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Objective: To assess multi-level factors influencing the sustainability of 26 social care pilots integrating medical and social services for Medicaid enrollees across California in newly developed Medicaid benefits., Study Setting and Design: This qualitative study assessed the sustainability of Whole Person Care (WPC) pilots implemented between 2016 and 2021. Pilots (n = 26) represented a majority of counties in California., Data Sources and Analytic Sample: Primary qualitative data were collected between June and August 2021 and included 58 hour-long, semi-structured individual and group interviews with administrators, middle managers, and frontline case management staff representing all WPC pilots. We used hybrid inductive-deductive thematic analysis to identify and analyze patterns, and outliers, in factors influencing sustainment. Deductive codes included established implementation science factors influencing the sustainability of new programs (e.g., innovation characteristics, capacity, processes and interactions, and context)., Principal Findings: Of 26 WPC pilots, 22 pilots sustained WPC by contracting with Medicaid managed care plans to provide services as part of newly developed Medicaid benefits. Three pilots chose not to sustain before the pilot period ended and one pilot decided not to sustain following completion of the full pilot. Factors influencing sustainability included: (1) program adaptability and flexibility; (2) funding structure and reimbursement requirements; (3) shared leadership with managed care plans; and (4) whether pilots chose to build out program infrastructure internally or contracted out core components to partner organizations. Many pilots, particularly those in rural areas, indicated that system and policy changes introduced as part of transitioning pilot services into Medicaid benefits reduced the sustainability of WPC for participating providers., Conclusions: Multi-level factors including program adaptability, funding, leadership, and capacity to build out infrastructure influenced the sustainability of WPC pilots. These findings have significant implications for health equity as equitable distribution of services, resources, and benefits from these programs can be supported through sustained implementation over time., (© 2024 Health Research and Educational Trust.)

Behavioral health integration (BHI) is increasingly implemented to expand capacity to address behavioral health conditions within primary care. Survey and claims data from the evaluation of the Public Hospital Redesign and Incentives in Medi-Cal program were used to examine the relationship between BHI and alcohol-related outcomes among Medicaid patients within 17 public hospitals in California. Key informant survey data measured hospital-level BHI at 3 levels (overall composite, infrastructure, and process domains, 10 themes). Multilevel logistic regression models estimated the relationship between BHI and outcomes indicating receipt of appropriate alcohol-related care (any primary care visit, any detoxification, timely initiation, timely engagement) and acute care (any emergency department [ED] visit or hospitalization, classified as alcohol-related or all-cause) in the year following an alcohol-related index encounter. Of 6196 patients, some had an alcohol-related primary care visit (33%), detoxification (16%), timely initiation (14%), or engagement in treatment (7%). ED visits resulting in discharge were more common (40% alcohol-related, 64% all-cause) than hospitalizations (15% alcohol-related, 26% all-cause). Controlling for patient-level characteristics, no significant relationships between overall BHI and these outcomes were observed. However, greater BHI infrastructure was associated with alcohol-related (odds ratio [OR] 1.86, 95% confidence interval [CI] 1.14-3.05) and all-cause hospitalization (OR 1.25, 95% CI 1.01-1.55). Associations emerged between BHI themes (eg, related to support of providers) and greater likelihood of alcohol-related detoxification, primary care visit, timely initiation, and acute care utilization. Findings suggest that implementing specific BHI components may improve receipt of alcohol-related treatment, and warrant future research into these relationships.

Background and Objectives: We describe "role-sharing" in home care, defined as family care partners and paid caregivers assisting with the same task(s)., Research Design and Methods: We studied 440 participants in the 2015 National Health and Aging Trends Study (NHATS) receiving paid help with self-care, mobility, or medical care. We describe patterns in receiving paid help only, help from care partners only, and role-sharing. We examine whether sole reliance on paid help or role-sharing differs by Medicaid-enrollment and dementia status., Results: Half (52.9%) of care networks involved role-sharing. Care networks involving role-sharing more often occurred among older adults with dementia (48.7% vs. 25.6%, p<0.001) and less often for those who were Medicaid-enrolled (32.1% vs. 49.4%, p<0.01). Those living with dementia more often experienced role-sharing in eating (OR 3.9 [95% CI 1.20, 8.50]), bathing (OR 2.7, [95% CI 1.50, 4.96]), dressing (OR 2.1 [95% CI 1.14, 3.86]), toileting (OR 2.9 [95% CI 1.23, 6.74]), and indoor mobility (OR 2.8 [95% CI 1.42, 5.56]), and less often received help solely from paid helpers with medication administration (OR 0.24, [95% CI 0.12, 0.46]). Medicaid-enrollees more often received paid help only in dressing (OR 2.0 [95% CI 1.12, 3.74]), outdoor (OR 2.4 [95% CI 1.28, 4.36]) and indoor mobility (OR 4.3 [95% CI 2.41, 7.62]), and with doctor visits (OR 2.8 [95% CI 1.29, 5.94])., Discussion and Implications: Role-sharing is common, especially among older adults living with dementia who are not Medicaid-enrolled. Strategies supporting information sharing and collaboration in home-based care merit investigation., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

The Medicaid program is the largest payer of opioid use disorder (OUD) treatment, including medications for OUD (MOUD). Because of budget neutrality requirements, some Medicaid programs use prescription drug caps to limit the monthly number of prescriptions an enrollee can fill. This study examined the association between Medicaid prescription drug caps and Medicaid-covered prescriptions for 2 forms of MOUD (buprenorphine and naltrexone) from 2017 to 2022 using fee-for-service and managed care data from Medicaid's State Drug Utilization Data. Ten states had monthly prescription drug caps, ranging from 3 to 6 prescriptions. Using multivariate linear regression, we estimated that enrollees in states with monthly drug caps filled 1489.3 fewer MOUD prescriptions per 100 000 enrollees. Further, compared with states with the smallest drug caps (3 drugs), enrollees in states with 4-, 5-, and 6-drug caps filled significantly more prescriptions per state-quarter (907.7, 562.6, and 438.9 more prescriptions, respectively). Our results were robust to sensitivity analyses. Monthly prescription drug caps were significantly associated with a reduction in Medicaid-covered MOUD prescriptions. Medicaid enrollees who need MOUD may be affected by indiscriminate prescription drug cap policies, potentially hindering ongoing efforts to mitigate the opioid crisis., Competing Interests: Conflicts of interest None reported. Please see ICMJE form(s) for author conflicts of interest. These have been provided as supplementary materials., (© The Author(s) 2024. Published by Oxford University Press on behalf of Project HOPE - The People-To-People Health Foundation, Inc.)

The Affordable Care Act (ACA), fully implemented in 2014, introduced reforms to Medicaid and the Children's Health Insurance Program (CHIP), aiming to enhance health care access for vulnerable populations. Key provisions that can influence health outcomes in adolescents and young adults (AYAs) with blood cancers include Medicaid expansion, which covers adults with income less than or equal to 138% of the federal poverty level based on modified adjusted gross income (MAGI), streamlined eligibility and enrollment processes, CHIP and Medicaid integration, and dependent coverage reform. Non-MAGI eligibility pathways based on age, disability, or waiver programs provide alternative routes for Medicaid coverage. By improving insurance coverage, providing affordable care and financial protection, and addressing health-related social needs such as transportation to care, Medicaid expansion has the potential to mitigate outcome disparities along the continuum of AYA blood cancer care. However, challenges persist due to coverage gaps in nonexpansion states, complexities in administrative processes to maintain continuous coverage, and barriers to accessing specialists for complex, AYA-focused multidisciplinary cancer care. The ending of the COVID-19 public health emergency's Medicaid Continuous Enrollment Provision has disrupted coverage for many AYAs. Given limited research evaluating the impact of the ACA on AYA blood cancer outcomes, more evidence is needed to guide future policies tailored to this vulnerable population. Despite encouraging progress following the ACA, continued collaborative efforts between policymakers, health care providers, patient advocates, and researchers are essential for identifying targeted strategies to ensure continuous and affordable coverage, access to specialized and coordinated care, and fewer disparities in AYA blood cancer outcomes., (Copyright © 2024 by The American Society of Hematology.)

Objectives: There is growing momentum to introduce value-based payment (VBP) approaches into dentistry to help improve population oral health status. However, there are very few VBP models available for dentistry. This study designs and analyzes the feasibility of introducing oral health episode of care (EOC) bundles for use by policy makers, payers, and dental providers., Methods: An oral health EOC bundle is a standardized care process based on a set of best practices that has the potential to improve patient care quality when all bundle items are provided. We used a panel of dental experts to guide the design of two preventive EOC bundles for children, a comprehensive examination bundle and a periodic examination bundle. We then conducted a 12-year retrospective longitudinal analysis to simulate the completion rate of the EOC bundles for children receiving Medicaid benefits in Arizona from 2008 to 2019., Results: An average of 805,229 children were enrolled annually in the Arizona Medicaid program across the 12-year period. Approximately 31% of the Medicaid enrolled children had a preventive dental visit twice a year, and 23% completed two preventive EOC bundles. On average, 126,602 (16%) of patients started the comprehensive examination bundle and 279,194 (35%) of patients started the periodic examination bundle. Overall completion rates for the Comprehensive Examination and Periodic Examination Bundles were 73% and 79% respectively., Conclusions: It is feasible to design a preventive oral health EOC bundle for children. The findings have implications for developing VBP approaches for oral health care., (© 2024 American Association of Public Health Dentistry.)

Background: The relationship between nursing home (NH) stays before death and hospice use is understudied. Methods: A retrospective cohort study of Connecticut Medicaid decedents with common hospice diagnoses who died between 2017 and 2020. Medicaid/Medicare claims identified NH stays, hospice use, short length of stay (LOS) (≤7 days), demographics, and diagnoses. Logistic regression models examined associations between NH stays with hospice use and LOS. Results: Among 26,261 decedents, 54.2% had NH stays (17.8% short-term, 36.4% long-term). Individuals with NH stays (vs. none) had reduced odds of hospice use (short-term odds ratio [OR]: 0.77 [95% confidence interval or CI: 0.71-0.82] and long-term OR: 0.47 [0.45-0.50]) and had higher odds of short hospice LOS (short-term OR: 2.67 [2.41-2.96] and long-term OR: 2.95 [2.69-3.22]). Conclusions: Further research is needed into why individuals with NH stays, especially long-term stays, are less likely to use hospice and more likely to have short LOS and how this difference relates to end-of-life care quality.

Objective: To identify collaboration strategies used to integrate health, behavioral health, and social services for Medicaid members in California's Medi-Cal Whole Person Care Pilot program (WPC)., Data Sources and Study Setting: WPC was a social care intervention implemented to identify and address eligible members' health, behavioral health, and social needs. Data included semi-structured key informant interviews conducted in 2018-2019 (n = 221) and 2021 (n = 167); pilot-level surveys; whole-network surveys of 507 organizations in all 25 pilots participating in WPC; and documents submitted by pilots to the state. Pilots served a total of 247,887 unique members between 2017 and 2021, the majority of whom were non-white (72%) and over half of whom experienced homelessness., Study Design/data Collection: Data were collected as part of the statewide evaluation of WPC. We analyzed qualitative data to examine strategies used by pilots to integrate care, network data to identify pilots that improved cross-sector collaboration (i.e., strengthened density or multiplexity of cross-sector ties) following WPC implementation, and comparative case analysis to identify strategies that differentiated pilots that improved collaboration from those that did not., Principal Findings: Pilots used multiple strategies to facilitate the integration of care. Network analyses identified 10 pilots that significantly improved either density or multiplexity of cross-sector ties, and one pilot with high cross-sector collaboration prior to WPC. Compared to pilots that did not improve cross-sector collaboration, these pilots meaningfully engaged partners in program design and implementation, used braided funds, and leveraged WPC to support broader systems change. These pilots also reported fewer challenges in developing and managing contractual relationships and ensuring meaningful use of data-sharing infrastructure by frontline staff responsible for care coordination., Conclusions: Data sharing is necessary but not sufficient for systems alignment. Collaboration strategies focused on addressing financial barriers to integration and strengthening normative and interpersonal integration are also needed., (© 2024 The Author(s). Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

This study reports the prevalence of inpatient, emergency department (ED), and outpatient mental health service usage of children/youth before, during, and after onset of the COVID-19 pandemic in Rhode Island. Additionally, we identify significant changes in usage across these time periods and the prevalence of each service type contingent upon various demographic profiles. This retrospective observational analysis used Rhode Island Medicaid claims to identify the unique children and youth who used inpatient, ED, and outpatient mental health services across three key time periods: pre-onset (March 2019-February 2020); onset (March 2020-February 2021); and post-onset (March 2021-February 2022). We used z-tests to analyze changes in the proportion of children/youth who accessed these services in each period. We examined relationships between demographic characteristics and time period with chi-square tests. Significant decreases in inpatient and ED usage were identified from pre-onset to onset (p < .05). While inpatient nearly returned to pre-pandemic usage in post-onset, ED usage remained lower. Outpatient usage increased significantly leading up to the pandemic but remained at similar levels between pre-onset and post-onset. From pre-onset to post-onset, females grew as a percentage of all inpatient, ED, and outpatient users. Over this same period, the proportion of inpatient users aged 12-18 increased and the proportion of ED and outpatient users aged 19-24 increased. Female usage of mental health services increased significantly, and older children/youth seemed to drive any significant increases. Future public health and disaster preparedness policies should focus on the unique mental health needs of these socially vulnerable groups., Competing Interests: Declarations. Ethics Approval: This is an observational study. This study was reviewed and determined to be exempt by the Institutional Review Board of the University of Pennsylvania. All data were fully anonymized prior to being accessed by the research team on July 10, 2023. Consent requirements were waived given that the researchers did not have access to data that could reidentify individuals. Competing Interests: The authors declare that they have no competing interests., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To quantify race, sex, comorbidities, Medicaid status, and compare health outcomes for Medicare-only versus Medicare/Medicaid dual-enrolees who developed a hard-to-heal venous leg ulcer (VLU)., Method: Medicare Limited Data Standard analytic hospital inpatient and outpatient department files were used to follow episodes of medical care for a VLU from 1 October 2015-2 October 2019. In an earlier study, patients diagnosed concurrently with chronic venous insufficiency and a VLU were propensity-matched. In this current work, cohorts were split into patients enrolled in Medicare-only and those enrolled in Medicare and Medicaid (dual-enrolees). Treatment methods were compared and the most commonly used cellular, acellular and matrix-like product (CAMP) among Medicare beneficiaries-dehydrated human amnion chorion membrane (DHACM)-was evaluated. Episode claims were used to document demographics, comorbidities and treatments of Medicare enrolees who developed VLUs and outcomes such as time to ulcer closure, rates of complications and hospital usage rates. Quality of life (QoL) metrics, such as pain and time to VLU closure, were compared across the groups., Results: Of the 555,284 Medicare beneficiaries evaluated in this analysis, 27% were Medicare/Medicaid dual-enrolees and 73% were Medicare-only enrolees. To qualify for Medicaid, patient income had to be ≤133% of the federal poverty level. Only 3% of Medicare-only patients and 6% of dual-enrolees had an Advantage plan, a lower rate than the general Medicare population. Dual-enrolees, compared to those covered by Medicare-only, demonstrated: a Charlson Comorbidity Index (CCI) score one point greater (p<0.0001); a higher percentage (16%) of patients from minority ethnic backgrounds; and significantly higher rates of emergency department visits (p<0.0001) and cellulitis (p=0.034). Dual-enrolees who received early and regularly applied CAMPs also reduced their treatment time by 21 days (p=0.0027), all of which can impact costs., Conclusion: The socioeconomic status of dual-enrolees included near poverty status, a higher percentage of patients from a minority ethnic background, and high rates of comorbidities compared to their Medicare-only counterparts. The VLUs of dual-enrolees took longer to close, developed more complications, and used significantly more hospital resources and expenses. Outcomes significantly improved when VLU episodes were treated with a CAMP, such as DHACM, while following parameters for use. Socioeconomic variables are associated with poor outcomes for patients with hard-to-heal (chronic) wounds. This should be tracked to find cost-effective interventions throughout their journey to provide equitable care and ensure they are not left behind. Greater access for dual-enrolees to CAMPs has the potential to improve clinical outcomes and patient QoL, while concomitantly reducing overall healthcare expenditure.

Patients may rely on health insurance physician directories to determine who is in-network and inaccuracies in these directories may lead to delayed access to treatment, unexpected out-of-pocket costs, and increased barriers to care. This cross-sectional study quantifies the accuracy of state-specific Medicaid directories regarding board-certified pediatric dermatologists, and compares physicians listed accurately with those listed inaccurately by type of practice and region of practice. The accuracy of all state Medicaid physician directories was 84.7%. Most states with board-certified pediatric dermatologists had directories that contained inaccuracies and directory accuracy varied significantly by practice type, but not region of practice., (© 2024 Wiley Periodicals LLC.)

In recent years, federal and state policy makers have expressed concern about retail pharmacy closures throughout the US. However, there is a dearth of timely information on the extent of such closures. We linked data from the National Council for Prescription Drug Programs on all US retail pharmacies to county-level data from the National Center for Health Statistics and ZIP Code Tabulation Area data from the American Community Survey to determine the number and percentage of pharmacy closures during the period 2010-21; identify pharmacy, neighborhood, and market characteristics associated with pharmacy closure; and estimate the risk for closure for independent pharmacies relative to chain pharmacies. We found that of the 88,930 retail pharmacies operating during 2010-20, 29.4 percent had closed by 2021. The risk for closure for pharmacies in predominantly Black and Latinx neighborhoods was higher than in White neighborhoods. Independent pharmacies were at greater risk for closure than chain pharmacies across all neighborhood and market characteristics. Policy makers should consider strategies to increase the participation of independent pharmacies in Medicare and Medicaid preferred networks managed by pharmacy benefit managers and to increase public insurance reimbursement rates for pharmacies that are at the highest risk for closure.

Background: Given persistent disparities in substance use disorder (SUD) treatment for Spanish speakers, it is important to understand whether major health policy changes may improve access to linguistically competent services. We estimate changes in the supply of SUD treatment facilities that both accept Medicaid as payment and offer services in Spanish after the Medicaid expansions under the Affordable Care Act., Methods: We use data from the Mental Health and Addiction Treatment Tracking Repository for years 2010-2020 to calculate the number of facilities per 100 that offered both services in Spanish and accepted Medicaid as payment, facilities per 100 that accepted Medicaid as a form of payment overall, and facilities per 100 that offered Spanish language services overall. We use a difference-in-differences strategy exploiting variation in the timing of the Medicaid expansions across states, and county-level variation in the share of Spanish speaking Latinos across and within states., Results: We find that treatment facilities that both accepted Medicaid as a form of payment and offered Spanish language services increased by roughly 2-3 per 100, on average, in counties with the highest shares of Spanish speakers compared to counties with low to medium shares. This increase may be explained by more facilities accepting Medicaid as a form of payment., Conclusion: The Medicaid expansions under the ACA produced a modest increase in the supply of SUD treatment facilities that both accepted Medicaid as payment and provided services in Spanish in areas with highest shares of Spanish speakers., Competing Interests: Declaration of Competing Interest No conflicts declared, (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: This cross-sectional study evaluated whether children with special health care needs (CSHCN) were more likely to use the emergency department (ED) for nontraumatic dental conditions (NTDCs) than children without special health care needs (SHCN). The study also examined whether the likelihood of receiving an opioid prescription after an NTDC-ED visit differed between children with and without SHCN., Methods: This analysis was based on 2017 Oregon Medicaid enrollment, claims, and pharmacy data (N = 225,614 children aged 3-17 years). To assess associations between SHCN, NTDC-ED use, and receipt of opioid prescriptions, confounding variable-adjusted odds ratios and 95% CIs were generated from logistic regression models., Results: Approximately 14% (n = 31,867) of children had an SHCN. The prevalence of NTDC-ED use was 0.36% (n = 807) for all children. In the confounding variable-adjusted model, the odds of NTDC-ED use were 1.6 times greater for CSHCN than children without SHCN (95% CI, 1.3 to 1.9; P < .001). Among children with an NTDC-ED visit, 8.3% received an opioid prescription. In the confounding variable-adjusted model, CSHCN were at lower odds of receiving an opioid prescription after an NTDC-ED visit than children without SHCN, but this difference was not statistically significant (odds ratio, 0.84; 95% CI, 0.4 to 1.6; P = .57)., Conclusions: CSHCN enrolled in Medicaid had significantly higher odds of having NTDC-ED visits than children without SHCN, but there was no significant difference between the 2 groups in the odds of receiving an opioid prescription after an NTDC-ED visit., Practical Implications: All children, especially those with SHCN, should have adequate access to office-based oral health care through a dental home to reduce use of the ED for NTDC., Competing Interests: Disclosures None of the authors reported any disclosures., (Copyright © 2024 American Dental Association. Published by Elsevier Inc. All rights reserved.)

Background: Studies that examine the impact of insurance type on the ease of obtaining genetic testing are scarce. Therefore, we aim to analyze how different types of insurance influence the time taken to obtain genetic test results among pediatric neurology patients., Methods: This was a retrospective cohort study from Dayton Children's Hospital. Patients who had at least one neurological genetic result found in the electronic medical record from January 1, 2014, to March 1, 2023, were included in the study. Variables collected include demographics, health insurance data, and genetic testing results., Results: A total of 141 patients were included. Most patients were male (51.8%), white (78.0%), and not Hispanic/Latino (96.5%). The mean age at the time of genetic testing was 7.9 years. Most patients had Medicaid as their primary insurance (60.3%) when compared with private insurance (39.7%). Two hundred fifteen genetic reports were examined (137 Medicaid charts and 78 private insurance charts). There was no statistically significant difference from mean time lapse between test order date and results date for Medicaid patients (27.3 days) versus private insurance (31.5 days, P = 0.40). Molecular genetics testing and epilepsy gene panel order were the most common tests ordered for both Medicaid (86.1%, 37.2%) and private insurance (88.5%, 39.7%, respectively)., Conclusions: The mean time between test order date and results date was comparable between private- and Medicaid-insured patients. Our results suggest that there is no significant difference for time to result between pediatric neurology patients who carry public versus private insurance for genetic testing., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

While a large literature examines the immediate and long-run effects of public health insurance, much less is known about the impacts of total program exposure on child developmental outcomes. This paper uses an instrumental variable strategy to estimate the effect of cumulative eligibility gain on cognitive and behavioral outcomes measured at three points during childhood. Our analysis leverages substantial variation in cumulative eligibility due to the dramatic public insurance expansions between the 1980s and 2000s. We find that increased eligibility improves child cognitive skills and present suggestive evidence on better behavioral outcomes. There are notable heterogeneous effects across the subgroups of interest. Both prenatal eligibility and childhood eligibility are important for driving gains in the test scores at older ages. Improved child health is found to be a mediator of the impact of increased eligibility., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: To describe the rate, timing, and primary diagnosis codes for emergency care visits up to 8 weeks (56 days) after live birth among Medicaid beneficiaries in North Carolina (NC). Materials and Methods: Using a linked dataset of Medicaid hospital claims and certificates of live birth, which included Medicaid beneficiaries who had a live-born infant in NC between January 1, 2013, and November 4, 2019, and met inclusion criteria ( n = 321,879), we estimated week-specific visit rates for emergency care visits that did not result in hospital admission (outpatient) and those that did (inpatient). We assessed the 10 leading diagnosis code categories for emergency care visits and described the characteristics of people with 0, 1, or ≥2 outpatient emergency care visits. Results: One in eight (12.4%) Medicaid beneficiaries had an emergency care visit that did not result in inpatient hospital admission during the first 8 weeks postpartum. Visit rates peaked in postpartum week 2. Diagnosis codes for nonspecific symptoms and substance use were the two leading diagnosis code categories for outpatient emergency care visits. Respiratory concerns and gastrointestinal concerns were the two leading diagnosis code categories for inpatient emergency care visits. Compared with those with zero outpatient emergency care visits, a greater proportion of people with ≥2 visits had less than a high school education, used tobacco during pregnancy, had Medicaid insurance outside of pregnancy, had mental health as a medical comorbidity, and/or had ≥2 medical comorbidities. Conclusions: These findings support scheduling health care visits early in the postpartum period, when emergency care visits are most frequent, and point to unmet needs for substance use support.

The CRISPR-based gene editing therapy exagamglogene autotemcel (exa-cel) recently received FDA approval for patients with severe sickle cell disease (SCD). The approval was based on a phase III trial (CLIMB SCD 121), which showed 97% efficacy of this treatment in eliminating vaso occlusive crises (VOCs) for 12 consecutive months. To help contextualize results from this trial, we aimed to investigate the proportion of patients with severe SCD who remain VOC-free for a 1-year period in routine clinical care. Using Medicaid claims data (2000-2018), we identified a cohort of patients, 12-35 years old with severe SCD, defined by ≥ 2 VOCs per year for 2 consecutive years, who met other exa-cel trial inclusion criteria to mimic a trial-like population. A VOC was identified using ICD diagnosis codes during hospitalization and ER visits. The primary outcome was the proportion of patients with no VOCs during a 1-year follow-up. A total of 7,425 patients with severe SCD [mean (SD) age: 20.5 (6.0) years, 54.6% females, 84% African Americans], had a mean of 5.2 VOCs, 5.1 ER visits and 3.5 hospitalizations per year during the baseline period. The proportion of patients with no VOCs during the 1-year follow-up was 7.7% (95% confidence interval: 7.1%-8.3%). In conclusion, less than one in 12 patients with severe SCD achieved VOC-free status within 1 year in routine clinical care. These findings suggest that the high efficacy observed for exa-cel in the trial, if replicated in routine clinical care, could translate into a significant public health impact., (© 2024 The Author(s). Clinical Pharmacology & Therapeutics © 2024 American Society for Clinical Pharmacology and Therapeutics.)

Problem: The high-value, midwifery-led birth centre (BC) model of care is underutilized in the United States, a country with high rates of obstetric intervention and maternal morbidity and mortality., Background: Birth setting decision-making is a complex, preference-sensitive, and resource-dependent process. Understanding how people choose BCs for care may help increase the utilization of BCs and generate positive perinatal outcomes., Aim: This study explores the decision-making experiences of people with Medicaid insurance who chose to give birth in a BC in Massachusetts by gathering interview data to interpret and provide meaning about their selection of birth setting., Methods: We employed a hermeneutic phenomenology study to interview people about their decision to give birth in a BC. Interview data were coded using a hybrid deductive-inductive approach and analyzed using reflexive thematic analysis to interpret and provide meaning., Findings: Twelve women participated in the study. Five themes emerged that described participants' decision-making processes: 1) Stepping Away from "the System," 2) Decision-Making with External Influences, 3) Accessing BC Care, 4) Finding a Home at the BC, and 5) Decision-Making as a Temporal Process., Discussion: The decision to choose a BC was a dynamic process that occurred over time and was influenced by factors such as the quality of care, accessibility, external influences, and the physical environment., Conclusion: Prioritizing an individual's capacity to choose their birth setting and fostering awareness about options in the context of informed decision-making are pivotal steps toward attaining equity in perinatal health. Securing public insurance coverage and equitable reimbursement for BCs represent essential policies aimed at facilitating universal access to the BC model for all people., Competing Interests: Declaration of competing interest We have no conflicts of interest to declare., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Public health care policymakers and payers are increasingly investing in efforts to address patients' health-related social needs (HRSNs) as a strategy for improving health while controlling or reducing costs. However, evidence regarding the implementation and impact of HRSN interventions remains limited. California's Whole Person Care Pilot program (WPC) was a Medicaid Section 1115 waiver demonstration program focused on the provision of care coordination and other services to address eligible beneficiaries' HRSN. In this study, we examine pilot-level variation in impact on acute care utilization and identify factors associated with differential outcomes. The majority of pilots reduced emergency department (ED) visits for enrollees relative to matched controls; however, only four pilots reduced both ED visits and hospitalizations. Coincidence analysis results highlight the importance of cross-sector partnerships, field-based outreach and engagement, and adequate program investment in differentiating pilots that reduced acute care utilization from those that did not., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Disparity in kidney transplant access has been demonstrated by a disproportionately low rate of kidney transplantation in socioeconomically disadvantaged patients. However, the information is not from national representative populations with end-stage kidney disease (ESKD). We aim to examine whether socioeconomic disparity for kidney transplant access exists by utilizing data from the All of Us Research Program., Materials and Methods: We analyzed data of adult ESKD patients using the All of Us Researcher Workbench. The association of socioeconomic data including types of health insurance, levels of education, and household incomes with kidney transplant access was evaluated by multivariable logistic regression analysis adjusted by baseline demographic, medical comorbidities, and behavioral information., Results: Among 4078 adults with ESKD, mean diagnosis age was 54 and 51.64% were male. The majority had Medicare (39.6%), were non-graduate college (75.79%), and earned $10 000-24 999 annual income (20.16%). After adjusting for potential confounders, insurance status emerged as a significant predictor of kidney transplant access. Individuals covered by Medicaid (adjusted odds ratio [AOR] 0.45; 95% confidence interval [CI], 0.35-0.58; P-value < .001) or uninsured (AOR 0.21; 95% CI, 0.12-0.37; P-value < .001) exhibited lower odds of transplantation compared to those with private insurance., Discussion/conclusion: Our findings reveal the influence of insurance status and socioeconomic factors on access to kidney transplantation among ESKD patients. Addressing these disparities through expanded insurance coverage and improved healthcare access is vital for promoting equitable treatment and enhancing health outcomes in vulnerable populations., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: Dentists' Medicaid participation is a critical factor affecting dental care access for Medicaid beneficiaries. An important gap in existing literature is the variation in participation across Medicaid dental Managed Care Organizations (MCOs) in states with more than one. This study examined the variation in participation overall and in predictors of dentist participation between two MCOs in Iowa's Dental Medicaid program., Methods: Data were obtained from a survey of Iowa private practice dentists (n = 1256). Responding general dentists (n = 497) were included in the final analytic sample. Univariate, bivariate, and multivariable logistic regression analyses were conducted to examine demographic and practice characteristics associated with dentist participation (acceptance of new Medicaid patients) between MCOs and by age category., Results: Among respondents, the proportions accepting new adults with Medicaid were 26% (MCO 1) and 7% (MCO 2); for children, they were 40% (MCO 1) and 11% (MCO 2). For adults, dentists who were too busy (MCO1) and solo practice dentists (MCO2) were positively significantly associated with the acceptance of new patients. For children, group and rural practice dentists, as well as dentists who worked <32 h/week were positively significantly associated with acceptance of new patients with MCO1., Conclusions: There was considerable variation in dentist-reported acceptance of new adult and child Medicaid patients, and in the factors affecting acceptance of new patients between MCOs in Iowa dental Medicaid. Future studies of Medicaid participation should consider variations by MCO in states with more than one dental MCO so as not to miss important factors affecting Medicaid participation., (© 2024 The Author(s). Journal of Public Health Dentistry published by Wiley Periodicals LLC on behalf of American Association of Public Health Dentistry.)

Context: Recent studies have highlighted Medicaid enrollment among middle- and higher-income populations and questioned whether the program is reaching those for whom it is intended., Methods: The authors use administrative tax data to measure Medicaid enrollment and income in 2017, they use survey data to measure monthly income, and they use administrative data to identify Medicaid enrollment pathways., Findings: Among 38.8 million nonelderly adults in Medicaid at any point in 2017, 24.4 million had annual income below their state's typical eligibility threshold, and 14.4 million (37%) had income above the threshold. Among those above the threshold, 3.5 million enrolled through a pathway allowing higher income (pregnant women, the "medically needy," and others). The authors also estimate that more than 12 million had at least one month with income below the threshold, and roughly 4 million had at least five months with income below the eligibility threshold., Conclusions: Pathways allowing higher income account for one quarter of enrollees with annual incomes above typical thresholds. Among low-income adults, month-to-month variation in income is common and can account for most or all of the remaining enrollees with annual incomes above typical thresholds. A complete accounting of eligibility status would require merged data on income, Medicaid enrollment, and family structure., (Copyright © 2024 by Duke University Press.)

Objectives: To evaluate access to dental care for children in the United States., Methods: The study population included children in 48 states and the District of Columbia. Using multiple data sources, dental care access was estimated at the community level by matching dental care supply and demand using mathematical modeling accounting for access constraints. Outcome measures included percent-met demand, travel distance, and percentage of underserved and unserved communities. Multiple scenarios to improve Medicaid/CHIP participation of dentists were evaluated., Results: Medicaid-insured and CHIP-insured children exhibited lower access compared to those privately insured. The percent-met demand was lower than 50% for Medicaid-insured children and CHIP-insured children for 42 and 34 states, respectively. Percent-met demand was higher than 50% for private-insured children except for Texas and West Virginia. Increasing Medicaid/CHIP participation of dentists resulted in improving access for public-insured children. At 100% Medicaid/CHIP participation, all states exhibited different degrees of percent-met demand increase for publicly insured children, from 7% to 46%. The percent-met demand across all children ranged in 23.8%-82.9% under 70% participation rate versus 22%-83% under 100% participation rate. No single participation rate improved access for all children uniformly across all states., Conclusions: This study found that dental care access was lower for children with public insurance than those with private access across all states, although states responded differently to changes in Medicaid/CHIP participation. Increasing access for children with public insurance would reduce disparities, but overall children's access to dental care would be better improved by expanding the oral health workforce., (© 2024 The Author(s). Journal of Public Health Dentistry published by Wiley Periodicals LLC on behalf of American Association of Public Health Dentistry.)

Objective: To systematically review Medicaid policies state-by-state for gender-affirming surgery coverage., Data Sources and Study Setting: Primary data were collected for each US state utilizing the LexisNexis legal database, state legislature publications, and Medicaid manuals., Study Design: A cross-sectional study evaluating Medicaid coverage for numerous gender-affirming surgeries., Data Collection/extraction Methods: We previously reported on state health policies that protect gender-affirming care under Medicaid coverage. Building upon our prior work, we systematically assessed the 27 states with protective policies to determine coverage for each type of gender-affirming surgery. We analyzed Medicaid coverage for gender-affirming surgeries in four domains: chest, genital, craniofacial and neck reconstruction, and miscellaneous procedures. Medicaid coverage for each type of surgery was categorized as explicitly covered, explicitly noncovered, or not described., Principal Findings: Among the 27 states with protective Medicaid policies, 17 states (63.0%) provided explicit coverage for at least one gender-affirming chest procedure and at least one gender-affirming genital procedure, while only eight states (29.6%) provided explicit coverage for at least one craniofacial and neck procedure (p = 0.04). Coverage for specific surgical procedures within these three anatomical domains varied. The most common explicitly covered procedures were breast reduction/mastectomy and hysterectomy (n = 17, 63.0%). The most common explicitly noncovered surgery was reversal surgery (n = 12, 44.4%). Several states did not describe the specific surgical procedures covered; thus, final coverage rates are indeterminate., Conclusions: In 2022, 52.9% of states had health policies that protected gender-affirming care under Medicaid; however, coverage for various gender-affirming surgical procedures remains both variable and occasionally unspecified. When specified, craniofacial and neck reconstruction is the least covered anatomical area compared with chest and genital reconstruction., (© 2024 The Author(s). Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Objectives: To compare patient access to urgent care centers (UCCs) with a diagnosis of sudden hearing loss based on insurance., Methods: One hundred twenty-five random UCCs in states with Medicaid expansion and 125 random UCCs in states without Medicaid expansion were contacted by a research assistant posing as a family member seeking care on behalf of a patient with a one-week history of sudden, unilateral hearing loss. Each clinic was called once as a Medicaid patient and once as a private insurance (PI) patient for 500 total calls. Each phone encounter was evaluated for insurance acceptance and self-pay price. Secondary outcomes included other measures of timely/accessible care. Chi-square/McNemar's tests and independent/paired sample t-tests were performed to determine whether there were statistically significant differences between expansion status and insurance type. Calls ended before answering questions were not included in the analysis., Results: Medicaid acceptance rate was significantly lower than PI (68.1% vs. 98.4%, p < 0.001). UCCs in Medicaid expansion states were significantly more likely to accept Medicaid (76.8% vs. 59.2%, p = 0.003). The mean wage-adjusted self-pay price was significantly greater in states with Medicaid expansion at $169.84 than in states without at $145.34 when called as a Medicaid patient (mean difference: $24.50, 95% Confidence Interval: $0.45-$48.54, p = 0.046). The rates of referral to an emergency department and self-pay price nondisclosure rates were greater for Medicaid calls than for private insurance calls (8.2% vs. 0.4% and 17.4% vs. 5.8%; p < 0.001 for both)., Conclusion: Medicaid patients with otologic emergencies face reduced access to care at UCCs., Level of Evidence: NA Laryngoscope, 134:5066-5072, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Competing Interests: Conflicts of interest None disclosed.

Objectives: This study aimed to examine the characteristics of foreign-born abortion patients compared to those born in the Unites States and to explore whether barriers for foreign-born patients varied by state Medicaid coverage of abortion care., Study Design: We used data from the Guttmacher Institute's 2021-2022 Abortion Patient Survey, a national sample of patients obtaining clinic-based abortion care in the United States. We compared sociodemographic characteristics of foreign- and US born respondents, as well as barriers to care. Among foreign-born patients, we compared those in Medicaid coverage states vs states that restrict Medicaid coverage., Results: Some 12% of the 6429 respondents were born outside the United States. Compared to US born patients, they were less likely to have Medicaid coverage and more likely to be Asian/Native Hawaiian/Pacific Islander or Hispanic, to have no health insurance, and to have completed the survey in Spanish. In addition, foreign-born patients were more likely to report delays because they did not know where to get an abortion (18.3% vs. 12.6% for US born). Compared to foreign-born patients living in Medicaid coverage states, those in non-Medicaid states reported multiple barriers, particularly related to cost: respondents in non-Medicaid states were three times as likely to pay out of pocket for abortion (75.8% vs 27.4%) and five times more likely to rely on financial assistance (24.1% vs 4.8%)., Conclusions: Foreign-born abortion patients face knowledge and financial barriers to accessing abortion care compared to those who are US born, and these financial burdens are amplified for those living in non-Medicaid coverage states., Implications: Abortion patients born outside the United States may have overcome many obstacles to obtain care. Expanding state Medicaid coverage of abortion could reduce cost burdens for foreign-born populations., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Mosaic Down syndrome is a triplication of chromosome 21 in some but not all cells. Little is known about the epidemiology of mosaic Down syndrome. We described prevalence of mosaic Down syndrome and the co-occurrence of common chronic conditions in 94,533 Medicaid enrolled adults with any Down syndrome enrolled from 2016 to 2019., Methods: We identified mosaic Down syndrome using the International Classification of Diseases and Related Health Problems, tenth edition code for mosaic Down syndrome and compared to those with nonmosaic Down syndrome codes. We identified chronic conditions using established algorithms and compared prevalence by mosaicism., Results: In total, 1966 (2.08%) had claims for mosaic Down syndrome. Mosaicism did not differ by sex or race/ethnicity with similar age distributions. Individuals with mosaicism were more likely to present with autism (13.9% vs. 9.6%) and attention deficit hyperactivity disorder (17.7% vs. 14.0%) compared to individuals without mosaicism. In total, 22.3% of those with mosaic Down syndrome and 21.5% of those without mosaicism had claims for Alzheimer's dementia (Prevalence difference: 0.8; 95% Confidence interval: -1.0, 2.8). The mosaic group had 1.19 times the hazard of Alzheimer's dementia compared to the nonmosaic group (95% CI: 1.0, 1.3)., Discussion: Mosaicism may be associated with a higher susceptibility to certain neurodevelopmental and neurodegenerative conditions, including Alzheimer's dementia. Our findings challenge previous assumptions about its protective effects in Down syndrome. Further research is necessary to explore these associations in greater depth., (© 2024 Wiley Periodicals LLC.)

Background and Aims: Extended release buprenorphine injection (INJ-BUP) has been available in the United States since 2018. INJ-BUP has the potential to positively impact opioid use disorder (OUD) treatment outcomes by providing additional treatment options. As one of the largest payers of OUD treatment in the US, Medicaid coverage is important for access and uptake of INJ-BUP. Uptake of INJ-BUP among Medicaid beneficiaries has not been described since 2019 and variation in uptake by state has not previously been explored. We aimed to measure prescribing of INJ-BUP for Medicaid beneficiaries since 2018, nationwide and by state., Methods: We analyzed State Drug Utilization Data from 2017 to 2022 and calculated the number of prescription fills for INJ-BUP and oral buprenorphine paid by Medicaid. To compare across states, we calculated the number of prescription fills per 100 Medicaid beneficiaries treated for OUD using data from Transformed Medicaid Statistical Information System Substance Use Disorder (T-MSIS SUD) Data Books. Data sources are publicly available., Results: The number of prescription fills for INJ-BUP paid by Medicaid increased from 4322 (0.1% of all buprenorphine prescription fills) in 2018 to 186 861 (2.0%) in 2022. Each year the increase in fills exceeded the prior year change, indicating accelerating uptake. There was notable variability across states., Conclusions: The number of extended release buprenorphine injection prescriptions among US Medicaid beneficiaries treated for opioid use disorder increased from over 4000 prescriptions in 2018 to over 185 000 in 2022 but uptake is much less than observed in other countries over shorter time periods., (© 2024 Society for the Study of Addiction.)

Objective: To examine differential changes in receipt of surgery at National Cancer Institute (NCI)-designated comprehensive cancer centers (NCI-CCC) and Commission on Cancer (CoC) accredited hospitals for patients with cancer more likely to be newly eligible for coverage under Affordable Care Act (ACA) insurance expansions, relative to those less likely to have been impacted by the ACA., Data Sources and Study Setting: Pennsylvania Cancer Registry (PCR) for 2010-2019 linked with discharge records from the Pennsylvania Health Care Cost Containment Council (PHC4)., Study Design: Outcomes include whether cancer surgery was performed at an NCI-CCC or a CoC-accredited hospital. We conducted a difference-in-differences analysis, estimating linear probability models for each outcome that control for residence in a county with above median county-level pre-ACA uninsurance and the interaction between county-level baseline uninsurance and cancer treatment post-ACA to capture differential changes in access between those more and less likely to become newly eligible for insurance coverage (based on area-level proxy). All models control for age, sex, race and ethnicity, cancer site and stage, census-tract level urban/rural residence, Area Deprivation Index, and year- and county-fixed effects., Data Collection/extraction Methods: We identified adults aged 26-64 in PCR with prostate, lung, or colorectal cancer who received cancer-directed surgery and had a corresponding surgery discharge record in PHC4., Principal Findings: We observe a differential increase in receiving care at an NCI-CCC of 6.2 percentage points (95% CI: 2.6-9.8; baseline mean = 9.8%) among patients in high baseline uninsurance areas (p = 0.001). Our estimate of the differential change in care at the larger set of CoC hospitals is positive (3.9 percentage points [95% CI: -0.5-8.2; baseline mean = 73.7%]) but not statistically significant (p = 0.079)., Conclusions: Our findings suggest that insurance expansions under the ACA were associated with increased access to NCI-CCCs., (© 2024 The Authors. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Purpose: There are known disparities in chronic pain severity, treatment, and opioid-related risks amongst individuals from lower socioeconomic status, including Medicaid beneficiaries, but little is known about whether Medicaid beneficiaries benefit in a similar way from multidisciplinary chronic pain rehabilitation. This study investigated differences in clinical outcomes between Medicaid and non-Medicaid beneficiaries who completed a 3-week multidisciplinary chronic pain rehabilitation program. Methods: Participants ( N  = 131) completed a broad range of clinical measures pre- and post-treatment including pain severity, pain interference, depression, anxiety, objective physical functioning, and opioid misuse risk. Patients with Medicaid were compared with non-Medicaid patients in terms of baseline characteristics and rate of change, utilizing two-factor repeated measures analyses of variance. Results: There were baseline characteristic differences, with Medicaid beneficiaries being more likely to be African American, have higher rates of pain, worse physical functioning, and lower rates of opioid use. Despite baseline differences, both groups demonstrated significantly improved outcomes across all measures ( p <.001) and no significant difference in rate of improvement. Conclusions: Results suggest that pain rehabilitation is as effective for Medicaid recipients as non-Medicaid recipients. Patients with Medicaid are particularly vulnerable to disparities in treatment, so efforts to expand access to multidisciplinary pain treatments are warranted.

Background: Psoriasis is a chronic, inflammatory skin condition requiring long-term care. However, many psoriasis patients may not regularly receive care. Several factors affect access to care in the United States, including health insurance status. Additionally, it is unknown how health insurance status impacts the healthcare-seeking behavior of psoriasis patients. Healthcare-seeking behavior is broadly defined as an individual's actions to prevent or treat a perceived health problem, such as visiting a physician's office. Because early diagnosis and timely treatment improve patient outcomes, determining how insurance status impacts psoriasis patients' healthcare-seeking behavior and their ability to get care is important. This allows us to identify patients at risk for being untreated or undertreated. In this study, we aimed to assess the relationship between insurance status and (1) the degree to which psoriasis patients delay seeking or receiving care and (2) the degree to which psoriasis patients are unable to obtain care., Methods: This population-based study used 20 years of data from the Medical Expenditure Panel Survey from 2002 to 2021. We calculated descriptive statistics and performed adjusted multivariable logistic regression analyses., Results: We identified a weighted total of 4,506,850 psoriasis patients. Compared to those with private insurance, psoriasis patients with public-only insurance were 2.7 times more likely to delay seeking or receiving care (95% CI, 1.26-5.87). Compared to private insurance patients, uninsured psoriasis patients were 3.4 times more likely to be unable to obtain care (95% CI, 1.31-8.92). Compared to those with public-only insurance, uninsured psoriasis patients were 3.7 times more likely to be unable to obtain care (95% CI, 1.32-10.38)., Conclusions: This study found that psoriasis patients with public-only insurance were significantly more likely to delay seeking or receiving care compared to those with private insurance. This study also found that uninsured psoriasis patients were significantly more likely to be unable to obtain care than psoriasis patients with private insurance and those with public-only insurance. Developing strategies to increase healthcare access is necessary to ensure equitable, timely, and appropriate care for all psoriasis patients, regardless of their insurance status., Competing Interests: Declarations. Ethics approval and consent to participate: This study used publicly available, de-identified data; therefore, it was exempt from Institutional Review Board approval. Consent for publication: Not applicable. Competing interests: Authors KS, AH, RKY, LG, RK, HCT, SNB, and DKY declare that they have no competing interests. AWA has served as a research investigator, scientific advisor, or speaker to AbbVie, Amgen, Almirall, Arcutis, ASLAN, Beiersdorf, BI, BMS, EPI, Incyte, Leo, UCB, Janssen, Lilly, Mindera, Nimbus, Novartis, Ortho, Sun, Dermavant, Dermira, Sanofi, Takeda, Organon, Regeneron, Pfizer, and Ventyx. AbbVie, Amgen, Almirall, Arcutis, ASLAN, Beiersdorf, BI, BMS, EPI, Incyte, Leo, UCB, Janssen, Lilly, Mindera, Nimbus, Novartis, Ortho, Sun, Dermavant, Dermira, Sanofi, Takeda, Organon, Regeneron, Pfizer and Ventyx provided support in the form of salaries for AWA, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript., (© 2024. The Author(s).)

Introduction: Many U.S. states expanded the generosity of Medicaid insurance coverage of tobacco dependence treatment (TDT) over the last fifteen years, but little is known about how coverage impacts cigarette smoking, especially for individuals with substance use disorder (SUD)., Methods: Data are from the 2009-2018 National Survey on Drug Use and Health (NSDUH) and include Medicaid beneficiaries 18-64 years old with past year SUD who smoked at least 100 cigarettes in their lifetime. Outcomes were smoking cessation, nicotine dependence, and number of cigarettes smoked per month. Difference-in-differences models were estimated for smoking behavior by state and year of comprehensive TDT coverage, estimating multivariable linear probability models, adjusted for sociodemographic characteristics, co-occurring mental illness, and area-level provider supply. All data were analyzed in 2023 and 2024., Results: Rates of nicotine dependence among individuals with past-year SUD increased slightly between 2009 and 2018 among individuals living in states with comprehensive TDT coverage (55.6% to 58.6%) and changed little among individuals living in states with no or partial TDT coverage (60.0% to 59.5%). Quit rates increased for individuals with SUD during this time, with no differences by comprehensive TDT coverage. In adjusted models, no significant association between comprehensive Medicaid TDT coverage and smoking behaviors was identified (e.g., cessation: β=-0.02, CI [-.08, .04]). One-year lagged outcomes and sensitivity analyses accounting for the differential time of initiation of state policies demonstrated similar results., Conclusions: Comprehensive TDT coverage had no differential effect on smoking cessation among ever smokers with or without SUD, and its expansion was not associated with changes in smoking behaviors for Medicaid beneficiaries with SUD. Other multilevel interventions may be needed to impact smoking cessation rates, such as awareness and education campaigns of expanded TDT coverage benefits, and interventions that reduce social and structural barriers to treatment., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: For the first time, our study tracked disparities in the utilization of audio-video and audio-only telehealth for outpatient visits before and during the COVID-19 pandemic., Methods: Using a dataset of de-identified claims corresponding to telehealth and in-person visits, a retrospective cohort study was conducted for all beneficiaries continuously enrolled in Arizona Medicaid between October 2019 and November 2020. Our definition of telehealth only covered outpatient services delivered remotely via the audio-video or audio-only modality. Outcomes of interest were indicators of telehealth (vs. in-person) service delivery and audio-video (vs. audio-only) delivery of a telehealth service. Multivariate models evaluated the association between each outcome and demographic factors, including age, urban/rural location, sex, and race/ethnicity., Results: In this cohort study of 1,799,537 beneficiaries, age over 75, male sex, Asian race, Black race, Hispanic ethnicity, and Native American race were associated with reduced odds of telehealth use for outpatient visits pre-pandemic. These deficits persisted for all groups except the Black race after the pandemic's onset. Throughout the study period, older age and Native American race were correlated with greater audio-video use while Black race indicated reduced odds of audio-video use. Hispanic ethnicity indicated lower odds of audio-video use only during the pandemic. Rural members exhibited greater odds of both overall telehealth and audio-video use for outpatient visits prior to the pandemic but both trends reversed as a rural-urban divide emerged during the pandemic. Spearman correlations between broadband access and audio-video uptake yielded no significant results pre-pandemic but a strong correlation emerged during the pandemic., Discussion: Pandemic-era telehealth expansions reduced but did not eliminate pre-existing disparities in telehealth and audio-video utilization for outpatient visits, indicating a need for health systems to better engage minority, elderly, and rural populations and continue to support audio-only telehealth., Competing Interests: Declarations:. Conflict of Interest:: The authors declare that they do not have a conflict of interest., (© 2024. The Author(s).)

Awareness of autism is rising, yet social determinants of health impact ages of diagnosis, and diagnostic load. Unequal rates of diagnoses may indicate biases in the healthcare system. This study investigates six prior diagnoses (ADHD, conduct, adjustment, anxiety, mood, and intellectual disability) assigned to children who are later diagnosed with autism. The study investigates how race, sex, and geographic factors were associated with age of diagnosis and diagnostic load. A sample of 13,850 (78.16% male and 14.43% Black, with 57.95% of children living in urban regions) children aged 2-10 who were diagnosed with autism on Missouri Medicaid between 2015 and 2019 were studied. Indicated that being White, living urban, and having more prior diagnoses were associated with older age of autism diagnosis. Using logistic regressions, being White was associated with a child being more likely diagnosed with all prior diagnoses aside from intellectual disability. Being male was related to a higher likelihood of ADHD, and lower likelihood of intellectual disability. Being White was associated with higher likelihood of most diagnoses, even in urban-only samples, potentially reflecting more access to providers and office visits. Living in rural areas was also associated with earlier diagnosis and more prior diagnoses such as ADHD and conduct, which may be due to types of providers or specialists seen. Future research should look at barriers to diagnosis and the advantages and disadvantages of a higher diagnostic load., (© 2024. The Author(s).)

Purpose: A population health pharmacy team was developed to improve health and increase reimbursement for patients with value-based care plans. The purpose of this study was to evaluate the impact of pharmacy involvement on care gap closure in Managed Medicaid patients., Methods: This was a single-center, retrospective cohort study of Managed Medicaid patients seen at outpatient facilities. Patients had a pharmacy risk score (PRS) of 6 or greater and had not achieved the Medicaid quality measures for both glycated hemoglobin (HbA1c) and blood pressure (BP). The intervention group included patients reviewed by pharmacy, compared to a control group of patients not reviewed by pharmacy. The primary outcome was closure of at least one care gap by the end of 2022. Secondary outcomes were the number of each type of gap closed, the frequency at which recommendations were made by pharmacists, and the frequency at which pharmacist recommendations were implemented by providers., Results: Data were collected for 80 patients for the period from January through October 2022. The primary outcome occurred in 37 (74%) patients in the intervention group and 15 (50%) patients in the control group (odds ratio, 2.85; P = 0.032). The HbA1c gap was closed in 30 (60%) patients in the intervention group and 8 (27%) patients in the control group. The BP gap was closed in 24 (48%) patients in the intervention group and 11 (37%) patients in the control group. The frequency with which recommendations were made by a pharmacist was associated with gap closure (P = 0.012). No significant difference was found based on the frequency at which recommendations were implemented by providers (P = 0.4)., Conclusion: Pharmacy intervention was associated with an almost 3-fold-higher likelihood of closing at least one care gap in Medicaid patients. HbA1c gap closure was achieved more frequently than BP gap closure due to pharmacy involvement. The frequency with which recommendations were made by pharmacy was associated with increased gap closure regardless of the frequency with which these recommendations were implemented by providers., (© American Society of Health-System Pharmacists 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background/Objectives : Tobacco use remains a significant public health issue, particularly among individuals with low incomes, including Medicaid recipients who often face multiple barriers to quitting. This study aimed to identify barriers, from the perspective of Medicaid managed care organizations (MCOs), influencing Medicaid recipient participation in tobacco cessation programs. Methods : Focus group interviews were conducted with Florida Medicaid MCOs to elicit processes for case identification, outreach, referral, program participation, and incentives. Answers were synthesized into themes. Results : Medicaid recipients were primarily identified through nicotine dependency claim codes or Health Risk Assessments (HRAs). Individuals were referred to state and local community tobacco cessation programs through text messaging and outreach by MCO case managers. The MCOs identified the following as barriers: primary care physicians (PCPs) with limited knowledge about cessation programs and pharmacologic treatments for nicotine dependence, low availability of health coaches, long wait times for entry into cessation programs, weak coordination between MCOs and cessation programs, and insufficient incentives for individuals for program participation. Suggested strategies to overcome barriers were continuing medical education (CME) for PCPs about tobacco cessation programs and prescription therapies, increasing the training of health coaches, more investment in quitlines, increasing data sharing between MCOs and cessation programs, and increasing incentives for individuals. Conclusions : These findings highlight the importance of engaging MCOs in discussions about policy and program improvements, as their insights can drive meaningful changes in how tobacco cessation and other preventive health programs are structured and implemented. Targeted interventions are needed to enhance tobacco cessation program participation among Medicaid recipients.

Enrollment in Medicare Advantage (MA) Dual-Eligible Special Needs Plans (D-SNPs) among individuals dually eligible for Medicare and Medicaid has more than tripled over the past decade. Little is known about whether D-SNP plan design differs from standard MA plan design nor whether this design reflects the needs of dual-eligible enrollees. We characterize the degree to which D-SNPs specialize in an important plan design dimension-provider networks. We find that in 2022, 46% of D-SNPs offer networks that are distinct from the insurer's standard MA plan networks. Compared with D-SNP networks that are shared with standard MA plans, specialized D-SNP networks include more psychiatrists, Ob/Gyn's, and neurologists, providers that specialize in treating conditions more common among dually eligible enrollees. Network specialization is more common among insurers participating in the local Medicaid market and less common in provider shortage areas, suggesting investment in Medicaid and reduced provider negotiation costs may facilitate specialization., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To test quantitative process measures characterizing the work of social needs case managers as they assisted patients with diverse health-related needs-spanning both medical and social domains., Study Setting and Design: The study analyzed secondary data on 7076 patients working with 147 case managers from the CommunityConnect social needs case management program in Contra Costa County, California from 2018 to 2021. The service-designed to be holistic with a focus on social determinants as root causes of health issues-helped patients navigate social services, health care, and mental health care., Data Sources and Analytic Sample: We used cross-sectional analyses to quantitatively characterize electronic health records (EHRs) derived measures of case management intensity (goal updates), duration (days goal was open), and outcomes for 19 different categories of health and social goals. Mixed-effects regression models were used to examine how work process measures varied according to goal categories. Models nested goals within patients within case managers and adjusted for patient-level covariates., Principal Findings: The most common goals were dental care (53%), food (40%), and housing (39%). In adjusted analyses, housing goals had significantly more case manager updates than any other type of goal with a marginal mean of 14.0 updates (95% CI: 13.4-14.7), were worked on for significantly longer (marginal mean of 417 days, 95% CI: 360-474) than any goal except dental care, and were least likely to be resolved. Utilities, insurance, and medication coordination goals were most likely to be resolved., Conclusions: Case managers and patients repeatedly worked on goals over many months. Meeting housing needs and accessing dental care were issues that were not easily resolved and required extensive follow-up. One-time referral interventions may need follow-up systems to meaningfully support social and health needs., (© 2024 Health Research and Educational Trust.)

This article reviews the role of Medicaid Waivers in homeless policy, and their emerging role as a mechanism to address homelessness. We evaluate the political development of Waivers in housing and homeless policy over the past thirty years, and investigate the status of current and approved Waivers targeting homelessness. We then consider how Waivers may shape homeless policy governance going forward, including the success of existing systems, and ethical questions related to the role of healthcare payers in solutions to homelessness. We find that the scope of Medicaid Waivers to address homelessness has always been present, but significantly expanded post Affordable Care Act (ACA) and more notably following the COVID-19 pandemic. These expansions brought new opportunities for states to fund responses to homelessness through Medicaid social determinants of health (SDoH) provisions providing wrap-around medical services for populations at-risk of or experiencing homelessness, and now through time-limited direct housing costs paired with essential medical services. Over one third of states have an 1115 Waiver specifically targeting homelessness, with nearly one in five states including provisions that cover direct housing costs (e.g., rent). Going forward, Medicaid's involvement in homeless policy has the potential to reshape state and local responses to homelessness., (Copyright © 2024 by Duke University Press.)

Unlabelled: Interoperability has been designed to improve the quality and efficiency of health care. It allows the Centers for Medicare and Medicaid Services to collect data on quality measures as a part of the Meaningful Use program. Covered providers who fail to provide data have lower rates of reimbursement. Unintended consequences also arise at each step of the data collection process: (1) providers are not reimbursed for the extra time required to generate data; (2) patients do not have control over when and how their data are provided to or used by the government; and (3) large datasets increase the chances of an accidental data breach or intentional hacker attack. After detailing the issues, we describe several solutions, including an appropriate data use review board, which is designed to oversee certain aspects of the process and ensure accountability and transparency., (© Irmgard Ursula Willcockson, Ignacio Herman Valdes. Originally published in JMIR Medical Informatics (https://medinform.jmir.org).)

Objective: To evaluate healthcare cost and utilization changes among Medicaid and dually eligible participants of a supportive housing program implemented by a managed care organization and community-based organization., Study Setting and Design: Healthcare claims were reviewed retrospectively for 80 program participants in one urban Pennsylvania county between 1/1/2018 and 9/28/2023 who had ≥6 months of claims data in both pre- and post-housing periods. Eligibility included age >18 years, Medicaid/Special Needs Plan enrollment, and housing need. Due to limited housing units, potential participants were prioritized by medical need and history of unplanned care., Data Sources and Analytic Sample: Healthcare cost and utilization were compared during pre- (i.e., 12 months before housing initiation) and post-periods (i.e., 12 months after housing initiation)., Principal Findings: Compared to the pre-period, significantly lower medical (-40.4%, p = 0.004), emergency department (-62.7%, p = 0.02), and total (-33.3%, p = 0.02) costs of care were observed in the post-period. Significantly lower primary care (-50.0%, p = 0.0003), specialist (-31.3%, p = 0.02), and emergency department (-50.0%, p = 0.03) utilization were also observed., Conclusions: Healthcare cost and utilization among medically complex individuals were lower with supportive housing. Future evaluations with randomized designs can address the potential causal impact of supportive housing as a healthcare intervention on specific outcomes., (© 2024 Health Research and Educational Trust.)

The impact of uncertainty in information systems is difficult to assess, especially when drawing conclusions from human observation records. In this study, we investigate survival variation in a population experiencing infectious disease as a proxy to investigate uncertainty problems. Using Centers for Medicare and Medicaid Services claims, we discovered 1,543,041 HIV+ persons, 363,425 of whom were observed dying from all-cause mortality. Once aggregated by HIV status, year of birth and year of death, Age-Period-Cohort disambiguation and regression models were constructed to produce explanations of variance in survival. We used Age-Period-Cohort as an alternative method to work around under-observed features of uncertainty like infection transmission, receiver host dynamics or comorbidity noise impacting survival variation. We detected ages that have a consistent, disproportionate share of deaths independent of study year or year of birth. Variation in seasonality of mortality appeared stable in regression models; in turn, HIV cases in the United States do not have a survival gain when uncertainty is uncontrolled for. Given the information complexity issues under observed exposure and transmission, studies of infectious diseases should either include robust decedent cases, observe transmission physics or avoid drawing conclusions about survival from human observation records.

Vaccine uptake is suboptimal among adult Medicaid beneficiaries. To evaluate factors affecting vaccine uptake among adult Medicaid beneficiaries and/or affecting healthcare providers who vaccinate adult Medicaid beneficiaries, we conducted a systematic literature review in Embase, Medline, Database of Abstracts of Reviews of Effects, and the Cochrane Library for articles published from January 2005 through July 2022 and relevant conferences. For included studies, data were extracted on the study characteristics, patient and provider cost barriers, patient and provider perceived risks/benefits, and other barriers faced by patients and providers. Quality assessments were conducted using a checklist from the Joanna Briggs Institute. Twenty-one studies analyzed patient-related factors (14 studies) and/or provider-related factors (8 studies). Reviewed studies indicate that vaccine uptake is influenced by insurance benefit and cost-coverage policies, including cost-sharing, access to vaccination services, and vaccine education and awareness. Financial factors, including reimbursement for vaccine acquisition and administration, influence providers' vaccination practices for Medicaid beneficiaries. Our findings suggest that reducing or eliminating vaccination cost-sharing, promoting vaccine education and awareness about the importance and safety of vaccines, increasing access, and exploring reimbursement rates equivalent with other public or private insurance plans could mitigate barriers to vaccination for the adult Medicaid population., Competing Interests: Please see ICMJE form(s) for author conflicts of interest. These have been provided as supplementary materials. E.M., L.H., M.G., A.H.G., and J.C. are employees of RTI Health Solutions or were employees of RTI Health Solutions at the time of this research. RTI Health Solutions received research funding from Merck Sharp & Dohme LLC, a subsidiary of Merck & Co., Inc., Rahway, NJ, United States; Pfizer; and GSK to conduct this work. S.P. is an employee of GSK who may own stock and/or stock options in GSK. A.L.E. and A.B. are current employees of Merck Sharp & Dohme LLC, a subsidiary of Merck & Co., Inc., Rahway, NJ, United States, who may own stock and/or stock options in Merck & Co., Inc., Rahway, NJ, United States. R.F. is an employee of Pfizer who may own stock and/or stock options in Pfizer., (© The Author(s) 2024. Published by Oxford University Press on behalf of Project HOPE - The People-To-People Health Foundation, Inc.)

In the United Sates, over 115,000 individuals are diagnosed with a gynecologic cancer annually with access to a gynecologic oncologist and evidence-based treatment remaining a persistent challenge. Coverage decisions by private and public insurance, including Medicaid and Medicare, play key roles in access to care, impacting oncologic outcomes. The expansion of Medicaid insurance under the Affordable Care Act improved early diagnosis, treatment, and survival in gynecologic cancers, but disparities remain for individuals in non-Medicaid expansion states. For individuals with Medicare or private insurance, coverage gaps and high out-of-pocket costs are barriers to cancer care, particularly for novel therapeutic treatments. Efforts to streamline care access, expand clinical trial participation, and reduce administrative burdens continue. Addressing these disparities require improving insurance literacy in patients and clinicians, coordination, and community partnerships to support equitable and comprehensive gynecologic cancer care., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: People diagnosed with a co-occurring serious mental illness (SMI; ie, major depressive disorder, bipolar disorder, or schizophrenia) but hospitalized for a nonpsychiatric condition experience higher rates of readmissions and other adverse outcomes, in part due to poorly coordinated care transitions. Current hospital-to-home transitional care programs lack a focus on the integrated social, medical, and mental health needs of these patients. The Thrive clinical pathway provides transitional care support for patients insured by Medicaid with multiple chronic conditions by focusing on posthospitalization medical concerns and the social determinants of health. This study seeks to evaluate an adapted version of Thrive that also meets the needs of patients with co-occurring SMI discharged from a nonpsychiatric hospitalization., Objective: This study aimed to (1) engage staff and community advisors in participatory implementation processes to adapt the Thrive clinical pathway for all Medicaid-insured patients, including those with SMI; (2) examine utilization outcomes (ie, Thrive referral, readmission, emergency department [ED], primary, and specialty care visits) for Medicaid-insured individuals with and without SMI who receive Thrive compared with usual care; and (3) evaluate the acceptability, appropriateness, feasibility, and cost-benefit of an adapted Thrive clinical pathway that is tailored for Medicaid-insured patients with co-occurring SMI., Methods: This study will use a prospective, type I hybrid effectiveness-implementation, stepped-wedge, cluster randomized controlled trial design. We will randomize the initiation of Thrive referrals at the unit level. Data collection will occur over 24 months. Inclusion criteria for Thrive referral include individuals who (1) are Medicaid insured, dually enrolled in Medicaid and Medicare, or Medicaid eligible; (2) reside in Philadelphia; (3) are admitted for a medical diagnosis for over 24 hours at the study hospital; (4) are planned for discharge to home; (5) agree to receive home care services; and (6) are aged ≥18 years. Primary analyses will use a mixed-effects negative binomial regression model to evaluate readmission and ED utilization, comparing those with and without SMI who receive Thrive to those with and without SMI who receive usual care. Using a convergent parallel mixed methods design, analyses will be conducted simultaneously for the survey and interview data of patients, clinicians, and health care system leaders. The cost of Thrive will be calculated from budget monitoring data for the research budget, the cost of staff time, and average Medicaid facility fee payments., Results: This research project was funded in October 2023. Data collection will occur from April 2024 through December 2025. Results are anticipated to be published in 2025-2027., Conclusions: We anticipate that patients with and without co-occurring SMI will benefit from the adapted Thrive clinical pathway. We also anticipate the adapted version of Thrive to be deemed feasible, acceptable, and appropriate by patients, clinicians, and health system leaders., Trial Registration: ClinicalTrials.gov NCT06203509; https://clinicaltrials.gov/ct2/show/NCT06203509., International Registered Report Identifier (irrid): DERR1-10.2196/64575., (©J Margo Brooks Carthon, Heather Brom, Kelvin Eyram Amenyedor, Michael O Harhay, Marsha Grantham-Murillo, Jacqueline Nikpour, Karen B Lasater, Daniela Golinelli, Pamela Z Cacchione, Amanda P Bettencourt. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 12.11.2024.)

Purpose: To investigate the association between insurance status and uveal melanoma (UM) care., Methods: We utilized the National Cancer Database to identify patients diagnosed with UM from 2004 to 2017. We examined the associations between patient sociodemographic characteristics, specifically insurance status, and UM care., Results: Of 7677 patients, 50% had private, 41% Medicare, 4% Medicaid, 3% other government, and 3% no insurance. Most initially received brachytherapy (66%), followed by enucleation/resection (19%) and other treatment (15%). Compared to private, Medicaid and no insurance were associated with higher odds of late-stage disease presentation ( p  < .05). Patients with Medicare, Medicaid, and no insurance had higher odds of enucleation/resection and lower odds of brachytherapy versus enucleation/resection ( p  < .05 for all). Medicaid and no insurance were associated with lower odds of other treatment versus enucleation/resection ( p  < .05)., Conclusions: Access barriers to UM care may exist based on insurance status and may be associated with later-stage presentation and more radical treatment.