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Swietek K, Jones KA, Bettger JP, French A, Maslow G, Norman KS, Lake AD, Carvalho M, Cholera R, Freed SS, Tchuisseu YP, Repka S, Whitaker RG. What Explains Inequalities in Telehealth Utilization Among North Carolina Medicaid Beneficiaries? Telemed J E Health 2024. [PMID: 38728091 DOI: 10.1089/tmj.2023.0563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
Background: Increased availability of telehealth can improve access to health care. However, there is evidence of persistent disparities in telehealth usage, as well as among people from minoritized racial and ethnic groups and rural residents. The objective of our work was to explore the degree to which disparities in telehealth use for behavioral health (BH) and musculoskeletal (MSK) related services during the COVID-19 pandemic are explained by observed beneficiary- and area-level characteristics. Methods: Using North Carolina Medicaid claims data of Medicaid beneficiaries with BH or MSK conditions, we apply nonlinear regression-based decomposition analysis-based models developed by Kitagawa, Oaxaca, and Blinder to determine which observed variables are associated with racial, ethnic, and rural inequalities in telehealth usage. Results: In the BH cohort, we found statistically significant differences in telehealth usage by race in the adult population, and by race, Hispanic ethnicity, and rurality in the pediatric population. In the MSK cohort, we found significant inequities by Hispanic ethnicity and rurality among adults, and by race and rurality among children. Inequalities in telehealth use between groups were small, ranging from 0.7 percentage points between urban and rural adults with MSK conditions to 3.8 percentage points between white adults and people of color among those with BH conditions. Overall, we found that racial and ethnic inequalities in telehealth use are not well explained by the observed variables in our data. Rural disparities in telehealth use are better explained by observed variables, particularly area-level broadband internet use. Conclusions: For inequalities between rural and urban residents, our analysis provides observational evidence that infrastructure such as broadband internet access is an important driver of differences in telehealth use. For racial and ethnic inequalities, the pathways may be more complex and difficult to measure, particularly when relying on administrative data sources in place of more detailed data on individual-level socioeconomic factors.
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Affiliation(s)
- Karen Swietek
- Health Care Evaluation Department, NORC at the University of Chicago, Cambridge, Massachusetts, USA
| | - Kelley A Jones
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Janet Prvu Bettger
- Duke-Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
| | - Alexis French
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gary Maslow
- Duke-Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
- Department of Psychiatry, Duke University School of Medicine, Durham, North Carolina, USA
| | - Katherine S Norman
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ashley D Lake
- Duke Physical Therapy Sports Medicine at the Center for Living, Duke Health, Durham, North Carolina, USA
| | - Marissa Carvalho
- Department of Physical Therapy and Occupational Therapy, Duke University Health System, Durham, North Carolina, USA
| | - Rushina Cholera
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke-Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Salama S Freed
- Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, USA
| | | | - Samantha Repka
- Duke-Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
| | - Rebecca G Whitaker
- Duke-Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
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Benitez J, Freed SS, Huang H, Oladele T. Did Medicaid Reimbursements Shape the Effects of Medicaid Expansion on Access to Health Care Among the Low-Income Population? J Gen Intern Med 2024:10.1007/s11606-023-08558-w. [PMID: 38172410 DOI: 10.1007/s11606-023-08558-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 12/01/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Whether variation in Medicaid reimbursement fees influenced the impacts of the Medicaid expansions is not well understood. OBJECTIVE We examine whether changes in health care access associated with Medicaid expansion are different in states with comparatively high Medicaid reimbursement rates compared against expanding in states with lower Medicaid reimbursement rates. DESIGN Using a difference-in-difference-in-difference (DDD or triple-difference) regression approach, we compare relative differences in Medicaid expansion effects between lower and higher reimbursement states. PARTICIPANTS 512,744 low-income adults aged 20-64 in the 2011-2019 Behavioral Risk Factor Surveillance System. MAIN MEASURES Health insurance coverage status, unmet medical needs due to cost, regular source for health care, and a regular/scheduled checkup within the past year. KEY RESULTS Medicaid expansion has significant and positive impacts on health coverage and access in both high- and low-fee states. In states with fee levels above the median Medicare-to-Medicaid ratios, expanding Medicaid eligibility reduced uninsurance rate by 15.2 percentage point (ppt, p < 0.01), shrank the cost-associated unmet medical need by 10.3 ppt (p < 0.01), improved access to usual source of care by 1.9 ppt (p < 0.1), and increased regular checkup by 14.4 ppt (p < 0.01), while such effects in low-fee states were 11.7 ppt (p < 0.01), 8.3 ppt (p < 0.01), 3.1 ppt (p < 0.1), and 12.3 ppt (p < 0.01), respectively. Our results suggest that Medicaid expansion effect on unmet medical need due to cost in higher-reimbursing states was 2.98 ppt (p < 0.05) larger than in lower-reimbursing states. Evidence suggests modest increases in health care access were more strongly associated with expansions in higher-fee states. CONCLUSIONS Medicaid's fee structure should be considered as a factor influencing large-scale coverage expansions.
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Affiliation(s)
- Joseph Benitez
- Department of Health Management & Policy, College of Public Health, University of Kentucky, Lexington, KY, USA.
| | - Salama S Freed
- Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, D.C, USA
| | - Huang Huang
- Department of Health Management & Policy, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Tolulope Oladele
- Department of Health Management & Policy, College of Public Health, University of Kentucky, Lexington, KY, USA
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Freed SS, Jones KA, Whitaker RG, Norman K, Carvalho M, Giri A, Lake A, Tchuisseu YP, Repka S, Vasudeva K, Bey N, Bettger JP. Evaluating Telehealth Uptake Among North Carolina Medicaid Beneficiaries With Musculoskeletal Conditions: Insights From the COVID-19 Pandemic. Med Care 2023; 61:750-759. [PMID: 37733405 DOI: 10.1097/mlr.0000000000001915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
BACKGROUND The shift from in-person to virtual visits, known as telehealth (TH), during the COVID-19 pandemic was a significant change for North Carolina (NC) Medicaid beneficiaries seeking treatment for musculoskeletal (MSK) conditions, as remote care for these conditions was previously unavailable. We used this policy change to investigate factors associated with TH uptake and whether TH availability mitigated disparities in access to care or affected emergency department (ED) visits among these beneficiaries. RESEARCH DESIGN Using 2019-2021 NC Medicaid claims, we identified beneficiaries receiving treatment for MSK conditions before COVID-19 (March 2019-February 2020) and analyzed uptake of newly available TH during COVID-19 (April 2020-March 2021). We used descriptive analysis and Poisson generalized estimating equations to quantify TH uptake, factors associated with TH uptake, and the association with ED visits during COVID-19. RESULTS Black and Hispanic beneficiaries were less likely to use TH compared with White and non-Hispanic counterparts (10%, P <0.001 and 20%, P =0.03, respectively). Adults eligible for Tailored Plans, specialized NC Medicaid plans for those with significant behavioral health needs or intellectual/developmental disabilities, were less likely to use TH [adjusted risk ratio (ARR):0.83, 95% CI (0.78, 0.87)]; youth eligible for Tailored Plans were more likely to use TH [ARR:1.28, 95% CI (1.16, 1.42)]. Lower county-level internet access was associated with lower TH use [ARR: 0.85, 95% CI (0.82, 0.99)]. No statistical difference in ED utilization was observed between TH users and non-users. CONCLUSIONS TH has the potential to deliver convenient care to beneficiaries with MSK conditions who can access it. Further research and policy changes should explore and address underlying factors driving disparities and improve equitable access to care for this population.
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Affiliation(s)
- Salama S Freed
- Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Kelley A Jones
- Department of Population Health Sciences, Duke University School of Medicine
| | | | - Katherine Norman
- Department of Population Health Sciences, Duke University School of Medicine
| | - Marissa Carvalho
- Department of Physical Therapy and Occupational Therapy, Duke Health, Durham NC
| | - Abhigya Giri
- Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Ashley Lake
- Duke Physical Therapy Sports Medicine at Center for Living, Duke University, Durham
| | | | | | - Karina Vasudeva
- Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Nadia Bey
- Duke Margolis Center for Health Policy, Duke University
| | - Janet Prvu Bettger
- Department of Health and Rehabilitation Sciences, Temple University, Philadelphia, PA
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Buntin MB, Freed SS, Lai P, Lou K, Keohane LM. Trends in and Factors Contributing to the Slowdown in Medicare Spending Growth, 2007-2018. JAMA Health Forum 2022; 3:e224475. [PMID: 36459161 PMCID: PMC9719052 DOI: 10.1001/jamahealthforum.2022.4475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Importance After decades of rapid increase, Medicare per-beneficiary spending growth was historically low in the period leading up to the passage of the Affordable Care Act. In the years immediately following the legislation, Medicare expenditure growth slowed even further. Objective To evaluate factors contributing to the slowdown in Medicare per-beneficiary spending growth. Design, Setting, and Participants In this cross-sectional study, expected spending growth for 2012 to 2015 and 2016 to 2018 was predicted holding payment rates and population characteristics constant. By contrasting predicted and actual spending growth during these periods, the contribution of population vs payment factors to the Medicare spending slowdown was determined. Analyses included all Medicare fee-for-service beneficiaries aged 65 years and older, ranging from 30 to 35 million beneficiaries annually between 2007 and 2018. Data analyses were conducted from January 2018 to August 2018 and updated with new data in June 2021. Main Outcomes and Measures The main outcome included annual growth in total per-beneficiary spending. The roles of payment rate changes and differences in the Medicare population over time were considered, including demographic characteristics and numbers of chronic conditions. Results Between 2008 to 2011 and 2012 to 2015, the adjusted annual Medicare Parts A and B per-beneficiary spending growth rate declined from 3.3% to -0.1%. From 2016 to 2018, the mean annual Medicare spending growth rate rose relative to the previous period but remained lower than in the baseline period at 1.7% per year. This slowdown extended across all sectors within Parts A and B, except for physician-administered drugs offered under Part B. Changes in payment rates (including sequestration measures) and beneficiary characteristics explained 44% of the difference in overall per-beneficiary spending growth between 2007 to 2011 and 2012 to 2015, and 63% between 2007 to 2011 and 2016 to 2018. Conclusions and Relevance In this cross-sectional study of trends in spending growth per Medicare beneficiary aged 65 years or older, results suggested that Medicare payment policy, including sector-specific payment rate changes and sequestration, will be a critical determinant of whether the Medicare spending growth slowdown persists.
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Affiliation(s)
- Melinda B. Buntin
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Salama S. Freed
- Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - Pikki Lai
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee,Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Klara Lou
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Laura M. Keohane
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
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Freed SS, Kaufman BG, Van Houtven CH, Saunders R. Using a home time measure to differentiate ACO performance for seriously ill populations. J Am Geriatr Soc 2022; 70:2666-2676. [PMID: 35620814 DOI: 10.1111/jgs.17882] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/16/2022] [Accepted: 04/23/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Alternative Payment Models (APMs) piloted by the Centers for Medicare and Medicaid Services (CMS) such as ACO Realizing Equity, Access and Community Health (REACH) seek to improve care and quality of life among seriously ill populations (SIP). Days at Home (DAH) was proposed for use in this model to evaluate organizational performance. It is important to assess the utility and feasibility of person-centered outcomes measures, such as DAH, as CMS seeks to advance care models for seriously ill beneficiaries. We leverage existing Accountable Care Organization (ACO) contracts to evaluate the feasibility of ACO-level DAH measure and examine characteristics associated with ACOs with more DAH. METHODS We calculated DAH for Medicare fee-for-service beneficiaries aged 68 and over who were retrospectively attributed to a Medicare ACO between 2014 and 2018 and met the seriously ill criteria. We then aggregated to the ACO level DAH for each ACO's seriously ill beneficiaries and risk-adjusted this aggregated measure. Finally, we evaluated associations between risk-adjusted DAH per person-year and ACO, beneficiary, and market characteristics. RESULTS ACOs' seriously ill beneficiaries spent an average of 349.3 risk-adjusted DAH per person-year. Risk-adjusted ACO variation, defined as the interquartile range, was 4.21 days (IQR = 347.32-351.53). Beneficiaries of ACOs are composed of a less racially diverse beneficiary cohort, opting for two-sided risk models, and operating in markets with fewer hospital and Skilled Nursing Facility beds had more DAH. CONCLUSIONS Substantial variation across ACOs in the DAH measure for seriously ill beneficiaries suggests the measure can differentiate between high and low performing provider groups. Key to the success of the metric is accurate risk adjustment to ensure providers have adequate resources to care for seriously ill beneficiaries. Organizational factors, such as the ACO size and level of risk, are strongly associated with more days at home.
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Affiliation(s)
- Salama S Freed
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,National Pharmaceutical Council, Washington, District of Columbia, USA
| | - Brystana G Kaufman
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Courtney H Van Houtven
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA.,Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Robert Saunders
- Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
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Abstract
OBJECTIVES To analyze the sources of per-beneficiary Medicare spending growth between 2007 and 2014, including the role of demographic characteristics, attributes of Medicare coverage, and chronic conditions. DATA SOURCES Individual-level Medicare spending and enrollment data. STUDY DESIGN Using an Oaxaca-Blinder decomposition model, we analyzed whether changes in price-standardized, per-beneficiary Medicare Part A and B spending reflected changes in the composition of the Medicare population or changes in relative spending levels per person. DATA EXTRACTION METHODS We identified a 5 percent sample of fee-for-service Medicare beneficiaries age 65 and above from years 2007 to 2014. RESULTS Mean payment-adjusted Medicare per-beneficiary spending decreased by $180 between the 2007-2010 and 2011-2014 time periods. This decline was almost entirely attributable to lower spending levels for beneficiaries. Notably, declines in marginal spending levels for beneficiaries with chronic conditions were associated with a $175 reduction in per-beneficiary spending. The decline was partially offset by the increasing prevalence of certain chronic diseases. Still, we are unable to attribute a large share of the decline in spending levels to observable beneficiary characteristics or chronic conditions. CONCLUSIONS Declines in spending levels for Medicare beneficiaries with chronic conditions suggest that changing patterns of care use may be moderating spending growth.
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Affiliation(s)
- Laura M. Keohane
- Department of Health PolicyVanderbilt University School of MedicineNashvilleTN
| | - Robert J. Gambrel
- Department of Health PolicyVanderbilt University School of MedicineNashvilleTN
| | - Salama S. Freed
- Department of Health PolicyVanderbilt University School of MedicineNashvilleTN
- Department of EconomicsVanderbilt UniversityNashvilleTN
| | - David Stevenson
- Department of Health PolicyVanderbilt University School of MedicineNashvilleTN
| | - Melinda B. Buntin
- Department of Health PolicyVanderbilt University School of MedicineNashvilleTN
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