Medicaid Integrated Purchasing for Physical and Behavioral Health: Early Adopters' Perceptions of Payment Reform Implementation in Washington State

The Centers for Medicare and Medicaid Innovation (CMMI) gave rise to the State Innovation Models (SIMs). Medicaid Integrated Purchasing for Physical and Behavioral Health, referred to as Payment Model 1 (PM1), was a core payment redesign area of the Washington State SIM project under which our research team was contracted to provide an evaluation. In doing so, we leveraged an open systems conceptual model to assess qualitatively Early Adopter stakeholders' perceived effects of implementation. Between 2017 and 2019, we conducted three rounds of interviews, examining themes of care coordination, common facilitators and barriers to integration, and potential concerns for sustaining the initiative into the future. Further, we noted the initiative's complexity may require the establishment of enduring partnerships, secure funding sources, and committed regional leadership to ensure longer-term success.

Intensive care management for high-risk veterans in a patient-centered medical home - do some veterans benefit more than others?

BACKGROUND

Primary care intensive management programs utilize interdisciplinary care teams to comprehensively meet the complex care needs of patients at high risk for hospitalization. The mixed evidence on the effectiveness of these programs focuses on average treatment effects that may mask heterogeneous treatment effects (HTEs) among subgroups of patients. We test for HTEs by patients' demographic, economic, and social characteristics.

METHODS

Retrospective analysis of a VA randomized quality improvement trial. 3995 primary care patients at high risk for hospitalization were randomized to primary care intensive management (n = 1761) or usual primary care (n = 1731). We estimated HTEs on ED and hospital utilization one year after randomization using model-based recursive partitioning and a pre-versus post-with control group framework. Splitting variables included administratively collected demographic characteristics, travel distance, copay exemption, risk score for future hospitalizations, history of hospital discharge against medical advice, homelessness, and multiple residence ZIP codes.

RESULTS

There were no average or heterogeneous treatment effects of intensive management one year after enrollment. The recursive partitioning algorithm identified variation in effects by risk score, homelessness, and whether the patient had multiple residences in a year. Within each distinct subgroup, the effect of intensive management was not statistically significant.

CONCLUSIONS

Primary care intensive management did not affect acute care use of high-risk patients on average or differentially for patients defined by various demographic, economic, and social characteristics.

IMPLICATIONS

Reducing acute care use for high-risk patients is complex, and more work is required to identify patients positioned to benefit from intensive management programs.

A conceptual model of health insurance stability in the United States health care system

In the U.S. health care system, people under age 65 are at risk of losing and regaining health insurance coverage over their lifetimes, which has important consequences for their physical and mental health. Despite the importance of insurance stability, we have an incomplete understanding about the complex factors influencing whether people lose and regain coverage. To advance our understanding of the dynamics of health insurance coverage and guide future research, our purpose is to present a new conceptual model of health insurance stability, where instability is defined as a person’s loss or change of coverage, which can occur more than once in a lifetime. Drawing from theory and evidence in the literature, we posit that personal and plan characteristics, the health system, and the environmental context – economic, social/cultural, political/judicial, and geographic – drive health insurance stability over the life course and are understudied. Studies are needed to identify the populations most at risk of experiencing insurance instability and vulnerability in health outcomes that results from such insecurity, which may suggest reforms and health policies at the individual, health system, or environment levels to reduce those risks.

Analytic Approaches to Assess the Impact of Local Spending on Sexually Transmitted Diseases

OBJECTIVE

To compare the estimated associations between annual STD (sexually transmitted diseases) expenditures per capita and STD rates among Florida and Washington local health departments (LHDs) from 2001-2017, using two approaches--a longitudinal regression model with lagged STD spending, and a regression model with the Arellano-Bond panel estimator.

DATA SOURCES

Secondary data for LHDs were obtained from Florida and Washington state government offices and combined with county sociodemographic and health system data from the federal government.

STUDY DESIGN

We examined LHDs in Florida and Washington using a longitudinal panel study design to estimate ecological relationships between annual STD expenditures per capita and annual STD incidence rates from 2001 to 2017 with LHDs as the unit of analysis. We compared two regression models: generalized estimating equations (GEE) and the Arellano-Bond panel estimator (an instrumental variable approach).

DATA COLLECTION

The secondary data were combined to build a longitudinal panel database for LHDs in Florida and Washington from 2001 to 2017.

PRINCIPAL FINDINGS

In the GEE model with both states, greater STD spending in a prior year was associated unexpectedly with greater STD incidence rates in succeeding years. The Arellano-Bond models for both states had the expected inverse associations but were not significant. In the Arellano-Bond models for Florida, a $1 increase in STD spending in previous years was followed by decreases in STD incidence rates ranging between 29 and 59 points in succeeding years (0.09 ≥ p ≥ 0.04).

CONCLUSIONS

In longitudinal panel data for LHDs in two states, the Arellano-Bond estimator, or other instrumental variable approach, is preferred over conventional regression models to obtain unbiased estimates of the relationship between annual STD spending rates and annual STD rates. Future studies will require accurate, standardized, and detailed longitudinal data and rigorous analytic approaches, such as those illustrated in our study. This article is protected by copyright. All rights reserved.

The one-year impact of accountable care networks among Washington State employees

OBJECTIVE

To estimate the impact of a new, two-sided risk model accountable care network (ACN) on Washington State employees and their families.

DATA SOURCES/STUDY SETTING

Administrative data (January 2013-December 2016) on Washington State employees.

STUDY DESIGN

We compared monthly health care utilization, health care intensity as measured through proxy pricing, and annual HEDIS quality metrics between the five intervention counties to 13 comparison counties, analyzed separately by age categories (ages 0-5, 6-18, 19-26, 18-64).

DATA COLLECTION/EXTRACTION METHODS

We used difference-in-difference methods and generalized estimating equations to estimate the effects after 1 year of implementation for adults and children.

PRINCIPAL FINDINGS

We estimate a 1-2 percentage point decrease in outpatient hospital visits due to the introduction of ACNs (adults: -1.8, P < .01; age 0-5: -1.2, P = .07; age 6-18: -1.2, P = .06; age 19-26; -1.2, P < .01). We find changes in primary and specialty care office visits; the direction of impact varies by age. Dependents age 19-26 were also responsive with inpatient admissions declines (-0.08 percentage points, P = .02). Despite changes in utilization, there was no evidence of changes in intensity of care and mixed results in the quality measures.

CONCLUSIONS

Washington's state employee ACN introduction changed health care utilization patterns in the first year but was not as successful in improving quality.

Statewide Evaluation of Washington's State Innovation Model Initiative: A Mixed-Methods Approach

The Washington State Innovation Model (SIM) $65 million Test Award from the Center for Medicare and Medicaid Innovation is a statewide intervention expected to improve population health, quality of care, and cost growth through 4 initiatives in 2016-2018: (1) regional accountable communities of health linking health and social services to address local needs; (2) a practice transformation support hub; (3) four value-based payment reform pilot projects mainly in state employee and Medicaid populations; and (4) data and analytic infrastructure development to support system transformation with common measures. A mixed-methods study design and data from the 2013-2018 Behavioral Risk Factor Surveillance System Surveys are used to estimate whether SIM resulted in changes in access to care, health behaviors, and health status in Washington's adult population. Semi-structured qualitative interviews also were conducted to assess stakeholder perceptions of SIM performance. SIM may have reduced binge drinking, but no effects were detected for heavy drinking, physical activity, smoking, having a regular doctor checkup, unmet health care needs, and fair or poor health status. Complex interventions, such as SIM, may have unintended consequences. SIM was associated unexpectedly with increased unhealthy days, but whether the association was related to the Initiative or other factors is unclear. Over 3 years, stakeholders generally agreed that SIM was implemented successfully and increased Washington's readiness for system transformation but had not yet produced expected outcomes, partly because SIM had not spread statewide. Stakeholders perceived that scaling up SIM statewide takes time to achieve and remains challenging.

Burnout and Patient Referral Among Primary Care Providers in Veterans Affairs Patient Aligned Care Teams (VA PACTs)

Using the Veterans Health Administration's 2018 national provider and staff survey, this study describes the practice patterns of 1453 primary care providers for specialty care consults, program referrals, secure messaging, and telephone visits; and examines whether the practice patterns are associated with provider burnout in primary care teamlets. About 51% of providers experienced moderate to severe burnout and 22% had severe burnout. Providers who embraced all 4 practice approaches had lower odds of severe burnout than providers endorsing none of the approaches (odds ratio range, 0.35-0.39). Associations were weaker for providers with moderate to severe burnout.

State-Level Evaluation of Washington's State Innovation Models (SIM) Initiative

The Washington State Innovation Models (SIM) $65 million Test Award from the Center for Medicare &amp; Medicaid Services' Innovation Center is a statewide intervention expected to improve population health, quality of care, and cost growth through four initiatives: 1) regional accountable communities of health linking health and social services to address local needs; 2) a practice transformation support hub; 3) four value-based payment reform pilot projects mainly in state employee and Medicaid populations; and 4) data and analytic infrastructure development to support system transformation with common measures. We develop a conceptual model based on diffusion theory and apply the RE-AIM evaluation framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance) to structure our evaluation. We find that in three years (2016-2018), SIM built the infrastructure for system transformation and increased Washington's readiness for health system change in the next decade. However, the initiatives have not spread statewide, which may take over 10 years.

The 10 Conditions That Increased Vermont's Readiness to Implement Statewide Health System Transformation

Following an arduous, 6-year policy-making process, Vermont is the first state implementing a unified, statewide all-payer integrated delivery system with value-based payment, along with aligned medical and social service reforms, for almost all residents and providers in a state. Commercial, Medicare, and Medicaid value-based payment for most Vermonters will be administered through a new statewide accountable care organization in 2018-2022. The purpose of this article is to describe the 10 conditions that increased Vermont's readiness to implement statewide system transformation. The authors reviewed documents, conducted internet searches of public information, interviewed key informants annually in 2014-2016, cross-validated factual and narrative interpretation, and performed content analyses to derive conditions that increased readiness and their implications for policy and practice. Four social conditions (leadership champions; a common vision; collaborative culture; social capital and collective efficacy) and 6 support conditions (money; statewide data; legal infrastructure; federal policy promoting payment reform; delivery system transformation aligned with payment reform; personnel skilled in system reform) increased Vermont's readiness for system transformation. Vermont's experience indicates that increasing statewide readiness for reform is slow, incremental, and exhausting to overcome the sheer inertia of large fee-based systems. The new payments may work because statewide, uniform population-based payment will affect the health care of almost all Vermonters, creating statewide, uniform provider incentives to reduce volume and making the current fee-based system less viable. The conditions for readiness and statewide system transformation may be more likely in states with regulated markets, like Vermont, than in states with highly competitive markets.

Inflammatory Bowel Disease (IBD) pharmacotherapy and the risk of serious infection: a systematic review and network meta-analysis

BACKGROUND

The magnitude of risk of serious infections due to available medical therapies of inflammatory bowel disease (IBD) remains controversial. We conducted a systematic review and network meta-analysis of the existing IBD literature to estimate the risk of serious infection in adult IBD patients associated with available medical therapies.

METHODS

Studies were identified by a literature search of PubMed, Cochrane Library, Medline, Web of Science, Scopus, EMBASE, and ProQuest Dissertations and Theses. Randomized controlled trials comparing IBD medical therapies with no restrictions on language, country of origin, or publication date were included. A network meta-analysis was used to pool direct between treatment comparisons with indirect trial evidence while preserving randomization.

RESULTS

Thirty-nine articles fulfilled the inclusion criteria; one study was excluded from the analysis due to disconnectedness. We found no evidence of increased odds of serious infection in comparisons of the different treatment strategies against each other, including combination therapy with a biologic and immunomodulator compared to biologic monotherapy. Similar results were seen in the comparisons between the newer biologics (e.g. vedolizumab) and the anti-tumor necrosis factor agents.

CONCLUSIONS

No treatment strategy was found to confer a higher risk of serious infection than another, although wide confidence intervals indicate that a clinically significant difference cannot be excluded. These findings provide a better understanding of the risk of serious infection from IBD pharmacotherapy in the adult population.

PROSPERO REGISTRATION

The protocol for this systematic review was registered on PROSPERO ( CRD42014013497 ).

Ethnic and gender variations in the associations between family cohesion, family conflict, and depression in older Asian and Latino adults

To examine the associations between family conflict, family cohesion and late-life depression in Latino and Asian populations and test if these associations vary by race/ethnicity and gender. We used a subsample of older adults from the National Latino Asian American Study (N = 395). All analyses were weighted and adjusted for individual and clinical characteristics. Greater family cohesion was associated with decrease in risk for depression in Latino and Asian older adult populations (OR: 0.68, 95% CI: 0.54, 0.84). These associations varied by gender, with men being more sensitive to family cohesion and family conflict than women. Asian older adults were more sensitive to family conflict, whereas Latino older adults were more sensitive to family cohesion. The quality of family relationships is strongly associated with late-life depression. Further research is needed to better understand the complex interplay between social support, ethnicity, and gender in latelife depression outcomes.

Health Outcomes of Population-Based Pharmacy Outreach to Increase Statin Use for Prevention of Cardiovascular Disease in Patients with Diabetes

BACKGROUND

In 2003, Group Health implemented a pharmacy-based, systemwide outreach effort to increase the preventive use of statins and angiotensin-converting enzyme inhibitors in enrollees at risk for cardiovascular disease, including all enrollees with diabetes.

OBJECTIVE

To estimate the associations between the use of statins and major vascular events and the total costs in 2006-2010 for enrollees with diabetes, using a pharmacy-based, systemwide outreach.

METHODS

In a 14-year (1997-2010) longitudinal cohort study design, the study population consisted of 6,975 Group Health enrollees with type 1 or type 2 diabetes, who were enrolled continuously and had no statin use before the Group Health outreach in 1997-2002. Health outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction, and stroke. Statin exposure was measured by cumulative statin use since 2003, weighted by the effect of the statin type and dose on the lowering of low-density lipoprotein levels. Regression models estimated associations between cumulative statin use, health outcomes, and total costs in 2006-2010.

RESULTS

Among enrollees with no statin use before outreach began in 2003, about half had no or low exposure to statins by the end of 2005. In 2006-2010, cumulative statin use was greater among enrollees with risk factors for cardiovascular disease. Greater statin use was related to lower cardiovascular deaths and incidence of stroke and myocardial infarction, greater but nonsignificant all-cause mortality, and unrelated to total costs.

CONCLUSIONS

Population-based pharmacy outreach increased statin use for eligible enrollees with diabetes, which was related to better cardiovascular outcomes. Generally, statin use was unrelated to all-cause mortality and total costs.

DISCLOSURES

This study was funded by Grant No. R21 HS019501 from the Agency for Healthcare Research and Quality (AHRQ) and was conducted as part of the AHRQ announcement Optimizing Prevention and Healthcare Management for the Complex Patient (R21; RFA-HS-10-009). Ralston and Anderson are employees of Group Health and the Group Health Research Institute, which provided the data for this study. Study concept and design were contributed by Grembowski, Ralston, and Anderson. Anderson assisted with data collection and analysis, and data interpretation was performed by Anderson, along with Grembowski and Ralston. The manuscript was prepared by Grembowski, along with Ralston and Anderson.

The facilitators and barriers associated with implementation of a patient-centered medical home in VHA

BACKGROUND

The patient-centered medical home (PCMH) is a team-based, comprehensive model of primary care. When effectively implemented, PCMH is associated with higher patient satisfaction, lower staff burnout, and lower hospitalization for ambulatory care-sensitive conditions. However, less is known about what factors contribute to (or hinder) PCMH implementation. We explored the associations of specific facilitators and barriers reported by primary care employees with a previously validated, clinic-level measure of PCMH implementation, the Patient Aligned Care Team Implementation Progress Index (Pi(2)).

METHODS

We used a 2012 survey of primary care employees in the Veterans Health Administration to perform cross-sectional, respondent-level multinomial regressions. The dependent variable was the Pi(2) categorized as high implementation (top decile, 54 clinics, 235 respondents), medium implementation (middle eight deciles, 547 clinics, 4537 respondents), and low implementation (lowest decile, 42 clinics, 297 respondents) among primary care clinics. The independent variables were ordinal survey items rating 19 barriers to patient-centered care and 10 facilitators of PCMH implementation. For facilitators, we explored clinic Pi(2) score decile both as a function of respondent-reported availability of facilitators and of rating of facilitator helpfulness.

RESULTS

The availability of five facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile: teamlet huddles (OR = 3.91), measurement tools (OR = 3.47), regular team meetings (OR = 2.88), information systems (OR = 2.42), and disease registries (OR = 2.01). The helpfulness of four facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile. Six barriers were associated with significantly higher odds of a respondent's clinic's Pi(2) scores being in the lowest versus highest decile, with the strongest associations for the difficulty recruiting and retaining providers (OR = 2.37) and non-provider clinicians (OR = 2.17). Results for medium versus low Pi(2) score clinics were similar, with fewer, smaller significant associations, all in the expected direction.

CONCLUSIONS

A number of specific barriers and facilitators were associated with PCMH implementation, notably recruitment and retention of clinicians, team huddles, and local education. These findings can guide future research, and may help healthcare policy makers and leaders decide where to focus attention and limited resources.

Implementing Value-Based Payment Reform: A Conceptual Framework and Case Examples

This article develops a conceptual framework for implementation of value-based payment (VBP) reform and then draws on that framework to systematically examine six distinct multi-stakeholder coalition VBP initiatives in three different regions of the United States. The VBP initiatives deploy the following payment models: reference pricing, "shadow" primary care capitation, bundled payment, pay for performance, shared savings within accountable care organizations, and global payment. The conceptual framework synthesizes prior models of VBP implementation. It describes how context, project objectives, payment and care delivery strategies, and the barriers and facilitators to translating strategy into implementation affect VBP implementation and value for patients. We next apply the framework to six case examples of implementation, and conclude by discussing the implications of the case examples and the conceptual framework for future practice and research.

Patient-centered medical home initiative produced modest economic results for Veterans Health Administration, 2010-12

In 2010 the Veterans Health Administration (VHA) began a nationwide initiative called Patient Aligned Care Teams (PACT) that reorganized care at all VHA primary care clinics in accordance with the patient-centered medical home model. We analyzed data for fiscal years 2003-12 to assess how trends in health care use and costs changed after the implementation of PACT. We found that PACT was associated with modest increases in primary care visits and with modest decreases in both hospitalizations for ambulatory care-sensitive conditions and outpatient visits with mental health specialists. We estimated that these changes avoided $596 million in costs, compared to the investment in PACT of $774 million, for a potential net loss of $178 million in the study period. Although PACT has not generated a positive return, it is still maturing, and trends in costs and use are favorable. Adopting patient-centered care does not appear to have been a major financial risk for the VHA.

Dental attendance among low-income women and their children following a brief motivational counseling intervention: A community randomized trial

This study tested a behavioral intervention to increase dental attendance among rural Oregonian low-income women and their children. It utilized a multi-site, single-blind, randomized trial design. Four hundred women were randomized into one of four conditions to receive prenatal or postpartum motivational interviewing/counseling (MI) or prenatal or postpartum health education (HE). Counselors also functioned as patient navigators. Primary outcomes were dental attendance during pregnancy for the mother and for the child by age 18 months. Attendance was obtained from the Oregon Division of Medical Assistance Programs and participant self-report. Statewide self-reported utilization data were obtained from the Oregon Pregnancy Risk Assessment Monitoring System (PRAMS). Maternal attendance was 92% in the prenatal MI group and 94% in the prenatal HE group (RR = 0.98; 95% CI = 0.93-1.04). Children's attendance was 54% in postpartum MI group and 52% in the postpartum HE group (RR = 1.03; 95% CI = 0.82-1.28). Compared to statewide PRAMS, attendance was higher during pregnancy for study mothers (45% statewide; 95% CI = 40-50%) and for their children by 24 months (36% statewide; 95% CI = 27-44%). MI did not lead to greater attendance when compared to HE alone and cost more to implement. High attendance may be attributable to the counselors' patient navigator function.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT01120041.

Emerging lessons from regional and state innovation in value-based payment reform: balancing collaboration and disruptive innovation

CONTEXT

In recent decades, practitioners and policymakers have turned to value-based payment initiatives to help contain spending on health care and to improve the quality of care. The Robert Wood Johnson Foundation funded 7 grantees across the country to design and implement value-based, multistakeholder payment reform projects in 6 states and 3 regions of the United States.

METHODS

As the external evaluator of these projects, we reviewed documents, conducted Internet searches, interviewed key stakeholders, cross-validated factual and narrative interpretation, and performed qualitative analyses to derive cross-site themes and implications for policy and practice.

FINDINGS

The nature of payment reform and its momentum closely reflects the environmental context of each project. Federal legislation such as the Patient Protection and Affordable Care Act and federal and state support for the development of the patient-centered medical home and accountable care organizations encourage value-based payment innovation, as do local market conditions for payers and providers that combine a history of collaboration with independent innovation and experimentation by individual organizations. Multistakeholder coalitions offer a useful facilitating structure for galvanizing payment reform. But to achieve the objectives of reduced cost and improved quality, multistakeholder payment innovation must overcome such barriers as incompatible information systems, the technical difficulties and transaction costs of altering existing billing and payment systems, competing stakeholder priorities, insufficient scale to bear population health risk, providers' limited experience with risk-bearing payment models, and the failure to align care delivery models with the form of payment.

CONCLUSIONS

From the evidence adduced in this article, multistakeholder, value-based payment reform requires a trusted, widely respected "honest broker" that can convene and maintain the ongoing commitment of health plans, providers, and purchasers. Change management is complex and challenging, and coalition governance requires flexibility and stable leadership, as market conditions and stakeholder engagement and priorities shift over time. Another significant facilitator of value-based payment reform is outside investment that enables increased investment in human resources, information infrastructure, and care management by provider organizations and their collaborators. Supportive community and social service networks that enhance population health management also are important enablers of value-based payment reform. External pressure from public and private payers is fueling a "burning bridge" between the past of fee-for-service payment models and the future of payments based on value. Robust competition in local health plan and provider markets, coupled with an appropriate mix of multistakeholder governance, pressure from organized purchasers, and regulatory oversight, has the potential to spur value-based payment innovation that combines elements of "reformed" fee-for-service with bundled payments and global payments.

Hemoglobin A1c, comorbid conditions and all-cause mortality in older patients with diabetes: a retrospective 9-year cohort study

AIMS

To examine whether hemoglobin A1c levels and comorbid conditions are related to all-cause mortality in a cohort of patients with type 1 or 2 diabetes receiving continuous care for 9 years. In patients with comorbid congestive heart failure (CHF), we test for 'reverse epidemiology,' or whether greater HbA1c values are associated with lower risk of mortality.

METHODS

The population for this longitudinal cohort study was 8820 Group Health enrollees in the Seattle area with type 1 or 2 diabetes in 1997 and enrolled continuously from 1997 to 2006. Comorbid conditions were hypertension, coronary artery disease, congestive heart failure, depression, and chronic pulmonary disease. Mistimed HbA1c scores were addressed by multiple imputation, and Cox proportional hazards models estimated associations controlling for other risk factors.

RESULTS

About 30% of the enrollees died in 1998-2006. CHF had the strongest association with all-cause mortality. Compared to enrollees with HbA1c ≥ 7.1% (54 mmol/mol) and < 7.5% (58 mmol/mol; 5th decile), enrollees with HbA1c < 6.4% (46 mmol/mol) had a significantly greater risk of death (HR range: 1.28-2.26). HbA1c > 7.5% had HR < 1.0 but were not significant. For enrollees with diabetes and CHF at baseline, HbA1c scores ≥ 8.7% (72 mmol/mol) had a significantly lower risk of death (HR range: 0.64-0.69).

CONCLUSIONS

In our patient population, HbA1c scores<6.4% have significantly higher all-cause mortality. CHF is a major determinant of all-cause mortality. Adults with comorbid CHF and high HbA1c scores have lower all-cause mortality.

Changes in office visit use associated with electronic messaging and telephone encounters among patients with diabetes in the PCMH

PURPOSE

Telephone- and Internet-based communication are increasingly common in primary care, yet there is uncertainty about how these forms of communication affect demand for in-person office visits. We assessed whether use of copay-free secure messaging and telephone encounters was associated with office visit use in a population with diabetes.

METHODS

We used an interrupted time series design with a patient-quarter unit of analysis. Secondary data from 2008-2011 spanned 3 periods before, during, and after a patient-centered medical home (PCMH) redesign in an integrated health care delivery system. We used linear regression models to estimate proportional changes in the use of primary care office visits associated with proportional increases in secure messaging and telephone encounters.

RESULTS

The study included 18,486 adults with diabetes. The mean quarterly number of primary care contacts increased by 28% between the pre-PCMH baseline and the postimplementation periods, largely driven by increased secure messaging; quarterly office visit use declined by 8%. In adjusted regression analysis, 10% increases in secure message threads and telephone encounters were associated with increases of 1.25% (95% CI, 1.21%-1.29%) and 2.74% (95% CI, 2.70%-2.77%) in office visits, respectively. In an interaction model, proportional increases in secure messaging and telephone encounters remained associated with increased office visit use for all study periods and patient subpopulations (P<.001).

CONCLUSIONS

Before and after a medical home redesign, proportional increases in secure messaging and telephone encounters were associated with additional primary care office visits for individuals with diabetes. Our findings provide evidence on how new forms of patient-clinician communication may affect demand for office visits.

Specialty use among patients with treated hypertension in a patient-centered medical home

BACKGROUND

Little is known about how delivery of primary care in the patient-centered medical home (PCMH) influences outpatient specialty care use.

OBJECTIVE

To describe changes in outpatient specialty use among patients with treated hypertension during and after PCMH practice transformation.

DESIGN

One-group, 48-month interrupted time series across baseline, PCMH implementation and post-implementation periods.

PATIENTS

Adults aged 18-85 years with treated hypertension.

INTERVENTION

System-wide PCMH redesign implemented across 26 clinics in an integrated health care delivery system, beginning in January 2009.

MAIN MEASURES

Resource Utilization Band variables from the Adjusted Clinical Groups case mix software characterized overall morbidity burden (low, medium, high). Negative binomial regression models described adjusted annual differences in total specialty care visits. Poisson regression models described adjusted annual differences in any use (yes/no) of selected medical and surgical specialties.

KEY RESULTS

Compared to baseline, the study population averaged 7% fewer adjusted specialty visits during implementation (P < 0.001) and 4% fewer adjusted specialty visits in the first post-implementation year (P = 0.02). Patients were 12% less likely to have any cardiology visits during implementation and 13% less likely during the first post-implementation year (P < 0.001). In interaction analysis, patients with low morbidity had at least 27% fewer specialty visits during each of 3 years following baseline (P < 0.001); medium morbidity patients had 9% fewer specialty visits during implementation (P < 0.001) and 5% fewer specialty visits during the first post-implementation year (P = 0.007); high morbidity patients had 3% (P = 0.05) and 5% (P = 0.009) higher specialty use during the first and second post-implementation years, respectively.

CONCLUSIONS

Results suggest that more comprehensive primary care in this PCMH redesign enabled primary care teams to deliver more hypertension care, and that many needs of low morbidity patients were within the scope of primary care practice. New approaches to care coordination between primary care teams and specialists should prioritize high morbidity, clinically complex patients.

A report on eight early-stage state and regional projects testing value-based payment

To help contain health care spending and improve the quality of care, practitioners and policy makers are trying to move away from fee-for-service toward value-based payment, which links providers' reimbursement to the value, rather than the volume, of services delivered. With funding from the Robert Wood Johnson Foundation, eight grantees across the country are designing and implementing value-based payment reform projects. For example, in Salem, Oregon, the Physicians Choice Foundation is testing "Program Oriented Payments," which include incentives for providers who follow a condition-specific program of care designed to meet goals set jointly by patient and provider. In this article we describe the funding rationale and the specific objectives, strategies, progress, and early stages of implementation of the eight projects. We also share some early lessons and identify prerequisites for success, such as ensuring that providers have broad and timely access to data so they can meet patients' needs in cost-effective ways.

Outcomes among chronically ill adults in a medical home prototype

OBJECTIVES

To compare quality, utilization, and cost outcomes for patients with selected chronic illnesses at a patient-centered medical home (PCMH) prototype site with outcomes for patients with the same chronic illnesses at 19 nonintervention control sites.

STUDY DESIGN

Nonequivalent pretest-posttest control group design.

METHODS

PCMH redesign results were investigated for patients with preexisting diabetes, hypertension, and/or coronary heart disease. Data from automated databases were collected for eligible enrollees in an integrated healthcare delivery system. Multivariable regression models tested for adjusted differences between PCMH patients and controls during the baseline and follow-up periods. Dependent measures under study included clinical processes and, outcomes, monthly healthcare utilization, and costs.

RESULTS

Compared with controls over 2 years, patients at the PCMH prototype clinic had slightly better clinical outcome control in coronary heart disease (2.20 mg/dL lower mean low-density lipoprotein cholesterol; P <.001). PCMH patients changed their patterns of primary care utilization, as reflected by 86% more secure electronic message contacts (P <.001), 10% more telephone contacts (P = .003), and 6% fewer in-person primary care visits (P <.001). PCMH patients had 21% fewer ambulatory care-sensitive hospitalizations (P <.001) and 7% fewer total inpatient admissions (P = .002) than controls. During the 2-year redesign, we observed 17% lower inpatient costs (P <.001) and 7% lower total healthcare costs (P <.001) among patients at the PCMH prototype clinic.

CONCLUSIONS

A clinic-level population-based PCMH redesign can decrease downstream utilization and reduce total healthcare costs in a subpopulation of patients with common chronic illnesses.

Washington state foster care: dental utilization and expenditures

OBJECTIVES

To identify factors associated with dental utilization and expenditures for children enrolled in Washington State (WA) foster care (FC).

METHODS

This cross-sectional study used 2008 Medicaid enrollment and claims files for children ages <18 years enrolled in the WA FC program for ≥11 months (N = 10,177). Regression models were used to examine associations between utilization and expenditures and sex, race, age group, Supplemental Security Income (SSI) (i.e., disability), substance abuse, behavior problems, placement setting (Foster Home Care, Kinship Care, Group Care, Other), and urbanicity.

RESULTS

Only 43 percent of the children utilized any dental care; the adjusted mean expenditure was $198.35 [95% confidence interval (CI) $181.35, $215.36]. Fewer utilized diagnostic (41 percent), preventive (39 percent), restorative (11 percent), or complex (5 percent) services. Associated with utilization (P ≤ 0.01) were: female [ARR = 1.05, 95% CI(1.01, 1.10)]; 0-2 years [ARR = 0.18, 95% CI(0.15, 0.21)], [3-5 years ARR = 0.78, 95% CI(0.74, 0.83)]; Native American [ARR = 0.85, 95% CI(0.80, 0.91)]; SSI [ARR = 1.10, 95% CI(1.04, 1.17)]; Kinship Care [ARR = 0.94, 95% CI(0.90, 0.98)]; Group Care [ARR = 1.25 95% CI(1.15, 1.37)]; and urban/rural urbanicity with population <20 K [ARR = 1.20 95% CI(1.12, 1.30)]. Associated with expenditures (P < 0.05) were: ages 0-2 years [-$153.66, 95% CI(-$168.33, -$139.00)], 3-5 years [-$98.71, 95% CI(-$116.78, -$80.65)], 6-11 years [-$16.83 95% CI(-$33.52, -$0.14)]; African American [-$32.05 95% CI(-$47.99, -$16.12)]; Kinship Care [$28.57 95% CI($14.00, $43.15)].

CONCLUSIONS

Most children enrolled in WA FC for ≥11 months during 2008 did not receive dental care. Research is needed to determine the level of unmet need among children in FC and interventions to improve access to oral health of the children. Enforcement of existing federal legislation is needed.

Paying physician group practices for quality: A statewide quasi-experiment

This article presents the results of a unique quasi-experiment of the effects of a large-scale pay-for-performance (P4P) program implemented by a leading health insurer in Washington state during 2001-2007. The authors received external funding to provide an objective impact evaluation of the program. The program was unique in several respects: (1) It was designed dynamically, with two discrete intervention periods-one in which payment incentives were based on relative performance (the "contest" period) and a second in which payment incentives were based on absolute performance compared to achievable benchmarks. (2) The program was designed in collaboration with large multispecialty group practices, with an explicit run-in period to test the quality metrics. Public reporting of the quality scorecard for all participating medical groups was introduced 1 year before the quality incentive payment program's inception, and continued throughout 2002-2007. (3) The program was implemented in stages with distinct medical groups. A control group of comparable group practices also was assembled, and difference-in-differences methodology was applied to estimate program effects. Case mix measures were included in all multivariate analyses. The regression design permitted a contrast of intervention effects between the "contest" approach in the sub-period of 2003-2004 and the absolute standard, "achievable benchmarks of care" approach in sub-period 2005-2007. Most of the statistically significant quality incentive program coefficients were small and negative (opposite to program intent). A consistent pattern of differential intervention impact in the sub-periods did not emerge. Cumulatively, the probit regression estimates indicate that neither the quality scorecard nor the quality incentive payment program had a significant positive effect on general clinical quality. Based on key informant interviews with medical leaders, practicing physicians, and administrators of the participating groups, the authors conclude that several factors likely combined to dampen program effects: (1) modest size of the incentive; (2) use of rewards only, rather than a balance of rewards and penalties; (3) targeting incentive payments to the group, thus potentially weakening incentive effects at the individual level.

County-level characteristics as predictors of dentists' ECC counseling in the USA: a survey study

Background

Transmission of Streptococcus mutans from mother-to-child can lead to Early Childhood Caries. A previous study identified characteristics and beliefs of general dentists about counseling pregnant women to reduce risk of infection and Early Childhood Caries. This study extends those findings with an analysis of county level factors.

Methods

In 2006, we surveyed 732 general dentists in Oregon, USA about dental care for pregnant women. Survey items asked about individual and practice characteristics. In the present study we matched those data to county level factors and used multinomial logistic regression to test the effects of the factors (i.e., dentist to population ratio, percentage of female dentists, percentage of females of childbearing age, and percentage of individuals living in poverty) on counseling behavior.

Results

County level factors were unrelated to counseling behavior when the models controlled for dentists' individual attitudes, beliefs, and practice level characteristics. The adjusted odds ratios for no counseling of pregnant patients (versus 100 percent counseling) were 1.1 (95% CI .8-1.7), 1.0 (1.0-1.1), 1.2 (.9-1.5), and 1.1 (1.0-1.2) for dentist/population ratio, percent female dentists, percent females of childbearing age, and percent in poverty, respectively Similar results were obtained when dentists who counseled some patients were compared to those counseling 100 percent of patients.

Conclusions

Community level factors do not appear to impact the individual counseling behavior of general dentists in Oregon, USA regarding the risk of maternal transmission of Early Childhood Caries.

Counseling on Early Childhood Caries transmission by dentists

OBJECTIVE

High levels of Streptococcus mutans on teeth of young children are predictive of Early Childhood Caries (ECC). Transmission from mother-to-child is common and studies have demonstrated treatment of the mother results in less ECC. The objective of this study was to determine how dentists have adopted the practice of counseling about ECC.

METHODS

In 2006 as part of a larger study on dental care for pregnant women, we surveyed 829 general dentists in Oregon. The questionnaire contained questions to capture the extent to which general dentists have adopted counseling pregnant women about ECC transmission, to describe personal and practice characteristics, and examine how dentists' views on the ease of adopting of new procedures related to ECC counseling. Multivariate logistic regression was used to identify separate and additive effects of demographic and practice characteristics, attitudes, and beliefs.

RESULTS

The adjusted odds of a dentist who strongly believed in the link between mothers and babies and provided ECC counseling were 1.60 (95% CI 1.3-2.0, P<0.01). The odds of a dentist who reported discussing ECC with staff members and provided counseling were 2.7 (95% CI 1.7-4.3, P<0.01). Male dentists were less likely to counsel patients than female dentists (Adjusted OR=0.5, 95% CI 0.3-1.0, p<0.05).

CONCLUSIONS

The strongest predictors of counseling patients about ECC were dentists' belief in the evidence of caries transmission and dentists' discussion of ECC during staff meetings.

Local public health delivery of maternal child health services: are specific activities associated with reductions in Black-White mortality disparities?

To identify which MCH services delivered by local health departments (LHD) appear associated with reducing differences in Black-White mortality. We used a time-trend design to investigate relationships between change in MCH activities provided by LHDs in 1993 and in 2005 and changes in 1993-2005 Black-White mortality disparities. Secondary data were analyzed for 558 US counties and multi-county districts. Independent variables included the six MCH services provided by LHDs and captured in the 1993 and 2005 NACCHO Profile of Local Public Health Departments surveys. MCH service variables represented change in each service from 1993 to 2005. Control variables included selected LHD characteristics and county-level socioeconomic, demographic, and health provider resource data. Absolute change in Black and White mortality rates and changes in the mortality disparity "gap" between these rates in 1993 and 2005 were examined as dependent variables. Among the MCH services examined, prenatal care had a significant beneficial relationship with Black all-age mortality change and with reducing the mortality "gap." Family planning services had a beneficial relationship with reducing the mortality "gap" for females in the jurisdictions in the study sample. WIC services indicated the most consistently beneficial relationship with both Black mortality and White mortality change, but these changes did not influence the mortality "gap" during the study period. LHD delivery of family planning and prenatal care by LHDs appears related to reductions in Black-White mortality disparities. Implications of this study suggest the importance of certain MCH services for reducing Black-White mortality disparities.

Does a large-scale organizational transformation toward patient-centered access change the utilization and costs of care for patients with diabetes?

The authors examined whether Group Health's Access Initiative changed the utilization and costs of care among enrollees with diabetes. Using a single (one-group) interrupted time series design, repeated-measures generalized estimating equation models were used to estimate changes in utilization and costs during the Initiative rollout (2002-2003) and to compare the slopes (annual rates of change) for utilization and costs during the Pre-Initiative period (1998-2002) to the slopes during Full-Implementation (2003-2006) among 9,871 members continuously enrolled from 1997 to 2006 with type 1 or 2 diabetes. Total costs increased in Full-Implementation, but the annual change in total costs did not change. Primary care visits declined, but primary care contacts grew, largely from the Initiative's introduction of secure messaging. Specialty visits did not change; however, the Initiative may have increased emergency visits. To reduce emergency visits, future access initiatives should include proactive and comprehensive outpatient care for patients with diabetes.

Social gradients in dental health among low-income mothers and their young children

For low-income mothers of children aged 3-6 years, we estimate whether social gradients exist between mothers' income, education, and employment status and mothers' perceptions of self and child dental and general health, and whether these relationships differ by racial/ethnic group. Disproportionate stratified sampling by racial/ethnic group selected 10,909 eligible children aged 3 to 6 in Medicaid in Washington State. Mothers (n=4,373) completed a mixed-mode (web, mail, telephone) survey. Mothers' education had a strong, gradient relationship with mother ratings of self and child dental health that was not explained by other measures. Similar gradients were found for mothers' employment status and income, but some associations were no longer significant (p>.05) after adjusting for oral health beliefs and behaviors, dental insurance, and regular dental care. Associations did not differ significantly by racial/ethnic group.

Provider factors and patient-reported healthcare discrimination in the Diabetes Study of California (DISTANCE)

OBJECTIVE

We examined provider-level factors and reported discrimination in the healthcare setting.

METHODS

With data from the Diabetes Study of Northern California (DISTANCE) - a race-stratified survey of diabetes patients in Kaiser Permanente Northern California - we analyzed patient-reported racial/ethnic discrimination from providers. Primary exposures were characteristics of the primary care provider (PCP, who coordinates care in this system), including specialty/type, and patient-provider relationship variables, including racial concordance.

RESULTS

Subjects (n=12,151) included 20% black, 20% Latino, 23% Asian, 30% white, and 6% other patients, with 2-8% reporting discrimination by racial/ethnic group. Patients seeing nurse practitioners as their PCP (OR=0.09; 95% CI: 0.01-0.67) and those rating their provider higher on communication (OR=0.70; 95% CI: 0.66-0.74) were less likely to report discrimination, while those with more visits (OR=1.10; 95% CI: 1.03-1.18) were more likely to report discrimination. Racial concordance was not significant once adjusting for patient race/ethnicity.

CONCLUSIONS

Among diverse diabetes patients in managed care, provider type and communication were significantly related to patient-reported discrimination.

PRACTICE IMPLICATIONS

Given potential negative impacts on patient satisfaction and treatment decisions, future studies should investigate which interpersonal aspects of the provider-patient relationship reduce patient perceptions of unfair treatment.

Correlates of patient-reported racial/ethnic health care discrimination in the Diabetes Study of Northern California (DISTANCE)

OBJECTIVES

We examined possible determinants of self-reported health care discrimination.

METHODS

We examined survey data from the Diabetes Study of Northern California (DISTANCE), a race-stratified sample of Kaiser diabetes patients. Respondents reported perceived discrimination, and regression models examined socioeconomic, acculturative, and psychosocial correlates.

RESULTS

Subjects (n=17,795) included 20% Blacks, 23% Latinos, 13% East Asians, 11% Filipinos, and 27% Whites. Three percent and 20% reported health care and general discrimination. Health care discrimination was more frequently reported by minorities (ORs ranging from 2.0 to 2.9 compared with Whites) and those with poorer health literacy (OR=1.10, 95% CI: 1.04-1.16), limited English proficiency (OR=1.91, 95% CI: 1.32-2.78), and depression (OR=1.53, 95% CI: 1.10-2.13).

CONCLUSIONS

In addition to race/ethnicity, health literacy and English proficiency may be bases of discrimination. Evaluation is needed to determine whether patients are treated differently or more apt to perceive discrimination, and whether depression fosters and/or follows perceived discrimination.

Risk of losing insurance during the transition into adulthood among insured youth with disabilities

To compare insured youth (age 15-25 years) with and without disabilities on risk of insurance loss. We conducted a cross-sectional study using data from the Survey of Income and Program Participation 2001. Descriptive statistics characterized insured youth who maintained and lost insurance for at least 3 months over a 3-year time frame. We conducted logistic regression to calculate the association between disability and insurance loss. Adjustment variables were gender, race, ethnicity, age, work or school status, poverty status, type of insurance at study onset, state generosity, and an interaction between disability and insurance type. This study includes 2,123 insured youth without disabilities, 320 insured youth with non-severe disabilities, and 295 insured youth with severe disabilities. Thirty-six percent of insured youth without disabilities lost insurance compared to 43% of insured youth with non-severe disabilities and 41% of insured youth with severe disabilities (P = .07). Youth with non-severe disabilities on public insurance have an estimated 61% lower odds of losing insurance (OR: 0.39; 95% CI: 0.16, 0.93; P = .03) compared to youth without disabilities on public insurance. Further, youth with severe disabilities on public insurance have an estimated 81% lower odds of losing insurance (OR: 0.19; 95% CI: 0.09, 0.40; P < .001) compared to youth without disabilities. When examining youth with private insurance, we find that youth with severe disabilities have 1.63 times higher odds (OR: 1.63; 95% CI: 1.03, 2.57; P = .04) of losing health insurance compared to youth without disabilities. Insurance type interacts with disability severity to affect odds of insurance loss among insured youth.

Health insurance regain after a spell of uninsurance: a longitudinal comparison of youth with and without disabilities transitioning into adulthood

PURPOSE

To examine insurance regain among youth with no, nonsevere, and severe disabilities.

METHODS

The data source for this study was the Survey of Income and Program Participation 2001. We examined insurance regain among youth with no, nonsevere, and severe disabilities between the ages of 15 and 25 using a longitudinal design. Kaplan-Meier survival functions provided estimates of uninsurance spell durations measured in waves, or 4-month intervals. We conducted a discrete time survival analysis adjusting for personal characteristics.

RESULTS

This study includes 1,310 youth who entered the SIPP with insurance and became uninsured. 985 youth (75%) regained insurance. Based on SIPP waves, median duration of uninsurance was two waves (between 5 and 8 months) for youth with severe disabilities and three waves (between 9 and 12 months) for youth with nonsevere disability. Youth with nonsevere disabilities had decreased odds of regaining health insurance compared to youth without disabilities (odds ratio .73; 95% confidence interval: .57, .92; p=.01).

CONCLUSIONS

Youth with severe disabilities and youth without disabilities had similar odds of and durations to insurance regain. In contrast, youth with nonsevere disabilities had lower odds of regaining insurance and experienced longer durations of uninsurance compared to peers without disabilities. We recommend additional research into the implications of Medicaid eligibility pathways and employment barriers for youth with nonsevere disabilities.

Linking mother access to dental care and child oral health

OBJECTIVES

The authors examined whether low-income mothers, who have a regular source of dental care (RSDC), rate the dental health of their young children higher than mothers without an RSDC.

METHODS

From a population of 108,151 children enrolled in Medicaid aged 3 to 6 years and their low-income mothers in Washington state, a disproportionate stratified random sample of 11,305 children aged 3 to 6 years was selected from enrollment records in four racial/ethnic groups: 3791 Black; 2806 Hispanic; 1902 White; and 2806 other racial/ethnic groups. A mixed-mode survey was conducted to measure mother RSDC and mother ratings of child's dental health and pain. The unadjusted response rate was 44%, yielding the following eligible mothers: 816 Black, 1309 Hispanic, 1379 White, 237 Asian, and 133 American-Indian. Separate regression models for Black, Hispanic, and White mothers estimated associations between the mothers having an RSDC and ratings of child dental health.

RESULTS

Across racial/ethnic groups, mothers with an RSDC consistently rated their children's dental health 0.15 higher on a 1-to-5 scale (where '1' means 'poor' and '5' means 'excellent') than mothers without an RSDC, controlling for child and mother characteristics and the mothers' propensity to have an RSDC. This difference can be interpreted as a net movement of one level up the scale by 15% of the population.

CONCLUSIONS

Across racial/ethnic groups, low-income mothers who have a regular source of dental care rate the dental health of their young children higher than mothers without an RSDC.

Group health cooperative's transformation toward patient-centered access

The Institute of Medicine suggests redesigning health care to ensure safe, effective, timely, efficient, equitable, and patient-centered care. The concept of patient-centered access supports these goals. Group Health, a mixed-model health care system, attempted to improve patients' access to care through the following changes: (a) offering a patient Web site with patient access to patient-physician secure e-mail, electronic medical records, and health promotion information; (b) offering advanced access to primary physicians; (c) redesigning primary care services to enhance care efficiency; (d) offering direct access to physician specialists; and (e) aligning primary physician compensation through incentives for patient satisfaction, productivity, and secure messaging with patients. In the 2 years following the redesign, patients reported higher satisfaction with certain aspects of access to care, providers reported improvements in the quality of service given to patients, and enrollment in Group Health stayed aligned with statewide trends in health care coverage.

Racial and ethnic differences in a regular source of dental care and the oral health, behaviors, beliefs and services of low-income mothers

OBJECTIVE

In a racial/ethnically-diverse sample of low-income mothers of children aged 3-6, we determine: (1) whether a regular source of dental care (RSDC), self-rated oral health, beliefs and behaviors differ by racial/ethnic group; (2) estimate whether a RSDC is associated with oral health, beliefs and behaviors, and whether these associations differ by racial/ethnic group; and (3) examine these relationships for mothers' dental utilization.

BASIC RESEARCH DESIGN

Cross-sectional survey. Participants From a population of 108,151 Medicaid children aged 3-6 in Washington state, U.S., 10,909 eligible children were sampled stratified by racial/ethnic group. Eligible mothers completed a mixed-mode survey in the following groups: Black (n=818), Hispanic (n=1310), or White (n=1382).

MAIN OUTCOME MEASURES

Measures were mothers' RSDC, personal characteristics, self-rated dental health, appearance of teeth, dental problems, brushing duration, flossing frequency, use of toothpicks or whiteners, belief that cleaning prevents cavities or loose teeth, and self-reported services at last dental visit.

RESULTS

About 38-40% of mothers had a RSDC. For Black, Hispanic and White mothers, having a RSDC was associated consistently with better oral health, greater likelihood of a dental cleaning and less likelihood of tooth extraction. RSDC was not associated generally with oral health beliefs and behaviors. Oral health behaviors differ by racial/ethnic group.

CONCLUSIONS

Relationships between RSDC and self-reported oral health, health behaviors, beliefs and dental services are similar for Black, Hispanic and White low-income mothers of young children. Oral health behaviors differ across racial/ethnic groups, which may have implications for mother and child oral health.

Evaluation of the group health cooperative access initiative: study design challenges in estimating the impact of a large-scale organizational transformation

The Institute of Medicine argues that poorly designed delivery systems are a major cause of low-quality care in the United States but does not present methods for evaluating whether its recommendations, when implemented by a health care organization, actually improve quality of care. We describe how time-series study designs using individual-level longitudinal data can be applied to address methodological challenges in our evaluation of the impact of the Group Health Cooperative "Access Initiative," an integrated set of 7 "patient-centered" reforms in its integrated delivery system that are consistent with the Institute of Medicine's recommendations. The methods may be generalizable to evaluating similar reforms in other integrated delivery systems with representative patient and physician data sources.

Linking mother and child access to dental care

OBJECTIVES

Among young children in low-income families covered by Medicaid, we estimated (according to racial/ethnic group) whether children who have mothers with a regular source of dental care at baseline have greater dental use in the subsequent year than children with mothers without a regular source.

METHODS

From a population of 108151 children (aged 3 to 6 years) who were enrolled in Medicaid and their low-income mothers in Washington state, a disproportionate stratified random sample of 11305 children aged 3 to 6 was selected from enrollment records in 4 racial/ethnic groups: black (3791), Hispanic (2806), white (1902), and other racial/ethnic groups (2806). In a prospective cohort design, we conducted a baseline survey of mothers and for respondents collected their children's Medicaid dental claims in the 1-year follow-up period. Mutivariable regression models estimated the associations between the mothers' having a regular source of dental care at baseline and their children's prospective dental use.

RESULTS

Approximately 38% of the mothers had a regular source of dental care. Among children of black and Hispanic mothers, having a mother with a regular source of dental care at baseline was associated with greater odds of receiving any dental care in the subsequent year. For children with dental use, children of black or Hispanic mothers with a regular source of dental care received 1.22 and 1.10 more preventive services, respectively. For children of white mothers, associations were in the same direction but not significant.

CONCLUSIONS

For young children of black and Hispanic mothers, dental care use is higher when their mothers have a regular source of dental care. For low-income young children with Medicaid, increasing the mothers' access to dental care may increase the children's use of dental and preventive services, which, in turn, may reduce racial/ethnic inequalities in oral health.

Access intervention in an integrated, prepaid group practice: effects on primary care physician productivity

OBJECTIVE

To estimate the joint effect of a multifaceted access intervention on primary care physician (PCP) productivity in a large, integrated prepaid group practice.

DATA SOURCES

Administrative records of physician characteristics, compensation and full-time equivalent (FTE) data, linked to enrollee utilization and cost information.

STUDY DESIGN

Dependent measures per quarter per FTE were office visits, work relative value units (WRVUs), WRVUs per visit, panel size, and total cost per member per quarter (PMPQ), for PCPs employed >0.25 FTE. General estimating equation regression models were included provider and enrollee characteristics.

PRINCIPAL FINDINGS

Panel size and RVUs per visit rose, while visits per FTE and PMPQ cost declined significantly between baseline and full implementation. Panel size rose and visits per FTE declined from baseline through rollout and full implementation. RVUs per visit and RVUs per FTE first declined, and then increased, for a significant net increase of RVUs per visit and an insignificant rise in RVUs per FTE between baseline and full implementation. PMPQ cost rose between baseline and rollout and then declined, for a significant overall decline between baseline and full implementation.

CONCLUSIONS

This organization-wide access intervention was associated with improvements in several dimensions in PCP productivity and gains in clinical efficiency.

Dissatisfaction with dental care among mothers of Medicaid-enrolled children

OBJECTIVES

This paper is part of a larger study examining the impact of mothers' having a regular source of dental care (RSDC) on utilization of dental care and oral health of their preschool children. We describe levels of satisfaction with care among mothers whose preschool children were enrolled in Medicaid in Washington State. We report mothers' satisfaction related to having a RSDC by type of dental setting/office.

METHODS

Disproportionate stratified sampling by racial/ethnic group selected 11 305 children aged 3-6 in Medicaid in Washington State. Mothers (n = 4373) completed a mixed-mode survey. Satisfaction with dental care was measured using the Dental Satisfaction Questionnaire (DSQ).

RESULTS

Overall mean DSQ was 57.1 +/- 9.9 (range 18-89). A higher score indicates greater satisfaction. There was not evidence of a difference in dissatisfaction by race/ethnicity but Blacks and Hispanics were less satisfied with pain management than Whites. The majority of respondents agreed with the statement that 'Dentists sometimes act rude to their patients.' Satisfaction is higher for mothers who have a regular private dentist they see consistently versus having a regular dentist through a public or non-profit clinic.

CONCLUSIONS

The satisfaction with dental care for this population is low, and considerably lower than found in other studies for primary medical care. Steps need to be taken to increase dental satisfaction and access to private dental clinics, and to increase perceived quality and pain management of dental care in both private clinics and public/non-profits serving low-income populations.

Disparities in regular source of dental care among mothers of medicaid-enrolled preschool children

For mothers of Medicaid children aged 3 to 6 years, we examined whether mothers' characteristics and local supply of dentists and public dental clinics are associated with having a regular source of dental care. Disproportionate stratified sampling by racial/ethnic group selected 11,305 children aged 3 to 6 in Medicaid in Washington State. Mothers (n=4,373) completed a mixed-mode survey that was combined with dental supply measures. Results reveal 38% of mothers had a regular dental place and 27% had a regular dentist. Dental insurance, greater education, income, length of residence, and better mental health were associated with having a regular place or dentist for Black, Hispanic, and White mothers, along with increased supply of private dentists and safety net clinics for White and Hispanic mothers. Mothers lacking a regular source of dental care may increase oral health disparities disfavoring their children.

Managed care and patient ratings of the quality of specialty care among patients with pain or depressive symptoms

BACKGROUND

Managed care efforts to regulate access to specialists and reduce costs may lower quality of care. Few studies have examined whether managed care is associated with patient perceptions of the quality of care provided by physician and non-physician specialists. Aim is to determine whether associations exist between managed care controls and patient ratings of the quality of specialty care among primary care patients with pain and depressive symptoms who received specialty care for those conditions.

METHODS

A prospective cohort study design was conducted in the offices of 261 primary physicians in private practice in Seattle in 1997. Patients (N = 17,187) were screened in waiting rooms, yielding a sample of 1,514 patients with pain only, 575 patients with depressive symptoms only, and 761 patients with pain and depressive symptoms. Patients (n = 1,995) completed a 6-month follow-up survey. Of these, 691 patients received specialty care for pain, and 356 patients saw mental health specialists. For each patient, managed care was measured by the intensity of managed care controls in the patient's health plan and primary care office. Quality of specialty care at follow-up was measured by patient rating of care provided by the specialists. Outcomes were pain interference and bothersomeness, Symptom Checklist for Depression, and restricted activity days.

RESULTS

The intensity of managed care controls in health plans and primary care offices was generally not associated with patient ratings of the quality of specialty care. However, pain patients in more-managed primary care offices had lower ratings of the quality of specialty care from physician specialists and ancillary providers.

CONCLUSION

For primary care patients with pain or depressive symptoms and who see specialists, managed care controls may influence ratings of specialty care for patients with pain but not patients with depressive symptoms.

Reducing oral health disparities: a focus on social and cultural determinants

Oral health is essential to the general health and well-being of individuals and the population. Yet significant oral health disparities persist in the U.S. population because of a web of influences that include complex cultural and social processes that affect both oral health and access to effective dental health care.

This paper introduces an organizing framework for addressing oral health disparities. We present and discuss how the multiple influences on oral health and oral health disparities operate using this framework. Interventions targeted at different causal pathways bring new directions and implications for research and policy in reducing oral health disparities.

Randomized pilot study to disseminate caries-control services in dentist offices

BACKGROUND

To determine whether education and financial incentives increased dentists' delivery of fluoride varnish and sealants to at risk children covered by capitation dental insurance in Washington state (U.S.).

METHODS

In 1999, 53 dental offices in Washington Dental Service's capitation dental plan were invited to participate in the study, and consenting offices were randomized to intervention (n = 9) and control (n = 10) groups. Offices recruited 689 capitation children aged 6-14 and at risk for caries, who were followed for 2 years. Intervention offices received provider education and fee-for-service reimbursement for delivering fluoride varnish and sealants. Insurance records were used to calculate office service rates for fluoride, sealants, and restorations. Parents completed mail surveys after follow-up to measure their children's dental utilization, dental satisfaction, dental fear and oral health status. Regression models estimated differences in service rates between intervention and control offices, and compared survey measures between groups.

RESULTS

Nineteen offices (34%) consented to participate in the study. Fluoride and sealant rates were greater in the intervention offices than the control offices, but the differences were not statistically significant. Restoration rates were lower in the intervention offices than the control offices. Parents in the intervention group reported their children had less dental fear than control group parents.

CONCLUSION

Due to low dentist participation the study lacked power to detect an intervention effect on dentists' delivery of caries-control services. The intervention may have reduced children's dental fear.

Dentists' and parents' perceptions of health, esthetics, and treatment of maxillary primary incisors

PURPOSE

Dentists' and parents' assessment of primary maxillary incisors regarding attractiveness, perceived health, and treatment preferences were investigated in this study.

METHODS

Sample groups of 103 general dentists, 67 pediatric dentists, 97 parents of children in low-income families and 112 parents of children in high-income families completed questionnaires presenting color photographs and radiographs of maxillary incisors. Questions addressed treatment need, health beliefs, and demographics.

RESULTS

All groups recognized grossly carious teeth and carious teeth with visible sinus tracts as unhealthy and unattractive. All agreed that grossly carious teeth warranted extraction (dentists = 92%, parents = 73%). For carious teeth with sinus tracts, dentists favored extraction and restorations while parents favored fluoride application. Dentists rated a dark incisor as healthy and not requiring treatment. Parents rated a dark incisor as neutral for attractiveness and health, but favored extraction or restoration. All groups found anterior steel crowns esthetically unacceptable. Trust of the dentist, pain for the child, and dentist skill was important for parents in treatment plan acceptance.

CONCLUSIONS

A dentist's inexperience in pediatrics may result in a failure to diagnose or recognize the significance of some conditions. Proper parental education can better inform parents on dental conditions requiring prompt professional attention. Although parents today are more involved in clinical decision-making, they still rely on the dentist's expertise and advice.

An ABCD program to increase access to dental care for children enrolled in Medicaid in a rural county

OBJECTIVES

The Access to Baby and Child Dentistry (ABCD) Program addresses the needs of families in obtaining dental care. In this study, the program was evaluated in rural Stevens County, Washington. Aims were to assess utilization of dental services, average dental expenditures per child, and oral health status.

METHODS

Medicaid-enrolled children aged 1-4 years were randomly assigned to the ABCD program (n=216) or to regular benefits (n=221). An outreach worker contacted each ABCD family and provided an orientation. Dental care utilization and expenditures were calculated from claims. A posttest-only design was used to evaluate oral health status.

RESULTS

An enrollment effect was seen in ABCD, but the difference between groups was not sustained. There was a doubling of utilization between groups for the youngest cohort, while the others showed no differences. In the first year the rate was higher for the entire ABCD group than for the children not in ABCD (34.0% vs 24.7%). Thirty-three percent of ABCD children (70/212) who had visited the dentist had >1 appointment compared to 21.5 percent (47/219) for the children not in ABCD who had visited the dentist. There was no overall difference in expenditures, while expenditures for preventive services were greater for ABCD. ABCD children had fewer teeth with initial caries. The average incremental cost per child per initial lesion prevented was 31.44 dollars.

CONCLUSION

ABCD most benefited the youngest cohort of children and improved health.

Parent satisfaction with emergency dental treatment at a children's hospital

PURPOSE

This study evaluated parental satisfaction with emergency dental treatment.

METHODS

One hundred twenty-two parents of children requiring emergency extraction of 1 or more primary teeth completed a survey designed to test the effect of provider, treatment, and demographic variables on parental satisfaction.

RESULTS

Most parents (>80%) indicated satisfaction with the treatment provided. Parents were most satisfied with treatment during clinic hours, treatment provided by an attending pediatric dentist, and treatment provided by male dentists. Satisfaction was correlated with the clarity of the provider explanation. Explanations by male dentists were perceived most positively. Parents of children receiving molar extraction(s) were more satisfied than parents of children with incisor extraction(s). Satisfaction did not correlate with ethnicity of the parent or patient, parent education level, funding sources, or use of an immobilization device. Parents preferred sedation for behavior management of the emergency patient.

CONCLUSIONS

To address the expectations and concerns of parents, dental professionals need to be attentive to the quality of dentist-parent communication and parental expectations during emergency services.