1
|
Liu BY, Rome BN. State Coverage and Reimbursement of Antiobesity Medications in Medicaid. JAMA 2024; 331:1230-1232. [PMID: 38483403 PMCID: PMC10941017 DOI: 10.1001/jama.2024.3073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 02/21/2024] [Indexed: 03/17/2024]
Abstract
This study examines state Medicaid coverage policies for antiobesity medications and their trends in Medicaid reimbursement from 2011 to 2022.
Collapse
Affiliation(s)
- Benjamin Y. Liu
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Benjamin N. Rome
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, Massachusetts
| |
Collapse
|
2
|
Hatfield LA. Trickle-Down Medicaid: Do Health Care Workers See Expansion Dollars? JAMA 2024; 331:652-653. [PMID: 38411657 DOI: 10.1001/jama.2023.27155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Affiliation(s)
- Laura A Hatfield
- Harvard Medical School, Boston, Massachusetts
- Statistical Editor, JAMA
| |
Collapse
|
3
|
Matta S, Chatterjee P, Venkataramani AS. Changes in Health Care Workers' Economic Outcomes Following Medicaid Expansion. JAMA 2024; 331:687-695. [PMID: 38411645 PMCID: PMC10900969 DOI: 10.1001/jama.2023.27014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Importance The extent to which changes in health sector finances impact economic outcomes among health care workers, especially lower-income workers, is not well known. Objective To assess the association between state adoption of the Affordable Care Act's Medicaid expansion-which led to substantial improvements in health care organization finances-and health care workers' annual incomes and benefits, and whether these associations varied across low- and high-wage occupations. Design, Setting, and Participants Difference-in-differences analysis to assess differential changes in health care workers' economic outcomes before and after Medicaid expansion among workers in 30 states that expanded Medicaid relative to workers in 16 states that did not, by examining US individuals aged 18 through 65 years employed in the health care industry surveyed in the 2010-2019 American Community Surveys. Exposure Time-varying state-level adoption of Medicaid expansion. Main Outcomes and Measures Primary outcome was annual earned income; secondary outcomes included receipt of employer-sponsored health insurance, Medicaid, and Supplemental Nutrition Assistance Program benefits. Results The sample included 1 322 263 health care workers from 2010-2019. Health care workers in expansion states were similar to those in nonexpansion states in age, sex, and educational attainment, but those in expansion states were less likely to identify as non-Hispanic Black. Medicaid expansion was associated with a 2.16% increase in annual incomes (95% CI, 0.66%-3.65%; P = .005). This effect was driven by significant increases in annual incomes among the top 2 highest-earning quintiles (β coefficient, 2.91%-3.72%), which includes registered nurses, physicians, and executives. Health care workers in lower-earning quintiles did not experience any significant changes. Medicaid expansion was associated with a 3.15 percentage point increase in the likelihood that a health care worker received Medicaid benefits (95% CI, 2.46 to 3.84; P < .001), with the largest increases among the 2 lowest-earning quintiles, which includes health aides, orderlies, and sanitation workers. There were significant decreases in employer-sponsored health insurance and increases in SNAP following Medicaid expansion. Conclusion and Relevance Medicaid expansion was associated with increases in compensation for health care workers, but only among the highest earners. These findings suggest that improvements in health care sector finances may increase economic inequality among health care workers, with implications for worker health and well-being.
Collapse
Affiliation(s)
- Sasmira Matta
- Department of Health Care Management, Wharton School, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Paula Chatterjee
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Atheendar S Venkataramani
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| |
Collapse
|
4
|
Koukounas KG, Thorsness R, Patzer RE, Wilk AS, Drewry KM, Mehrotra R, Rivera-Hernandez M, Meyers DJ, Kim D, Trivedi AN. Social Risk and Dialysis Facility Performance in the First Year of the ESRD Treatment Choices Model. JAMA 2024; 331:124-131. [PMID: 38193961 PMCID: PMC10777251 DOI: 10.1001/jama.2023.23649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/22/2023] [Indexed: 01/10/2024]
Abstract
Importance The End-Stage Renal Disease Treatment Choices (ETC) model randomly selected 30% of US dialysis facilities to receive financial incentives based on their use of home dialysis, kidney transplant waitlisting, or transplant receipt. Facilities that disproportionately serve populations with high social risk have a lower use of home dialysis and kidney transplant raising concerns that these sites may fare poorly in the payment model. Objective To examine first-year ETC model performance scores and financial penalties across dialysis facilities, stratified by their incident patients' social risk. Design, Setting, and Participants A cross-sectional study of 2191 US dialysis facilities that participated in the ETC model from January 1 through December 31, 2021. Exposure Composition of incident patient population, characterized by the proportion of patients who were non-Hispanic Black, Hispanic, living in a highly disadvantaged neighborhood, uninsured, or covered by Medicaid at dialysis initiation. A facility-level composite social risk score assessed whether each facility was in the highest quintile of having 0, 1, or at least 2 of these characteristics. Main Outcomes and Measures Use of home dialysis, waitlisting, or transplant; model performance score; and financial penalization. Results Using data from 125 984 incident patients (median age, 65 years [IQR, 54-74]; 41.8% female; 28.6% Black; 11.7% Hispanic), 1071 dialysis facilities (48.9%) had no social risk features, and 491 (22.4%) had 2 or more. In the first year of the ETC model, compared with those with no social risk features, dialysis facilities with 2 or more had lower mean performance scores (3.4 vs 3.6, P = .002) and lower use of home dialysis (14.1% vs 16.0%, P < .001). These facilities had higher receipt of financial penalties (18.5% vs 11.5%, P < .001), more frequently had the highest payment cut of 5% (2.4% vs 0.7%; P = .003), and were less likely to achieve the highest bonus of 4% (0% vs 2.7%; P < .001). Compared with all other facilities, those in the highest quintile of treating uninsured patients or those covered by Medicaid experienced more financial penalties (17.4% vs 12.9%, P = .01) as did those in the highest quintile in the proportion of patients who were Black (18.5% vs 12.6%, P = .001). Conclusions In the first year of the Centers for Medicare & Medicaid Services' ETC model, dialysis facilities serving higher proportions of patients with social risk features had lower performance scores and experienced markedly higher receipt of financial penalties.
Collapse
Affiliation(s)
- Kalli G. Koukounas
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | | | - Rachel E. Patzer
- Regenstrief Institute, Indianapolis, Indiana
- Department of Surgery, Division of Transplant Surgery, Indiana University School of Medicine, Indianapolis
| | - Adam S. Wilk
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kelsey M. Drewry
- Regenstrief Institute, Indianapolis, Indiana
- Department of Surgery, Division of Transplant Surgery, Indiana University School of Medicine, Indianapolis
| | - Rajnish Mehrotra
- Division of Nephrology, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Maricruz Rivera-Hernandez
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - David J. Meyers
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Daeho Kim
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Amal N. Trivedi
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| |
Collapse
|
5
|
McIntyre A, Aboulafia G, Sommers BD. Preliminary Data on "Unwinding" Continuous Medicaid Coverage. N Engl J Med 2023; 389:2215-2217. [PMID: 37991840 DOI: 10.1056/nejmp2311336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Affiliation(s)
- Adrianna McIntyre
- From the Harvard T.H. Chan School of Public Health, Boston (A.M., B.D.S.), and Harvard University, Cambridge (G.A.) - both in Massachusetts
| | - Gabriella Aboulafia
- From the Harvard T.H. Chan School of Public Health, Boston (A.M., B.D.S.), and Harvard University, Cambridge (G.A.) - both in Massachusetts
| | - Benjamin D Sommers
- From the Harvard T.H. Chan School of Public Health, Boston (A.M., B.D.S.), and Harvard University, Cambridge (G.A.) - both in Massachusetts
| |
Collapse
|
6
|
Adashi EY, O'Mahony DP, Cohen IG. Maternal Mortality Crisis and Extension of Medicaid Postpartum Coverage. JAMA 2023; 330:911-912. [PMID: 37594892 DOI: 10.1001/jama.2023.15380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
This Viewpoint discusses the maternal mortality crisis in the US, the need for an extension of Medicaid postpartum coverage, and the residual challenges across the US related to maternal health.
Collapse
Affiliation(s)
| | | | - I Glenn Cohen
- Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, Harvard Law School, Harvard University, Cambridge, Massachusetts
| |
Collapse
|
7
|
Abstract
This Viewpoint discusses potential benefits and unintended consequences of out-of-pocket cost caps in Medicare and the employer-sponsored health insurance market and provides suggested policy opportunities to address shortcomings.
Collapse
Affiliation(s)
- J Frank Wharam
- Department of Medicine, Duke University, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Durham, North Carolina
| | | |
Collapse
|
8
|
Fine JR, Ransdell JM, Pinheiro PS, Kwon D, Reis IM, Barredo JC, Isrow DM. The Effect of Health Insurance on Pediatric Cancer Survival: An Analysis of Children Evaluated for Radiation Therapy in Diverse Multicenter Health Systems. J Pediatr Hematol Oncol 2023; 45:e662-e670. [PMID: 37278568 DOI: 10.1097/mph.0000000000002678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 03/21/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Understanding the role of health insurance in cancer survival in a diverse population of pediatric radiation oncology patients could help to identify patients at risk of adverse outcomes. MATERIALS AND METHODS Data were collected from cancer patients evaluated for radiation therapy, age < 19, diagnosed from January 1990 to August 2019. Predictors of recurrence-free survival (RFS) and overall survival (OS) were analyzed by univariable and multivariable Cox regression. Variables included health insurance, diagnosis type, sex, race/ethnicity, and socioeconomic status deprivation index. RESULTS The study included 459 patients with a median diagnosis age of 9 years. Demographic breakdown was 49.5% Hispanic, 27.2% non-Hispanic White, and 20.7% non-Hispanic Black. There were 203 recurrences and 86 deaths observed over a median follow-up of 2.4 years. Five-year RFS was 59.8% (95% CI, 51.6, 67.0) versus 36.5% (95% CI, 26.6, 46.6), and 5-year OS was 87.5% (95% CI, 80.9, 91.9) versus 71.0% (95% CI, 60.3, 79.3) in private pay insurance versus Medicaid/Medicare, respectively. Multivariable showed Medicaid/Medicare patients experienced a 54% higher risk of recurrence (hazard ratio: 1.54, 95% CI, 1.08, 2.20) and 79% higher risk of death (hazard ratio: 1.79, 95% CI, 1.02, 3.14) than privately insured patients. CONCLUSIONS Significant disadvantages in RFS and OS were identified in radiation oncology patients with Medicaid/Medicare insurance, even after adjusting for clinical and demographic variables.
Collapse
Affiliation(s)
| | | | - Paulo S Pinheiro
- Sylvester Comprehensive Cancer Center
- Department of Public Health Science, University of Miami Miller School of Medicine
| | - Deukwoo Kwon
- Division of Biostatistics, Department of Public Health Sciences, Miller School of Medicine, University of Miami
- Biostatistics and Bioinformatics Core Resource, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami
| | - Isildinha M Reis
- Division of Biostatistics, Department of Public Health Sciences, Miller School of Medicine, University of Miami
- Biostatistics and Bioinformatics Core Resource, Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami
| | | | - Derek M Isrow
- Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
| |
Collapse
|
9
|
Dolin CD, Mullin AM, Ledyard RF, Bender WR, South EC, Durnwald CP, Burris HH. Neighborhood Deprivation and Racial Disparities in Early Pregnancy Impaired Glucose Tolerance. Int J Environ Res Public Health 2023; 20:6175. [PMID: 37372761 PMCID: PMC10298257 DOI: 10.3390/ijerph20126175] [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] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/30/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023]
Abstract
OBJECTIVE There is mounting evidence that neighborhoods contribute to perinatal health inequity. We aimed (1) to determine whether neighborhood deprivation (a composite marker of area-level poverty, education, and housing) is associated with early pregnancy impaired glucose intolerance (IGT) and pre-pregnancy obesity and (2) to quantify the extent to which neighborhood deprivation may explain racial disparities in IGT and obesity. STUDY DESIGN This was a retrospective cohort study of non-diabetic patients with singleton births ≥ 20 weeks' gestation from 1 January 2017-31 December 2019 in two Philadelphia hospitals. The primary outcome was IGT (HbA1c 5.7-6.4%) at <20 weeks' gestation. Addresses were geocoded and census tract neighborhood deprivation index (range 0-1, higher indicating more deprivation) was calculated. Mixed-effects logistic regression and causal mediation models adjusted for covariates were used. RESULTS Of the 10,642 patients who met the inclusion criteria, 49% self-identified as Black, 49% were Medicaid insured, 32% were obese, and 11% had IGT. There were large racial disparities in IGT (16% vs. 3%) and obesity (45% vs. 16%) among Black vs. White patients, respectively (p < 0.0001). Mean (SD) neighborhood deprivation was higher among Black (0.55 (0.10)) compared with White patients (0.36 (0.11)) (p < 0.0001). Neighborhood deprivation was associated with IGT and obesity in models adjusted for age, insurance, parity, and race (aOR 1.15, 95%CI: 1.07, 1.24 and aOR 1.39, 95%CI: 1.28, 1.52, respectively). Mediation analysis revealed that 6.7% (95%CI: 1.6%, 11.7%) of the Black-White disparity in IGT might be explained by neighborhood deprivation and 13.3% (95%CI: 10.7%, 16.7%) by obesity. Mediation analysis also suggested that 17.4% (95%CI: 12.0%, 22.4%) of the Black-White disparity in obesity may be explained by neighborhood deprivation. CONCLUSION Neighborhood deprivation may contribute to early pregnancy IGT and obesity-surrogate markers of periconceptional metabolic health in which there are large racial disparities. Investing in neighborhoods where Black patients live may improve perinatal health equity.
Collapse
Affiliation(s)
- Cara D. Dolin
- Department of Obstetrics and Gynecology, Women’s Health Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH 44195, USA
| | - Anne M. Mullin
- Tufts University School of Medicine, Boston, MA 02111, USA
| | - Rachel F. Ledyard
- Division of Neonatology, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Whitney R. Bender
- Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, Richmond, VA 23298, USA
| | - Eugenia C. South
- Urban Health Lab, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Celeste P. Durnwald
- Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Heather H. Burris
- Division of Neonatology, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard Davis Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| |
Collapse
|
10
|
Schoenbrunner A, Beckmeyer A, Kunnath N, Ibrahim A, Pawlik TM, Venkataramani A, Kuzon WM, Diaz A. Association Between California's State Insurance Gender Nondiscrimination Act and Utilization of Gender-Affirming Surgery. JAMA 2023; 329:819-826. [PMID: 36917051 PMCID: PMC10015311 DOI: 10.1001/jama.2023.0878] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/03/2023] [Indexed: 03/15/2023]
Abstract
Importance Gender-affirming surgery is often beneficial for gender-diverse or -dysphoric patients. Access to gender-affirming surgery is often limited through restrictive legislation and insurance policies. Objective To investigate the association between California's 2013 implementation of the Insurance Gender Nondiscrimination Act, which prohibits insurers and health plans from limiting benefits based on a patient's sex, gender, gender identity, or gender expression, and utilization of gender-affirming surgery among California residents. Design, Setting, and Participants Population epidemiology study of transgender and gender-diverse patients undergoing gender-affirming surgery (facial, chest, and genital surgery) between 2005 and 2019. Utilization of gender-affirming surgery in California before and after implementation of the Insurance Gender Nondiscrimination Act in July 2013 was compared with utilization in Washington and Arizona, control states chosen because of geographic similarity and because they expanded Medicaid on the same date as California-January 1, 2014. The date of last follow-up was December 31, 2019. Exposures California's Insurance Gender Nondiscrimination Act, implemented on July 9, 2013. Main Outcomes and Measures Receipt of gender-affirming surgery, defined as undergoing at least 1 facial, chest, or genital procedure. Results A total of 25 252 patients (California: n = 17 934 [71%]; control: n = 7328 [29%]) had a diagnosis of gender dysphoria. Median ages were 34.0 years in California (with or without gender-affirming surgery), 39 years (IQR, 28-49 years) among those undergoing gender-affirming surgery in control states, and 36 years (IQR, 22-56 years) among those not undergoing gender-affirming surgery in control states. Patients underwent at least 1 gender-affirming surgery within the study period in 2918 (11.6%) admissions-2715 (15.1%) in California vs 203 (2.8%) in control states. There was a statistically significant increase in gender-affirming surgery in the third quarter of July 2013 in California vs control states, coinciding with the timing of the Insurance Gender Nondiscrimination Act (P < .001). Implementation of the policy was associated with an absolute 12.1% (95% CI, 10.3%-13.9%; P < .001) increase in the probability of undergoing gender-affirming surgery in California vs control states observed in the subset of insured patients (13.4% [95% CI, 11.5%-15.4%]; P < .001) but not self-pay patients (-22.6% [95% CI, -32.8% to -12.5%]; P < .001). Conclusions and Relevance Implementation in California of its Insurance Gender Nondiscrimination Act was associated with a significant increase in utilization of gender-affirming surgery in California compared with the control states Washington and Arizona. These data might inform state legislative efforts to craft policies preventing discrimination in health coverage for state residents, including transgender and gender-diverse patients.
Collapse
Affiliation(s)
- Anna Schoenbrunner
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus
| | | | - Nicholas Kunnath
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Andrew Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Taubman College of Architecture and Urban Planning, University of Michigan, Ann Arbor
| | | | - Atheendar Venkataramani
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
- Opportunity for Health Labs, University of Pennsylvania, Philadelphia
| | | | - Adrian Diaz
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Department of Surgery, The Ohio State University, Columbus
| |
Collapse
|
11
|
|
12
|
Harris E. Medicaid Expansion Tied to Reduction in Postpartum Hospitalizations. JAMA 2023; 329:458. [PMID: 36696140 DOI: 10.1001/jama.2023.0393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
|
13
|
Abstract
IMPORTANCE Family income is known to be associated with children's health; the association may be particularly pronounced among lower-income children in the US, who tend to have more limited access to health resources than their higher-income peers. OBJECTIVE To investigate the association of family income with claims-based measures of morbidity and mortality among children and adolescents in lower-income families in the US enrolled in Medicaid or the Children's Health Insurance Program. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional analysis included 795 000 participants aged 5 to 17 years enrolled in Medicaid (Medicaid Analytic eXtract claims, 2011-2012) living in families with income below 200% of the federal poverty threshold (American Community Survey, 2008-2013). Follow-up ended in December 2021. EXPOSURES Family income relative to the federal poverty threshold. MAIN OUTCOMES AND MEASURES Record of International Classification of Diseases, Ninth Revision codes for an infection, mental health disorder, injury, asthma, anemia, or substance use disorder and death record within 10 years of observation (Social Security Administration death records through 2021). RESULTS Among 795 000 individuals in the sample (all statistics weighted: mean [SD] income-to-poverty ratio, 90% [53%]; mean [SD] age, 10.6 [3.9] years; 56% aged 10 to 17 years), 33% had a diagnosed infection, 13% had a mental health disorder, 6% had an injury, 5% had asthma, 2% had anemia, 1% had a substance use disorder, and 0.6% died between 2011 and 2021, with the mean (SD) age at death of 19.8 (4.2) years. For those aged 5 to 9 years, higher family income was associated with lower adjusted prevalence of all outcomes, except mortality: children in families with an additional 100% income relative to the federal poverty threshold had 2.3 (95% CI, 1.8-2.9) percentage points fewer infections, 1.9 (95% CI, 1.5-2.2) percentage points fewer mental health diagnoses, 0.7 (95% CI, 0.5-0.8) percentage points fewer injuries, 0.3 (95% CI, 0.09-0.5) percentage points less asthma, 0.2 (95% CI, 0.08-0.3) percentage points less anemia, and 0.06 (95% CI, 0.03-0.09) percentage points fewer substance use disorder diagnoses. Except for injury and anemia, the associations were more pronounced among those aged 10 to 17 years than those 5 to 9 years (P for interaction <.05). For those aged 10 to 17 years, an additional 100% income relative to the federal poverty threshold was associated with a lower 10-year mortality rate by 0.18 (95% CI, 0.12-0.25) percentage points. CONCLUSIONS AND RELEVANCE Among children and adolescents in the US aged 5 to 17 years with family income under 200% of the federal poverty threshold who accessed health care through Medicaid or the Children's Health Insurance Program, higher family income was significantly associated with a lower prevalence of diagnosed infections, mental health disorders, injury, asthma, anemia, and substance use disorders and lower 10-year mortality. Further research is needed to understand whether these associations are causal.
Collapse
Affiliation(s)
| | - Vinayak Bhatia
- Department of Statistics, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Maria Polyakova
- Department of Health Policy, School of Medicine, Stanford University, Stanford, California
- National Bureau of Economic Research (NBER), Cambridge, Massachusetts
| |
Collapse
|
14
|
Abstract
IMPORTANCE Medicaid is the largest health insurance program by enrollment in the US and has an important role in financing care for eligible low-income adults, children, pregnant persons, older adults, people with disabilities, and people from racial and ethnic minority groups. Medicaid has evolved with policy reform and expansion under the Affordable Care Act and is at a crossroads in balancing its role in addressing health disparities and health inequities against fiscal and political pressures to limit spending. OBJECTIVE To describe Medicaid eligibility, enrollment, and spending and to examine areas of Medicaid policy, including managed care, payment, and delivery system reforms; Medicaid expansion; racial and ethnic health disparities; and the potential to achieve health equity. EVIDENCE REVIEW Analyses of publicly available data reported from 2010 to 2022 on Medicaid enrollment and program expenditures were performed to describe the structure and financing of Medicaid and characteristics of Medicaid enrollees. A search of PubMed for peer-reviewed literature and online reports from nonprofit and government organizations was conducted between August 1, 2021, and February 1, 2022, to review evidence on Medicaid managed care, delivery system reforms, expansion, and health disparities. Peer-reviewed articles and reports published between January 2003 and February 2022 were included. FINDINGS Medicaid covered approximately 80.6 million people (mean per month) in 2022 (24.2% of the US population) and accounted for an estimated $671.2 billion in health spending in 2020, representing 16.3% of US health spending. Medicaid accounted for an estimated 27.2% of total state spending and 7.6% of total federal expenditures in 2021. States enrolled 69.5% of Medicaid beneficiaries in managed care plans in 2019 and adopted 139 delivery system reforms from 2003 to 2019. The 38 states (and Washington, DC) that expanded Medicaid under the Affordable Care Act experienced gains in coverage, increased federal revenues, and improvements in health care access and some health outcomes. Approximately 56.4% of Medicaid beneficiaries were from racial and ethnic minority groups in 2019, and disparities in access, quality, and outcomes are common among these groups within Medicaid. Expanding Medicaid, addressing disparities within Medicaid, and having an explicit focus on equity in managed care and delivery system reforms may represent opportunities for Medicaid to advance health equity. CONCLUSIONS AND RELEVANCE Medicaid insures a substantial portion of the US population, accounts for a significant amount of total health spending and state expenditures, and has evolved with delivery system reforms, increased managed care enrollment, and state expansions. Additional Medicaid policy reforms are needed to reduce health disparities by race and ethnicity and to help achieve equity in access, quality, and outcomes.
Collapse
Affiliation(s)
- Julie M Donohue
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Evan S Cole
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | | | - Marian Jarlenski
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Jamila D Michener
- Department of Government and School of Public Policy, Cornell University, Ithaca, New York
| | - Eric T Roberts
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| |
Collapse
|
15
|
Bartlett VL, Ross JS, Balasuriya L, Rhee TG. Association of Psychiatric Diagnoses and Medicaid Coverage with Length of Stay Among Inpatients Discharged to Skilled Nursing Facilities. J Gen Intern Med 2022; 37:3070-3079. [PMID: 35048298 PMCID: PMC9485316 DOI: 10.1007/s11606-021-07320-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 12/08/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Inpatients with psychiatric diagnoses often require higher levels of care in skilled nursing facilities (SNFs) and are more likely to be covered by Medicaid, which reimburses SNFs at significantly lower rates than Medicare and commercial payors. OBJECTIVE To characterize factors affecting length of stay in inpatients discharged to SNFs. DESIGN A retrospective cross-sectional study design using 2016-2018 data from National Inpatient Sample. PARTICIPANTS Inpatients aged ≥ 40 who were discharged to SNFs. EXPOSURES Primary discharge diagnosis (medical, psychiatric, or substance use) and primary payor. MAIN OUTCOMES AND MEASURES Length of stay, categorized non-exclusively as >3 days, >7 days, or > 14 days. RESULTS Among 9,821,155 inpatient discharges to SNFs between 2016 and 2018, 95.7% had medical primary discharge diagnoses, 3.3% psychiatric diagnoses, and 1.0% substance use diagnoses; Medicare was the most common primary payor (83.3%), followed by private insurance (7.9%), Medicaid (6.6%), and others (2.2%). Median length of stay for all patients was 5.0 days (interquartile range [IQR], 3.0-8.0), 5.0 (IQR, 3.0-8.0) for those with medical diagnoses, 8.0 (IQR, 4.0-15.0) for psychiatric diagnoses, and 5.0 (IQR, 3.0-8.0) for substance use diagnoses. After multivariable adjustment, compared to patients with medical diagnoses, patients with psychiatric diagnoses were more likely to have hospital stays > 3, > 7, and > 14 days, respectively (p < 0.001). Compared to Medicare patients, Medicaid patients were more likely to have hospital stays > 3, > 7, and > 14 days, respectively (p < 0.001). Compared to patients with medical diagnoses, those with psychiatric diagnoses were also more likely to have lengths of stay 1 times, 1.5 times, and 2 times greater than the national geometric mean length of stay for that diagnosis-related group (p < 0.001). CONCLUSIONS Patients discharged to SNFs after inpatient hospitalization for psychiatric diagnoses and with Medicaid coverage were more likely to have longer lengths of stay than patients with medical diagnoses and those with Medicare coverage, respectively.
Collapse
Affiliation(s)
| | - Joseph S Ross
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Lilanthi Balasuriya
- National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, USA
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
- Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, CT, USA.
| |
Collapse
|
16
|
McConnell MA, Rokicki S, Ayers S, Allouch F, Perreault N, Gourevitch RA, Martin MW, Zhou RA, Zera C, Hacker MR, Chien A, Bates MA, Baicker K. Effect of an Intensive Nurse Home Visiting Program on Adverse Birth Outcomes in a Medicaid-Eligible Population: A Randomized Clinical Trial. JAMA 2022; 328:27-37. [PMID: 35788794 PMCID: PMC9257581 DOI: 10.1001/jama.2022.9703] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Improving birth outcomes for low-income mothers is a public health priority. Intensive nurse home visiting has been proposed as an intervention to improve these outcomes. OBJECTIVE To determine the effect of an intensive nurse home visiting program on a composite outcome of preterm birth, low birth weight, small for gestational age, or perinatal mortality. DESIGN, SETTING, AND PARTICIPANTS This was a randomized clinical trial that included 5670 Medicaid-eligible, nulliparous pregnant individuals at less than 28 weeks' gestation, enrolled between April 1, 2016, and March 17, 2020, with follow-up through February 2021. INTERVENTIONS Participants were randomized 2:1 to Nurse Family Partnership program (n = 3806) or control (n = 1864). The program is an established model of nurse home visiting; regular visits begin prenatally and continue through 2 postnatal years. Nurses provide education, assessments, and goal-setting related to prenatal health, child health and development, and maternal life course. The control group received usual care services and a list of community resources. Neither staff nor participants were blinded to intervention group. MAIN OUTCOMES AND MEASURES There were 3 primary outcomes. This article reports on a composite of adverse birth outcomes: preterm birth, low birth weight, small for gestational age, or perinatal mortality based on vital records, Medicaid claims, and hospital discharge records through February 2021. The other primary outcomes of interbirth intervals of less than 21 months and major injury or concern for abuse or neglect in the child's first 24 months have not yet completed measurement. There were 54 secondary outcomes; those related to maternal and newborn health that have completed measurement included all elements of the composite plus birth weight, gestational length, large for gestational age, extremely preterm, very low birth weight, overnight neonatal intensive care unit admission, severe maternal morbidity, and cesarean delivery. RESULTS Among 5670 participants enrolled, 4966 (3319 intervention; 1647 control) were analyzed for the primary maternal and neonatal health outcome (median age, 21 years [1.2% non-Hispanic Asian, Indigenous, or Native Hawaiian and Pacific Islander; 5.7% Hispanic; 55.2% non-Hispanic Black; 34.8% non-Hispanic White; and 3.0% more than 1 race reported [non-Hispanic]). The incidence of the composite adverse birth outcome was 26.9% in the intervention group and 26.1% in the control group (adjusted between-group difference, 0.5% [95% CI, -2.1% to 3.1%]). Outcomes for the intervention group were not significantly better for any of the maternal and newborn health primary or secondary outcomes in the overall sample or in either of the prespecified subgroups. CONCLUSIONS AND RELEVANCE In this South Carolina-based trial of Medicaid-eligible pregnant individuals, assignment to participate in an intensive nurse home visiting program did not significantly reduce the incidence of a composite of adverse birth outcomes. Evaluation of the overall effectiveness of this program is incomplete, pending assessment of early childhood and birth spacing outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03360539.
Collapse
Affiliation(s)
- Margaret A. McConnell
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Abdul Latif Jameel Poverty Action Lab (J-PAL), Massachusetts Institute of Technology, Cambridge
| | - Slawa Rokicki
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, New Jersey
| | - Samuel Ayers
- Center for Education Policy Research, Harvard Graduate School of Education, Cambridge, Massachusetts
| | - Farah Allouch
- Department of Epidemiology, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Nicolas Perreault
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Michelle W. Martin
- Department of Social and Behavioral Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Chloe Zera
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| | - Michele R. Hacker
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Alyna Chien
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Mary Ann Bates
- Abdul Latif Jameel Poverty Action Lab (J-PAL), Massachusetts Institute of Technology, Cambridge
- Center for Education Policy Research, Harvard Graduate School of Education, Cambridge, Massachusetts
- Now with Cradle-to-Career Data System, State of California, Sacramento
| | - Katherine Baicker
- Abdul Latif Jameel Poverty Action Lab (J-PAL), Massachusetts Institute of Technology, Cambridge
- National Bureau of Economic Research (NBER), Cambridge, Massachusetts
- University of Chicago Harris School of Public Policy, Chicago, Illinois
| |
Collapse
|
17
|
Cliff BQ, Hirth RA, Ayanian JZ. Enrollee Premiums in Medicaid - Insights from Michigan. N Engl J Med 2022; 386:2352-2354. [PMID: 35713548 DOI: 10.1056/nejmp2201059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Betsy Q Cliff
- From the Division of Health Policy and Administration, University of Illinois Chicago School of Public Health, Chicago (B.Q.C.); and the Department of Health Management and Policy, School of Public Health (R.A.H., J.Z.A.), the Division of General Medicine, Medical School (J.Z.A.), the Gerald R. Ford School of Public Policy (J.Z.A.), and the Institute for Healthcare Policy and Innovation (R.A.H., J.Z.A.), University of Michigan, Ann Arbor
| | - Richard A Hirth
- From the Division of Health Policy and Administration, University of Illinois Chicago School of Public Health, Chicago (B.Q.C.); and the Department of Health Management and Policy, School of Public Health (R.A.H., J.Z.A.), the Division of General Medicine, Medical School (J.Z.A.), the Gerald R. Ford School of Public Policy (J.Z.A.), and the Institute for Healthcare Policy and Innovation (R.A.H., J.Z.A.), University of Michigan, Ann Arbor
| | - John Z Ayanian
- From the Division of Health Policy and Administration, University of Illinois Chicago School of Public Health, Chicago (B.Q.C.); and the Department of Health Management and Policy, School of Public Health (R.A.H., J.Z.A.), the Division of General Medicine, Medical School (J.Z.A.), the Gerald R. Ford School of Public Policy (J.Z.A.), and the Institute for Healthcare Policy and Innovation (R.A.H., J.Z.A.), University of Michigan, Ann Arbor
| |
Collapse
|
18
|
Navathe AS, Chandrashekar P, Chen C. Making Value-Based Payment Work for Federally Qualified Health Centers: Toward Equity in the Safety Net. JAMA 2022; 327:2081-2082. [PMID: 35575800 DOI: 10.1001/jama.2022.8285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Amol S Navathe
- Perelman School of Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | | | | |
Collapse
|
19
|
Werner RM, Konetzka RT, Grabowski DC, Stevenson DG. Reforming Nursing Home Financing, Payment, and Oversight. N Engl J Med 2022; 386:1869-1871. [PMID: 35551508 PMCID: PMC9623821 DOI: 10.1056/nejmp2203429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Rachel M Werner
- From the Leonard Davis Institute of Health Economics and Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.M.W.); the Department of Public Health Sciences, University of Chicago, Chicago (R.T.K.); the Department of Health Care Policy, Harvard Medical School, Boston (D.C.G.); and the Department of Health Policy, Vanderbilt University School of Medicine, Nashville (D.G.S.)
| | - R Tamara Konetzka
- From the Leonard Davis Institute of Health Economics and Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.M.W.); the Department of Public Health Sciences, University of Chicago, Chicago (R.T.K.); the Department of Health Care Policy, Harvard Medical School, Boston (D.C.G.); and the Department of Health Policy, Vanderbilt University School of Medicine, Nashville (D.G.S.)
| | - David C Grabowski
- From the Leonard Davis Institute of Health Economics and Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.M.W.); the Department of Public Health Sciences, University of Chicago, Chicago (R.T.K.); the Department of Health Care Policy, Harvard Medical School, Boston (D.C.G.); and the Department of Health Policy, Vanderbilt University School of Medicine, Nashville (D.G.S.)
| | - David G Stevenson
- From the Leonard Davis Institute of Health Economics and Perelman School of Medicine, University of Pennsylvania, Philadelphia (R.M.W.); the Department of Public Health Sciences, University of Chicago, Chicago (R.T.K.); the Department of Health Care Policy, Harvard Medical School, Boston (D.C.G.); and the Department of Health Policy, Vanderbilt University School of Medicine, Nashville (D.G.S.)
| |
Collapse
|
20
|
Abstract
This Viewpoint documents the history, value, and success of the 340B Pricing Program, which is under threat from pharmaceutical corporations’ withdrawal and from a pending Supreme Court decision and offers 2 legislative fixes to address the concerns raised by the pharmaceutical companies.
Collapse
Affiliation(s)
- Ryan P Knox
- Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, Massachusetts
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ameet Sarpatwari
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
21
|
Suran M. More Black Individuals Insured After Affordable Care Act. JAMA 2022; 327:1538. [PMID: 35471527 DOI: 10.1001/jama.2022.6233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
|
22
|
Opoku ST, Apenteng BA, Kimsey L, Peden A, Owens C. COVID-19 and social determinants of health: Medicaid managed care organizations' experiences with addressing member social needs. PLoS One 2022; 17:e0264940. [PMID: 35271632 PMCID: PMC8912251 DOI: 10.1371/journal.pone.0264940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 02/14/2022] [Indexed: 11/18/2022] Open
Abstract
Background The significant adverse social and economic impact of the COVID-19 pandemic has cast broader light on the importance of addressing social determinants of health (SDOH). Medicaid Managed Care Organizations (MMCOs) have increasingly taken on a leadership role in integrating medical and social services for Medicaid members. However, the experiences of MMCOs in addressing member social needs during the pandemic has not yet been examined. Aim The purpose of this study was to describe MMCOs’ experiences with addressing the social needs of Medicaid members during the COVID-19 pandemic. Methods The study was a qualitative study using data from 28 semi-structured interviews with representatives from 14 MMCOs, including state-specific markets of eight national and regional managed care organizations. Data were analyzed using thematic analysis. Results Four themes emerged: the impact of the pandemic, SDOH response efforts, an expanding definition of SDOH, and managed care beyond COVID-19. Specifically, participants discussed the impact of the pandemic on enrollees, communities, and healthcare delivery, and detailed their evolving efforts to address member nonmedical needs during the pandemic. They reported an increased demand for social services coupled with a significant retraction of community social service resources. To address these emerging social service gaps, participants described mounting a prompt and adaptable response that was facilitated by strong existing relationships with community partners. Conclusion Among MMCOs, the COVID-19 pandemic has emphasized the importance of addressing member social needs, and the need for broader consideration of what constitutes SDOH from a healthcare delivery standpoint.
Collapse
Affiliation(s)
- Samuel T. Opoku
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, United States of America
- * E-mail:
| | - Bettye A. Apenteng
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, United States of America
| | - Linda Kimsey
- Department of Health Policy and Community Health, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, United States of America
| | - Angie Peden
- Center for Public Health Practice and Research, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, United States of America
| | - Charles Owens
- Center for Public Health Practice and Research, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, United States of America
| |
Collapse
|
23
|
Abstract
BACKGROUND Intentional injury (both self-harm and interpersonal) is a major cause of morbidity and mortality, yet there are little data on the per-person cost of caring for these patients. Extant data focus on hospital charges related to the initial admission but does not include actual dollars spent or follow-up outpatient care. The Affordable Care Act has made Medicaid the primary payor of intentional injury care (39%) in the United States and the ideal source of cost data for these patients. We sought to determine the total and per-person long-term cost (initial event and following 24 months) of intentional injury among Maryland Medicaid recipients. METHODS Retrospective cohort study of Maryland Medicaid claims was performed. Recipients who submitted claims after receiving an intentional injury, as defined by the International Classification of Diseases, Tenth Revision, between October 2015 and October 2017, were included in this study. Subjects were followed for 24 months (last participant enrolled October 2017 and followed to October 2019). Our primary outcome was the dollars paid by Medicaid. We examined subgroups of patients who harmed themselves and those who received repeated intentional injury. RESULTS Maryland Medicaid paid $11,757,083 for the care of 12,172 recipients of intentional injuries between 2015 and 2019. The per-person, 2-year health care cost of an intentional injury was a median of $183 (SD, $5,284). These costs were highly skewed: min, $2.56; Q1 = 117.60, median, $182.80; Q3 = $480.82; and max, $332,394.20. The top 5% (≥95% percentile) required $3,000 (SD, $6,973) during the initial event and $8,403 (SD, $22,024) per served month thereafter, or 55% of the overall costs in this study. CONCLUSION The long-term, per-person cost of intentional injury can be high. Private insurers were not included and may experience different costs in other states. LEVEL OF EVIDENCE Economic and Value Based Evaluations; level III.
Collapse
Affiliation(s)
- Zachary D W Dezman
- From the Department of Emergency Medicine (Z.D.W.D.), Department of Epidemiology and Public Health (Z.D.W.D.), and R Adams Shock Trauma Center, University of Maryland School of Medicine, Baltimore (P.T.); Hilltop Institute (I.S.), Erickson School of Aging Studies (I.S.), and Information Systems (I.S.), University of Maryland, Baltimore County, Catonsville, Maryland
| | | | | |
Collapse
|
24
|
Evangelist M, Wu P, Shaefer HL. Emergency unemployment benefits and health care spending during Covid. Health Serv Res 2022; 57:15-26. [PMID: 34517427 PMCID: PMC8652441 DOI: 10.1111/1475-6773.13772] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To estimate the impact of the $600 per week Federal Pandemic Unemployment Compensation (FPUC) payments on health care services spending during the Covid pandemic and to investigate if this impact varied by state Medicaid expansion status. DATA SOURCES This study leverages novel, publicly available data from Opportunity Insights capturing consumer credit and debit card spending on health care services for January 18-August 15, 2020 as well as information on unemployment insurance claims, Covid cases, and state policy changes. STUDY DESIGN Using triple-differences estimation, we leverage two sources of variation-within-state change in the unemployment insurance claims rate and the introduction of FPUC payments-to estimate the moderating effect of FPUC on health care spending losses as unemployment rises. Results are stratified by state Medicaid expansion status. EXTRACTION METHODS Not applicable. PRINCIPAL FINDINGS For each percentage point increase in the unemployment insurance claims rate, health care spending declined by 1.0% (<0.05) in Medicaid expansion states and by 2.0% (<0.01) in nonexpansion states. However, FPUC partially mitigated this association, boosting spending by 0.8% (<0.001) and 1.3% (<0.05) in Medicaid expansion and nonexpansion states, respectively, for every percentage point increase in the unemployment insurance claims rate. CONCLUSIONS We find that FPUC bolstered health care spending during the Covid pandemic, but that both the negative consequences of unemployment and moderating effects of federal income supports were greatest in states that did not adopt Medicaid expansion. These results indicate that emergency federal spending helped to sustain health care spending during a period of rising unemployment. Yet, the effectiveness of this program also suggests possible unmet demand for health care services, particularly in states that did not adopt Medicaid expansion.
Collapse
Affiliation(s)
- Michael Evangelist
- Department of Sociology, Poverty SolutionsUniversity of MichiganAnn ArborMichiganUSA
| | - Pinghui Wu
- Gerald R. Ford School of Public Policy, Poverty SolutionsUniversity of MichiganAnn ArborMichiganUSA
| | - H. Luke Shaefer
- Gerald R. Ford School of Public Policy, Poverty SolutionsUniversity of MichiganAnn ArborMichiganUSA
| |
Collapse
|
25
|
Abstract
This economic evaluation uses 2019 Medicare cost report data to examine the unreimbursed Medicaid costs among nonprofit and for-profit US hospitals.
Collapse
Affiliation(s)
- Ge Bai
- Johns Hopkins Carey Business School, Johns Hopkins University, Baltimore, Maryland
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Hossein Zare
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Global Health Services and Administration, University of Maryland Global Campus, Adelphi
| | | |
Collapse
|
26
|
Abstract
ABSTRACT In recent years, calls to address gun violence through public health approaches have increased. However, securing funding for health-based community violence intervention models has remained a challenge. New actions suggest that this may be shifting. Upon taking office, the Biden administration announced a series of funding opportunities for these programs, which ranged from competitive grant programs to a proposed 8-year, $5 billion plan. Less publicized, but just as important, is the administration's announcement that Medicaid can be used to reimburse this work, specifically noting the eligibility of hospital-based violence intervention and prevention programs. For these programs, this creates a predictable and reliable funding source that has not existed to date. This integration of violence prevention programming in the traditional health care and financing systems represents a critical inflection point in the United States' shifting response to community violence. However, the decision to use this optional benefit lies with each state. States should strongly consider harnessing Medicaid as a wise investment to address the United States' gun violence epidemic. LEVEL OF EVIDENCE Economic and value-based evaluation, level IV.
Collapse
Affiliation(s)
- Claudia Zavala
- From the Department of Strategic Partnerships and Research (C.Z.), Health Alliance for Violence Intervention, Jersey City, New Jersey; Department of Emergency Medicine (S.B.), University of California Davis, Sacramento, California; and Department of Emergency Medicine (K.R.F.), University of Maryland School of Medicine, Baltimore, Maryland
| | | | | |
Collapse
|
27
|
Munnich EL, Richards MR. Long-run growth of ambulatory surgery centers 1990-2015 and Medicare payment policy. Health Serv Res 2022; 57:66-71. [PMID: 34318499 PMCID: PMC8763276 DOI: 10.1111/1475-6773.13707] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 05/27/2021] [Accepted: 06/29/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To examine long-run growth in the ambulatory surgery center (ASC) industry and potential factors influencing its trajectory. DATA SOURCES National data for all Medicare-certified ASCs (1990-2015) and outpatient discharge records from the state of Florida in 2007. STUDY DESIGN We documented the number of ASCs in the United States over time and decomposed the trend into underlying ASC market entry and exit behavior. We then examined the plausibility of 2008 Medicare payment reforms to influence the trend changes. DATA EXTRACTION METHODS Data on ASC openings and closures are obtained from the Centers for Medicare and Medicaid Services Provider of Service files. Secondary data on ASC volume in Florida are obtained from the Florida Agency for Health Care Administration. PRINCIPAL FINDINGS The number of ASCs in the United States grew 5%-10% annually between 1990 and 2007 but by 1% or less beginning in 2008. This change coincided with substantive reductions in Medicare payments for key ASC services. The annual number of new ASCs was as much as 50% lower following the payment change. CONCLUSIONS ASCs are an important competitor for outpatient services, but growth has slowed dramatically. Sharp changes in new ASC entry align with less generous Medicare fees.
Collapse
Affiliation(s)
- Elizabeth L. Munnich
- Department of EconomicsCollege of Business, University of LouisvilleLouisvilleKentuckyUSA
| | - Michael R. Richards
- Department of EconomicsHankamer School of Business, Baylor UniversityWacoTexasUSA
| |
Collapse
|
28
|
Khorrami P, Sinha MS, Bhanja A, Allen HL, Kesselheim AS, Sommers BD. Differences in Diabetic Prescription Drug Utilization and Costs Among Patients With Diabetes Enrolled in Colorado Marketplace and Medicaid Plans, 2014-2015. JAMA Netw Open 2022; 5:e2140371. [PMID: 35029667 PMCID: PMC8760612 DOI: 10.1001/jamanetworkopen.2021.40371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/29/2021] [Indexed: 12/05/2022] Open
Abstract
Importance Increasing prices of antidiabetic medications in the US have raised substantial concerns about the effects of drug affordability on diabetes care. There has been little rigorous evidence comparing the experiences of patients with diabetes across different types of insurance coverage. Objective To compare the utilization patterns and costs of prescription drugs to treat diabetes among low-income adults with Medicaid vs those with Marketplace insurance in Colorado during 2014 and 2015. Design, Setting, and Participants This cross-sectional study included diabetic patients enrolled in Colorado Medicaid and Marketplace plans who were aged 19 to 64 years and had incomes between 75% and 200% of the federal poverty level during 2014 and 2015. Data analysis was conducted from September 2020 to April 2021. Exposures Health insurance through Colorado Medicaid or Colorado's state-based Marketplace. Main Outcomes and Measures Primary outcomes were drug utilization (prescription drug fills) and drug costs (total costs and out-of-pocket costs). The secondary outcome was months with an active prescription for noninsulin antidiabetic medications. An all payer claims database was combined with income data, and linear models were used to adjust for clinical and demographic confounders. Results Of 22 788 diabetic patients included in the study, 20 245 were enrolled in Medicaid and 2543 in a Marketplace plan. Marketplace-eligible individuals were older (mean [SD] age, 52.12 [10.60] vs 47.70 [11.33] years), and Medicaid-eligible individuals were more likely to be female (12 429 [61.4%] vs 1413 [55.6%]). Medicaid-eligible patients were significantly more likely than Marketplace-eligible patients to fill prescriptions for dipeptidyl peptidase 4 inhibitors (adjusted difference, -3.7%; 95% CI, -5.3 to -2.1; P < .001) and sulfonylureas (adjusted difference, -6.6%; 95% CI, -8.9 to -4.3; P < .001). Overall rates of insulin use were similar in the 2 groups (adjusted difference, -2.3%; -5.1 to 0.5; P = .11). Out-of-pocket costs for noninsulin medications were 84.4% to 95.2% lower and total costs were 9.4% to 54.2% lower in Medicaid than in Marketplace plans. Out-of-pocket costs for insulin were 76.7% to 94.7% lower in Medicaid than in Marketplace plans, whereas differences in total insulin costs were mixed. The percentage of months of apparent active medication coverage was similar between the 2 groups for 4 of 5 drug classes examined, with Marketplace-eligible patients having a greater percentage of months than Medicaid-eligible patients for sulfonylureas (adjusted difference, 5.3%; 95% CI, 0.3%-10.4%; P = .04). Conclusions and Relevance In this cross-sectional study, drug utilization across multiple drug classes was higher and drug costs were significantly lower for adults with diabetes enrolled in Medicaid than for those with subsidized Marketplace plans. Patients with Marketplace coverage had a similar percentage of months with an active prescription as patients with Medicaid coverage.
Collapse
Affiliation(s)
- Peggah Khorrami
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Michael S. Sinha
- Harvard-MIT Center for Regulatory Science, Harvard Medical School, Boston, Massachusetts
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aditi Bhanja
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Heidi L. Allen
- Columbia University School of Social Work, New York, New York
| | - Aaron S. Kesselheim
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin D. Sommers
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| |
Collapse
|
29
|
Bensken WP, Ciesielski TH, Williams SM, Stange KC, Sajatovic M, Koroukian SM. Inconsistent Medicaid Coverage is Associated with Negative Health Events for People with Epilepsy. J Health Care Poor Underserved 2022; 33:1036-1053. [PMID: 35574892 PMCID: PMC9147776 DOI: 10.1353/hpu.2022.0079] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Examine the association between gaps in Medicaid coverage and negative health events (NHEs) for people with epilepsy (PWE). METHODS Using five years of Medicaid claims for PWE, we identified gaps in Medicaid coverage. We used logistic regression to evaluate the association between a gap in coverage and being in the top quartile of NHEs and factors associated with having a gap. These models adjusted for: demographics, residence, medication adherence, disease severity, and comorbidities. RESULTS Of 186,616 PWE, 21.7% had a gap in coverage. The odds of being in the top quartile of NHEs per year were 66% higher among those with a gap (OR: 1.66; 95% CI: 1.61, 1.70). Being female, younger, and having psychiatric comorbidities increased the odds of having a gap. CONCLUSIONS Gaps in Medicaid coverage are associated with being a high utilizer during covered periods. Specific groups could be targeted with interventions to reduce churning.
Collapse
Affiliation(s)
- Wyatt P. Bensken
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Timothy H. Ciesielski
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Scott M. Williams
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Kurt C. Stange
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio
- Center for Community Health Integration, Departments of Family Medicine & Community Health and Sociology, Case Western Reserve University, Cleveland, OH
| | - Martha Sajatovic
- Departments of Neurology and Psychiatry, University Hospitals Cleveland Medical Center and School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Siran M. Koroukian
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| |
Collapse
|
30
|
Schuster ALR, Perraillon MC, Paul JJ, Leiferman JA, Battaglia C, Morrato EH. The Effect of the Affordable Care Act on Women's Postpartum Insurance and Depression in 5 States That Did Not Expand Medicaid, 2012-2015. Med Care 2022; 60:22-28. [PMID: 34670222 PMCID: PMC8811754 DOI: 10.1097/mlr.0000000000001652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Before the Affordable Care Act (ACA), most women who gained pregnancy-related Medicaid were not eligible for Medicaid as parents postpartum. The ACA aimed to expand health insurance coverage, in part, by expanding Medicaid; introducing mandates; reforming regulations; and establishing exchanges with federal subsidies. Federal subsidies offer a means to coverage for individuals with income at 100%-400% of the federal poverty level who do not qualify for Medicaid. OBJECTIVE The objective of this study was to identify the effects of the ACA's non-Medicaid provisions on women's postpartum insurance coverage and depressive symptoms in nonexpansion states with low parental Medicaid thresholds. PARTICIPANTS Women with incomes at 100%-400% of the federal poverty level who had prenatal insurance and completed the Pregnancy Risk Assessment Monitoring System (2012-2015). SETTING Five non-Medicaid expansion states with Medicaid parental eligibility thresholds below the federal poverty level. DESIGN Interrupted time-series analyses were conducted to examine changes between pre-ACA (January 2012-November 2013) and post-ACA (December 2013-December 2015) trends for self-reported loss of postpartum insurance and symptoms of postpartum depression. RESULTS The sample included 9,472 women. Results showed significant post-ACA improvements where the: (1) trend for loss of postpartum insurance reversed (change of -0.26 percentage points per month, P=0.047) and (2) level of postpartum depressive symptoms decreased (change of -3.5 percentage points, P=0.042). CONCLUSIONS In these 5 states, the ACA's non-Medicaid provisions were associated with large increases in retention of postpartum insurance and reductions in postpartum depressive symptoms, although depressive symptoms findings are sensitive to model specification.
Collapse
Affiliation(s)
| | | | | | - Jenn A Leiferman
- Community & Behavioral Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Elaine H Morrato
- Departments of Health Systems, Management, and Policy
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, IL
| |
Collapse
|
31
|
Metzger GA, Asti L, Quinn JP, Chisolm DJ, Xiang H, Deans KJ, Cooper JN. Association of the Affordable Care Act Medicaid Expansion with Trauma Outcomes and Access to Rehabilitation among Young Adults: Findings Overall, by Race and Ethnicity, and Community Income Level. J Am Coll Surg 2021; 233:776-793.e16. [PMID: 34656739 PMCID: PMC8627499 DOI: 10.1016/j.jamcollsurg.2021.08.694] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/21/2021] [Accepted: 08/25/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Low-income young adults disproportionately experience traumatic injury and poor trauma outcomes. This study aimed to evaluate the effects of the Affordable Care Act's Medicaid expansion, in its first 4 years, on trauma care and outcomes in young adults, overall and by race, ethnicity, and ZIP code-level median income. STUDY DESIGN Statewide hospital discharge data from 5 states that did and 5 states that did not implement Medicaid expansion were used to perform difference-in-difference (DD) analyses. Changes in insurance coverage and outcomes from before (2011-2013) to after (2014-2017) Medicaid expansion and open enrollment were examined in trauma patients aged 19 to 44 years. RESULTS Medicaid expansion was associated with a decrease in the percentage of uninsured patients (DD -16.5 percentage points; 95% CI, -17.1 to -15.9 percentage points). This decrease was larger among Black patients but smaller among Hispanic patients than White patients. It was also larger among patients from lower-income ZIP codes (p < 0.05 for all). Medicaid expansion was associated with an increase in discharge to inpatient rehabilitation (DD 0.6 percentage points; 95% CI, 0.2 to 0.9 percentage points). This increase was larger among patients from the lowest-compared with highest-income ZIP codes (p < 0.05). Medicaid expansion was not associated with changes in in-hospital mortality or readmission or return ED visit rates overall, but was associated with decreased in-hospital mortality among Black patients (DD -0.4 percentage points; 95% CI, -0.8 to -0.1 percentage points). CONCLUSIONS The Affordable Care Act Medicaid expansion, in its first 4 years, increased insurance coverage and access to rehabilitation among young adult trauma patients. It also reduced the socioeconomic disparity in inpatient rehabilitation access and the disparity in in-hospital mortality between Black and White patients.
Collapse
Affiliation(s)
- Gregory A Metzger
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH
| | - Lindsey Asti
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - John P Quinn
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Medical Student Research Program, College of Medicine, The Ohio State University, Columbus, OH
| | - Deena J Chisolm
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH; Division of Health Services Management & Policy, College of Public Health, The Ohio State University, Columbus, OH
| | - Henry Xiang
- Center for Pediatric Trauma Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Injury Research and Policy, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH; Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH; Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH.
| |
Collapse
|
32
|
Lee G, Dee EC, Orav EJ, Kim DW, Nguyen PL, Wright AA, Lam MB. Association of Medicaid expansion and insurance status, cancer stage, treatment and mortality among patients with cervical cancer. Cancer Rep (Hoboken) 2021; 4:e1407. [PMID: 33934574 PMCID: PMC8714536 DOI: 10.1002/cnr2.1407] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Currently, little is known about the effect of the Patient Protection and Affordable Care Act's Medicaid expansion on care delivery and outcomes in cervical cancer. AIM We evaluated whether Medicaid expansion was associated with changes in insurance status, stage at diagnosis, timely treatment, and survival outcomes in cervical cancer. METHODS AND RESULTS Using the National Cancer Database, we performed a difference-in-differences (DID) cross-sectional analysis to compare insurance status, stage at diagnosis, timely treatment, and survival outcomes among cervical cancer patients residing in Medicaid expansion and nonexpansion states before (2011-2013) and after (2014-2015) Medicaid expansion. January 1, 2014 was used as the timepoint for Medicaid expansion. The primary outcomes of interest were insurance status, stage at diagnosis, treatment within 30 and 90 days of diagnosis, and overall survival. Fifteen thousand two hundred sixty-five patients (median age 50) were included: 42% from Medicaid expansion and 58% from nonexpansion states. Medicaid expansion was significantly associated with increased Medicaid coverage (adjusted DID = 11.0%, 95%CI = 8.2, 13.8, p < .01) and decreased rates of uninsured (adjusted DID = -3.0%, 95%CI = -5.2, -0.8, p < .01) among patients in expansion states compared with non-expansion states. However, Medicaid expansion was not associated with any significant changes in cancer stage at diagnosis or timely treatment. There was no significant change in survival from the pre- to post-expansion period in either expansion or nonexpansion states, and no significant differences between the two (DID-HR = 0.95, 95%CI = 0.83, 1.09, p = .48). CONCLUSION Although Medicaid expansion was associated with an increase in Medicaid coverage and decrease in uninsured among patients with cervical cancer, the effects of increased coverage on diagnosis and treatment outcomes may have yet to unfold. Future studies, including longer follow-up are necessary to understand the effects of Medicaid expansion.
Collapse
Affiliation(s)
- Grace Lee
- Harvard Radiation Oncology ProgramBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Radiation OncologyBrigham and Women's Hospital/Dana Farber Cancer InstituteBostonMassachusettsUSA
| | - Edward Christopher Dee
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Radiation OncologyBrigham and Women's Hospital/Dana Farber Cancer InstituteBostonMassachusettsUSA
| | - E. John Orav
- Department of Medicine, Division of General Internal Medicine in BostonBrigham and Women's HospitalBostonMassachusettsUSA
- Department of BiostatisticsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Daniel W. Kim
- Harvard Radiation Oncology ProgramBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Radiation OncologyBrigham and Women's Hospital/Dana Farber Cancer InstituteBostonMassachusettsUSA
| | - Paul L. Nguyen
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Radiation OncologyBrigham and Women's Hospital/Dana Farber Cancer InstituteBostonMassachusettsUSA
| | - Alexi A. Wright
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Medical OncologyDana Farber Cancer InstituteBostonMassachusettsUSA
| | - Miranda B. Lam
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Radiation OncologyBrigham and Women's Hospital/Dana Farber Cancer InstituteBostonMassachusettsUSA
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| |
Collapse
|
33
|
Grady A, Fiori A, Patel D, Nysenbaum J. Profile of Medicaid enrollees with sickle cell disease: A high need, high cost population. PLoS One 2021; 16:e0257796. [PMID: 34705847 PMCID: PMC8550393 DOI: 10.1371/journal.pone.0257796] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 09/10/2021] [Indexed: 11/18/2022] Open
Abstract
Sickle cell disease is a progressively debilitating genetic condition that affects red blood cells and can result in a variety of serious medical complications, reduced life expectancy, and diminished quality of life. Medicaid nationwide covered 66 percent of sickle cell disease hospitalizations in 2004 and 58 percent of emergency department visits for the disease between 1999 and 2007. Using Medicaid data from four states with large populations that account for more than one-third of Medicaid program enrollment, we examined the characteristics of those with sickle cell disease. We found instances of mortality rates more than nine times the age-adjusted population average (in Texas, a mortality rate for Medicaid enrollees with SCD of 1.11 percent compared to 0.12 percent overall); rates of disability-related eligibility-which is associated with long-term Medicaid enrollment-of up to 69 percent; and half or more of affected enrollees having (all-cause) hospital stays, emergency department visits, and opioid prescription fills. With gene therapies on the horizon that will spur discussions of treatment coverage, costs, and outcomes for people with sickle cell disease, it is important for relevant stakeholders to understand the affected populations.
Collapse
Affiliation(s)
- April Grady
- Manatt Health Strategies, Washington, DC, United States of America
| | - Anthony Fiori
- Manatt Health Strategies, New York, New York, United States of America
| | - Dhaval Patel
- Manatt Health Strategies, New York, New York, United States of America
| | | |
Collapse
|
34
|
Abstract
BACKGROUND Nearly 1-in-10 trauma patients in the United States are readmitted within 30 days of discharge, with a median hospital cost of more than $8,000 per readmission. There are national efforts to reduce readmissions in trauma care, but we do not yet understand which are potentially preventable. Our study aims to quantify the potentially preventable readmissions (PPRs) in trauma care to serve as the anchor point for ongoing efforts to curb hospital readmissions and ultimately, bring preventable readmissions to zero. METHODS We identified inpatient hospitalizations after trauma and readmissions within 90 days in the 2017 National Readmissions Database (NRD). Potentially preventable readmissions were defined as the Agency for Healthcare Research and Quality-defined Ambulatory Care Sensitive Conditions, in addition to superficial surgical site infection, acute kidney injury/acute renal failure, and aspiration pneumonitis. Mean costs for these admissions were calculated using the NRD. A multivariable logistic regression model was used to characterize the relationship between patient characteristics and PPR. RESULTS A total of 1,320,083 patients were admitted for trauma care in the 2017 NRD, and 137,854 (10.4%) were readmitted within 90 days of discharge. Of these readmissions, 22.7% were potentially preventable. The mean cost was $10,001/PPR, resulting in $313,802,278 in cost to the US health care system. Of readmitted trauma patients younger than 65 years, Medicaid or Medicare patients had 2.7-fold increased odds of PPRs compared with privately insured patients. Patients of any age with congestive heart failure had 2.9 times increased odds of PPR, those with chronic obstructive pulmonary disease or complicated diabetes mellitus had 1.8 times increased odds, and those with chronic kidney disease had 1.7 times increased odds. Furthermore, as the days from discharge increased, the proportion of readmissions due to PPRs increased. CONCLUSION One-in-five trauma readmissions are potentially preventable, which account for more than $300 million annually in health care costs. Improved access to postdischarge ambulatory care may be key to minimizing PPRs, especially for those with certain comorbidities. LEVEL OF EVIDENCE Economic and value-based evaluations, level II.
Collapse
Affiliation(s)
- Pooja U Neiman
- From the Department of Surgery (C.S.B., J.R.M., N.F.S., M.R.H., J.W.S.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (P.U.N.), Brigham and Women's Hospital, Boston, Massachusetts; and Center for Healthcare Outcomes and Policy (P.U.N., C.S.B., J.R.M., N.F.S., M.R.H., J.W.S.), and National Clinical Scholars Program (P.U.N.), University of Michigan, Ann Arbor, Michigan
| | | | | | | | | | | |
Collapse
|
35
|
Greenberg JA, Thiesmeyer JW, Ullmann TM, Egan CE, Valle Reyes F, Moore MD, Ivanov NA, Laird AM, Finnerty BM, Zarnegar R, Fahey TJ, Beninato T. Association of the Affordable Care Act with access to highest-volume centers for patients with thyroid cancer. Surgery 2021; 171:132-139. [PMID: 34489109 DOI: 10.1016/j.surg.2021.04.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/02/2021] [Accepted: 04/20/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Disparities exist in access to high-volume surgeons, who have better outcomes after thyroidectomy. The association of the Affordable Care Act's Medicaid expansion with access to high-volume thyroid cancer surgery centers remains unclear. METHODS The National Cancer Database was queried for all adult thyroid cancer patients diagnosed from 2010 to 2016. Hospital quartiles (Q1-4) defined by operative volume were generated. Clinicodemographics and adjusted odds ratios for treatment per quartile were analyzed by insurance status. An adjusted difference-in-differences analysis examined the association between implementation of the Affordable Care Act and changes in payer mix by hospital quartile. RESULTS In total, 241,448 patients were included. Medicaid patients were most commonly treated at Q3-Q4 hospitals (Q3 odds ratios 1.05, P = .020, Q4 1.11, P < .001), whereas uninsured patients were most often treated at Q2-Q4 hospitals (Q2 odds ratios 2.82, Q3 2.34, Q4 2.07, P < .001). After expansion, Medicaid patients had lower odds of surgery at Q3-Q4 compared with Q1 hospitals (odds ratios Q3 0.82, P < .001 Q4 0.85, P = .002) in expansion states, but higher odds of treatment at Q3-Q4 hospitals in nonexpansion states (odds ratios Q3 2.23, Q4 1.86, P < .001). Affordable Care Act implementation was associated with increased proportions of Medicaid patients within each quartile in expansion compared with nonexpansion states (Q1 adjusted difference-in-differences 5.36%, Q2 5.29%, Q3 3.68%, Q4 3.26%, P < .001), and a decrease in uninsured patients treated at Q4 hospitals (adjusted difference-in-differences -1.06%, P = .001). CONCLUSIONS Medicaid expansion was associated with an increased proportion of Medicaid patients undergoing thyroidectomy for thyroid cancer in all quartiles, with increased Medicaid access to high-volume centers in expansion compared with nonexpansion states.
Collapse
Affiliation(s)
- Jacques A Greenberg
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/JacquesGreenbe2
| | - Jessica W Thiesmeyer
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/JessicaThiesme1
| | - Timothy M Ullmann
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/TUllmannMD
| | - Caitlin E Egan
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/CaitlinEgan18
| | | | - Maureen D Moore
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/maureenmooremd
| | - Nikolay A Ivanov
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/n_a_ivanov
| | - Amanda M Laird
- Department of Surgery Rutgers-Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ. https://twitter.com/amlaird
| | - Brendan M Finnerty
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/FinnertyMD
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/RasaZarnegarMD
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medicine, New York, NY. https://twitter.com/tjf3endosurg
| | - Toni Beninato
- Department of Surgery Rutgers-Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.
| |
Collapse
|
36
|
Hirth RA, Cliff BQ, Kullgren JT, Ayanian JZ. Cost-sharing With Medicaid Expansion in Michigan: Obligations and Propensity to Pay. Med Care 2021; 59:785-788. [PMID: 34081674 DOI: 10.1097/mlr.0000000000001579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Six states expanding Medicaid under the Affordable Care Act have obtained waivers to incorporate cost-sharing. OBJECTIVE We describe the magnitude and distribution of cost-sharing imposed by the Healthy Michigan Plan and enrollees' propensity to pay. RESEARCH DESIGN Enrollees are followed for at least 18 months (6-mo baseline period for utilization and spending before receipt of first cost-sharing statement; ≥12 mo follow-up thereafter to ascertain obligations and payments). Analyses stratified by income, comparing enrollees with income less than Federal Poverty Level (FPL) who faced only utilization-based copayments and those greater than or equal to FPL who also faced premium contributions. SUBJECTS A total of 158,322 enrollees aged 22-62 who initially enrolled during the first year of the program and remained continuously enrolled ≥18 months. RESULTS Among those enrolled ≥18 months, 51.0% faced cost-sharing. Average quarterly invoices were $4.85 ($11.11 for those with positive invoices) for income less than FPL and $26.71 ($30.93 for those with positive invoices) for incomes greater than or equal to FPL. About half of enrollees with obligations made at least partial payments, with payments being more likely among those >100% FPL. Payment of the full obligation was highest in the initial 6 months. CONCLUSIONS Many payment obligations go uncollected, suggesting that in a system without the threat of disenrollment, the impacts of cost-sharing may be muted. Similarly, the ability of cost-sharing to defray the program's budgetary impact may also be less than anticipated.
Collapse
Affiliation(s)
- Richard A Hirth
- Department of Health Management and Policy, University of Michigan School of Public Health
- University of Michigan Institute for Healthcare Policy & Innovation
- Department in Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Betsy Q Cliff
- Department of Health Policy and Administration, University of Illinois-Chicago School of Public Health, Chicago, IL
| | - Jeffrey T Kullgren
- University of Michigan Institute for Healthcare Policy & Innovation
- Department in Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
- VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - John Z Ayanian
- Department of Health Management and Policy, University of Michigan School of Public Health
- University of Michigan Institute for Healthcare Policy & Innovation
- Department in Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| |
Collapse
|
37
|
Abstract
Maternal mortality has been increasing in the United States over the past 3 decades, while decreasing in all other high-income countries during the same period. Cardiovascular conditions account for over one fourth of maternal deaths, with two thirds of deaths occurring in the postpartum period. There are also significant healthcare disparities that have been identified in women experiencing maternal morbidity and mortality, with Black women at 3 to 4 times the risk of death as their White counterparts and women in rural areas at heightened risk for cardiovascular morbidity and maternal morbidity. However, many maternal deaths have been shown to be preventable, and improving access to care may be a key solution to addressing maternal cardiovascular mortality. Medicaid currently finances almost half of all births in the United States and is mandated to provide coverage for women with incomes up to 138% of the federal poverty level, for up to 60 days postpartum. In states that have not expanded coverage, new mothers become uninsured after 60 days. Medicaid expansion has been shown to reduce maternal mortality, particularly benefiting racial and ethnic minorities, likely through reduced insurance churn, improved postpartum access to care, and improved interpregnancy care. However, even among states with Medicaid expansion, significant care gaps exist. An additional proposed intervention to improve access to care in these high-risk populations is extension of Medicaid coverage for 1 year after delivery, which would provide the most benefit to women in Medicaid nonexpanded states, but also improve care to women in Medicaid expanded states.
Collapse
Affiliation(s)
- Janki P. Luther
- Cardiovascular DivisionWashington University School of MedicineSt. LouisMO
| | - Daniel Y. Johnson
- Cardiovascular DivisionWashington University School of MedicineSt. LouisMO
| | - Karen E. Joynt Maddox
- Cardiovascular DivisionWashington University School of MedicineSt. LouisMO
- Center for Health Economics and PolicyInstitute for Public Health at Washington UniversitySt. LouisMO
| | - Kathryn J. Lindley
- Cardiovascular DivisionWashington University School of MedicineSt. LouisMO
| |
Collapse
|
38
|
Huynh KA, Jayaram M, Wang C, Lane M, Wang L, Momoh AO, Chung KC. Factors Associated With State-Specific Medicaid Expansion and Receipt of Autologous Breast Reconstruction Among Patients Undergoing Mastectomy. JAMA Netw Open 2021; 4:e2119141. [PMID: 34342650 PMCID: PMC8335577 DOI: 10.1001/jamanetworkopen.2021.19141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Despite demonstrated psychosocial benefits, autologous breast reconstruction remains underutilized. An analysis of the association between Medicaid expansion and autologous breast reconstruction has yet to be performed. OBJECTIVE To compare autologous breast reconstruction rates and determine the association between Medicaid expansion and breast reconstruction. DESIGN, SETTING, AND PARTICIPANTS A retrospective cross-sectional study was performed using the State Inpatient Database from January 1, 2012, through September 30, 2015, and included 51 340 patients. Patients were identified using the International Classification of Diseases, Ninth Revision, codes for breast cancer, mastectomy, and autologous breast reconstruction. Data from states that expanded Medicaid (New Jersey, New York, and Washington) were compared with states that did not expand Medicaid (Florida, North Carolina, and Wisconsin). Data were analyzed from June 1, 2020, through February 28, 2021. EXPOSURES The Patient Protection and Affordable Care Act's Medicaid expansion was implemented in 2014; the preexpansion period ranged from 2012 to 2013 (2 years), whereas the postexpansion period ranged from 2014 to 2015 quarter 3 (1.75 years). MAIN OUTCOMES AND MEASURES Primary outcomes included use of autologous breast reconstruction before and after expansion. Independent covariates included patient demographics, comorbidities, and state of residence. RESULTS Among 45 850 patients who underwent mastectomy and 9215 patients who received autologous breast reconstruction, 36 777 (67%) were White and 32 205 (59%) had private insurance. The use of immediate or delayed autologous reconstruction increased from 18.1% (4951 of 27 290) to 23.0% (4264 of 18 560) throughout the study period. Compared with 2012, the odds of reconstruction were 64% higher in 2015 (odds ratio [OR], 1.64; 95% CI, 1.48-1.80; P < .001). African American (OR, 1.43; 95% CI, 1.33-1.55; P < .001) and Hispanic (OR, 1.44; 95% CI, 1.31-1.60; P < .001) patients had higher odds of reconstruction compared with White patients regardless of state of residence. However, Medicaid expansion was associated with a 28% decrease in the odds of reconstruction (OR, 0.72; 95% CI, 0.61-0.87; P < .001) for African American patients, a 40% decrease (OR, 0.60; 95% CI, 0.50-0.74; P < .001) for Hispanic patients, and 20% decrease (OR, 0.80; 95% CI, 0.67-0.96; P = .01) for patients with Asian, Native American, or other minority race/ethnicity. Medicaid expansion was not associated with changes in the odds of reconstruction for White patients. CONCLUSIONS AND RELEVANCE In this cross-sectional study, although the odds of receiving autologous breast reconstruction increased annually, Medicaid expansion was associated with decreased odds of reconstruction for African American patients, Hispanic patients, and other patients of color.
Collapse
Affiliation(s)
- Kristine A. Huynh
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Mayank Jayaram
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Chang Wang
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Megan Lane
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Lu Wang
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Adeyiza O. Momoh
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Kevin C. Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
| |
Collapse
|
39
|
Jaramillo JD, Arnow K, Trickey AW, Dickerson K, Wagner TH, Harris AHS, Tran LD, Bereknyei S, Morris AM, Spain DA, Knowlton LM. Acquisition of Medicaid at the time of injury: An opportunity for sustainable insurance coverage. J Trauma Acute Care Surg 2021; 91:249-259. [PMID: 33783416 DOI: 10.1097/ta.0000000000003195] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Uninsured trauma patients are at higher risk of mortality, limited access to postdischarge resources, and catastrophic health expenditure. Hospital Presumptive Eligibility (HPE), enacted with the 2014 Affordable Care Act, enables uninsured patients to be screened and acquired emergency Medicaid at the time of hospitalization. We sought to identify factors associated with successful acquisition of HPE insurance at the time of injury, hypothesizing that patients with higher Injury Severity Score (ISS) (ISS >15) would be more likely to be approved for HPE. METHODS We identified Medicaid and uninsured patients aged 18 to 64 years with a primary trauma diagnosis (International Classification of Diseases, Tenth Revision) in a large level I trauma center between 2015 and 2019. We combined trauma registry data with review of electronic medical records, to determine our primary outcome, HPE acquisition. Descriptive and multivariate analyses were performed. RESULTS Among 2,320 trauma patients, 1,374 (59%) were already enrolled in Medicaid at the time of hospitalization. Among those uninsured at arrival, 386 (40.8%) acquired HPE before discharge, and 560 (59.2%) remained uninsured. Hospital Presumptive Eligibility patients had higher ISS (ISS >15, 14.8% vs. 5.7%; p < 0.001), longer median length of stay (2 days [interquartile range, 0-5 days] vs. 0 [0-1] days, p < 0.001), were more frequently admitted as inpatients (64.5% vs. 33.6%, p < 0.001), and discharged to postacute services (11.9% vs. 0.9%, p < 0.001). Patient, hospital, and policy factors contributed to HPE nonapproval. In adjusted analyses, Hispanic ethnicity (vs. non-Hispanic Whites: aOR, 1.58; p = 0.02) and increasing ISS (p ≤ 0.001) were associated with increased likelihood of HPE approval. CONCLUSION The time of hospitalization due to injury is an underused opportunity for intervention, whereby uninsured patients can acquire sustainable insurance coverage. Opportunities to increase HPE acquisition merit further study nationally across trauma centers. As administrative and trauma registries do not capture information to compare HPE and traditional Medicaid patients, prospective insurance data collection would help to identify targets for intervention. LEVEL OF EVIDENCE Economic, level IV.
Collapse
Affiliation(s)
- Joshua D Jaramillo
- From the Division of General Surgery, Department of Surgery (J.D.J., K.D.), Stanford University School of Medicine; Department of Surgery, (K.A., A.W.T., T.H.W., A.H.S.H., L.D.T., S.B., A.M.M., L.M.K.), Stanford-Surgery Policy Improvement Research and Education Center, Stanford University School of Medicine; and Department of Surgery (D.A.S., L.M.K.), Section of Trauma, Surgical Critical Care and Acute Care Surgery (L.M.K.), Stanford University, Stanford, California
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
Medicaid presents both legislative and regulatory challenges and opportunities. As it moves a legislative agenda forward, the Biden administration also will confront a series of immediate regulatory matters, some of which have been made urgent because of pending judicial action. Chief among these pressing matters are ending Medicaid work requirements and block grant experiments, rescinding the public charge rule, ensuring optimal use of Medicaid's enrollment and renewal simplification tools, rescinding the Title X family planning rule (which has enormous implications for Medicaid beneficiaries), and, when the time comes, preparing states to wind down the "Families First" Medicaid maintenance of effort protection while avoiding erroneous beneficiary disenrollment. The administration could consider encouraging remaining nonexpansion states to pursue §1115 Medicaid expansion experiments; additionally, the administration could pursue Medicaid pandemic recovery demonstrations to support health system recovery during the long period that lies ahead. Thus, while certain advances must await legislation, the administration can move Medicaid forward through executive action.
Collapse
|
41
|
Abstract
IMPORTANCE Medical debt is an increasing concern in the US, yet there is limited understanding of the amount and distribution of medical debt, and its association with health care policies. OBJECTIVE To measure the amount of medical debt nationally and by geographic region and income group and its association with Medicaid expansion under the Affordable Care Act. DESIGN, SETTING, AND PARTICIPANTS Data on medical debt in collections were obtained from a nationally representative 10% panel of consumer credit reports between January 2009 and June 2020 (reflecting care provided prior to the COVID-19 pandemic). Income data were obtained from the 2014-2018 American Community Survey. The sample consisted of 4.1 billion person-month observations (nearly 40 million unique individuals). These data were used to estimate the amount of medical debt (nationally and by geographic region and zip code income decile) and to examine the association between Medicaid expansion and medical debt (overall and by income group). EXPOSURES Geographic region (US Census region), income group (zip code income decile), and state Medicaid expansion status. MAIN OUTCOMES AND MEASURES The stock (all unpaid debt listed on credit reports) and flow (new debt listed on credit reports during the preceding 12 months) of medical debt in collections that can be collected on by debt collectors. RESULTS In June 2020, an estimated 17.8% of individuals had medical debt (13.0% accrued debt during the prior year), and the mean amount was $429 ($311 accrued during the prior year). The mean stock of medical debt was highest in the South and lowest in the Northeast ($616 vs $167; difference, $448 [95% CI, $435-$462]) and higher in poor than in rich zip code income deciles ($677 vs $126; difference, $551 [95% CI, $520-$581]). Between 2013 and 2020, the states that expanded Medicaid in 2014 experienced a decline in the mean flow of medical debt that was 34.0 percentage points (95% CI, 18.5-49.4 percentage points) greater (from $330 to $175) than the states that did not expand Medicaid (from $613 to $550). In the expansion states, the gap in the mean flow of medical debt between the lowest and highest zip code income deciles decreased by $145 (95% CI, $95-$194) while the gap increased by $218 (95% CI, $163-$273) in the nonexpansion states. CONCLUSIONS AND RELEVANCE This study provides an estimate of the amount of medical debt in collections in the US based on consumer credit reports from January 2009 to June 2020, reflecting care delivered prior to the COVID-19 pandemic, and suggests that the amount of medical debt was highest among individuals living in the South and in lower-income communities. However, further study is needed regarding debt related to COVID-19.
Collapse
Affiliation(s)
- Raymond Kluender
- Harvard Business School, Harvard University, Boston, Massachusetts
| | - Neale Mahoney
- Stanford University, Stanford, California
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Francis Wong
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Wesley Yin
- National Bureau of Economic Research, Cambridge, Massachusetts
- University of California, Los Angeles
| |
Collapse
|
42
|
Wilkie W, Mohamed N, Remily E, Etcheson J, Castrodad ID, Walker A, Delanois R. Comparing Outcomes for Female Total Knee Arthroplasty Patients Under Global Budget Revenue. Orthopedics 2021; 44:e266-e273. [PMID: 33373460 DOI: 10.3928/01477447-20201216-02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Maryland implemented the all-payer, rater-setting Global Budget Revenue (GBR) payment model in 2014 to reduce cost and improve quality. This study assessed the effect of GBR on total knee arthroplasty (TKA) outcomes by sex. Specifically, the authors assessed (1) demographics and (2) outcomes of males and females undergoing TKA before and after GBR implementation. The Maryland State Inpatient Database was queried from 2011 to 2016. There were 71,066 TKAs (male, n=25,413; female, n=45,634). For continuous and categorical variables, t testing and chi-square analyses were used, respectively. Difference-in-difference analyses using multiple regression compared changes in sex from the pre-GBR period (2011-2013) with the post-GBR period (2014-2016). The female proportion decreased (-1.9%; P=.040). Proportionally more TKA patients were Hispanic and Asian, from high-income areas, using Medicare and Medicaid, and morbidly obese (all P<.001). The mean length of stay (LOS), charges, and costs were decreased after GBR implementation (all P<.001). More patients were discharged routine and had fewer readmissions (both P<.001). There were fewer complications, including deep venous thromboses/pulmonary emboli, urinary tract infections, and blood transfusions (all P<.001). The difference-in-difference analyses suggested more females were discharged with home health care and had longer LOS than did males (both P<.001). The GBR appears to meet its main objective of cost reduction and improvements in quality of care. However, the proportion of females receiving TKA decreased, and their LOS did not improve as much as that of males. As other states consider global budgets, more research is needed to ensure this all-payer, rate-setting, capitated system does not cause decreased access to care. [Orthopedics. 2021;44(2):e266-e273.].
Collapse
|
43
|
Toraih E, Hussein M, Tatum D, Reisner A, Kandil E, Killackey M, Duchesne J, Taghavi S. The burden of readmission after discharge from necrotizing soft tissue infection. J Trauma Acute Care Surg 2021; 91:154-163. [PMID: 33755642 DOI: 10.1097/ta.0000000000003169] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The need for extensive surgical debridement with necrotizing soft tissue infections (NSTIs) may put patients at high risk for unplanned readmission. However, there is a paucity of data on the burden of readmission in patients afflicted with NSTI. We hypothesized that unplanned readmission would significantly contribute to the burden of disease after discharge from initial hospitalization. METHODS The Nationwide Readmission Database was used to identify adults undergoing debridement for NSTI hospitalizations from 2010 to 2017. Risk factors for 90-day readmission were assessed by Cox proportional hazards regression. RESULTS There were a total of 82,738 NSTI admissions during the study period, of which 25,076 (30.3%) underwent 90-day readmissions. Median time to readmission was 25 days (interquartile range, 9-49 days). Fragmentation of care, longer length of index stay (>2 weeks), and Medicaid status were independent risk factors for readmission. Median cost of a readmission was US $10,543. Readmission added 174,640 hospital days to episodes of care over the study period, resulting in an estimated financial burden of US $1.4 billion. CONCLUSION Unplanned readmission caused by NSTIs is common and costly. Interventions that target patients at risk for readmission may help decrease the burden of disease. LEVEL OF EVIDENCE Economic/Epidemiological, level IV.
Collapse
Affiliation(s)
- Eman Toraih
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | | | | | | | | | | | | | | |
Collapse
|
44
|
Khavjou OA, Anderson WL, Honeycutt AA, Bates LG, Hollis ND, Grosse SD, Razzaghi H. State-Level Health Care Expenditures Associated With Disability. Public Health Rep 2021; 136:441-450. [PMID: 33673781 PMCID: PMC8203048 DOI: 10.1177/0033354920979807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Given the growth in national disability-associated health care expenditures (DAHE) and the changes in health insurance-specific DAHE distribution, updated estimates of state-level DAHE are needed. The objective of this study was to update state-level estimates of DAHE. METHODS We combined data from the 2013-2015 Medical Expenditure Panel Survey, 2013-2015 Behavioral Risk Factor Surveillance System, and 2014 National Health Expenditure Accounts to calculate state-level DAHE for US adults in total, per adult, and per (adult) person with disability (PWD). We adjusted expenditures to 2017 prices and assessed changes in DAHE from 2003 to 2015. RESULTS In 2015, DAHE were $868 billion nationally (range, $1.4 billion in Wyoming to $102.8 billion in California) accounting for 36% of total health care expenditures (range, 29%-41%). From 2003 to 2015, total DAHE increased by 65% (range, 35%-125%). In 2015, DAHE per PWD were highest in the District of Columbia ($27 839) and lowest in Alabama ($12 603). From 2003 to 2015, per-PWD DAHE increased by 13% (range, -20% to 61%) and per-capita DAHE increased by 28% (range, 7%-84%). In 2015, Medicare DAHE per PWD ranged from $10 067 in Alaska to $18 768 in New Jersey. Medicaid DAHE per PWD ranged from $9825 in Nevada to $43 365 in the District of Columbia. Nonpublic-health insurer per-PWD DAHE ranged from $7641 in Arkansas to $18 796 in Alaska. CONCLUSION DAHE are substantial and vary by state. The public sector largely supports the health care costs of people with disabilities. State policy makers and other stakeholders can use these results to inform the development of public health programs that support and provide ongoing health care to people with disabilities.
Collapse
Affiliation(s)
- Olga A. Khavjou
- Public Health Economics Program, RTI International, Research Triangle Park, NC, USA
| | - Wayne L. Anderson
- Aging, Disability, and Long-Term Care Program, RTI International, Research Triangle Park, NC, USA
| | - Amanda A. Honeycutt
- Public Health Economics Program, RTI International, Research Triangle Park, NC, USA
| | - Laurel G. Bates
- Public Health Economics Program, RTI International, Research Triangle Park, NC, USA
| | - NaTasha D. Hollis
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Scott D. Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Hilda Razzaghi
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| |
Collapse
|
45
|
Fung V, McCarthy S, Price M, Hull P, Cook BL, Hsu J, Newhouse JP. Payment Discrepancies and Access to Primary Care Physicians for Dual-eligible Medicare-Medicaid Beneficiaries. Med Care 2021; 59:487-494. [PMID: 33973937 PMCID: PMC8486346 DOI: 10.1097/mlr.0000000000001525] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Physicians often receive lower payments for dual-eligible Medicare-Medicaid beneficiaries versus nondual Medicare beneficiaries because of state reimbursement caps. The Affordable Care Act (ACA) primary care fee bump temporarily eliminated this differential in 2013-2014. OBJECTIVE To examine how dual payment policy impacts primary care physicians' (PCP) acceptance of duals. RESEARCH DESIGN We assessed differences in the likelihood that PCPs had dual caseloads of ≥10% or 20% in states with lower versus full dual reimbursement using linear probability models adjusted for physician and area-level traits. Using a triple-difference approach, we examined changes in dual caseloads for PCPs versus a control group of specialists in states with fee bumps versus no change during years postbump versus prebump. SUBJECTS PCPs and specialists (cardiologists, orthopedic surgeons, general surgeons) that billed fee-for-service Medicare. MEASURES State dual payment policies and physicians' dual caseloads as a percentage of their Medicare patients. RESULTS In 2012, 81% of PCPs had dual caseloads of ≥10% and this was less likely among PCPs in states with lower versus full dual reimbursement (eg, difference=-4.52 percentage points; 95% confidence interval, -6.80 to -2.25). The proportion of PCPs with dual caseloads of ≥10% or 20% decreased significantly between 2012 and 2017 and the fee bump was not consistently associated with increases in dual caseloads. CONCLUSIONS Pre-ACA, PCPs' participation in the dual program appeared to be lower in states with lower reimbursement for duals. Despite the ACA fee bump, dual caseloads declined over time, raising concerns of worsening access to care.
Collapse
Affiliation(s)
- Vicki Fung
- Mongan Institute, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | | | - Mary Price
- Mongan Institute, Massachusetts General Hospital, Boston, MA
| | - Peter Hull
- Department of Economics, University of Chicago, Chicago, IL
| | - Benjamin Lê Cook
- Health Equity Research Lab, Cambridge Health Alliance and Harvard Medical School, Cambridge, MA
- Department of Psychiatry, Harvard Medical School, Boston, MA
| | - John Hsu
- Mongan Institute, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Joseph P. Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, MA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA
- Harvard Kennedy School, Cambridge, MA
| |
Collapse
|
46
|
Benevides TW, Carretta HJ, Rust G, Shea L. Racial and ethnic disparities in benefits eligibility and spending among adults on the autism spectrum: A cohort study using the Medicare Medicaid Linked Enrollees Analytic Data Source. PLoS One 2021; 16:e0251353. [PMID: 34032811 PMCID: PMC8148358 DOI: 10.1371/journal.pone.0251353] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/24/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Research on children and youth on the autism spectrum reveal racial and ethnic disparities in access to healthcare and utilization, but there is less research to understand how disparities persist as autistic adults age. We need to understand racial-ethnic inequities in obtaining eligibility for Medicare and/or Medicaid coverage, as well as inequities in spending for autistic enrollees under these public programs. METHODS We conducted a cross-sectional cohort study of U.S. publicly-insured adults on the autism spectrum using 2012 Medicare-Medicaid Linked Enrollee Analytic Data Source (n = 172,071). We evaluated differences in race-ethnicity by eligibility (Medicare-only, Medicaid-only, Dual-Eligible) and spending. FINDINGS The majority of white adults (49.87%) were full-dual eligible for both Medicare and Medicaid. In contrast, only 37.53% of Black, 34.65% Asian/Pacific Islander, and 35.94% of Hispanic beneficiaries were full-dual eligible for Medicare and Medicare, with most only eligible for state-funded Medicaid. Adjusted logistic models controlling for gender, intellectual disability status, costly chronic condition, rural status, county median income, and geographic region of residence revealed that Black beneficiaries were significantly less likely than white beneficiaries to be dual-eligible across all ages. Across these three beneficiary types, total spending exceeded $10 billion. Annual total expenditures median expenditures for full-dual and Medicaid-only eligible beneficiaries were higher among white beneficiaries as compared with Black beneficiaries. CONCLUSIONS Public health insurance in the U.S. including Medicare and Medicaid aim to reduce inequities in access to healthcare that might exist due to disability, income, or old age. In contrast to these ideals, our study reveals that racial-ethnic minority autistic adults who were eligible for public insurance across all U.S. states in 2012 experience disparities in eligibility for specific programs and spending. We call for further evaluation of system supports that promote clear pathways to disability and public health insurance among those with lifelong developmental disabilities.
Collapse
Affiliation(s)
- Teal W. Benevides
- Department of Occupational Therapy, College of Allied Health Sciences, Augusta University, Augusta, GA, United States of America
| | - Henry J. Carretta
- College of Medicine, Florida State University, Tallahassee, FL, United States of America
| | - George Rust
- College of Medicine, Florida State University, Tallahassee, FL, United States of America
| | - Lindsay Shea
- A.J. Drexel Autism Institute, Drexel University, Philadelphia, PA, United States of America
| |
Collapse
|
47
|
Levitt L, Inserro A. Pandemic to bring painful choices for states, policy makers: a Q&A with Larry Levitt. Am J Manag Care 2021; 26:192-193. [PMID: 32436674 DOI: 10.37765/ajmc.2020.43150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
To mark the 25th anniversary of the journal, each issue in 2020 will include an interview with a healthcare thought leader. For the May issue, we turned to Larry Levitt, MPP, executive vice president for health policy for the Kaiser Family Foundation.
Collapse
|
48
|
Michel KF, Spaulding A, Jemal A, Yabroff KR, Lee DJ, Han X. Associations of Medicaid Expansion With Insurance Coverage, Stage at Diagnosis, and Treatment Among Patients With Genitourinary Malignant Neoplasms. JAMA Netw Open 2021; 4:e217051. [PMID: 34009349 PMCID: PMC8134994 DOI: 10.1001/jamanetworkopen.2021.7051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Health insurance coverage is associated with improved outcomes in patients with cancer. However, it is unknown whether Medicaid expansion through the Patient Protection and Affordable Care Act (ACA) was associated with improvements in the diagnosis and treatment of patients with genitourinary cancer. OBJECTIVE To assess the association of Medicaid expansion with health insurance status, stage at diagnosis, and receipt of treatment among nonelderly patients with newly diagnosed kidney, bladder, or prostate cancer. DESIGN, SETTING, AND PARTICIPANTS This case-control study included adults aged 18 to 64 years with a new primary diagnosis of kidney, bladder, or prostate cancer, selected from the National Cancer Database from January 1, 2011, to December 31, 2016. Patients in states that expanded Medicaid were the case group, and patients in nonexpansion states were the control group. Data were analyzed from January 2020 to March 2021. EXPOSURES State Medicaid expansion status. MAIN OUTCOMES AND MEASURES Insurance status, stage at diagnosis, and receipt of cancer and stage-specific treatments. Cases and controls were compared with difference-in-difference analyses. RESULTS Among a total of 340 552 patients with newly diagnosed genitourinary cancers, 94 033 (27.6%) had kidney cancer, 25 770 (7.6%) had bladder cancer, and 220 749 (64.8%) had prostate cancer. Medicaid expansion was associated with a net decrease in uninsured rate of 1.1 (95% CI, -1.4 to -0.8) percentage points across all incomes and a net decrease in the low-income population of 4.4 (95% CI, -5.7 to -3.0) percentage points compared with nonexpansion states. Expansion was also associated with a significant shift toward early-stage diagnosis in kidney cancer across all income levels (difference-in-difference, 1.4 [95% CI, 0.1 to 2.6] percentage points) and among individuals with low income (difference-in-difference, 4.6 [95% CI, 0.3 to 9.0] percentage points) and in prostate cancer among individuals with low income (difference-in-difference, 3.0 [95% CI, 0.3 to 5.7] percentage points). Additionally, there was a net increase associated with expansion compared with nonexpansion in receipt of active surveillance for low-risk prostate cancer of 4.1 (95% CI, 2.9 to 5.3) percentage points across incomes and 4.5 (95% CI, 0 to 9.0) percentage points among patients in low-income areas. CONCLUSIONS AND RELEVANCE These findings suggest that Medicaid expansion was associated with decreases in uninsured status, increases in the proportion of kidney and prostate cancer diagnosed in an early stage, and higher rates of active surveillance in the appropriate, low-risk prostate cancer population. Associations were concentrated in population residing in low-income areas and reinforce the importance of improving access to care to all patients with cancer.
Collapse
Affiliation(s)
- Katharine F. Michel
- University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Aleigha Spaulding
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City
| | - Ahmedin Jemal
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - K. Robin Yabroff
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Daniel J. Lee
- University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Xuesong Han
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia
| |
Collapse
|
49
|
Abstract
BACKGROUND Traumatic brain injury (TBI) is a serious public health problem in the United States. Each year, TBIs substantially contribute to health care costs, which vary by severity. This is important to consider given the variability in recovery time by severity. RESEARCH DESIGN This study quantifies the annual incremental health care costs of nonfatal TBI in 2016 for the US population covered by a private health insurance, Medicaid, or Medicare health plan. This study uses MarketScan and defines severity with the abbreviated injury scale for the head and neck region. Nonfatal health care costs were compared by severity. RESULTS The estimated 2016 overall health care cost attributable to nonfatal TBI among MarketScan enrollees was $40.6 billion. Total estimated annual health care cost attributable to TBI for low severity TBIs during the first year postinjury were substantially higher than costs for middle and high severity TBIs among those with private health insurance and Medicaid. CONCLUSIONS This study presents economic burden estimates for TBI that underscore the importance of developing strategies to prevent TBIs, regardless of severity. Although middle and high severity TBIs were more costly at the individual level, low severity TBIs, and head injuries diagnosed as "head injury unspecified" resulted in higher total estimated annual health care costs attributable to TBI.
Collapse
Affiliation(s)
| | - Lara DePadilla
- Overdose Prevention, National Center for Injury Prevention and Control, CDC, Atlanta, GA
| | | |
Collapse
|
50
|
DeLia D, Nova J, Chakravarty S, Tiderington E, Kelly T, Cantor JC. Effects of Permanent Supportive Housing on Health Care Utilization and Spending Among New Jersey Medicaid Enrollees Experiencing Homelessness. Med Care 2021; 59:S199-S205. [PMID: 33710096 DOI: 10.1097/mlr.0000000000001443] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Permanent supportive housing (PSH) programs have the potential to improve health and reduce Medicaid expenditures for beneficiaries experiencing homelessness. However, most research on PSH has been limited to small samples of narrowly defined populations. OBJECTIVE To evaluate the effects of PSH on Medicaid enrollees across New Jersey. RESEARCH DESIGN Linked data from the Medicaid Management Information System and the Homeless Management Information System were used to compare PSH-placed Medicaid enrollees with a matched sample of other Medicaid enrollees experiencing homelessness. Comparisons of Medicaid-financed health care utilization and spending measures were made in a difference-in-differences framework 6 quarters before and after PSH placement. SUBJECTS A total of 1442 Medicaid beneficiaries enrolled in PSH and 6064 Medicaid-enrolled homeless individuals not in PSH in 2013-2014. RESULTS PSH placement is associated with a 14.3% reduction in emergency department visits (P<0.001) and a 25.2% reduction in associated spending (P<0.001). PSH also appears to reduce inpatient utilization and increase pharmacy spending with neutral effects on primary care visits and total costs of care (TCOC). CONCLUSIONS Placement in PSH is associated with lower hospital utilization and spending. No relationship was found, however, between PSH placement and TCOC, likely due to increased pharmacy spending in the PSH group. Greater access to prescription drugs may have improved the health of PSH-placed individuals in a way that reduced hospital episodes with neutral effects on TCOC.
Collapse
Affiliation(s)
- Derek DeLia
- Medstar Health Research Institute, Hyattsville, MD
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, DC
| | - Jose Nova
- Center for State Health Policy, Institute for Health, Health Care Policy and Aging Research
| | - Sujoy Chakravarty
- Center for State Health Policy, Institute for Health, Health Care Policy and Aging Research
| | | | | | - Joel C Cantor
- Center for State Health Policy, Institute for Health, Health Care Policy and Aging Research
- Edward J. Bloustein School of Planning and Public Policy, Rutgers University, New Brunswick, NJ
| |
Collapse
|