab and Center for Pediatric Clinical Effectiveness (A Vasan, CC Kenyon, and AG Fiks), Children's Hospital of Philadelphia, Pa; Leonard Davis Institute of Health Economics (A Vasan, AS Venkataramani, CC Kenyon, and AG Fiks), University of Pennsylvania, Philadelphia, Pa.
| | - Alexander G Fiks
- Department of Pediatrics (A Vasan, CC Kenyon, and AG Fiks), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa; PolicyLab and Center for Pediatric Clinical Effectiveness (A Vasan, CC Kenyon, and AG Fiks), Children's Hospital of Philadelphia, Pa; Leonard Davis Institute of Health Economics (A Vasan, AS Venkataramani, CC Kenyon, and AG Fiks), University of Pennsylvania, Philadelphia, Pa.
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Zhu JM, Rumalla KC, Polsky D. New Opportunities to Strengthen Medicaid Managed Care Network Adequacy Standards. JAMA HEALTH FORUM 2023; 4:e233194. [PMID: 37801304 PMCID: PMC10617367 DOI: 10.1001/jamahealthforum.2023.3194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
This Viewpoint discusses new standards proposed by the Centers for Medicare &amp; Medicaid Services for ensuring that Medicare managed care networks meet enrollees’ needs.
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Affiliation(s)
- Jane M Zhu
- Division of General Internal Medicine, Oregon Health & Science University, Portland
| | - Kranti C Rumalla
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Daniel Polsky
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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13
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Hu JC, Cummings JR, Ji X, Wilk AS. State-Level Variation in Medicaid Managed Care Enrollment and Specialty Care for Publicly Insured Children. JAMA Netw Open 2023; 6:e2336415. [PMID: 37796501 PMCID: PMC10556966 DOI: 10.1001/jamanetworkopen.2023.36415] [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] [Received: 06/09/2023] [Accepted: 08/24/2023] [Indexed: 10/06/2023] Open
Abstract
Importance Medicaid and Children's Health Insurance Program cover almost 50% of children with special health care needs (CSHCN). CSHCN often require specialty services and have been increasingly enrolled in Medicaid managed care (MMC) plans, but there is a dearth of recent national studies on specialty care access among publicly insured children and particularly CSHCN. Objective To provide recent, nationwide evidence on the association of MMC penetration with specialty care access among publicly insured children, with a special focus on CSHCN. Design, Setting, and Participants This cross-sectional study used nationally representative data from the 2016 to 2019 National Survey of Children's Health to identify publicly insured children in 41 states that administered comprehensive managed care organizations for Medicaid. Data analysis was performed from May 2022 to March 2023. Exposure Form CMS-416 data were used to measure state-year level share of Medicaid-enrolled children who were covered by MMC (ie, MMC penetration). Main Outcomes and Measures Measures of specialty care access included whether, in the past year, the child had (1) any visit to non-mental health (MH) specialists, (2) any visit to MH professionals, and (3) any unmet health care needs and (4) whether the caregiver ever felt frustrated getting services for their child. Logistic regression models were used to examine the association of MMC penetration with specialty care access among all publicly insured children, and separately for CSHCN and non-CSHCN. Results Among 20 029 publicly insured children, 7164 (35.8%) were CSHCN, 9537 (48.2%) were female, 4110 (37.2%) were caregiver-reported Hispanic, and 2812 (21.4%) were caregiver-reported non-Hispanic Black (all percentages are weighted). MMC was not associated with significant changes in any visit to non-MH specialists and unmet health care needs. In addition, MMC penetration was positively associated with caregiver frustration among all children (adjusted odds ratio, 1.23; 95% CI, 1.03-1.48; P = .02) and was negatively associated with any visit to MH professionals among CSHCN (adjusted odds ratio, 0.75; 95% CI, 0.58-0.98; P = .04). Conclusions and Relevance In this cross-sectional study evaluating MMC and specialty care access for publicly insured children, increased MMC enrollment was not associated with improved specialty care access for publicly insured children, including CSHCN. MMC was associated with less access to specialties like MH and increased frustrations among caregivers seeking services for their children.
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Affiliation(s)
- Ju-Chen Hu
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Now with Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Janet R. Cummings
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Xu Ji
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
- Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Adam S. Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
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14
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Goulding M, Ryan G, Frisard C, Stevens EM, Person S, Goldberg R, Garg A, Lemon SC. Disparities in Receipt of Guideline-adherent Blood Pressure Screening: An Observational Examination of Electronic Health Record Data from a Massachusetts Healthcare System. J Pediatr 2023; 261:113592. [PMID: 37399919 PMCID: PMC10530438 DOI: 10.1016/j.jpeds.2023.113592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 06/19/2023] [Accepted: 06/26/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE To describe the prevalence of blood pressure (BP) screening according to the 2017 American Academy of Pediatrics (AAP) guidelines and differences according to social vulnerability indicators. STUDY DESIGN We extracted electronic health record data from January 1, 2018, through December 31, 2018, from the largest healthcare system in Central Massachusetts. Outpatient visits for children aged 3-17 years without a prior hypertension diagnosis were included. Adherence was defined by the American Academy of Pediatrics guideline (≥1 BP screening for children with a body mass index [BMI] of <95th percentile) and at every encounter for children with a BMI of ≥95th percentile). Independent variables included social vulnerability indicators at the patient level (insurance type, language, Child Opportunity Index, race/ethnicity) and clinic level (location, Medicaid population). Covariates included child's age, sex, and BMI status, and clinic specialty, patient panel size, and number of healthcare providers. We used direct estimation to calculate prevalence estimates and multivariable mixed effects logistic regression to determine the odds of receiving guideline-adherent BP screening. RESULTS Our sample comprised 19 695 children (median age, 11 years; 48% female) from 7 pediatric and 20 family medicine clinics. The prevalence of guideline-adherent BP screening was 89%. In our adjusted model, children with a BMI of ≥95th percentile, with public insurance, and who were patients at clinics with larger Medicaid populations and larger patient panels had a lower odds of receiving guideline-adherent BP screening. CONCLUSIONS Despite overall high adherence to BP screening guidelines, patient- and clinic-level disparities were identified.
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Affiliation(s)
- Melissa Goulding
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA.
| | - Grace Ryan
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA
| | - Christine Frisard
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA
| | - Elise M Stevens
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA
| | - Sharina Person
- Division of Biostatistics and Health Service Research, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA
| | - Robert Goldberg
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA
| | - Arvin Garg
- Department of Pediatrics, Child Health Equity Center, University of Massachusetts Chan Medical School, UMass Memorial Children's Medical Center, Worcester, MA
| | - Stephenie C Lemon
- Division of Preventive and Behavioral Medicine, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA
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Meiselbach MK, Drake C, Zhu JM, Manibusan B, Nagy D, Sorbero MJ, Saloner B, Stein BD, Polsky D. State Policy and the Breadth of Buprenorphine-Prescriber Networks in Medicaid Managed Care. Med Care Res Rev 2023; 80:423-432. [PMID: 37083043 PMCID: PMC10680055 DOI: 10.1177/10775587231167514] [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: 04/22/2023]
Abstract
Provider networks in Medicaid Managed Care (MMC) play a crucial role in ensuring access to buprenorphine, a highly effective treatment for opioid use disorder. Using a difference-in-differences approach that compares network breadth across provider specialties and market segments within the same state, we investigated the association between three Medicaid policies and the breadth of MMC networks for buprenorphine prescribers: Medicaid expansion, substance use disorder (SUD) network adequacy criteria, and SUD carveouts. We found that both Medicaid expansion and SUD network adequacy criteria were associated with substantially increased breadth in buprenorphine-prescriber networks in MMC. In both cases, we found that the associations were largely driven by increases in the network breadth of primary care physician prescribers. Our findings suggest that Medicaid expansion and SUD network adequacy criteria may be effective strategies at states' disposal to improve access to buprenorphine.
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Affiliation(s)
| | | | - Jane M. Zhu
- Oregon Health & Science University, Portland, USA
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16
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Roberts JE, Williams K, Dallas J, Eckert M, Huie L, Smitherman E, Soulsby WD, Zhao Y, Son MBF. Insurance Status and Tumor Necrosis Factor Inhibitor Initiation Among Children With Juvenile Idiopathic Arthritis in the CARRA Registry. J Rheumatol 2023; 50:1047-1057. [PMID: 36521922 PMCID: PMC10303749 DOI: 10.3899/jrheum.220871] [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] [Accepted: 12/06/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Prompt escalation to tumor necrosis factor inhibitors (TNFis) is recommended for children with juvenile idiopathic arthritis (JIA) and ongoing disease activity despite treatment with conventional disease-modifying antirheumatic drugs (cDMARDs). It is unknown whether these recommendations are equitably followed for children with different insurance types. We assessed the association of insurance coverage on the odds and timing of TNFi use. METHODS We conducted a retrospective study of children with newly diagnosed JIA in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry. We compared the odds of starting a TNFi in the first year and time from cDMARD to TNFi initiation between those with public and private insurance. RESULTS We identified 1086 children with new JIA diagnoses. Publicly insured children had significantly higher active joint counts and parent/patient global assessment scores at the enrollment visit. They were also more likely to have polyarticular arthritis compared to those with private insurance. Odds of any TNFi use in the first year did not differ between publicly and privately insured children. Publicly insured children were escalated from cDMARD to TNFi more quickly than privately insured children. CONCLUSION Children who were publicly insured had more severe disease and polyarticular involvement at registry enrollment compared to those who were privately insured. Whereas overall TNFi use did not differ between children with different insurance types, publicly insured children were escalated more quickly, consistent with their increased disease severity. Further research is needed to determine why insurance coverage type is associated with disease severity, including how other socioeconomic factors affect presentation to care.
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Affiliation(s)
- Jordan E Roberts
- J.E. Roberts, MD, MPH, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, and Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, and Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts;
| | - Kathryn Williams
- K. Williams, MS, J. Dallas, BA, M.B.F. Son, MD, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Johnathan Dallas
- K. Williams, MS, J. Dallas, BA, M.B.F. Son, MD, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mary Eckert
- M. Eckert, BS, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Livie Huie
- L. Huie, BA, E. Smitherman, MD, MSc, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Emily Smitherman
- L. Huie, BA, E. Smitherman, MD, MSc, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - William D Soulsby
- W.D. Soulsby, MD, University of California at San Francisco, San Francisco, California
| | - Yongdong Zhao
- Y. Zhao, MD, PhD, Seattle Children's Hospital, University of Washington School of Medicine, and Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, USA
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17
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Zhu JM, Meiselbach MK, Drake C, Polsky D. Psychiatrist Networks In Medicare Advantage Plans Are Substantially Narrower Than In Medicaid And ACA Markets. Health Aff (Millwood) 2023; 42:909-918. [PMID: 37406238 PMCID: PMC10377344 DOI: 10.1377/hlthaff.2022.01547] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
Medicare Advantage now covers twenty-eight million older adults, many of whom have mental health needs. Enrollees are often restricted to providers who participate in a health plan's network, which may present a barrier to care. We used a novel data set linking network service areas, plans, and providers to compare psychiatrist network breadth-the percentage of providers in a given area that are considered "in network" for a plan-across Medicare Advantage, Medicaid managed care, and Affordable Care Act plan markets. We found that nearly two-thirds of psychiatrist networks in Medicare Advantage were narrow (that is, they contained fewer than 25 percent of providers in a network's service area) compared with approximately 40 percent in Medicaid managed care and Affordable Care Act plan markets. We did not observe similar differences in network breadth for primary care physicians or other physician specialists across markets. Amid efforts to strengthen network adequacy, our findings suggest that psychiatrist networks in Medicare Advantage are particularly narrow, which may disadvantage enrollees as they attempt to obtain mental health services.
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Affiliation(s)
- Jane M Zhu
- Jane M. Zhu , Oregon Health & Science University, Portland, Oregon
| | | | - Coleman Drake
- Coleman Drake, University of Pittsburgh, Pittsburgh, Pennsylvania
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18
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Hu JC, Cummings JR, Ji X, Wilk AS. Evaluating Medicaid Managed Care Network Adequacy Standards And Associations With Specialty Care Access For Children. Health Aff (Millwood) 2023; 42:759-769. [PMID: 37276470 PMCID: PMC10706697 DOI: 10.1377/hlthaff.2022.01439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Medicaid managed care plans cover more than 80 percent of Medicaid-enrolled children, including many children with special health care needs (CSHCN). Federal rules require states to set network adequacy standards to improve specialty care access for Medicaid managed care enrollees. Using a quasi-experimental design and 2016-19 National Survey of Children's Health data, we examined the association between quantitative network adequacy standards and access to specialty care among 8,614 Medicaid-enrolled children, including 3,157 with special health care needs, in eighteen states. Outcomes included whether the child had any visit to non-mental health specialists, any visit to mental health professionals, or any unmet health care needs and whether the caregiver ever felt frustrated in getting services for the child in the past year. We observed no association between the adoption of any quantitative network adequacy standard and the above outcomes among Medicaid-enrolled children. Among CSHCN, however, adopting any quantitative standard was positively associated with caregivers feeling frustrated in getting services for the child, especially among CSHCN who visited non-mental health specialists. Without additional interventions, adopting new network adequacy standards may have unintended consequences for CSHCN.
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Affiliation(s)
- Ju-Chen Hu
- Ju-Chen Hu , Emory University, Atlanta, Georgia
| | | | - Xu Ji
- Xu Ji, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
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19
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Johnson E, Axeen S, Vosooghi A, Lam CN, Bluthenthal R, Schneberk T. Interrupted Time Series Analysis: Patient Characteristics and Rates of Opioid-Use-Disorder-Related Emergency Department Visits in the Los Angeles County Public Hospital System during COVID-19. Healthcare (Basel) 2023; 11:healthcare11070979. [PMID: 37046906 PMCID: PMC10093818 DOI: 10.3390/healthcare11070979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/20/2023] [Accepted: 03/26/2023] [Indexed: 03/31/2023] Open
Abstract
The COVID-19 pandemic led to disruptions in care for vulnerable patients, in particular patients with opioid use disorder (OUD). We aimed to examine OUD-related ED visits before and during the COVID-19 pandemic and determine if patient characteristics for OUD-related ED visits changed in the context of the pandemic. We examined all visits to the three public safety net hospital EDs in Los Angeles County from April 2019 to February 2021. We performed interrupted time series analyses examining OUD-related ED visits from Period 1, April 2019 to February 2020, compared with Period 2, April 2020 to February 2021, by race/ethnicity and payor group. We considered OUD-related ED visits as those which included any of the following: discharge diagnosis related to OUD, patients administered buprenorphine or naloxone while in the ED, and visits where a patient was prescribed buprenorphine or naloxone on discharge. There were 5919 OUD-related ED visits in the sample. OUD-related visits increased by 4.43 (2.82–6.03) per 1000 encounters from the pre-COVID period (9.47 per 1000 in February 2020) to the COVID period (13.90 per 1000 in April 2020). This represented an increase of 0.41/1000 by white patients, 0.92/1000 by black patients, and 1.83/1000 by Hispanic patients. We found increases in OUD-related ED visits among patients with Medicaid managed care of 2.23/1000 and in LA County safety net patients by 3.95/1000 ED visits. OUD-related ED visits increased during the first year of the COVID pandemic. These increases were significant among black, white, and Hispanic patients, patients with Medicaid managed care, and LA County Safety net patients. These data suggest public emergency departments served as a stopgap for patients suffering from OUD in Los Angeles County during the pandemic and can be utilized to guide preventative interventions in vulnerable populations.
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Thorndike AL, Peterson L, Spitzer S, Patel S, Smithey A, Moore JE, Cook SC, Chin MH. Advancing health equity through partnerships of state Medicaid agencies, Medicaid managed care organizations, and health care delivery organizations. Front Public Health 2023; 11:1104843. [PMID: 36969681 PMCID: PMC10035573 DOI: 10.3389/fpubh.2023.1104843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/16/2023] [Indexed: 03/11/2023] Open
Abstract
BackgroundReducing health inequities in marginalized populations, including people with Medicaid insurance, requires care transformation to address medical and social needs that is supported and incentivized by tailored payment methods. Collaboration across health care stakeholders is essential to overcome health system fragmentation and implement sustainable reform in the United States (U.S.). This paper explores how multi-stakeholder teams operationalized the Roadmap to Advance Health Equity model during early stages of their journey to (a) build cultures of equity and (b) integrate health equity into care transformation and payment reform initiatives.MethodsAdvancing Health Equity: Leading Care, Payment, and Systems Transformation is a national program in the U.S. funded by the Robert Wood Johnson Foundation that brings together multi-stakeholder teams to design and implement initiatives to advance health equity. Each team consisted of representatives from state Medicaid agencies, Medicaid managed care organizations, and health care delivery organizations in seven U.S. states. Between June and September 2021, semi-structured interviews were conducted with representatives (n = 23) from all seven teams about experiences implementing the Roadmap to Advance Health Equity model with technical assistance from Advancing Health Equity.ResultsFacilitators of building cultures of equity included (1) build upon preexisting intra-organizational cultures of equity, (2) recruit and promote diverse staff and build an inclusive culture, and (3) train staff on health equity and anti-racism. Teams faced challenges building inter-organizational cultures of equity. Facilitators of identifying a health equity focus area and its root causes included (1) use data to identify a health equity focus and (2) overcome stakeholder assumptions about inequities. Facilitators of implementing care transformation and payment reform included (1) partner with Medicaid members and individual providers and (2) support and incentivize equitable care and outcomes with payment. Facilitators of sustainability planning included (1) identify evidence of improved health equity focus and (2) maintain relationships among stakeholders. Teams faced challenges determining the role of the state Medicaid agency.ConclusionsMulti-stakeholder teams shared practical strategies for implementing the Roadmap to Advance Health Equity that can inform future efforts to build intra- and inter-organizational cultures of equity and integrate health equity into care delivery and payment systems.
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Affiliation(s)
- Anna L. Thorndike
- Pritzker School of Medicine, University of Chicago, Chicago, IL, United States
- *Correspondence: Anna L. Thorndike
| | - Lauren Peterson
- Crown Family School of Social Work, Policy, and Practice, University of Chicago, Chicago, IL, United States
| | - Sivan Spitzer
- Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel
| | - Shilpa Patel
- Center for Health Care Strategies, Trenton, NJ, United States
| | - Anne Smithey
- Center for Health Care Strategies, Trenton, NJ, United States
| | - Jennifer E. Moore
- Department of Obstetrics and Gynecology, School of Medicine, University of Michigan, Ann Arbor, MI, United States
- Institute for Medicaid Innovation, Washington, DC, United States
| | - Scott C Cook
- Department of Medicine, University of Chicago, Chicago, IL, United States
| | - Marshall H. Chin
- Department of Medicine, University of Chicago, Chicago, IL, United States
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21
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Govier DJ, Hickok A, Edwards ST, Weaver FM, Gordon H, Niederhausen M, Hynes DM. Early Impact of VA MISSION Act Implementation on Primary Care Appointment Wait Time. J Gen Intern Med 2023; 38:889-897. [PMID: 36307640 PMCID: PMC9616400 DOI: 10.1007/s11606-022-07800-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 09/08/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Through Community Care Networks (CCNs) implemented with the VA MISSION Act, VA expanded provider contracting and instituted network adequacy standards for Veterans' community care. OBJECTIVE To determine whether early CCN implementation impacted community primary care (PC) appointment wait times overall, and by rural/urban and PC shortage area (HPSA) status. DESIGN Using VA administrative data from February 2019 through February 2020 and a difference-in-differences approach, we compared wait times before and after CCN implementation for appointments scheduled by VA facilities that did (CCN appointments) and did not (comparison appointments) implement CCNs. We ran regression models with all appointments, and stratified by rural/urban and PC HPSA status. All models adjusted for Veteran characteristics and VA facility-level clustering. APPOINTMENTS 13,720 CCN and 40,638 comparison appointments. MAIN MEASURES Wait time, measured as number of days from authorization to use community PC to a Veteran's first corresponding appointment. KEY RESULTS Overall, unadjusted wait times increased by 35.7 days ([34.4, 37.1] 95% CI) after CCN implementation. In adjusted analysis, comparison wait times increased on average 33.7 days ([26.3, 41.2] 95% CI, p < 0.001) after CCN implementation; there was no significant difference for CCN wait times (across-group mean difference: 5.4 days, [-3.8, 14.6] 95% CI, p = 0.25). In stratified analyses, comparison wait time increases ranged from 29.6 days ([20.8, 38.4] 95% CI, p < 0.001) to 42.1 days ([32.9, 51.3] 95% CI, p > 0.001) after CCN implementation, while additional differences for CCN appointments ranged from 13.4 days ([3.5, 23.4] 95% CI, p = 0.008) to -15.1 days ([-30.1, -0.1] 95% CI, p = 0.05) for urban and PC HPSA appointments, respectively. CONCLUSIONS After early CCN implementation, community PC wait times increased sharply at VA facilities that did and did not implement CCNs, regardless of rural/urban or PC HPSA status, suggesting community care demand likely overwhelmed VA resources such that CCNs had limited impact.
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Affiliation(s)
- Diana J Govier
- VA Portland Health Care System (VAPORHCS), Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, USA
- OHSU - PSU School of Public Health, Oregon Health & Sciences University & Portland State University, Portland, OR, USA
| | - Alex Hickok
- VA Portland Health Care System (VAPORHCS), Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, USA
| | - Samuel T Edwards
- VA Portland Health Care System (VAPORHCS), Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, USA
- Oregon Health & Sciences University, Portland, OR, USA
| | - Frances M Weaver
- Edward Hines, Jr. VA Hospital, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines, IL, USA
- Loyola University Chicago, Chicago, IL, USA
| | - Howard Gordon
- Edward Hines, Jr. VA Hospital, Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines, IL, USA
- Jesse Brown VA Medical Center, Chicago, IL, USA
- University of Illinois at Chicago, Chicago, IL, USA
| | - Meike Niederhausen
- VA Portland Health Care System (VAPORHCS), Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, USA
- OHSU - PSU School of Public Health, Oregon Health & Sciences University & Portland State University, Portland, OR, USA
- Oregon Health & Sciences University, Portland, OR, USA
| | - Denise M Hynes
- VA Portland Health Care System (VAPORHCS), Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, USA.
- OHSU - PSU School of Public Health, Oregon Health & Sciences University & Portland State University, Portland, OR, USA.
- College of Public Health and Human Sciences and the Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR, USA.
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22
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Jeung C, Attanasio LB, Geissler KH. Transitions in Health Insurance During the Perinatal Period Among Patients With Continuous Insurance Coverage. JAMA Netw Open 2022; 5:e2239803. [PMID: 36322086 PMCID: PMC9631105 DOI: 10.1001/jamanetworkopen.2022.39803] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
IMPORTANCE Although health insurance continuity is important during the perinatal period to improve birth outcomes and reduce maternal morbidity and mortality, insurance disruptions are common. However, little is known about insurance transitions among insurance types for individuals who remained insured during the perinatal period. OBJECTIVE To examine insurance transitions for birthing individuals with continuous insurance, including those with Medicaid and Medicaid managed care coverage, before, during, and after pregnancy. DESIGN, SETTING, AND PARTICIPANTS This cohort study used January 1, 2014 to December 31, 2018 data from the Massachusetts All-Payer Claims Database. The sample included deliveries from January 1, 2015, to December 31, 2017, to birthing individuals aged 18 to 44 years old with continuous insurance for 12 months before and after delivery. Data were analyzed from November 9, 2021, to September 2, 2022. EXPOSURE Insurance type at delivery. MAIN OUTCOMES AND MEASURES The primary outcome was a binary indicator of any transition in insurance type from 12 months before and/or after delivery. The secondary outcomes were measures of any predelivery transition (12 months before delivery month) and any transition during the postpartum period (delivery month to 12 months post partum). Multivariate logit regression models were used to analyze the association of an insurance transition in the perinatal period with insurance type in the delivery month, controlling for age and socioeconomic status based on a 5-digit zip code. RESULTS The analytic sample included 97 335 deliveries (mean [SD] maternal age at delivery, 30.4 [5.5] years). Of these deliveries, 23.4% (22 794) were insured by Medicaid and 28.1% (27 347) by Medicaid managed care in the delivery month. A total of 37.1% of the sample (36 127) had at least 1 insurance transition during the 12 months before and/or after delivery. In regression-adjusted analyses, those individuals covered by Medicaid and Medicaid managed care at delivery were 47.0 (95% CI, 46.3-47.7) percentage points and 50.1 (95% CI, 49.4-50.8) percentage points, respectively, more likely to have an insurance transition than those covered by private insurance. Those covered by Marketplace plans at delivery had a 33.1% (95% CI, 31.4%-34.8%) regression-adjusted predicted probability of having a postpartum insurance transition. CONCLUSIONS AND RELEVANCE Results of this study showed that insurance transitions during the perinatal period occurred for more than 1 in 3 birthing individuals with continuous insurance and were more common among those with Medicaid or Medicaid managed care at delivery. Further research is needed to examine the role of insurance transitions in health care use and outcomes during the perinatal period.
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Affiliation(s)
- Chanup Jeung
- University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst
| | - Laura B. Attanasio
- University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst
| | - Kimberley H. Geissler
- University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst
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23
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Zhu JM, Charlesworth CJ, Polsky D, McConnell KJ. Phantom Networks: Discrepancies Between Reported And Realized Mental Health Care Access In Oregon Medicaid. Health Aff (Millwood) 2022; 41:1013-1022. [PMID: 35787079 PMCID: PMC9876384 DOI: 10.1377/hlthaff.2022.00052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Understanding the extent to which beneficiaries can "realize" access to reported provider networks is imperative in mental health care, where there are significant unmet needs. We compared listings of providers in network directories against provider networks empirically constructed from administrative claims among members who were ages sixty-four and younger and enrolled in Oregon's Medicaid managed care organizations between January 1 and December 31, 2018. "In-network" providers were those with any medical claims filed for at least five unique Medicaid beneficiaries enrolled in a given health plan. They included primary care providers, specialty mental health prescribers, and nonprescribing mental health clinicians. Overall, 58.2 percent of network directory listings were "phantom" providers who did not see Medicaid patients, including 67.4 percent of mental health prescribers, 59.0 percent of mental health nonprescribers, and 54.0 percent of primary care providers. Significant discrepancies between the providers listed in directories and those whom enrollees can access suggest that provider network monitoring and enforcement may fall short if based on directory information.
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Affiliation(s)
- Jane M. Zhu
- Oregon Health & Science University, Portland, Oregon
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24
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DiGiorgio AM, Tantry EK. Commentary: Loss to Follow-up and Unplanned Readmission After Emergent Surgery for Acute Subdural Hematoma. Neurosurgery 2022; 91:e79-e80. [DOI: 10.1227/neu.0000000000002060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 05/10/2022] [Indexed: 11/18/2022] Open
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25
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Inferior Clinical Outcomes for Patients with Medicaid Insurance following Surgery for Degenerative Lumbar Spondylolisthesis: A Prospective Registry Analysis of 608 Patients. World Neurosurg 2022; 164:e1024-e1033. [DOI: 10.1016/j.wneu.2022.05.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 11/19/2022]
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26
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Tawil M, DiGiorgio AM. Competition in California’s Medi-Cal Managed Care Market Assessed by Herfindahl-Hirschman Index. INQUIRY: THE JOURNAL OF HEALTH CARE ORGANIZATION, PROVISION, AND FINANCING 2022; 59:469580221127063. [PMID: 36168304 PMCID: PMC9520176 DOI: 10.1177/00469580221127063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Evaluating market competition is an important practice to assess how the forces and components at play in a select market interact. Healthcare markets are similar to any other market present in the world, where competition can be present or absent in the exchange of goods and services. Applying a standard measure of assessing market competition, the Herfindahl-Hirschman Index, to California’s Medi-Cal managed care marketplace, it is found that there is no competition present in all of California’s counties as defined by the common interpretation of the Herfindahl-Hirschman Index. A distinctive trend in markets is that when less competition is present, the cost of goods and services increases to reflect the principles of supply and demand. California Medi-Cal markets follow this trend of less competitive markets being associated with increased adult midpoint costs. These findings help further to elucidate California’s Medi-Cal marketplace on a county-by county level.
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Affiliation(s)
- Michael Tawil
- School of Medicine, University of California, San Francisco, CA, USA
| | - Anthony M. DiGiorgio
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
- Institute for Health Policy Studies, University of California, San Francisco, CA, USA
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