Search

The Medicaid Delivery System Reform Incentive Payment (DSRIP) program has been among the most widely adopted value-based payment strategies to drive improved population health management among safety net populations. Using comprehensive claims data from New Jersey and difference-in-differences modeling, the authors examine the impact of DSRIP pay-for-performance disease management programs on outcomes related to targeted chronic conditions. The authors find DSRIP reduced asthma hospitalizations and emergency department visits, pneumonia readmissions, and improved alcohol and drug treatment. Positive program-specific findings are encouraging for future DSRIP-like initiatives and demonstrate provider ability to successfully adapt to payment reforms.

Project ECHO (Extension for Community Healthcare Outcomes), a tele-mentoring program for health care providers, has been shown to improve provider-reported outcomes, but there is insufficient research on patient-level outcomes.To evaluate the impact of primary care provider (PCP) participation in Project ECHO on the care of Medicaid enrollees with diabetes.New Jersey Medicaid claims and encounter data and difference-in-differences models were used to compare utilization and spending between Medicaid patients seen by PCPs participating in a Project ECHO program to those of matched nonparticipating PCPs.A total of 1776 adult Medicaid beneficiaries (318 with diabetes), attributed to 25 participating PCPs; and 9126 total (1454 diabetic) beneficiaries attributed to 119 nonparticipating PCPs.Utilization and spending for total inpatient, diabetes-related inpatient, emergency department, primary care, and endocrinologist services; utilization of hemoglobin A1c tests, eye exams, and diabetes prescription medications among diabetics, and total Medicaid spending.Participation in Project ECHO was associated with decreases of 44.3% in inpatient admissions (P=0.001) and 61.9% in inpatient spending (P=0.021) among treatment relative to comparison patients. Signs of most other outcome estimates were consistent with hypothesized program effects but without statistical significance. Sensitivity analyses largely confirmed these findings.We find evidence that Project ECHO participation was associated with large and statistically significant reductions of inpatient hospitalization and spending. The study was observational and limited by a small sample of participating PCPs. This study demonstrates the feasibility and potential value of quasi-experimental evaluation of Project ECHO patient outcomes using claims data.

PURPOSE: Diabetes and hypertension are two common comorbidities that affect breast cancer patients, particularly Black women. Disruption of chronic disease management during cancer treatment has been speculated. Therefore, this study examined the implementation of clinical practice guidelines and health outcomes for these comorbidities before and during cancer treatment. METHODS: We used a population-based, prospective cohort of Black women diagnosed with breast cancer (2012–2016) in New Jersey (N=563). Chronic disease management for diabetes and hypertension were examined 12-months before and after breast cancer diagnosis and compared using McNemar’s test for matched paired and paired t-tests. RESULTS: Among this cohort, 18.1% had a co-diagnosis of diabetes and 47.2% had a co-diagnosis of hypertension. Implementation of clinical practice guidelines and health outcomes that differed in the 12-months before and after cancer diagnosis included: lipid screening (64.5% before versus 50.0% after diagnosis; p=0.004), glucose screening (72.7% versus 90.7%; p

BACKGROUND: Black women are more likely to have comorbidity at breast cancer diagnosis compared with White women, which may account for half of the Black-White survivor disparity. Comprehensive disease management requires a coordinated team of healthcare professionals including primary care practitioners, but few studies have examined shared care in the management of comorbidities during cancer care, especially among racial/ethnic minorities. OBJECTIVE: To examine whether the type of medical team composition is associated with optimal clinical care management of comorbidities. DESIGN: We used the Women’s Circle of Health Follow-up Study, a population-based cohort of Black women diagnosed with breast cancer. The likelihood of receiving optimal comorbidity management after breast cancer diagnosis was compared by type of medical team composition (shared care versus cancer specialists only) using binomial regression. PARTICIPANTS: Black women with a co-diagnosis of diabetes and/or hypertension at breast cancer diagnosis between 2012 and 2016 (N = 274). MAIN MEASURES: Outcome—optimal clinical care management of diabetes (i.e., A1C test, LDL-C test, and medical attention for nephropathy) and hypertension (i.e., lipid screening and prescription for hypertension medication). Main predictor—shared care, whether the patient received care from both a cancer specialist and a primary care provider and/or a medical specialist within the 12 months following a breast cancer diagnosis. KEY RESULTS: Primary care providers were the main providers involved in managing comorbidities and 90% of patients received shared care during breast cancer care. Only 54% had optimal comorbidity management. Patients with shared care were five times (aRR: 4.62; 95% CI: 1.66, 12.84) more likely to have optimal comorbidity management compared with patients who only saw cancer specialists. CONCLUSIONS: Suboptimal management of comorbidities during breast cancer care exists for Black women. However, our findings suggest that shared care is more beneficial at achieving optimal clinical care management for diabetes and hypertension than cancer specialists alone.

PURPOSE: Racial and ethnic disparities in cancer care near the end of life (EOL) have been recognized, but EOL care experienced by Medicaid beneficiaries is not well understood. We assessed the prevalence of aggressive EOL care and hospice enrollment for Medicaid beneficiaries and determined whether racial and ethnic disparities exist. PATIENTS AND METHODS: We identified Medicaid beneficiaries (age 21-64 years) who were diagnosed from 2011 to 2015 with stage IV breast and colorectal cancer and who died by January 2016 through a New Jersey State Cancer Registry–Medicaid claims linked data set. We measured aggressive EOL care (> 1 hospitalization, > 1 emergency department [ED] visit, any intensive care unit [ICU] admission in the last 30 days of life, and receipt of chemotherapy in the last 14 days of life) and hospice enrollment. Multivariable logistic regression models were used to determine factors associated with aggressive EOL care and hospice enrollment. RESULTS: Of the 349 patients, 217 (62%) received at least one of the following measures of aggressive EOL care: > 1 hospitalization (27%), > 1 ED visit (31%), ICU admission (30%), and chemotherapy (34%). The adjusted odds of receiving any aggressive care were 1.87 times higher (95% CI, 1.08 to 3.26) for non-Hispanic (NH) Black patients compared with NH White patients. Only 39% of patients enrolled in hospice. No significant differences in hospice enrollment were observed by race or ethnicity. CONCLUSION: The majority of Medicaid patients with advanced cancer received aggressive EOL care and were not enrolled in hospice. NH Black patients were more likely to receive aggressive EOL care. Further work to understand processes leading to suboptimal EOL care within Medicaid populations and among racial and ethnic minority groups is warranted.

Elective admission to the epilepsy monitoring unit (EMU) is an essential service provided by epilepsy centers, particularly for those with drug-resistant epilepsy. Given previously characterized racial and socioeconomic healthcare disparities in the management of epilepsy, we sought to understand access and utilization of this service in New Jersey (NJ). We examined epilepsy hospitalizations in NJ between 2014 and 2016 using state inpatient and emergency department (ED) databases. We stratified admissions by race/ethnicity and primary payer and used these to estimate and compare (1) admission rates per capita in NJ, as well as (2) admission rates per number of ED visits for each group. Patients without insurance underwent elective EMU admission at the lowest rates across all racial/ethnic groups and payer types studied. Black patients with Medicaid and private insurance were admitted at disproportionately low rates relative to their number of ED visits. Hispanic/Latino and Asian/Pacific Islanders with private insurance, Hispanic/Latinos with Medicaid, and Asian/Pacific Islanders with Medicare were also admitted at low rates per capita within each respective payer category. Future studies should focus on addressing causal factors driving healthcare disparities in epilepsy, particularly for patients without adequate health insurance coverage and those who have been historically underserved by the healthcare system.

PURPOSE: Black women are disproportionately burdened by comorbidities and breast cancer. The complexities of coordinating care for multiple health conditions can lead to adverse consequences. Care coordination may be exacerbated when care is received outside the same health system, defined as care fragmentation. We examine types of practice setting for primary and breast cancer care to assess care fragmentation. MATERIALS AND METHODS: We analyzed data from a prospective cohort of Black women diagnosed with breast cancer in New Jersey who also had a prior diagnosis of diabetes and/or hypertension (N = 228). Following breast cancer diagnosis, we examined types of practice setting for first primary care visit and primary breast surgery, through medical chart abstraction, and identified whether care was used within or outside the same health system. We used multivariable logistic regression to explore sociodemographic and clinical factors associated with care fragmentation. RESULTS: Diverse primary care settings were used: medical groups (32.0%), health systems (29.4%), solo practices (23.7%), Federally Qualified Health Centers (8.3%), and independent hospitals (6.1%). Surgical care predominately occurred in health systems (79.8%), with most hospitals being Commission on Cancer–accredited. Care fragmentation was experienced by 78.5% of Black women, and individual-level factors (age, health insurance, cancer stage, and comorbidity count) were not associated with care fragmentation ( P > .05). CONCLUSION: The majority of Black breast cancer survivors with comorbidities received primary care and surgical care in different health systems, illustrating care fragmentation. Strategies for care coordination and health care delivery across health systems and practice settings are needed for health equity.

Policy Points Medicaid policymakers have a growing interest in addressing homelessness as a social determinant of health and driver of the potentially avoidable use of expensive medical services. Drawing on extensive document reviews and in-depth interviews in four early-adopter states, we examined the implementation of Medicaid's Section 1115 demonstration waivers to test strategies to finance tenancy support services for persons experiencing or at risk of homelessness. CONTEXT The Affordable Care Act extended Medicaid eligibility to large numbers of individuals experiencing or at risk of homelessness. This legislative development and the growing recognition of homelessness as a significant social determinant of health have encouraged advocates and policymakers to seek new ways to use Medicaid to provide housing supports. METHODS We conducted 28 semistructured interviews with 36 stakeholders in four states. The stakeholders were government administrators, health care providers, nonprofit housing staff, and consultants. We supplemented these interviews with extensive reviews of public documents, media accounts, think-tank reports, and published literature. We also conducted a systematic inductive qualitative analysis. FINDINGS We identified seven challenges to the successful implementation of tenancy support demonstration projects: resolving the housing supply and NIMBY, removing silos between health care and homeless services providers, enrolling and retaining the target populations in Medicaid, contracting with and paying tenancy support providers, recruiting and retaining key workers, ensuring Medicaid's waiver durability, and reducing administrative crowd-out and waiver burden. CONCLUSIONS Notwithstanding these challenges, three of the four states have made significant progress in launching their initiatives. At this point, the fourth state has delayed its start-up to consider alternatives to a Medicaid demonstration waiver to provide tenancy supports. The experience of the four states suggests lessons for Medicaid officials in other jurisdictions that are interested in pursuing tenancy support initiatives. Nevertheless, the limitations of tenancy support waiver programs suggest that federal policymakers should consider allowing states to more directly subsidize housing costs for those experiencing or at risk of homelessness as an optional Medicaid benefit.

BACKGROUND Permanent supportive housing (PSH) programs have the potential to improve health and reduce Medicaid expenditures for beneficiaries experiencing homelessness. However, most research on PSH has been limited to small samples of narrowly defined populations. OBJECTIVE To evaluate the effects of PSH on Medicaid enrollees across New Jersey. RESEARCH DESIGN Linked data from the Medicaid Management Information System and the Homeless Management Information System were used to compare PSH-placed Medicaid enrollees with a matched sample of other Medicaid enrollees experiencing homelessness. Comparisons of Medicaid-financed health care utilization and spending measures were made in a difference-in-differences framework 6 quarters before and after PSH placement. SUBJECTS A total of 1442 Medicaid beneficiaries enrolled in PSH and 6064 Medicaid-enrolled homeless individuals not in PSH in 2013-2014. RESULTS PSH placement is associated with a 14.3% reduction in emergency department visits (P

BACKGROUND Cancer outcomes for Medicaid enrollees may be affected by patients' primary care (PC) utilization and complex Medicaid enrollment dynamics, which have recently changed for many states under the Affordable Care Act. METHODS With New Jersey State Cancer Registry and linked Medicaid claims data, a retrospective cohort study was conducted for patients with incident breast, colorectal, or invasive cervical cancer (aged 21-64 years) diagnosed in 2012-2014. Associations of Medicaid enrollment factors and PC utilization with the stage at diagnosis and treatment delays were examined with multivariate logistic regression models. RESULTS The study included 19,209 total cancer cases and 3253 linked Medicaid cases. Medicaid cases were more likely to be diagnosed at a late stage and to experience treatment delays in comparison with non-Medicaid cases. In adjusted analyses, Medicaid cases with 1 or more PC visits before the diagnosis had lower odds of a late-stage diagnosis (odds ratio, 0.47; 95% confidence interval, 0.33-0.67) in comparison with Medicaid cases with no outpatient visits. New enrollees (

Government sponsored pay-for-performance systems (P4P) have emerged in many contexts, including those featuring third-party federalism such as Medicaid. In this vein, voluntary networks called Medicaid accountable care organizations (ACOs) seek to achieve health care savings while boosting the quality of care. Drawing on evidence from four states, this study probes how collaborative governance strategies that downplay formal democratic controls and enhance administrative flexibility shaped the response to two implementation problems. We find that administrative flexibility, combined with signals of support from political principals, helped galvanize ACO formation but undermined efforts to tailor performance metrics to the needs of Medicaid enrollees.

Purpose: Black women newly diagnosed with breast cancer and who have multiple comorbidities at the time of cancer diagnosis require greater care coordination to simultaneously manage cancer care and other chronic conditions. Care coordination may be complicated when multiple clinicians from diverse disciplines are involved in managing care and are located in different health systems, defined as care fragmentation. Given that Black women are disproportionately burdened by comorbidities and breast cancer, we examined the degree of care fragmentation and care coordination experienced by this group from a health system and care team perspective using two population-based cohorts. Methods: We analyzed data from two separate cohorts of Black women diagnosed with breast cancer who had diabetes and/or cardiovascular disease. In the first study we used the Women's Circle of Health Follow-Up Study (n=228) to examine types of practice setting for first primary care visit and primary breast surgery, and, through medical chart abstraction, identified whether care visit was within or outside the same health system. In a separate study, we identified women from the SEER-Medicare database (n=3,420) diagnosed with breast cancer and used encounter claims to examine the complexity and composition of the clinical care team. Results: Care fragmentation was experienced by 79% of Black women in the Women's Circle of Health Follow-Up Study, and individual-level factors (age, health insurance, cancer stage, and comorbidity count) were not associated with care fragmentation (p>.05). In the SEER-Medicare cohort, the most common clinical care team composition was oncology with primary care (45%) followed by oncology, primary care, and medical subspecialty (26%). In the adjusted model, Black women were more likely to have a clinical care team of higher complexity if they had cardiopulmonary disease (OR: 1.74; 95% CI: 1.68, 1.81) or diabetes (OR: 1.69; 95% CI: 1.63,1.75) compared with hypertension only. Women were also less likely to have a complex care team if they were dual Medicaid-Medicare covered (OR: 0.56; 95% CI: 0.48, 0.65) compared with Medicare only, rural residents (OR: 0.54; 95% CI: 0.42, 0.65) compared with urban, or diagnosed with stage III cancer (OR: 0.59; 95% CI: 0.47, 0.75) compared with stage I. Conclusion: The majority of Black breast cancer survivors with comorbidities see multiple clinicians from diverse disciplines and in different health systems, illustrating high care coordination demands and care fragmentation. However, the impact of the health system and care team on care outcomes still need to be assessed, and this includes care transitions into survivorship. To address cancer care disparities experienced by Black women, future research should consider examining clinician's perspectives regarding roles and responsibilities for chronic disease management and cancer care, as well as address care fragmentation across diverse healthcare delivery settings. Citation Format: Michelle Doose, Janeth I. Sanchez, Dana Verhoeven, Veronica Chollette, Joel C. Cantor, Jesse J Plascak, Michael Steinberg, Chi-Chen Hong, Kitaw Demissie, Elisa Bandera, Jennifer Tsui, Sallie J. Weaver. Fragmentation of care among Black women who have breast cancer and multiple comorbidities [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr IA-36.

RESEARCH OBJECTIVE: Persons with intellectual and developmental disabilities (IDD) have complex medical needs and experience gaps in care due to their unique needs, and challenges faced by health professionals in responding to them. We characterize New Jersey Medicaid‐enrolled individuals with IDD and examine racial and ethnic (RE) disparities in ambulatory care (AC) quality and the extent to which RE gaps are explained by patient and health system factors. We focus on the potential positive effect of home and community‐based services (HCBS) provided through Medicaid waiver programs in mitigating disparities and improving care. STUDY DESIGN: Utilizing New Jersey Medicaid comprehensive claims data over 2011‐2017, quality of AC was assessed using AC sensitive preventable hospitalizations (PH), IDD‐specific PH (IDDPH), and ED visits. Additional metrics including rates of preventive care visits (cancer screening, vaccination) and quality of behavioral health (BH) care will be available by the time of the conference. Econometric modeling of disparities utilized the Institute of Medicine as well as the Residual Direct Effect approaches that adjust for patient characteristics (sex, age, number of chronic and IDD conditions, presence of BH condition), allowing for mediation of disparities through provider and system‐level factors, for example, average quality of AC in zip code of residence. Difference‐in‐difference estimation examined how availability of HCBS waiver services impacted differences in quality across racial/ethnic groups. Findings from analysis utilizing an area‐level instrumental variable addressing potential selection into waiver services and access to IDD‐specialized providers will be available for the conference. Statistical significance was assessed at P = .05 threshold. POPULATION STUDIED: 37 078 Medicaid‐enrolled individuals of age 22+ over 2011‐2017, who reside: a) in DD intermediate care facilities, or b) in the community and receive HCBS from waiver programs, or c) in the community, do not receive Medicaid‐paid HCBS and diagnosed with one or more of 13 IDD conditions. We examined ambulatory care among 92.7% of this population (n = 34 382) who were always in the community. PRINCIPAL FINDINGS: 44.2% of the community population was female, the mean age was 45.5 years, 59.3% had a BH condition, 25.6% had 3+ chronic conditions, and 49.4% were enrolled in HCBS waivers that provide services such as case management, day habilitation, and assistive technology. Among them, black (OR = 0.55) and Hispanic (OR = 0.21) populations had lower adjusted odds of being enrolled in waivers providing HCBS. Among those not receiving Medicaid‐paid HCBS, blacks had higher odds of PH (OR = 1.50), ED visits (OR = 1.33), and IDDPH (OR = 1.11). Hispanics had higher odds of ED visits (OR = 1.12). However, these disparities did not exist for individuals enrolled in HCBS waiver programs. CONCLUSIONS: Our analysis sheds light on RE disparities in AC outcomes within the IDD population using established measures of care quality and identifies several mechanisms associated with such disparities. We found a positive effect of HCBS on these outcomes in mitigating such disparities. IMPLICATIONS FOR POLICY OR PRACTICE: These findings underscore the beneficial role played by state waivers in ensuring provision of HCBS to individuals with IDD and, additionally, may guide formulation of performance metrics within Medicaid managed care contracts, and guidelines for health professionals offering specific IDD and medical services. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

BACKGROUND: Lack of health insurance coverage is associated with poor access and receipt of cancer care and survival in the United States. Disruptions in coverage are common among low-income populations, but little is known about associations of disruptions with cancer care, including prevention, screening, and treatment, as well as outcomes of stage at diagnosis and survival. METHODS: We conducted a systematic review of studies of health insurance coverage disruptions and cancer care and outcomes published between 1980 and 2019. We used the PubMed, EMBASE, Scopus, and CINAHL databases and identified 29 observational studies. Study characteristics and key findings were abstracted and synthesized qualitatively. RESULTS: Studies evaluated associations between coverage disruptions and prevention or screening (31.0%), treatment (13.8%), end-of-life care (10.3%), stage at diagnosis (44.8%), and survival (20.7%). Coverage disruptions ranged from 4.3% to 32.8% of patients age-eligible for breast, cervical, or colorectal cancer screening. Between 22.1% and 59.5% of patients with Medicaid gained coverage only at or after cancer diagnosis. Coverage disruptions were consistently statistically significantly associated with lower receipt of prevention, screening, and treatment. Among patients with cancer, those with Medicaid disruptions were statistically significantly more likely to have advanced stage (odds ratios = 1.2-3.8) and worse survival (hazard ratios = 1.28-2.43) than patients without disruptions. CONCLUSIONS: Health insurance coverage disruptions are common and adversely associated with receipt of cancer care and survival. Improved data infrastructure and quasi-experimental study designs will be important for evaluating the associations of federal and state policies on coverage disruptions and care and outcomes.

Policy Points Large numbers of homeless adults gained Medicaid coverage under the Affordable Care Act, increasing policymaker interest in strategies to improve care and reduce avoidable hospital costs for homeless populations. Compared with nonhomeless adult Medicaid beneficiaries, homeless adult beneficiaries have higher levels of health care needs, due in part to mental health issues and substance use disorders. Homeless adults are also more likely to visit the emergency department or require inpatient admissions. Emergency care and inpatient admissions may sometimes be avoided when individuals have high-quality community-based care and healthful living conditions. Offering tenancy support services that help homeless adults achieve stable housing may therefore be a cost-effective strategy for improving the health of this vulnerable population while reducing spending on avoidable health care interventions. Medicaid beneficiaries with disabling health conditions and more extensive histories of homelessness experience the most potentially avoidable health care interventions and spending, with the greatest opportunity to offset the cost of offering tenancy support benefits. Context Following Medicaid expansion under the Affordable Care Act, the number of homeless adults enrolled in Medicaid has increased. This has spurred interest in developing Medicaid-funded tenancy support services (TSS) for homeless populations as a way to reduce Medicaid spending on health care for these individuals. An emerging body of evidence suggests that such TSS can reduce avoidable health care spending. Methods Drawing on linked Homeless Management Information System and Medicaid claims and encounter data, this study describes the characteristics of homeless adults who could be eligible for Medicaid TSS in New Jersey and compares their Medicaid utilization and spending patterns to matched nonhomeless beneficiaries. Findings More than 8,400 adults in New Jersey were estimated to be eligible for Medicaid TSS benefits in 2016, including approximately 4,000 living in permanent supportive housing, 800 formally designated as chronically homeless according to federal guidelines, 1,300 who were likely eligible for the chronically homeless designation, and over 2,000 who were at risk of becoming chronically homeless. Homeless adults in our study were disproportionately between the ages of 30 and 64 years, male, and non-Hispanic blacks. The homeless adults we studied also tended to have very high burdens of mental health and substance use disorders, including opioid-related conditions. Medicaid spending for a homeless beneficiary who was potentially eligible for TSS was 10% ($1,362) to 27% ($5,727) more than spending for a nonhomeless Medicaid beneficiary matched on demographic and clinical characteristics. Hospital inpatient and emergency department utilization accounted for at least three-fourths of "excess" Medicaid spending among the homeless groups. Conclusions A large group of high-need Medicaid beneficiaries could benefit from TSS, and Medicaid funding for TSS could reduce avoidable Medicaid utilization and spending.

Video-electroencephalogram (EEG) monitoring in the epilepsy monitoring unit (EMU) is essential for managing epilepsy and seizure mimics. Evaluation of care in the EMU would benefit from a validated code set capable of identifying EMU admissions from administrative databases comprised of large, diverse cohorts. We assessed the ability of code-based queries to parse EMU admissions from administrative billing records in a large academic medical center over a four-year period, 2016-2019. We applied prespecified queries for admissions coded as follows: 1) elective, 2) receiving video-EEG monitoring, and 3) including diagnoses typically required by major US healthcare payers for EMU admission. Sensitivity (Sn), specificity (Sp), and predictive value positive/negative (PVP, PVN) were determined. Two approaches were highly effective. Incorporating epilepsy, seizure, or seizure mimic codes as the admitting diagnosis (assigned at admission; Sn 96.3%, Sp 100.0%, PVP 98.3%, and PVN 100.0%) or the principal diagnosis (assigned after discharge; Sn 94.9%, Sp 100.0%, PVP 98.8%, and PVN 100.0%) identified elective adult EMU admissions with comparable reliability (p = 0.096). The addition of surgical procedure codes further separated EMU admissions for intracranial EEG monitoring. When applied to larger, more comprehensive datasets, these code-based queries should enhance our understanding of EMU utilization and access to care on a scalable basis.

Medicaid is vastly more important than Medicare or private insurance in funding long-term care (LTC). However, states vary tremendously in their commitment to Medicaid LTC. This article advances knowledge of the origins, nature, and implications of this variation. After examining the degree of variation in state spending on Medicaid LTC, we show how federal policy has over the past fifty years steadily increased state discretion to shape these services. This decentralization largely reflects the potency of the intergovernmental lobby—governors and other state officials—in influencing federal policy. While fueling state variation, the intergovernmental lobby has also provided valuable political support that has helped Medicaid grow and resist retrenchment. After considering policy options that could mitigate Medicaid LTC inequities rooted in state differences, we assess how the catalytic forces that have fueled growth in Medicaid LTC may be insufficient to protect the program from future erosion.

The individual health insurance market has played a small but important role in providing coverage to those without access to group insurance or public programs. With implementation of the Affordable Care Act (ACA), the individual market has attained a more prominent role. However, achieving accessible and affordable coverage in this market is a long-standing challenge, in large part due to the threat of adverse risk selection. New Jersey pursued comprehensive reforms beginning in the 1990s to achieve a stable, accessible, and affordable individual market. We review how adverse risk selection can pose a challenge to achieving such objectives in the individual health insurance market. We follow this discussion by describing the experience of New Jersey through three rounds of legislative reform and through the first year of the implementation of the ACA coverage provisions. While the New Jersey reforms did not require individuals to purchase coverage, its experiences with direct and indirect market subsidies and regulations guiding plan design, issuance, and rating have important implications for how the ACA may achieve its coverage goals in the absence of the controversial individual purchase mandate.

Purpose: Hypertension and diabetes are common comorbidities present at breast cancer diagnosis, which may account for half of the Black-White breast cancer survival disparity. Having a coordinated team of medical providers to manage both breast cancer and comorbidities for patients can improve care quality and outcomes; however, these relationships are understudied. Therefore, we examined 1) type of medical provider involved in diabetes and hypertension clinical care management and 2) whether type of physician team was associated with optimal clinical care management of diabetes and hypertension during breast cancer care. Methods: We used medical and pharmacy records and interview data from the Women’s Circle of Health Follow-Up Study, an ongoing population-based cohort of Black breast cancer survivors. Women with diabetes or hypertension for at least one year prior to breast cancer diagnosis (2012-2016) were included (N=274). Optimal diabetes management was categorized as physician order of HbA1c test, LDL-cholesterol test, and medical attention for nephropathy; and optimal hypertension management was categorized as physician order of lipid screen and prescription for hypertension medications within the 12-months post cancer diagnosis. Visits with any cancer specialist, primary care provider, or medical specialist were examined and then categorized as shared care (visits with both a cancer specialist and primary care physician and/or medical specialist) or cancer specialist only. The likelihood of receiving optimal clinical care management for either diabetes and hypertension during breast cancer care was compared by type of physician team using multivariable binomial regression, adjusting for age and health insurance at diagnosis, cancer stage, and comorbidity type and disease severity. Results: 86% of patients had a primary care visit in the 12-months after diagnosis. Most clinical care for comorbidities were managed by primary care providers (diabetes tests: 65% HbA1c, 88% LDL- cholesterol, 60% microalbuminuria; hypertension: 88% lipid screen, 85% hypertension medications). Half of all measures were ordered within 6 months of diagnosis. Only half (49%) of patients received optimal comorbid clinical care management and 90% received shared care. Patients with shared care were four times more likely to have optimal clinical care management for diabetes and hypertension compared with patients who only saw cancer specialists (aRR: 4.41; 95% CI: 1.57, 12.34). Conclusions: These findings are important in that shared care may promote optimal clinical care management for diabetes and hypertension and lead to reduced mortality and improved outcomes, particularly for racial/ethnic minority patients with a greater burden of chronic conditions. Future research is needed to explore the processes of shared care to determine whether medical providers are performing clinical care independently or if providers are communicating to coordinate patients’ care. Citation Format: Michelle Doose, Michael B. Steinberg, Cathleen Y. Xing, Yong Lin, Joel C. Cantor, Chi-Chen Hong, Kitaw Demissie, Elisa V. Bandera, Jennifer Tsui. Examining medical providers’ involvement in diabetes and hypertension clinical care management of Black breast cancer patients [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D070.

PURPOSE: Quality of cancer care experienced by Medicaid beneficiaries near the end-of-life (EOL) is not well understood. Measures endorsed by national organizations discourage aggressive EOL care and encourage timely referrals to hospice care. We sought to 1) assess the prevalence of aggressive EOL care and hospice enrollment for Medicaid beneficiaries with advanced cancer, and 2) determine whether racial/ethnic disparities exist in patterns of EOL care. METHODS: We used a New Jersey State Cancer Registry-Medicaid claims linked dataset to identify Medicaid beneficiaries (ages 21-64) diagnosed with stage IV breast and colorectal cancer from 2011-2015 and died by January 2016. We measured aggressive EOL care using the four measures: >1 hospitalization, >1 emergency department (ED), any intensive care unit (ICU) admission in the last 30 days before death; receipt of chemotherapy in the last 14 days before death; and a composite measure for “any aggressive care” using the four measures described. We measured hospice enrollment after diagnosis, and hospice enrollment in the last 3 days of life. We used descriptive statistics and multivariate logistic regression models to assess the relationship between race/ethnicity and outcome measures (i.e., rates of aggressive EOL care and hospice use). We adjusted for sex, age at diagnosis, year of diagnosis, length of survival, cancer type, comorbidities, and Medicaid managed care status. RESULTS: We identified 349 patients diagnosed with stage IV breast and colorectal cancer. More than half (56%) identified as a racial/ethnic minority, including 33% Non-Hispanic (NH) Blacks, 18% Hispanics, and 5% NH-Asian Pacific Islanders. Nearly two-thirds of patients (62%) received at least one measure of aggressive EOL care. Almost one-third had >1 hospitalization (27%), >1 ED visit (31%), or were admitted to the ICU (30%) in the last 30 days of life; or received chemotherapy (34%) in the last 14 days of life. Compared to NH-Whites, NH-Blacks had higher odds of receiving any aggressive EOL care (aOR 1.87, 95% CI: 1.08-3.26), >1 hospitalization (aOR 1.98, 95% CI: 1.13-3.47), and >1 ED visit (aOR 1.79, 95% CI: 1.05-3.06), after adjusting for other demographic and tumor characteristics. Among all patients, only 39% of patients enrolled in hospice, while 14% enrolled in hospice in the last 3 days of life. No significant differences in hospice enrollment were observed by race/ethnicity in the multivariate models. CONCLUSION: The majority of Medicaid patients with advanced cancer received aggressive EOL care and did not enroll in hospice. Although all patients in our study were Medicaid beneficiaries, NH-Blacks were twice as likely to receive aggressive EOL care compared to NH-Whites. These racial/ethnic disparities suggest further work is warranted, particularly in larger datasets with greater numbers of diverse cancer patients, to understand the multilevel processes beyond socioeconomic or health insurance status, that lead to suboptimal EOL care. Citation Format: Annie W Yang, David Goldin, Jose Nova, Jyoti Malhotra, Joel Cantor, Jennifer Tsui. Racial disparities in health care utilization at the end of life among New Jersey Medicaid beneficiaries with advanced cancer [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C018.

Purpose: Medicaid enrollees with cancer are less likely to receive treatment consistent with established guidelines. It remains unclear what specific factors are associated with non-receipt or delays in guideline-concordant cancer care among Medicaid patients. In this study, we examine receipt of guideline-concordant Medicaid enrollees with breast or colorectal cancer. Methods: We linked data from the New Jersey State Cancer Registry and Medicaid claims and encounter files for patients diagnosed with a first primary breast (BC) or colorectal (CRC) cancer from 2011-2015. We assess guideline-concordant treatment using National Comprehensive Cancer Network and American Society of Clinical Oncology criteria, which include endocrine therapy within 1 year, radiation therapy within 1 year, and adjuvant chemotherapy within 120 days for BC patients; and, postoperative chemotherapy within 9 months, radiation therapy within 6 months, and adjuvant chemotherapy within 4 months for CRC patients that fit the specific clinical criteria for each guideline. For each guideline, patients were placed in one of the three categories: 1.) on-time concordant care, 2.) delayed concordant care, 3.) non-receipt of concordant care. Delayed concordant care included patients with guideline-directed care outside of the indicated timeframe. We used multivariate ordinal logistic regression to determine the independent effects of demographic, health care utilization, and Medicaid enrollment factors on the 3-level concordance measure. Results: Rates of guideline concordant care were: 69.5% for BC endocrine therapy, 63.4% for BC radiation therapy, 76.4% for BC adjuvant chemotherapy, 69.4% for CRC postoperative chemotherapy, 91.9% for CRC radiation therapy, and 68.4% for CRC adjuvant chemotherapy. An additional 10.1% of BC patients received delayed care for endocrine therapy. An additional 14.1% of CRC patients received delayed care for postoperative chemotherapy. Ordinal logit models showed BC patients enrolled through the New Jersey Cancer Education and Early Detection program had a 29.3 percentage point higher probability of on-time care for endocrine therapy compared to women not enrolled through the program (p Citation Format: Jennifer Tsui, Derek DeLia, Jose Nova, Antoinette Stroup, Dawn L. Hershman, Joel Cantor. Factors associated with receipt of guideline-concordant treatment among Medicaid enrollees with breast and colorectal cancer [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A140.

Video-electroencephalogram (EEG) monitoring in the epilepsy monitoring unit (EMU) is essential for managing epilepsy and seizure mimics. Evaluation of care in the EMU would benefit from a validated code set capable of identifying EMU admissions from administrative databases comprised of large, diverse cohorts. We assessed the ability of code-based queries to parse EMU admissions from administrative billing records in a large academic medical center over a four-year period, 2016–2019. We applied prespecified queries for admissions coded as follows: 1) elective, 2) receiving video-EEG monitoring, and 3) including diagnoses typically required by major US healthcare payers for EMU admission. Sensitivity (Sn), specificity (Sp), and predictive value positive/negative (PVP, PVN) were determined. Two approaches were highly effective. Incorporating epilepsy, seizure, or seizure mimic codes as the admitting diagnosis (assigned at admission; Sn 96.3%, Sp 100.0%, PVP 98.3%, and PVN 100.0%) or the principal diagnosis (assigned after discharge; Sn 94.9%, Sp 100.0%, PVP 98.8%, and PVN 100.0%) identified elective adult EMU admissions with comparable reliability (p = 0.096). The addition of surgical procedure codes further separated EMU admissions for intracranial EEG monitoring. When applied to larger, more comprehensive datasets, these code-based queries should enhance our understanding of EMU utilization and access to care on a scalable basis., Highlights • Code-based queries identify elective EMU admissions from a hospital billing dataset • Inclusion of diagnoses required by payers for EMU admission increased accuracy • Use of these queries may facilitate monitoring of EMU utilization in large cohorts.

Objectives To describe emergency department (ED) utilization for oral conditions (OCs) focusing on total volume, costs, repeat utilization, small area predictors, and implications for dental and medical care coordination. Methods Administrative and demographic data for New Jersey were used to identify users of the ED for OCs and a group of “high users,” defined as individuals with four or more ED visits for OCs during 2008-2010. Cost-to-charge ratios were used to estimate costs, and linear regression models applied to zip codes were used to determine strongest predictors of small area variation in ED use for OCs. Results ED visits for OC generated $25.5 million in costs during 2008-2010. High users represented 4.2 percent of all users and 21.3 percent of ED visits for OCs. Almost all high users had a diagnosis of “dental disorder not otherwise specified,” and tobacco use disorder was the most common comorbid medical condition. Young adults (ages 19-34), non-Hispanic blacks, and the medically uninsured were over-represented among high users. High users routinely spread their use across multiple hospitals (e.g., 40 percent of them visited three or more hospitals). Local dentist supply and ED use for other conditions were significant predictors of zip code-level ED use for OCs. Conclusions Coordination of medical and dental treatment might improve health and reduce costs if targeted to high user populations. Health-care delivery reforms, such as accountable care organizations, could provide vehicles for achieving this coordination. Important challenges include fragmentation of ED visits across hospitals, adequacy of dentist supply, and broader reliance on the ED for health problems.

In a recent paper published in Health Services Research, Burgdorf (2014) critiqued our prior research (Monheit et al. 2011) demonstrating that state laws expanding young adult dependent coverage led to an increase in the likelihood of such coverage.1 Using Current Population Survey (CPS) data similar to our earlier study, applying a comparable difference-in-difference estimation framework, implementing several falsification tests, and most important, drawing a distinction between parental and spousal dependent coverage, Burgdorf asserts that our conclusion regarding the impact of this coverage expansion is flawed. In reaching this conclusion, Burgdorf asserts that the increase in dependent coverage of young adults through the state reforms was driven by enrollment in spousal dependent coverage rather than in parental dependent coverage.2 As a consequence, Burgdorf raises serious doubts about our conclusion that the state reforms had the intended effect of increasing young adult dependent coverage through a parent's private insurance plan. While we welcome further research that helps to clarify the role of these state insurance reforms and further quantifies their impact on young adult coverage and other outcomes, we believe that Burgdorf's conclusion regarding our work is implausible. Our assertion is based on the following points.

A small but growing number of states are turning to accountable care concepts to improve their Medicaid programs. In 2011 New Jersey enacted the Medicaid Accountable Care Organization (ACO) Demonstration Project to offer local provider coalitions the opportunity to share any savings they generate. Impetus came from initiatives in Camden that aim to reduce costs through improved care coordination among hospital high users and that have received considerable media attention and substantial federal and private grant support. Though broadly similar to Medicare and commercial ACOs, the New Jersey demonstration addresses the unique concerns faced by Medicaid populations. Using hospital all-payer billing data, we estimate savings from care improvement efforts among inpatient and emergency department high users in thirteen communities that are candidates for participation in the New Jersey demonstration. We also examine their characteristics to inform Medicaid accountable care strategies. We find substantial variation in the share of high-user hospital patients across the study communities and high rates of avoidable use and costs among these patients. The potential savings among Medicaid enrollees are considerable, particularly if Medicaid ACOs can develop ways to successfully address the high burden of chronic illness and behavioral health conditions prevalent in the prospective demonstration communities.

In spite of major coverage expansions under the Patient Protection and Affordable Care Act (ACA), a large proportion of immigrants will continue to remain outside the scope of coverage. Because various provisions of the ACA seek to enhance access, advancing knowledge about immigrant access to health care is necessary. The authors apply the well-known Andersen model on health care access to two measures—one focusing on perceptions of unmet health care needs and the other on physician visits during the last year. Using data from the New Jersey Family Health Survey, the authors find that prior to implementation of the ACA coverage expansions, immigrants in New Jersey reported lower levels of unmet health care needs despite poorer self-rated health compared with U.S.-born residents. The article concludes with a discussion of the use of Andersen model for studying immigrant health care access and the broader implications of the findings.

Eleven states with Medicaid expansion had a larger increase in Medicaid inpatient admissions and emergency department visits and a larger decrease in commercial insurance–paid inpatient admissions and self-paid emergency department visits than states without expansion.

Background: Use of multiple hospitals by patients with multiple chronic conditions (MCC) may undermine emerging care coordination initiatives. Objective: The aim of this study was to assess the prevalence and correlates of fragmented hospital use among high users with MCC and derive implications for care management. Research Design: Using all-payer hospital billing data, we follow a 2-year cohort of patients with at least 2 inpatient stays, identifying those with MCC and calculating the percentage using multiple hospitals and applying multivariate Poisson regression to predict correlates of multiple hospital use. Subjects: The subjects included in our study were New Jersey adults with at least 2 inpatient stays during a 24-month period between 2007 and 2010. Results: Nearly 80% of the study cohort had Z2 chronic conditions and >30% had fragmented hospital use. The probability of visiting multiple hospitals was positively associated with the number of chronic conditions present at admission, total number of admissions, lower hospital market concentration, and injury or behavioral health diagnoses. Over 40% of patients with Z4 stays had multiple hospital use. Conclusions: Fragmentation of hospital care occurs frequently among high utilizers with MCC. Although multiple hospital use is not necessarily inappropriate, it may present barriers to effective care coordination for complex patients with MCC, leading to higher costs or worse outcomes. Leaders of innovative delivery reforms such as Accountable Care Organizations should monitor and coordinate care for multiple hospital users, especially those with MCC.

Objective: Analyze statistical risks facing CMS and Accountable Care Organizations (ACOs) under the Medicare Shared Savings Program (MSSP). Methods: We calculate the probability that shared savings formulas lead to inappropriate payment, payment denial, and/or financial penalties, assuming that ACOs generate real savings in Medicare spending ranging from 0–10%. We also calculate expected payments from CMS to ACOs under these scenarios. Results: The probability of an incorrect outcome is heavily dependent on ACO enrollment size. For example, in the MSSP two-sided model, an ACO with 5,000 enrollees that keeps spending constant faces a 0.24 probability of being inappropriately rewarded for savings and a 0.26 probability of paying an undeserved penalty for increased spending. For an ACO with 50,000 enrollees, both of these probabilities of incorrect outcomes are equal to 0.02. The probability of inappropriate payment denial declines as real ACO savings increase. Still, for ACOs with 5,000 patients, the probability of denial is at least 0.15 even when true savings are 5–7%. Depending on ACO size and the real ACO savings rate, expected ACO payments vary from $115,000 to $35.3 million. Discussion: Our analysis indicates there may be greater statistical uncertainty in the MSSP than previously recognized. CMS and ACOs will have to consider this uncertainty in their financial, administrative, and care management planning. We also suggest analytic strategies that can be used to refine ACO payment formulas in the longer term to ensure that the MSSP (and other ACO initiatives that will be influenced by it) work as efficiently as possible.

One of the first implemented provisions of the Patient Protection and Affordable Care Act (ACA) permits young adults aged up to 26 years to obtain health insurance as dependents on a parent's private health plan. This provision recognized that young adults are the age group most likely to lack health insurance. In 2009, the year before the ACA-dependent coverage expansion, 31.4 percent of adults in the targeted age range, 19–25 years old, lacked coverage, nearly double the national rate (DeNavas-Walt, Proctor, and Smith 2011). This high likelihood of being without coverage has compromised young adults' access to health services, their financial protection against incurring substantial medical debt, and the ability to address their frequently observed obesity and alcohol and tobacco use that lead to health and economic problems in later adulthood (Merluzzi and Nairn 1999; Callahan and Cooper 2005; Nicholson et al. 2009). The ACA-dependent coverage provision builds upon laws enacted by nearly two thirds of the states that sought to expand young adult coverage (Cantor et al. 2012). Two evaluations of the state-level expansions found increases in young adult-dependent coverage that were offset by reductions in other sources of coverage (Levine, McKnight, and Heep 2011; Monheit et al. 2011). One of these studies tested the impact of these state policies on the number of uninsured young adults and found no net impact (Monheit et al. 2011). ACA-dependent coverage rules promise to improve upon prior state expansions, since the federal law includes more liberal eligibility requirements and it extends to young adults whose parents are enrolled in large self-insured group plans that are exempt from state laws. A variety of early descriptive analyses suggest a substantial impact of the ACA's dependent coverage provision (Martinez and Cohen 2011; Mendes 2011; Fronstin 2012). One analysis estimated that the number of young adults (aged 19–25 years) with health insurance increased by 2.5 million between September 2010 and June 2011 without a corresponding coverage increase for those aged 26–35 years (Sommers and Schwartz 2011). These trends are consistent with a 2011 study that estimated large numbers of employers enrolling young adult dependents under the ACA rules (Claxton et al. 2011). To date, most analyses of the ACA young adult provision have not specifically examined its direct impact on dependent coverage and none have rigorously identified the early impact of the federal law apart from the contribution of prior state laws and prevailing economic conditions. Although Sommers and Kronick (2012) found a statistically significant increase in private coverage of young adults eligible to enroll as dependents under the ACA (aged 19–25 years) relative to a slightly older age group (aged 26–34 years) between 2005–2009 and 2010, their study did not control for possible differences between ACA-targeted young adults and their control group in demographic characteristics, eligibility for state-dependent coverage expansions, or for economic trends. As regards the latter, the weak economy over this period made it more difficult for young adults to find jobs that offer coverage, and encouraged them to retain student status or live with their parents, possibly contributing to increased enrollment through a parent's plan. The goal of our study is to provide the first rigorous analysis of this ACA coverage provision, which controls for young adult characteristics, economic trends, and the inter-relationship between the ACA young adult provisions and prior state-level reforms. ACA Young Adult Dependent Coverage Provisions and Prior State Laws Beginning with the first plan renewal as of September 23, 2010, the ACA requires health insurers and employer group plans, including self-insured plans, to provide coverage to dependents under age 26 years(P.L. 111–152 §2301). This requirement applies to all adult children under age 26 years regardless of marital status, residency, financial dependency, or other characteristics. Plans held prior to the ACA, known as “grandfathered plans,” are not required to enroll young adult dependents who are offered employer-sponsored coverage. However, beginning in 2014 even grandfathered plans will be required to cover young adult dependents regardless of whether they are offered a plan. Plans covering young adult dependents may not treat them differently than other dependents in determining benefits or premiums. The ACA also extended the same favorable tax treatment afforded to other employer-sponsored insurance premiums to the coverage of young adult dependents through the end of the tax year of their 26th birthday. Prior state laws apply only to state regulated plans, not large employer self-funded plans. Moreover, all but a few states implementing dependent coverage expansions limited eligibility to unmarried young adults (Cantor et al. 2012). Most of the reform states also imposed state residency requirements, and some required or permitted insurers to charge added premiums for enrolled young adults. The federal law does not include any of these limitations, and it preempts these state restrictions for young adults under age 26 years.

While national guidelines recommend the use of therapeutic hypothermia (TH) for the treatment of out-of-hospital cardiac arrest (OHCA), adoption of the technique has been slow. In addition, little is known about how TH is applied in practice. This study sought to characterize the adoption and implementation of TH by acute care hospitals in the state of New Jersey.A survey of all 73 acute care hospitals in New Jersey was conducted to solicit information about TH adoption, application, and methods. Additional information was gained through a review of 18 written TH protocols (covering 21 hospitals).After growing slowly from 2004 to 2008, TH use among New Jersey hospitals accelerated between 2009 and 2011. By 2011, 68.4% of New Jersey hospitals had a TH program in place, with an additional 13.6% indicating plans to begin one. Most hospitals indicated low volumes of OHCA patients (e.g., ≤10 per month). There was no relationship between OHCA volume and development of a TH program. The per hospital volume of OHCA patients receiving TH is even lower given the extensive patient exclusion criteria used by many facilities. TH hospitals vary widely in their TH exclusion criteria and cooling equipment and methods.The vast majority of New Jersey hospitals are now organized to implement national TH guidelines for initial survivors of OHCA. However, limited volumes of OHCA cases per hospital and lack of uniformity on how the guidelines are implemented raise new questions about the effectiveness of current practice in postarrest care. More detailed analysis of TH volumes versus outcomes and comparative studies of TH techniques are required to optimize postarrest care.

The Patient Protection and Affordable Care Act (ACA) requires that adults up to age twenty-six be permitted to enroll as dependents on their parents' health plans. This article examines the experiences of states that enacted dependent expansion laws. Drawing on public information from thirty-one enacting states and case studies of four diverse reform states, it derives lessons that are pertinent to the implementation of this ACA provision. Dependent coverage laws vary across the states, but most impose residency, marital status, and other restrictions. The federal Employee Retirement Income Security Act further limits the reach of state laws. Eligibility for expanded coverage under the ACA is much broader. Rules in some states requiring or allowing separate premiums for adult dependents may also discourage enrollment compared with rules in other states (and the ACA), where these costs must be factored into family premiums. Business opposition in some states led to more restrictive regulations, especially for how premiums are charged, which in turn raised greater implementation challenges. Case study states did not report substantial young adult dependent coverage take-up, but early enrollment experience under ACA appears to be more positive. Long-term questions remain about the implications of this policy for risk pooling and the distribution of premium costs.

The authors use a statewide survey to examine care seeking behavior in the emergency department (ED). Most patients who go to the ED (69.3%) do so mainly for conditions they believe are urgent. Time before seeking ED care is highly variable from immediately (28.7%) to more than 1 week (7.0%) and is only weakly related to the perceived urgency of medical condition. Healthier individuals initiate ED care more rapidly than sicker patients. In retrospect, 80.4% of patients would go to the same ED if they had the same medical episode but this percentage falls substantially with increased ED waiting time. Subject to some limitations uncovered in model specification tests, the study highlights several correlates of ED care seeking behavior that may be useful for designing strategies to divert some patients away from the ED. It also raises larger questions, however, about whether diversion is optimal from patient and health system perspectives.

This article examines associations of socio-demographic and health-care indicators, and the statistic 'mortality amenable to health care' (amenable mortality) across the US states. There is over two-fold variation in amenable mortality, strongly associated with the percentages of state populations that are poor or black. Controlling for poverty and race with bi- and multi-variate analyses, several indicators of health system performance, such as hospital readmission rates and preventive care for diabetics, are significantly associated with amenable mortality. A significant crude association of 'uninsurance' and amenable mortality rates is no longer statistically significant when poverty and race are controlled. Overall, there appear to be opportunities for states to focus on specific modifiable health system performance indicators. Comparative rates of amenable mortality should be useful for estimating potential gains in population health from delivering more timely and effective care and for tracking the health outcomes of efforts to improve health system performance.

Children with special health care needs (CSHCN) require more health care than other children; hence adequate health insurance is critical. The Maternal and Child Health Bureau defined three components of adequacy: (1) coverage of needed benefits and services; (2) reasonable costs; and (3) ability to see needed providers. This study compares cost burden, access to care, and patient/provider communication within New Jersey's SCHIP for CSHCN versus those without such needs. We used data from the 2003 NJ FamilyCare (NJFC) Supplement to the New Jersey Family Health Survey on 444 children enrolled in NJFC and 145 children disenrolled from NJFC but covered by other insurance at the time of the survey. The CSHCN Screener was used to identify CSHCN. CSHCN in NJFC had 1.5 times the odds of an unmet need for health care; 2.7 times the odds of a cost burden; and 2.2 times the odds of any coverage or service inadequacy than those without SHCN, even when demographic factors and NJFC plan level (which is based on income) were taken into account. CSHCN enrolled in NJFC have more difficulties in some areas of access to care and cost burden. Patterns of access to care, cost burden, and patient/provider communication were similar for children formerly in NJFC who had other types of insurance at the time of the survey. Future studies should use comprehensive measures of adequacy of coverage, including attitudinal, structural and economic perspectives.

Among the U.S. population, young adults are more likely to lack health insurance than any other age group, with potentially serious consequences for their health and financial well-being. In 2008, 28.6 percent of persons ages 18–24 and 26.5 percent of those between 25 and 34 lacked coverage. By comparison, less than a fifth of persons ages 35–64 and less than a tenth of children under age 18 were uninsured (DeNavas-Walt, Proctor, and Smith 2009). The relatively high uninsured rate of young adults has important implications for their access to health care, protection against the financial consequences of illness, and may indirectly impact their future health and health care needs. For example, uninsured young adults are three to four times more likely than their insured peers to delay or forgo medical care due to costs and two to four times less likely to see a medical provider, have a usual source of care, or fill a prescription due to cost (Callahan and Cooper 2005; Nicholson et al. 2009;). Additionally, uninsured young adults are twice as likely as those with coverage to have trouble paying medical bills and to have medical debt (Nicholson et al. 2009). Lack of coverage may also compromise young adults' ability to address their frequently observed obesity and alcohol and tobacco use that lead to health and economic problems in adulthood (Merluzzi and Nairn 1999). Several reasons help to explain why young adults lack coverage. Completion of high school or college frequently results in loss of eligibility as a dependent on a parent's health plan. Young adults who fail to obtain postsecondary education or high-skilled vocational training may lack the human capital necessary for jobs that provide health insurance. Such transitions lead to sharp increases in young adult uninsured rates: 38 percent of high school graduates who did not go to college were without coverage for some subsequent period, and after turning age 19, uninsured rates increase to nearly 29 percent for young adults ages 19–29, up from 11 percent for children 18 and under (Nicholson et al. 2009). State efforts to improve access to affordable coverage through regulation of small group and individual health insurance markets may have unintended consequences for young adults. In states that tightly constrain premium variation based on individual health status, young adults may face premiums that fail to reflect their actuarial risk and together with their relatively low incomes, may make coverage economically unattractive. Apart from affordability, some young adults may have a low demand for coverage due to their relatively good health, attitudes toward risk taking, and lack of information regarding the health and financial consequences of going without coverage. In response to the significant disparity in coverage for young adults relative to other age groups, by 2008, 21 states had implemented legislation requiring private insurers to expand dependent coverage. As shown in Table 1, Utah was the first state to do so in 1995, permitting adults through age 25 to enroll in a parent's plan.1 Between 2003 and 2006, six other states followed suit, including New Jersey, which implemented the most expansive dependent eligibility (through age 29 with an expansion through age 30 beginning January 2009). In 2007 through January 2008, 14 additional states implemented expansion policies. In addition, as of mid-August 2009, 8 other states had enacted adult dependent coverage expansions that were implemented after January 2008 or not yet implemented (National Conference of State Legislatures 2009). Table 1 States Implementing Adult Dependent Coverage Expansions by January 2008 Among enacting states, requirements for eligibility vary on the basis of age limits, marital status, residence with parents, transitions from prior insurance, among other factors. In all cases, state laws do not apply to self-funded employer benefit programs due to their exemption from state regulation under a provision of the 1974 Employee Retirement Income Security Act (ERISA). Such an exemption will likely limit the reach of the expansion legislation because many large employers offer self-funded health benefits.2 Of the 21 states implementing expansions through January 2008 (Table 1), 19 increased eligibility of nonstudents an average of 5.3 additional years, and 14 increased eligibility for full-time students by an average of 3.5 years. In this paper, we address the question of whether state implementation of expanded dependent coverage has been effective in increasing coverage among young adults. We do so through an econometric analysis of the relationship between the implementation of this policy and its impact on young adults' health insurance status. We address the issue of policy endogeneity, consider the expansion's effect on different groups of young adults, examine the timing of the legislation's impact, and consider how the distribution of young adult coverage might change were all states to implement the expansions. For our most expansive sample, young adults ages 19–29, we find that state expansion legislation had a small impact on their insurance status, increasing coverage as a dependent on employer-sponsored insurance (ESI) by 1.52 percentage points (an 8.5 percent increase in such coverage over the 17.9 percent of targeted young adults in this group with dependent coverage in the preintervention period). For young adults ages 19–25 who live with their parents, ESI dependent coverage increased by 3.84 percentage points (an 11.9 percent increase over the 32.4 percent of targeted young adults with dependent coverage in the preimplementation period). In all cases, we also find that the increase in dependent coverage was largely offset by a reduction of coverage as an ESI policyholder. We find no impact on young adult uninsured rates, suggesting that the expansion legislation may have had an unintended consequence of reducing young adult coverage as an ESI policyholder.

Background: Low-income and racial/ethnic minority cancer patients in the United States, particularly those with Medicaid coverage, are more likely to be diagnosed with later-stage cancer and experience worse survival compared to other groups. Recent national and state Medicaid policy initiatives, including the Medicaid eligibility expansion, aim to increase access to care, improve quality, and reduce costs. It is unclear, however, whether these non-cancer specific system-level efforts will have an impact on cancer care quality for Medicaid-insured patients. Currently, few cancer-specific analyses are available from early Medicaid redesign implementation periods (2012 and beyond) to inform possible care improvement strategies for vulnerable cancer patients. Methods: Through a recent linkage of New Jersey State Cancer Registry (NJSCR), one of twenty SEER regions, and Medicaid claims/encounter/enrollment data, we examined the effect of primary care (PC) utilization on late-stage diagnosis (stage III/IV) and treatment delays for breast (BC), colorectal (CRC), or invasive cervical cancer (ICC) diagnosed from 2012-2014. We compared late-stage diagnosis and treatment delays (> 90 days) by PC utilization (one or more visits 2-12 months prior to diagnosis), Medicaid-related factors (eligibility category, enrollment days prediagnosis, coverage gaps, managed care enrollment), and tumor and demographic characteristics. Adjusted logistic regression models were used to identify factors independently associated with improved timeliness of treatment and late-stage disease. Results: A total of 1,919 BC, 1,068 CRC, and 256 ICC non-elderly, Medicaid-insured adults were identified in the linked dataset. Nearly half of cancer patients (49%) in the linked cohort were African American or Hispanic. Compared to non-Medicaid cases, significantly higher proportions of linked Medicaid cases were diagnosed with later-stage disease (BC: 21% vs. 10%, p Conclusions: These findings indicate that Medicaid cancer patients diagnosed in the early ACA implementation period continue to be composed of significantly higher proportions of later-stage cases, thus requiring more aggressive treatment, leading to potential complications, worse outcomes, and higher overall costs of care. Targeted strategies to improve continuity of care and access to primary care within safety-net settings prior to a cancer diagnosis are needed to reduce late-stage cancer burden in this population. More detailed monitoring of cancer-related quality metrics across managed care organizations may also be warranted. Cancer care providers must also plan for high levels of late-stage diagnosis among newly enrolled Medicaid patients with cancer. Citation Format: Jennifer Tsui, Derek DeLia, Jose Nova, Rotter David, Kulkarni Aishwarya, Demissie Kitaw, Stroup Antoinette, Joel C. Cantor. Primary care utilization, late-stage diagnosis, and timeliness of treatment among Medicaid cancer patients: Early signals following the ACA expansion [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr PR07.

Opinion polls have become a staple of American political and public policy discourse. Dozens of polls sponsored by national news organizations, private foundations, and interest groups were conducted in the run-up to the 2008 presidential election (e.g., CBS News 2007; AARP 2008; Blendon et al. 2008; Harvard 2008; Kaiser 2008;). Opinion polling has also figured prominently in state-level health reform discussions (e.g., Blendon et al. 2006). Rising aspirations for reform make it likely that health reform polls will be with us for the foreseeable future. This article examines one important issue underlying the validity of estimates from surveys of health care opinions and support for reform: the role of wireless telephone substitution. Traditionally, landline telephone sampling frames have been used for health and other public opinion polls. Sample coverage in landline frames was strong until the early 2000s, when it began to erode rapidly. In the first half of 2004, 4.4 percent of adults were “wireless only,” an estimate that reached 17.0 percent by 2008 (Blumberg and Luke 2008). In addition, nearly as many adults (14.4 percent) live in households with landline telephones but receive all or most of their calls on wireless phones (Blumberg and Luke 2008). Combined, these estimates suggest that nearly one in three adults is excluded from or may be underrepresented in traditional landline-only surveys. There is limited research on the impact of wireless substitution on estimates of opinions about health care reform. One study found no difference between landline and wireless-only respondents in opinions about whether health care would be an important issue in their 2008 presidential vote (Pew 2008a). Available research on correlates of wireless substitution suggests that there may be bias in health reform opinion polls that exclude cellular phone users. Data from the National Health Interview Survey (NHIS) documents that wireless-only users are more likely than those with landlines to be Hispanic or black, low income, young, and medically uninsured (Blumberg and Luke 2008). Wireless-only users also report more health care access barriers, mental health problems, and are more likely to engage in binge drinking and smoking (Blumberg and Luke 2008; Currivan, Roe, and Stockdale 2008;). Research on the 2008 election showed a small bias in political ideology and preferences in polls excluding cell phones (Pew 2008b). Those who have landlines but receive “all or almost all calls … on cell phones” fell between wireless-only and landline groups in measures of health behaviors, access, and coverage in the NHIS (Blumberg and Luke 2008). Adults with both landlines and wireless phones who were reached by wireless phone in preelection polls held similar preferences as the wireless-only group (Pew 2008b). These results suggest that individuals with access to landlines but who rely mainly on their wireless phones may be underrepresented in traditional landline-only samples. The magnitude of bias arising from wireless substitution depends on the size of the population that cannot be reached by landline and the extent of differences in opinions between landline and wireless groups. This article draws on a 2007 health reform opinion poll conducted in New Jersey to provide an estimate of the size of the population excluded from a landline sample and to measure differences in a broad range of questions between wireless and landline populations. After quantifying the extent of differences across all poll domains, we focus on possible bias in measures related to support for coverage strategies that have been advanced in reform debates at the national and state levels.

Racial disparities in cardiac services are well documented; however, policies to close these gaps have not been studied. This paper evaluates a New Jersey certificate-of-need reform to reduce disparities in diagnostic coronary angiography. The number of angiography facilities in New Jersey doubled following reform, and a large black-white disparity was eliminated-a trend not observed in nearby states. Surprisingly, increases in service to African American patients following reform were concentrated in hospitals licensed before reform, while the newly licensed facilities contributed relatively little to reducing disparities. We hypothesize that added hospital competition contributed to the reduction in disparities.