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Item Open Access Addressing Housing-Related Social Needs Through Medicaid: Lessons From North Carolina's Healthy Opportunities Pilots Program.(Health affairs (Project Hope), 2024-02) Huber, Katie; Nohria, Raman; Nandagiri, Vibhav; Whitaker, Rebecca; Tchuisseu, Yolande Pokam; Pylypiw, Nicholas; Dennison, Meaghan; Van Stekelenburg, Brianna; Van Vleet, Amanda; Perez, Maria Ramirez; Morreale, Madlyn C; Thoumi, Andrea; Lyn, Michelle; Saunders, Robert S; Bleser, William KNorth Carolina Medicaid's Healthy Opportunities Pilots program is the country's first comprehensive program to evaluate the impact of paying community-based organizations to provide eligible Medicaid enrollees with an array of evidence-based services to address four domains of health-related social needs, one of which is housing. Using a mixed-methods approach, we mapped the distribution of severe housing problems and then examined the design and implementation of Healthy Opportunities Pilots housing services in the three program regions. Four cross-cutting implementation and policy themes emerged: accounting for variation in housing resources and needs to address housing insecurity, defining and pricing housing services in Medicaid, engaging diverse stakeholders across sectors to facilitate successful implementation, and developing sustainable financial models for delivery. The lessons learned and actionable insights can help inform the efforts of stakeholders elsewhere, particularly other state Medicaid programs, to design and implement cross-sectoral programs that address housing-related social needs by leveraging multiple policy-based resources. These lessons can also be useful for federal policy makers developing guidance on addressing housing-related needs in Medicaid.Item Open Access Behavioral Health Service Utilization and Cost for North Carolina’s Foster Children: A Report for Partnering For Excellence(2014-04-18) Foosness, SusanExecutive Summary Introduction The foster care population in North Carolina, which hovered around 8,882 children as of August 2013, is of special interest to policymakers, politicians, Medicaid officials, child welfare professionals, and healthcare providers. This group of infants through young adults faces unique challenges in their educational, social, emotional, developmental, and physical growth. Their elevated needs put extra pressure on already stressed systems with limited financial resources. High levels of behavioral health and emotional problems lead to placement disruptions, costly interventions, and require extra diligence on the part of caseworkers, foster parents, and professionals to manage crises and keep foster children safe. It is essential to identify strategies to address the behavioral health needs of foster children within the constraints of limited resources, and in ways that take advantage of the most recent research on evidence-based treatments. These strategies should aim to reduce placement disruptions and promote healthy outcomes for foster children. By using existing data collection systems within the Department of Social Services and Local Management Entity-Managed Care Organizations (LME-MCOs), we can gain important insight into this population’s health and mental health needs, access to services, utilization, and cost. These data will also provide us with an opportunity to improve the existing systems and recommend policy changes. Policy Question How can county Departments of Social Services (DSS) and Local Management Entity-Managed Care Organizations (LME-MCOs) use existing data to better manage the foster care population and improve mental health outcomes? Policy Recommendations 1. Stakeholders should focus on increasing the frequency and quality of trauma-informed comprehensive clinical assessments for children in contact with child welfare. 2. Cardinal Innovations and behavioral health providers should continue to expand the service array of Evidence Based Practices available in Rowan County. 3. Cardinal Innovations should expand their use of care coordination to all children in DSS custody. 4. Cardinal Innovations and Rowan County DSS should identify high-cost and high utilization indicators in cases and target them with wraparound services like care coordination and additional case management at DSS. 5. DSS should implement data collection systems to monitor and track every placement change for children in DSS custody and note the specific reason. 6. DSS and Cardinal Innovations should encourage continuity of care with behavioral health providers and insist that barriers to treatment or placement stability be addressed. 7. DSS workers should be trained to recognize the different types of evidence-based therapies available and how to access them in their community. Methodology The data required for this project was obtained by Dr. Rosanbalm and the Partnering for Excellence pilot through Benchmarks and de-identified for analysis. The data come from four major databases from the State Data Warehouse and Cardinal Innovations Healthcare Solutions. These data include Child Protective Services (CPS) Data, Service Information System (SIS) Data, Child Placement and Payment System (CPPS) Data, and Medicaid Behavioral Health Services Data. The analysis conducted was intended to be exploratory, not causal, in nature. The goal was to obtain a thorough understanding of the baseline relationships between child welfare and behavioral health services in Rowan County. Without a counterfactual group or quasi-experimental design, it was not possible to make causal inferences about the effect of behavioral health services on the child welfare population. After the available data was analyzed, a reported was created based on initial interpretations and shared with Benchmarks, Cardinal, and county DSS stakeholders for further analysis and to guide final recommendations. The recommendations are informed by the existing literature from academia, child welfare practice, evidence-based treatments, and advocacy and policy groups. The data analysis from Rowan County has led to specific recommendations to improve county practices and policies, inform the Partnering for Excellence pilot, and suggest recommendations that could be implemented statewide in North Carolina. Discussion Children in foster care, by definition, have experienced trauma including the removal from their family and entry into foster care, and have likely experienced child abuse or neglect. We know from the research and experience that these foster children have increased mental health issues and psychiatric diagnoses. There may be barriers that delay or prevent foster children from receiving timely, comprehensive, and useful mental health assessments and further delays in entering evidence-based treatment to address their mental health issues. The data analysis in this paper confirms what the literature on foster children across the United States has found: foster children have significantly greater behavioral health issues, utilize more services, and account for a disproportionate amount of behavioral health expenditures. The analysis presented in this paper highlights a concern that there may be inadequate and inconsistent behavioral health assessments of high-risk children who have contact with CPS, and particularly for children in DSS custody. There may be practical barriers or case coordination issues that are preventing timely and comprehensive clinical assessments of these children. For example, the decreased rates of assessment among Hispanic children may indicate linguistic, cultural, or insurance barriers for undocumented children. Prior to the development of Partnering for Excellence the workforce in Rowan County was unable to accommodate the need for trauma-informed comprehensive clinical assessments. This may explain the use of developmentally inappropriate diagnostic labels or treatment services in the data. For example, it’s concerning that twelve 6 to 11 year old children received substance abuse treatment services. While these children may have been experimenting with substances, substance abuse treatment models are developmentally inappropriate for young children and their issues may have been better addressed by behavioral health services. Additionally, diagnosis of personality disorders in children under 18 years old, MST with children under 12 (as was the case with 10 children), and bipolar diagnoses in young children are all concerning practices that may stem from a lack of experience or resources in the community. It is well established in the literature and anecdotally that foster children’s undiagnosed and untreated mental health issues can lead to challenging externalizing behaviors (tantrums, aggression, lying, etc.) that strain their relationships with their foster parents and can lead to placement disruption. Foster care placements also frequently disrupt for administrative or policy reasons. Either way, the effect and feelings of rejection and instability are the same for the foster child. Research has shown that placement disruptions, particularly in the first 100 days of care, exacerbate foster children’s mental health issues and are associated with more frequent placement changes in the future. Placement disruption may also be associated with increased reliance on the Medicaid-funded residential treatment placements. Placement disruptions and entry into the residential treatment pipeline can delay reunification, prevent adoption or guardianship, and may be correlated with re-entry into foster care. DSS placement disruptions create administrative costs for the Department, disrupt behavioral health service delivery, and can lead to expensive reliance on residential treatment. This entire chain of negative events fails to capture the real and intangible costs to the child’s education and physical and emotional well-being, nor the increased costs associated with administrative procedures, school changes, court procedures, and informal case management. The analysis presented in this paper highlights the concerns about placement stability for children in DSS custody. Children with short first placements (less than 100 days) and more than one placement go on to have more placements overall and these placements are short, indicating that these children are “bouncing around” through placements. Placement instability is also associated with increased average behavioral health expenditures. It follows then, that these children have likely received multiple psychiatric diagnoses and are receiving a wide spectrum of behavioral health services with limited success. Finally, this paper emphasizes the value in utilizing wraparound services such as care coordination by the LME-MCO or Multisystemic Therapy (MST) prior to or following more expensive and intensive residential treatment options. Care coordination can improve the communication between providers, help ensure continuity of care during placement changes, and delay or prevent hospitalizations and other crises. MST has demonstrated effectiveness in preventing out-of-home placements and can effectively address conduct disorder behaviors that can lead to placement disruption and later reliance on institutional care or criminal behavior. For further information regarding this report please contact the author, Susan Cohen Foosness, MSW at sdc28@duke.edu.Item Open Access Best Practices for Modernizing Integrated Public Benefits Applications(2023-04-19) Holtzman, RachelMany state agencies around the country are trying to modernize applications for public benefits programs in their state. This work often involves developing an integrated application for two or more public benefits, and then engineering an online portal on which to host the integrated application. Because most state agencies lack the technological expertise to do this work in-house, they hire third party vendors and consulting firms to help. This report thus seeks to answer the question: What can be learned about best practices for equitable applications, from states that have modernized their remote integrated benefits applications for Medicaid, Supplemental Nutrition Assistance Program (SNAP) and/or Temporary Assistance for Needy Families (TANF) programs since the Affordable Care Act? To answer this question, the researcher conducted 24 interviews with Subject Matter Experts involved in designing, building, launching, administering, and/or researching integrated benefits applications. Findings include best practices for the processes of hiring, building, launching, and conducting outreach related to integrated benefits applications. States must also ensure that the benefits applications are human-centered, meaning that the features and capabilities of the application facilitate equitable access and successful enrollment by applicants with diverse backgrounds, identities, and needs.Item Open Access Clinical Characteristics, Oral Anticoagulation Patterns, and Outcomes of Medicaid Patients With Atrial Fibrillation: Insights From the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF I) Registry.(J Am Heart Assoc, 2016-05-04) O'Brien, Emily C; Kim, Sunghee; Thomas, Laine; Fonarow, Gregg C; Kowey, Peter R; Mahaffey, Kenneth W; Gersh, Bernard J; Piccini, Jonathan P; Peterson, Eric DBACKGROUND: Whereas insurance status has been previously associated with care patterns, little is currently known about the association between Medicaid insurance and the clinical characteristics, treatment, or outcomes of patients with atrial fibrillation (AF). METHODS AND RESULTS: We used data from adults with AF enrolled in the Outcomes Registry for Better Informed Treatment of AF (ORBIT-AF), a national outpatient registry conducted at 176 community, multispecialty sites. The primary outcome of interest was the proportion of patients prescribed any oral anticoagulation (OAC; warfarin or novel oral anticoagulants [NOAC]). Secondary outcomes of interest included the proportion of patients prescribed NOACs (dabigatran or rivaroxaban); time in therapeutic range (TTR) for warfarin users, all-cause mortality, stroke/systemic embolism, and major bleed. Of 10 133 patients, N=470 (4.6%) had Medicaid insurance. Medicaid patients were similarly likely to receive OAC at baseline (72.8% vs 76.3%; unadjusted P=0.079), but less likely to receive NOAC at baseline or follow-up (12.1% vs 16.3%; unadjusted P=0.019). After risk adjustment, Medicaid status was associated with lower use of OAC at baseline among patients with high stroke risk (odds ratio [OR]=0.68; 95% CI=0.49, 0.94), but was not associated with OAC use overall (OR=0.82; 95% CI=0.61, 1.09). Among warfarin users, median TTR was lower among Medicaid patients (60% vs 68%; P<0.0001; adjusted TTR difference, -2.9; 95% CI=-5.7, -0.2; P=0.04). Use of an NOAC over 2 years of follow-up was not statistically different by insurance. Compared with non-Medicaid patients, Medicaid patients had higher unadjusted rates of mortality, stroke/systemic embolism, and major bleeding; however, these differences were attenuated following adjustment for clinical characteristics. CONCLUSIONS: In a contemporary AF cohort, use of OAC overall and use of NOACs were not significantly lower among Medicaid patients relative to others. However, among warfarin users, Medicaid patients spent less time in therapeutic range compared with those with other forms of insurance.Item Open Access Cost of capital to the hospital sector.(J Health Econ, 1988-03) Sloan, FA; Valvona, J; Hassan, M; Morrisey, MAThis paper provides estimates of the cost of equity and debt capital to for-profit and non-profit hospitals in the U.S. for the years 1972-83. The cost of equity is estimated using, alternatively, the Capital Asset Pricing Model and Arbitrage Pricing Theory. We find that the cost of equity capital, using either model, substantially exceeded anticipated inflation. The cost of debt capital was much lower. Accounting for the corporate tax shield on debt and capital paybacks by cost-based insurers lowered the net cost of capital to hospitals.Item Open Access Discharge against medical advice from hospitalizations for substance use disorders: The potential impact of the Affordable Care Act.(Drug and alcohol dependence, 2019-04) Zhu, He; Wu, Li-TzyOBJECTIVES:To explore whether the Affordable Care Act (ACA) enactment is associated with changes in the proportion of discharge against medical advice (DAMA) among hospitalizations due to substance use disorders (SUDs). METHODS:Data were drawn from the 2012-2015 National Inpatient Samples. The sample comprised hospitalizations with a principal diagnosis of SUD (i.e., SUD-involved hospitalization) for patients aged 18-64 years (unweighted N = 287,629). Interrupted time series analyses were conducted to evaluate the effect of the ACA on monthly proportions of DAMA among SUD-involved hospitalizations. RESULTS:Overall, approximately 11% of SUD-involved hospitalizations were DAMA. DAMA was most frequently found among hospitalizations for primary opioid use disorder (pre-ACA: 16.4%; post-ACA: 17.2%). Despite the increase in the Medicaid coverage after ACA enactment, there was no significant change in the proportion of DAMA before and after ACA periods across various demographic groups and clinical conditions. Time series analyses also indicated no significant trend effect on the proportion of DAMA during the pre- and post-ACA months. CONCLUSIONS:As many as 1 in 10 SUD-involved hospitalizations were considered as DAMA. Concerted efforts are needed to enhance insurance benefits for SUDs and patients' knowledge of SUD treatment benefits in order to increase SUD treatment engagement and completion and to reduce DAMA, especially for substance-using patients with Medicaid or opioid use disorder.Item Open Access Does Medicaid pay more to a program of all-inclusive care for the elderly (PACE) than for fee-for-service long-term care?(J Gerontol A Biol Sci Med Sci, 2013-01) Wieland, Darryl; Kinosian, Bruce; Stallard, Eric; Boland, RebeccaBACKGROUND: In rebalancing from nursing homes (NHs), states are increasing access of NH-certified dually eligible (Medicare/Medicaid) patients to community waiver programs and Programs of All-Inclusive Care for the Elderly (PACE). Prior evaluations suggest Medicaid's PACE capitation exceeds its spending for comparable admissions in alternative care, although the latter may be underestimated. We test whether Medicaid payments to PACE are lower than predicted fee-for-service outlays in a long-term care admission cohort. METHODS: Using grade-of-membership methods, we model health deficits for dual eligibles aged 55 or more entering waiver, PACE, and NH in South Carolina (n = 3,988). Clinical types, membership vectors, and program type prevalences are estimated. We calculate a blend, fitting PACE between fee-for-service cohorts, whose postadmission 1-year utilization was converted to attrition-adjusted outlays. PACE's capitation is compared with blend-based expenditure predictions. RESULTS: Four clinical types describe population health deficits/service needs. The waiver cohort is most represented in the least impaired type (1: 47.1%), NH entrants in the most disabled (4: 38.5%). Most prevalent in PACE was a dementia type, 3 (32.7%). PACE's blend was waiver: 0.5602 (95% CI: 0.5472, 0.5732) and NH: 0.4398 (0.4268, 0.4528). Average Medicaid attrition-adjusted 1-year payments for waiver and NH were $4,177 and $77,945. The mean predicted cost for PACE patients in alternative long-term care was $36,620 ($35,662 and $37,580). PACE's Medicaid capitation was $27,648-28% below the lower limit of predicted fee-for-service payments. CONCLUSIONS: PACE's capitation was well under outlays for equivalent patients in alternative care-a substantial savings for Medicaid. Our methods provide a rate-setting element for PACE and other managed long-term care.Item Open Access Ensuring Healthy Children: The Effect of Health Insurance on Primary Health Care for Children(2010-12-10) Sanderson, AnthonyBackground Past studies have typically focused on the effect of health insurance on primary health care for children, but few have assessed the effect the type of health insurance coverage has on primary care. This research studied the effect of health insurance status—uninsured, private insurance, public coverage, or other insurance—on the accessibility, continuity, and comprehensiveness of primary health care for children. Methods This research analyzed a sample of 39,225 children under 18 years of age from the 2006-2009 National Health Interview Survey, a nationally representative sample of households in the United States. The response rate for children was 75.2 percent. Logistic regression models were used to analyze the effect of health insurance on health status and three aspects of primary care: accessibility (physician visit; usual source of care; time since health professional visit), continuity, (usual source and site of care), and comprehensiveness (physical). Excellent or very good health status was the final dependent variable. Results Compared to children with private health insurance, uninsured children and Medicaid or State Children’s Health Insurance Program (SCHIP) beneficiaries are 27% (p<0.001) and 89.4% (p<0.01) as likely, respectively, to have visited a physician within the last twelve months (LTM). Approximately 73% of uninsured children reported having a usual source of care, compared to 96% of children with private insurance and 98% of Medicaid/SCHIP beneficiaries. Children with private health insurance are at least twice as likely to report “excellent or very good” health as children with any other health insurance status (p<0.001). After controlling for the confounding effects of age, citizenship, mother’s education, father’s education, health status, poverty status, race/ethnicity, and region, Medicaid/SCHIP coverage is associated with similar, if not better, accessibility, continuity, and comprehensiveness of primary care compared to children with private insurance. Conclusions Although by many indicators Medicaid and SCHIP enrollees have worse primary care than children with private health insurance, Medicaid and SCHIP beneficiaries are more likely to have risk factors that are associated with poorer primary care and poorer child health status. Nevertheless, clear relationships cannot be established to conclude how government health insurance programs perform relative to private insurance. Health insurance status is an important predictor, but not the only predictor, of the accessibility, continuity, and comprehensiveness of primary care. Other important risk factors include adolescence, non-U.S. citizenship, low levels of mother’s education, poverty, and residence in the West or South.Item Open Access Estimation and validation of a multiattribute model of Alzheimer disease progression.(Med Decis Making, 2010-11) Stallard, Eric; Kinosian, Bruce; Zbrozek, Arthur S; Yashin, Anatoliy I; Glick, Henry A; Stern, YaakovOBJECTIVES: To estimate and validate a multiattribute model of the clinical course of Alzheimer disease (AD) from mild AD to death in a high-quality prospective cohort study, and to estimate the impact of hypothetical modifications to AD progression rates on costs associated with Medicare and Medicaid services. DATA AND METHODS: The authors estimated sex-specific longitudinal Grade of Membership (GoM) models for AD patients (103 men, 149 women) in the initial cohort of the Predictors Study (1989-2001) based on 80 individual measures obtained every 6 mo for 10 y. These models were replicated for AD patients (106 men, 148 women) in the 2nd Predictors Study cohort (1997-2007). Model validation required that the disease-specific transition parameters be identical for both Predictors Study cohorts. Medicare costs were estimated from the National Long Term Care Survey. RESULTS: Sex-specific models were validated using the 2nd Predictors Study cohort with the GoM transition parameters constrained to the values estimated for the 1st Predictors Study cohort; 57 to 61 of the 80 individual measures contributed significantly to the GoM models. Simulated, cost-free interventions in the rate of progression of AD indicated that large potential cost offsets could occur for patients at the earliest stages of AD. CONCLUSIONS: AD progression is characterized by a small number of parameters governing changes in large numbers of correlated indicators of AD severity. The analysis confirmed that the progression of AD represents a complex multidimensional physiological process that is similar across different study cohorts. The estimates suggested that there could be large cost offsets to Medicare and Medicaid from the slowing of AD progression among patients with mild AD. The methodology appears generally applicable in AD modeling.Item Open Access Evaluation of a self-management implementation intervention to improve hypertension control among patients in Medicaid.(Translational behavioral medicine, 2011-03) Bosworth, Hayden B; Dubard, C Annette; Ruppenkamp, Jill; Trygstad, Troy; Hewson, Denis Levis; Jackson, George LElevated blood pressure can lead to serious patient morbidity and mortality. The aim of the study was to evaluate the implementation of a tailored multifaceted program, administered by care managers in a Medicaid setting to improve hypertension medication adherence. The program enrolled 558 Medicaid patients. Patients had at least one phone call by care managers. The individually tailored program focused on improving lifestyle and medication adherence. The primary outcome was the medication possession ratio (MPR), calculated using fill history from pharmacy claims. We observed an improvement of medication possession from 55% 9-12 months prior to program enrollment to 77% 9-12 months post initiation of the program. We demonstrated 12 month sustainability and increased MPR. Personal interaction by phone allows the intervention to be tailored to participants' current concerns, health goals, and specific barriers to achieving these goals.Item Open Access Implementing Health Related Social Needs Screening in an Outpatient Clinic.(Journal of primary care & community health, 2022-01) Nohria, Raman; Xiao, Nan; Guardado, Rubeen; Drainoni, Mari-Lynn; Smith, Cara; Nokes, Keith; Byhoff, ElenaIntroduction/objectives
Health-related social needs (HRSN) screening efforts have reported high rates of identified social needs. Little is known if efforts to conduct HRSN screening in resource-constrained federally-qualified health centers (FQHC) successfully captures a representative patient population.Methods
This cross-sectional study extracted EMR data from 2016 to 2020 for 4731 screened patients from 7 affiliated clinics of a FQHC. Unscreened patients were pulled as a random sample from the study period. A multivariable logistic regression was used to identify sociodemographic traits, chronic disease diagnoses and burden, and clinic visit type and frequency associated with being screened for HRSN.Results
BHC screened 4731 unique patients or <1% of the total clinic population. Screened patients had a median of 3.3 (±2.5) unmet HRSN. Medicaid patients had higher odds of being screened (aOR = 1.38, CI 1.19-1.61) relative to Medicare patients. The odds of being screened for social needs increased with more provider visits per year: compared to fewer than 1 visit per year, patients with 1 to 3 provider visits (aOR = 2.06, CI 1.73-2.32), 4 to 6 provider visits (aOR = 3.34, CI 2.89-3.87), and more than 6 provider visits (aOR = 5.16, CI 4.35-6.12) all had higher odds of social needs screening. Patients with a higher comorbid disease burden (>2 conditions, aOR = 2.80, CI 2.07-3.79) had higher odds of screening.Conclusions
Our findings demonstrate an increased likelihood to screen patients who visit outpatient services more often and have a higher comorbid disease burden. To meet state-level Medicaid requirements, resource-constrained FQHCs that implement clinic wide HRSN screening may be well served to identify a priori strategies to ensure representative and equitable screening across the patient population.Item Open Access Inferior Clinical Outcomes for Patients with Medicaid Insurance After Surgery for Degenerative Lumbar Spondylolisthesis: A Prospective Registry Analysis of 608 Patients.(World neurosurgery, 2022-08) Chan, Andrew K; Letchuman, Vijay; Mummaneni, Praveen V; Burke, John F; Agarwal, Nitin; Bisson, Erica F; Bydon, Mohamad; Foley, Kevin T; Shaffrey, Christopher I; Glassman, Steven D; Wang, Michael Y; Park, Paul; Potts, Eric A; Shaffrey, Mark E; Coric, Domagoj; Knightly, John J; Fu, Kai-Ming; Slotkin, Jonathan R; Asher, Anthony L; Virk, Michael S; Kerezoudis, Panagiotis; Alvi, Mohammed A; Guan, Jian; Haid, Regis W; DiGiorgio, AnthonyBackground
It remains unclear how type of insurance coverage affects long-term, spine-specific patient-reported outcomes (PROs). This study sought to elucidate the impact of insurance on clinical outcomes after lumbar spondylolisthesis surgery.Methods
The prospective Quality Outcomes Database registry was queried for patients with grade 1 degenerative lumbar spondylolisthesis who underwent single-segment surgery. Twenty-four-month PROs were compared and included Oswestry Disability Index, Numeric Rating Scale (NRS) back pain, NRS leg pain, EuroQol-5D, and North American Spine Society Satisfaction.Results
A total of 608 patients undergoing surgery for grade 1 degenerative lumbar spondylolisthesis (mean age, 62.5 ± 11.5 years and 59.2% women) were selected. Insurance types included private insurance (n = 319; 52.5%), Medicare (n = 235; 38.7%), Medicaid (n = 36; 5.9%), and Veterans Affairs (VA)/government (n = 17; 2.8%). One patient (0.2%) was uninsured and was removed from the analyses. Regardless of insurance status, compared to baseline, all 4 cohorts improved significantly regarding ODI, NRS-BP, NRS-LP, and EQ-5D scores (P < 0.001). In adjusted multivariable analyses, compared with patients with private insurance, Medicaid was associated with worse 24-month postoperative Oswestry Disability Index (β = 10.2; 95% confidence interval [CI], 3.9-16.5; P = 0.002) and NRS leg pain (β =1.3; 95% CI, 0.3-2.4; P = 0.02). Medicaid was associated with worse EuroQol-5D scores compared with private insurance (β = -0.07; 95% CI -0.01 to -0.14; P = 0.03), but not compared with Medicare and VA/government insurance (P > 0.05). Medicaid was associated with lower odds of reaching ODI minimal clinically important difference (odds ratio, 0.2; 95% CI, 0.03-0.7; P = 0.02) compared with VA/government insurance. NRS back pain and North American Spine Society satisfaction did not differ by insurance coverage (P > 0.05).Conclusions
Despite adjusting for potential confounding variables, Medicaid coverage was independently associated with worse 24-month PROs after lumbar spondylolisthesis surgery compared with other payer types. Although all improved postoperatively, those with Medicaid coverage had relatively inferior improvements.Item Open Access Insurance status as a mediator of clinical presentation, type of intervention, and short-term outcomes for patients with metastatic spine disease.(Cancer epidemiology, 2022-02) Price, Meghan J; De la Garza Ramos, Rafael; Dalton, Tara; McCray, Edwin; Pennington, Zach; Erickson, Melissa; Walsh, Kyle M; Yassari, Reza; Sciubba, Daniel M; Goodwin, Andrea N; Goodwin, C RoryBackground
It is well established that insurance status is a mediator of disease management, treatment course, and clinical outcomes in cancer patients. Our study assessed differences in clinical presentation, treatment course, mortality rates, and in-hospital complications for patients admitted to the hospital with late-stage cancer - specifically, metastatic spine disease (MSD), by insurance status.Methods
The United States National Inpatient Sample (NIS) database (2012-2014) was queried to identify patients with visceral metastases, metastatic spinal cord compression (MSCC) or pathological fracture of the spine in the setting of cancer. Clinical presentation, type of intervention, mortality rates, and in-hospital complications were compared amongst patients by insurance coverage (Medicare, Medicaid, commercial or unknown). Multivariable logistical regression and age sensitivity analyses were performed.Results
A total of 48,560 MSD patients were identified. Patients with Medicaid coverage presented with significantly higher rates of MSCC (p < 0.001), paralysis (0.008), and visceral metastases (p < 0.001). Patients with commercial insurance were more likely to receive surgical intervention (OR 1.43; p < 0.001). Patients with Medicaid < 65 had higher rates of prolonged length of stay (PLOS) (OR 1.26; 95% CI, 1.01-1.55; p = 0.040) while both Medicare and Medicaid patients < 65 were more likely to have non-routine discharges. In-hospital mortality rates were significantly higher for patients with Medicaid (OR 2.66; 95% CI 1.20-5.89; p = 0.016) and commercial insurance (OR 1.58; 95% CI 1.09-2.27;p = 0.013) older than 65.Conclusion
Given the differing severity in MSD presentation, mortality rates, and rates of PLOS by insurance status, our results identify disparities based on insurance coverage.Item Open Access Measuring disease-free survival and cancer relapse using Medicare claims from CALGB breast cancer trial participants (companion to 9344).(J Natl Cancer Inst, 2006-09-20) Lamont, Elizabeth B; Herndon, James E; Weeks, Jane C; Henderson, I Craig; Earle, Craig C; Schilsky, Richard L; Christakis, Nicholas A; Cancer and Leukemia Group BTo determine the accuracy with which Medicare claims data measure disease-free survival in elderly Medicare beneficiaries with cancer, we performed a criterion validation study. We merged gold-standard clinical trial data of 45 elderly patients with node-positive breast cancer who were treated on the Cancer and Leukemia Group B (CALGB) adjuvant breast trial 9344 with Centers for Medicare and Medicaid Services (CMS) data files and compared the results of a CMS-based algorithm with the CALGB disease-free survival information to determine sensitivity and specificity. For 5-year disease-free survival, the sensitivity of the CMS-based algorithm was 100% (95% confidence interval [CI] = 81% to 100%), the specificity was 97% (95% CI = 83% to 100%), and the area under the receiver operator curve was 98[corrected]% (95% CI = 95[corrected]% to 100%). For 2-year disease-free survival, the test characteristics were less favorable: sensitivity was 83% (95% CI = 36% to 100%), specificity was 95% (95% CI = 83% to 100%), and area under the receiver operator curve was 89[corrected]% (95% CI = 72[corrected]% to 100%).Item Open Access Medicaid Managed Care Programs and Healthcare Markets(2017) Chehal, Puneet KaurMy dissertation research offers insights about the effects of Medicaid managed care (MMC) programs from Kentucky’s statewide market-based program. Kentucky’s significant reforms to introduce a comprehensive MMC program just one year after the passage of the ACA can provide valuable lessons for other rural states with substantial poor populations.
In the first study, I explore Kentucky’s 2011 introduction of MMC and the quality of hospitals used by Medicaid recipients. Kentucky’s MMC program is a post-Affordable Care Act (ACA) market-based program that uses a small set of competing managed-care organizations (MCOs) to administer Medicaid benefits. Using a quasi-experimental research design, I explore whether the introduction of MMC changes the hospitals used by pregnant Medicaid-insured mothers for their deliveries and whether the quality of these hospitals is different compared to the hospitals used before the policy change. I also test whether the changes in hospitals used by pregnant Medicaid-insured mothers for their deliveries differ in smaller counties with fewer hospitals and Medicaid recipients compared to those in larger counties with more hospitals and Medicaid recipients. My analysis uses hospital quality measures designed by the Agency for Healthcare Research and Quality to measure hospital quality. I find that Medicaid-insured pregnant women from nonmetropolitan counties have an increased probability of delivering in the highest quality local hospitals as opposed to the lowest quality local hospitals. In contrast, I find that Medicaid-insured pregnant women from metropolitan counties have a decreased probability of delivering in the highest quality local hospitals and increased probability of delivering in lower quality local hospitals. Since Kentucky’s metropolitan counties have high quality hospitals and its nonmetropolitan counties have some of the poorest quality hospitals in the state, these findings may be positive for patient outcomes and program costs. Additional research evaluating patient outcomes and identifying the causal mechanisms responsible for changes in the hospitals used by Medicaid recipients is needed.
Motivated by my findings in the first chapter, in my second chapter I exploit Kentucky’s reforms to explore potential mechanisms that link MMC to changes in the hospitals used by Medicaid-insured pregnant women for their deliveries. I focus on hospital network status and physician-hospital arrangements, which are the terms by which physicians practice in hospitals. These arrangements can affect the hospital ultimately used by physicians’ patients and may be designed specifically for the purposes of joint contracting with insurers. After using reduced form hospital choice models to estimate the change in the hospitals used by pregnant women in Kentucky in response to the introduction of MMC, I introduce measures of hospital network status and physician-hospital arrangements to my analysis. The primary policy effects on the hospitals used by Medicaid-insured women for deliveries remain unchanged, including the two covariates that suggest that other mechanisms with opposing effects to hospital-network status and physician-hospital arrangements are responsible for the changes in hospitals used by Medicaid-insured women. Future research should consider the role of information in provider choice after the introduction of MMC.
In the third chapter, I shift my focus to considering how well Kentucky’s MMC program navigated expanding Medicaid eligibility. Specifically, I explore the impact of the ACA on disparities in access to medical providers in MMC programs. In states expanding Medicaid eligibility, low-income communities with pre-existing elevated numbers of uninsured people experienced larger gains in coverage from the ACA than other communities. While researchers have reported that there is increased physician participation in states that expanded Medicaid, researchers have yet to explore whether increases in physician participation coincided with areas experiencing the greatest increases in Medicaid coverage or inadequate access to medical services. In these programs, Medicaid recipients access care from provider networks created by the health maintenance organizations (HMOs) selected by states to administer Medicaid benefits. Using an original dataset on Kentucky’s Medicaid HMO networks, I use a difference-in-differences framework to compare provider network participation before and after the implementation of the ACA across counties. Specifically, I compare counties with differing levels of pre-ACA uninsured rates, medically underserved populations and poverty. I find provider network participation is greater in counties experiencing smaller increases in Medicaid coverage but subtly larger participation in counties with medically underserved areas or high poverty.
Item Open Access Mind the Gap: A Comparative Analysis of Adolescent Mental Health, Social Determinants of Health, and Medicaid Policy in North Carolina(2023-12-11) Rory, SmithThis study examines the relationship between adolescent mental health care, social determinants of health, and the development of Medicaid across two North Carolina counties. Specifically, this thesis focuses on Durham County, a relatively urban area with several unincorporated suburbs, and Transylvania County, a rural community of approximately 30,000 inhabitants. Much research has been conducted on the relationship between social determinants of health, and access to and quality of adolescent mental health care. However, the multi-dimensional relationship between all three variables, as well as the influence of Medicaid policy and service innovations, remains unsettled. Through qualitative interviews and inductive analysis, this thesis investigates the differences between how adolescent mental health care is provided in each community. Additionally, it explores the extent to which adolescent mental health services address social determinants of health, and the role of Medicaid policy in the perceived effectiveness of those initiatives. Qualitative analysis of 15 interviews with healthcare providers, community leaders, and Medicaid care managers suggests that the mechanisms by which adolescent mental health and social determinants of health are addressed differ between the two counties, with clinical and nonprofit efforts emphasized in Durham and Transylvania Counties respectively. Yet in both communities, the efforts perceived as most successful rely on collaboration and community organization across various stakeholder groups. Across all interviews, challenges of healthcare access, fragmentation, and discontinuity of care emerged, highlighting a discrepancy between how behavioral health and SDOH innovations are proposed and how they truly affect North Carolinian adolescents.Item Embargo Stroke and Neurodevelopmental Delays in Sickle Cell Disease(2023) Knight, La'Kita Maria JohnsonIn the United States of America, Sickle Cell Disease (SCD) affects 100,000 Americans, predominantly African Americans. In North Carolina (NC), there are approximately 5,578 people living with SCD, which includes both children and adults. Of those affected, 39% are 18 years of age or younger. Strokes are a major disease-related complication that children with SCD too often experience. Some complications include motor and cognitive delays, neurodevelopmental delays (NDD), decline in academic learning and attainment, poor test scores, high school dropout and/or unemployment (later in life). The purpose of this dissertation was to address the problems of stroke prevention and NDD in children with SCD. Therefore, we analyzed hydroxyurea (HU) adherence as well as transcranial Doppler (TCD) screening prevalence and proportion in a statewide Medicaid sample in an attempt to evaluate primary stroke prevention in children ages 2 to 16 years old with SCD. The purpose of this dissertation was achieved through a systematic literature review that explored the prevalence, severity, and associated risk factors for NDD in children with SCD less than or equal to 5 years. Secondary data analyses of the NC Medicaid database was used to examine the following: 1) HU adherence rates for 12- and 24-month cohorts; 2) associations of individual related sociodemographic characteristics with HU adherence; 3) the prevalence rate of children with annual TCD screenings; 4) the proportion of children with zero, 1, 2, 3 or more TCD screening claims; and 5) the prevalence rate of TCD screening claims for age, sex, residential location, and HU adherence. The methods used in the data chapters were descriptive statistics, frequencies, percentages, and chi-square was used to determine differences in HU adherence for both the 12 and 24-month cohorts (Chapter 3), Cochran-Armitage Trend Test and the Cochran-Mantel-Haenszel Test were used to evaluate the proportion of TCD claims with 2, 3, and more levels (Chapter 4), and a Poisson Regression was used to fit the effect of TCD screening claims on sociodemographic characteristics, HU adherence, and to determine the rate of TCD screenings for each of the individual predictor variables (Chapter 4). The findings from this dissertation highlighted a wide range of motor and language deficits among children ages 0 to 5 years old with SCD (Chapter 2). Other major findings included low HU utilization (Chapter 3) and low TCD screening prevalence (Chapter 4) among children ages 2 to 16 years old with SCD on NC Medicaid. Additionally, children with poor HU adherence were less likely to have TCD screening claims (Chapter 4). Therefore, tailored interventions are needed to help mitigate the problems of poor HU utilization as well as TCD screening rates among children with SCD.
Item Open Access The Impact of Medicaid Expansion on Health Care Access, Utilization, and Health(2017-12-06) Yan, Brandon W.Under the Affordable Care Act (ACA), 32 states expanded Medicaid coverage to include adults with household incomes up to 138% of the Federal Poverty Level. Today, Medicaid remains a subject of intense state and federal budgetary and policy debates. To analyze the impact of the ACA’s Medicaid expansion on adults in poverty, I used national data from the 2011-2016 Behavioral Risk Factor Surveillance System to assess trends in health access, preventive service utilization, and health outcomes. I further stratified the analysis to investigate differential impacts on subpopulations including breakdowns by income, race, and age. As measured by rates of uninsurance, inability to afford doctor visits, and lacking a personal doctor, health care access improved significantly more in states that expanded Medicaid than those that did not. Medicaid expansion was associated with a 5.4% decrease in the uninsured rate and a 1.9% increase in the probability of having a routine checkup in the past 12 months. Whites and adults ages 55-64 experienced some of the greatest gains in health care access and routine checkup utilization. Health status improvement approached significance nationally but was significant among those in the $10,000-$14,999 income group. Medicaid expansion was also associated with increases in diagnoses of high blood pressure and high cholesterol. These findings indicate sustained improvements in access to care and evidence of changes in utilization and health that differ by population subgroups. Federal and state policymakers should weigh these benefits in considering Medicaid reforms and Medicaid expansion adoption.Item Open Access United States Emergency Department Use of Medications with Pharmacogenetic Recommendations.(The western journal of emergency medicine, 2021-09-23) Limkakeng, Alexander T; Manandhar, Pratik; Erkanli, Alaatin; Eucker, Stephanie A; Root, Adam; Voora, DeepakIntroduction
Emergency departments (ED) use many medications with a range of therapeutic efficacy and potential significant side effects, and many medications have dosage adjustment recommendations based on the patient's specific genotype. How frequently medications with such pharmaco-genetic recommendations are used in United States (US) EDs has not been studied.Methods
We conducted a cross-sectional analysis of the 2010-2015 National Hospital Ambulatory Medical Care Survey (NHAMCS). We reported the proportion of ED visits in which at least one medication with Clinical Pharmacogenetics Implementation Consortium (CPIC) recommendation of Level A or B evidence was ordered. Secondary comparisons included distributions and 95% confidence intervals of age, gender, race/ethnicity, ED disposition, geographical region, immediacy, and insurance status between all ED visits and those involving a CPIC medication.Results
From 165,155 entries representing 805,726,000 US ED visits in the 2010-2015 NHAMCS, 148,243,000 ED visits (18.4%) led to orders of CPIC medications. The most common CPIC medication was tramadol (6.3%). Visits involving CPIC medications had higher proportions of patients who were female, had private insurance and self-pay, and were discharged from the ED. They also involved lower proportions of patients with Medicare and Medicaid.Conclusion
Almost one fifth of US ED visits involve a medication with a pharmacogenetic recommendation that may impact the efficacy and toxicity for individual patients. While direct application of genotyping is still in development, it is important for emergency care providers to understand and support this technology given its potential to improve individualized, patient-centered care.Item Open Access We both led Medicare and Medicaid. Biden’s vaccine mandate for health-care workers must stand.(Washington Post, 2022-01-07) McClellan, Mark; Slavitt, Andy; Green, Patricia