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Objective: To examine the relationship between the level of state funding for Home-and Community-Based Services (HCBS) and state overall and dimension-specific performances in Long-Term Services and Supports (LTSS). Data Sources and Study Setting: We employed state-level secondary data from the Medicaid LTSS Annual Expenditures Reports, the American Association of Retired Persons (AARP) State Scorecards, the U.S. Census, and Federal Reserve Economic data, spanning the timeframe of 2010-2020. Study Design: Overall state LTSS rankings, along with dimension-specific rankings, were modeled separately against state Medicaid spending on HCBS relative to total Medicaid spending on LTSS. All models were adjusted for state covariates, secular trend, and state fixed effects. Data Collection/Extraction Methods: The study sample included all 50 states and the District of Columbia. However, California, Delaware, Illinois, and Virginia were excluded from FY2019 due to missing data on Medicaid HCBS expenditures. Principal Findings: Every 10 percentage-point increase in the proportion of Medicaid LTSS spending to HCBS demonstrated 2.05 points improvement (95% confidence interval [CI]: -3.88 to 0.22, p = 0.03) in rankings for state overall LTSS system performance, 2.92 points improvement (95% CI: -4.87 to 0.98, p < 0.01) in rankings for the Choice of Setting and Provider dimension, as well as 1.73 points (95% CI: -3.14 to 0.32, p = 0.02) ranking improvement in the dimension of Effective Transitions. Conclusions: Our study suggested promising effects of increased state funding for HCBS on LTSS performance. KEYWORDS care transitions, Home- and Community-Based Services, Long-Term Services and Supports, Medicaid, quality of care, 1 | INTRODUCTION Long-Term Services and Supports (LTSS) encompasses diverse medical and personal care that support individuals with functional limitations and chronic illnesses. As the primary payer of LTSS in [...]

Objective: To test whether the impacts of Medicaid's Home and Community-Based Services (HCBS) expenditures have been equitable. Data Sources and Study Setting: This is a secondary data analysis. We linked annual data on state-level Medicaid HCBS expenditures with individual data from U.S. Health and Retirement Study (HRS; 2006-2016). Study Design: We evaluated the association between state-level HCBS expenditure quartiles and the risk of experiencing challenges in basic or instrumental activities of daily living (I/ADLs) without assistance (unmet needs for care). We fitted generalized estimating equations (GEE) with a Poisson distribution, log link function, and an unstructured covariance matrix. We controlled demographics, time, and place-based fixed effects and estimated models stratified by race and ethnicity, gender, and urbanicity. We tested the robustness of results with negative controls. Data Collection/Extraction Methods: Our analytic sample included HRS Medicaid beneficiaries, aged 55+, who had difficulty with [greater than or equal to]1 I/ADL (n = 2607 unique respondents contributing 4719 person-wave observations). Principal Findings: Among adults with IADL difficulty, higher quartiles of HCBS expenditure (vs. the lowest quartile) were associated with a lower overall prevalence of unmet needs for care (e.g., Prevalence Ratio [PR], Q4 vs. Q1: 0.91, 95% CI: 0.84-0.98). This protective association was concentrated among non-Hispanic white respondents (Q4 vs. Ql: 0.82, 95% CI: 0.73-0.93); estimates were imprecise for Hispanic individuals and largely null for non-Hispanic Black participants. We found no evidence of heterogeneity by gender or urbanicity. Negative control robustness checks indicated that higher quartiles of HCBS expenditure were not associated with (1) the risk of reporting I/ADL difficulty among 55+ Medicaid beneficiaries, and (2) the risk of unmet care needs among non-Medicaid beneficiaries. Conclusion: The returns to higher state-level HCBS expenditures under Medicaid for older adults with I/ADL disability do not appear to have been equitable by race and ethnicity. KEYWORDS aging/elderly/geriatrics, long term care, Medicaid, social determinants of health, 1 | INTRODUCTION It is estimated that more than 12 million older adults need some form of long-term care and this number is expected to reach 27 million by 2050. [...]

Objective: To quantify shared patient relationships between primary care physicians (PCPs) and cardiologists and oncologists and the degree to which those relationships were captured within insurance networks. Data Sources: Secondary analysis of Vericred data on physician networks, CareSet data on physicians' shared Medicare patients, and insurance plan attributes from Health Insurance Compare. Data validation exercises used data from Physician Compare and IQVIA. Study Design: Cross-sectional study of the PCP-to-specialist in-network shared patient percentage (primary outcome). We also categorized networks by insurance market segment (Medicare Advantage [MA], Medicaid managed care, small-group or individually purchased), insurance plan type, and network breadth. Data Extraction: We analyzed data on 219,982 PCPs, 29,400 cardiologists, and 22,745 oncologists who, in 2021, accepted MA (n = 941 networks), Medicaid managed care (n = 293), and individually-purchased (n = 332) and small-group (n = 501) plans. Principal Findings: Networks captured, on average, 64.6% of PCP-cardiology shared patient ties, and 61.8% of PCP-oncologist ties. Less than half of in-network ties (44.5% and 38.9%, respectively) were among physicians with a common organizational affiliation. After adjustment for network breadth, we found no evidence of differences in the shared patient percentage across insurance market segments or networks of different types (p-value >0.05 for all comparisons). An exception was among national versus local and regional networks, where we found that national plans captured fewer shared patient ties, particularly among the narrowest networks (58.4% for national networksvs. 64.7% for local and regional networks for PCP-cardiology). Conclusions: Given recent trends toward narrower networks, our findings underscore the importance of incorporating additional and nuanced measures of network composition to aid plan selection (for patients) and to guide regulatory oversight. KEY WORDS health policy, insurance, insurance benefits, managed care programs, provider networks What is known on this topic * Enrollment in private insurance plans is expected to grow, and private plans are increasingly limiting the number of in-network providers and/or limiting coverage of out-of-network care. * Interspecialty communication among physicians is an important determinant of care quality, spending, and the experience of care for both physicians and patients. * Health services research on provider networks focuses almost exclusively on the breadth of networks, but not on their composition or quality. What this study adds * We develop a novel measure of the degree to which insurance plan networks capture interspecialty relationships among primary care physicians and specialists in oncology and cardiology. * We investigate variation in this measure across insurance market segments, plan types, and network breadth sizes. * In 2021, private insurance networks captured approximately two-thirds of patient-sharing relationships. We find substantial variation in the degree to which narrow network plans capture these relationships., 1 | INTRODUCTION The majority of insured people in the US are covered by private health plans. With few exceptions, these plans require receipt of care from in-network clinicians to [...]

Objective: To investigate the use and timing of market introduction of authorized generics (AGs), which unlike independent generics are sold by the brand-name drug manufacturer under a generic label. Data Sources: This study used public Medicaid prescription drug use data from 2014 to 2020. Study Design: This cross-sectional study measured the percentage of filled prescriptions for AGs, compared with brand-name and independent generic versions. We also identified the frequency and characteristics of AGs marketed at least 1 year before independent generics. Data Extraction Methods: Drugs were classified based on manufacturer-reported data to Medicaid. Principal Findings: From 2014 to 2020, 1023 AGs accounted for 175 million filled Medicaid prescriptions. These represented 4% of Medicaid prescription drug use, and 16% of medication use among products with AGs available. Among 393 AGs for drugs without generic competition before 2014, 139 (35%) were marketed at least 1 year before independent generics or had no independent generic competition through December 2020. Conclusions: AGs represented a small share of Medicaid prescription drug use from 2014 to 2020, but when AGs were available, they accounted for sizeable market share. Among the minority of cases in which AGs were marketed a year or more before independent generics, manufacturers may be using AGs to bolster brandname drug prices or to undermine independent generic competition, meriting further attention by regulators. KEYWORDS authorized genericsgeneric drugs, health policy, Medicaid, prescription drugs What is known on this topic * Unlike traditional generic drugs made by independent manufacturers, brand-name drug manufacturers can introduce authorized generics (AGs), which are the same drug sold under a different label. * Authorized generics may be introduced at any time and are frequently introduced at the same time as independent generics. What this study adds * Authorized generics account for 4% of all Medicaid drug use and 16% of use among drugs with an AG version available. * Approximately one third of AGs were marketed at least 1 year before independent generics, raising concerns about AGs' impact on competition., 1 | METHODS 1.1 | Data sources We used a public database of drugs covered by the Medicaid Drug Rebate Program (MDRP), which includes drugs used by Medicaid patients since [...]

Objective: To develop easy to use and validated predictive models to identify beneficiaries experiencing homelessness from administrative data. Data Sources: We pooled enrollment and claims data from enrollees of the California Whole Person Care (WPC) Medicaid demonstration program that coordinated the care of a subset of Medicaid beneficiaries identified as high utilizers in 26 California counties (25 WPC Pilots). We also used public directories of social service and health care facilities. Study Design: Using WPC Pilot-reported homelessness status, we trained seven supervised learning algorithms with different specifications to identify beneficiaries experiencing homelessness. The list of predictors included address- and claims-based indicators, demographics, health status, health care utilization, and county-level homelessness rate. We then assessed model performance using measures of balanced accuracy (BA), sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve (area under the curve [AUC]). Data Collection/Extraction Methods: We included 93,656 WPC enrollees from 2017 to 2018, 37,441 of whom had a WPC Pilot-reported homelessness indicator. Principal Findings: The random forest algorithm with all available indicators had the best performance (87% BA and 0.95 AUC), but a simpler Generalized Linear Model (GLM) also performed well (74% BA and 0.83 AUC). Reducing predictors to the top 20 and top five most important indicators in a GLM model yields only slightly lower performance (86% BA and 0.94 AUC for the top 20 and 86% BA and 0.91 AUC for the top five). Conclusions: Large samples can be used to accurately predict homelessness in Medicaid administrative data if a validated homelessness indicator for a small subset can be obtained. In the absence of a validated indicator, the likelihood of homelessness can be calculated using county rate of homelessness, address- and claim-based indicators, and beneficiary age using a prediction model presented here. These approaches are needed given the rising prevalence of homelessness and the focus of Medicaid and other payers on addressing homelessness and its outcomes. KEYWORDS administrative data, homelessness, machine learning algorithms, Medicaid What is known on this topic * Homelessness is a social determinant of health and well-established evidence demonstrates that individuals experiencing homelessness have poor health and high use of health care. * Addressing social determinants of health is increasingly a goal of public and private payers and providers, but most lack data on the homelessness status of the populations they serve. * Various methods of identifying homelessness using administrative data have been tried using specific populations and limited data, but their accuracy in determining homelessness is unknown. What this study adds * We identify easy and validated predictive models to identify individuals experiencing homelessness using variables available in administrative data. * We identify the top 20 and top five most important variables in predicting homelessness. * We offer more advanced and simpler but well-performing logit regression models and the related regression coefficients that could be easily applied to identify homelessness., 1 | INTRODUCTION Over half a million persons are estimated to be experiencing homelessness In the United States on a given night. (1) Well-established evidence demonstrates that individuals experiencing homelessness [...]

2024 MAY 16 (NewsRx) -- By a News Reporter-Staff News Editor at Women's Health Weekly -- Researchers detail new data in health services. According to news reporting from the University [...]

The CareQuest Institute for Oral Health, a national nonprofit focused on creating a more accessible, equitable, and integrated oral health system, reported its analysis reveals that 12 million people across [...]

The CareQuest Institute for Oral Health, a national nonprofit focused on creating a more accessible, equitable, and integrated oral health system, reported its analysis reveals that 12 million people across [...]

Ekso Bionics announced that the Pricing, Data Analysis, and Coding contractor for the Centers for Medicare & Medicaid, CMS, Services has determined a final payment level of $91,031.93 for Medicare [...]

Consumer advocates cheered when the New Jersey State Comptroller recently suspended four nursing homes from Medicaid — calling the enforcement tactic a “model for nursing home enforcement nationwide.” Provider leaders [...]

Nursing homes would need to spend more than $6.8 billion annually to meet a proposed federal staffing mandate, which also would require them to hire more than 102,000 new workers [...]

2023 FEB 16 (NewsRx) -- By a News Reporter-Staff News Editor at Women's Health Weekly -- Researchers detail new data in Diagnostics and Screening - Breast Cancer Screening. According to [...]

2022 NOV 17 (NewsRx) -- By a News Reporter-Staff News Editor at Women's Health Weekly -- A new study on Oncology - Gynecologic Cancer is now available. According to news [...]

Objective: To provide new evidence on the effects of large-scale public health insurance expansions, associated with the Affordable Care Act (ACA), on the availability of specialty mental health care treatment in the United States. We measure availability with the probability that a provider accepts Medicaid. Data Source/Study Setting: The National Mental Health Services Survey (N-MHSS) 2010-2018. Study Design: A quasi-experimental differences-in-differences design using observational data. Data Collection: The N-MHSS provides administrative data on the universe of specialty mental health care providers in the United States. Response rates are above 90 percent in all years. Data cover 85 019 provider/year observations. Principal Findings: ACA-Medicaid expansion increases the probability that a provider accepts Medicaid by 1.69 percentage points. 95 percent confidence interval: [0.0017,0.0321], which corresponds to an increase from 87.27 percent pre-expansion to 90.27 percent postexpansion in expansion states or a 1.94 percent increase. We observe spillovers to Medicare, although this finding is sensitive to specification. Conclusions: This study provides evidence on the impact of ACA-Medicaid expansion on accepted forms of payment for specialty mental health care treatment. Findings suggest that expansion increases availability of providers who deliver valuable care for enrollees with severe mental illness. These findings may help policy makers reflecting on the future directions of the US health care delivery system. KEYWORDS availability, health care, mental illness, public insurance, 1 | INTRODUCTION The American Psychiatric Association defines mental illness as 'health conditions involving changes in thinking, emotion, or behavior' that are 'associated with distress and/or problems functioning in social, [...]

Objective: To estimate the association between the implementation of parity in coverage for mental health and substance use disorder (MHSUD) services within the Medicaid program and MHSUD service use. Data Sources/Study Setting: Wisconsin Medicaid enrollment and claims data from 2013 to 2015. In April 2014, Wisconsin Medicaid transitioned childless adult beneficiaries from coverage with limited MHSUD services to parity-consistent coverage. Preparity, they only had Medicaid coverage for MHSUD visits to psychiatrists and the emergency department, while parent beneficiaries had parity-consistent coverage. Study Design: The study uses a difference-in-differences design to compare outcome changes for childless adult and parent beneficiaries. Data Collection/Extraction Methods: We identified 76, 569 childless adult and parent beneficiaries aged 18-64 who were continuously enrolled for the 2-year study period. Principal Findings: Introducing parity-consistent coverage within Medicaid was associated with increased utilization of Medicaid-reimbursed MHSUD services: outpatient, prescription medication, ED, and inpatient. Increased MHSUD outpatient visits were driven by increased visits to nonpsychiatrists. Conclusions: Parity's effects on MHSUD service use have been studied in the context of private insurance, but its impact among Medicaid beneficiaries has not. Our findings suggest that parity implementation in Medicaid could increase access to effective MHSUD services in a high-need population. KEYWORDS adult, Medicaid/economics, Medicaid/organization & administration. Mental Health Services/economics. Mental Health Services/legislation & jurisprudence, substance-related disorders/economics, 1 | INTRODUCTION Rates of mental health and substance use disorders (MHSUDs) in the adult Medicaid population are higher than for adults with Medicare or private health insurance. (1,2) Available, [...]

Background: Prior authorization of prescription medications is a policy tool that can potentially impact care quality and patient safety. Objective: To examine the effectiveness of a mandatory peer-review program in reducing antipsychotic prescriptions among Medicaid-insured children, accounting for secular trends that affected antipsychotic prescribing nationally. Data Source: Medicaid Analytical extracts (MAX) with administrative claims for health services provided between January 2006 and December 2011. Study Design: This retrospective, observational study examined prescription claims records from Washington State (Washington) and compared them to a synthetic control drawing from 20 potential donor states that had not implemented any antipsychotic prior authorization program or mandatory peer review for Medicaid-insured children during the study period. This method provided a means to control for secular trends by simulating the antipsychotic use trajectory that the program state would have been expected to experience in the absence of the policy implementation. Principal Findings: Before the policy implementation, antipsychotic use prevalence closely tracked those of the synthetic control (6.17 per 1000 in Washington vs. 6.21 in the synthetic control group). Within two years after the policy was implemented, prevalence decreased to 4,04 in Washington and remained stable in the synthetic control group (6.47). corresponding to an approximately 38% decline. Conclusion: Prior authorization program designs and implementations vary widely. This mandatory peer-review program, with an authorization window and two-stage rollout, was effective in moving population level statistics toward safe and judicious use of antipsychotic medications in children. KEYWORDS antipsychotic medications, children and adolescents, mandatory peer review, Medicaid, prior authorization, synthetic control method, 1 | INTRODUCTION Safe and effective use of antipsychotic medications for children and adolescents [hereafter, children] in the United States remains a pressing treatment issue in behavioral health care. Antipsychotic [...]

Objective: To evaluate episode-based payments for upper respiratory tract infections (URI) and perinatal care in Arkansas's Medicaid population. Study Setting: Upper respiratory infection and perinatal episodes among Medicaid-covered individuals in Arkansas and comparison states from fiscal year (FY) 2011 to 2014. Study Design: Cross-sectional observational analysis using a difference-in-difference design to examine outcomes associated with URI and perinatal episodes of care (EOC) from 2011 to 2014. Key dependent variables include antibiotic use, emergency department visits, physician visits, hospitalizations, readmission, and preventive screenings. Data Collection: Claims data from the Medicaid Analytic Extract for Arkansas, Mississippi, and Missouri from 2010 to 2014 with supplemental county-level data from the Area Health Resource File (AHRF). Principal Findings: The URI EOC reduced the probability of antibiotic use (marginal effect [ME] = -1.8, 90% CI: -2.2, -1.4), physician visits (ME = 0.6, 90% CI: -0.8, -0.4), improved the probability of strep tests for children diagnosed with pharyngitis (ME = 9.4, 90% CI: 8.5, 10.3), but also increased the probability of an emergency department (ED) visit (ME = 0.1, 90% CI: 0.1, 0.2), relative to the comparison group. For perinatal EOCs, we found a reduced probability of an ED visit during pregnancy (ME = 0.1, 90% CI: -0.2, -0.0). an increased probability of screening for HIV (ME = 6.2, 90% CI: 4.0, 8.5), chlamydia (ME = 9.5, 90% CI: 7.2, 11.8), and group [BETA] strep-test (ME = 2.6, 90% CI: 0.5,4.6). relative to the comparison group. Predelivery and postpartum hospitalizations also increased (ME = 1.2,90% CI: 0.4,2.0; ME = 0.4, 90% CI: 0.0,0.8. respectively), relative to the comparison group. Conclusion: Upper respiratory infection and perinatal EOCs for Arkansas Medicaid beneficiaries produced mixed results. Aligning shared savings with quality metrics and cost-thresholds may help achieve quality targets and disincentivize over utilization within the EOC, but may also have unintended consequences. KEYWORDS bundled payment, Medicaid, perinatal care, upper respiratory infection, utilization, 1 I INTRODUCTION The Centers for Medicare and Medicaid Services (CMS) have focused on efforts to move away from fee-for-service (FFS)-based payment toward value-based purchasing to improve quality of care [...]

Objective: To develop, test, and validate the performance of ICD-10-CM claims-based case definitions for identifying children with sickle cell anemia (SCA). Data Sources: Medicaid administrative claims (2016) for children Study Design: This study is a secondary data analysis. Data Collection/Extraction Methods: Using specific SCA-related (D5700, D5701, and D5702) and nonspecific (D571) diagnosis codes, 23 SCA case definitions were applied to Michigan Medicaid claims (2016) to identify children with SCA. Measures of performance (sensitivity, specificity, area under the ROC curve) were calculated using newborn screening results as the gold standard. A parallel analysis was conducted using New York State Medicaid claims and newborn screening data. Principal Findings: In Michigan Medicaid, 1597 children had >1 D57x claim; 280 (18 percent) were diagnosed with SCA. Measures of performance varied, with sensitivities from 0.02 to 0.97 and specificities from 0.88 to 1.0. The case definition of >1 outpatient visit with a SCA-related or D571 code had the highest area under the ROC curve, with a sensitivity of 95 percent and specificity of 92 percent. The same definition also had the highest performance in New York Medicaid (n = 2454), with a sensitivity of 94 percent and specificity of 86 percent. Conclusions: Children with SCA can be accurately identified in administrative claims using this straightforward case definition. This methodology can be used to monitor trends and use of health services after transition to ICD-10-CM. KEYWORDS administrative claims, ICD-10-CM, sickle cell anemia, 1 | INTRODUCTION Sickle cell disease is an inherited blood disorder that affects approximately 100 000 Americans. (1) There are many subtypes of sickle cell disease. Sickle cell anemia (SCA) [...]

Objective: To examine the effect of rural hospital closures on EMS response time (minutes between dispatch notifying unit and arriving at scene); transport time (minutes between unit leaving the scene and arriving at destination); and total activation time (minutes between 9-1-1 call to responding unit returning to service), as longer EMS times are associated with worse patient outcomes. Data Sources/Study Setting: We use secondary data from the National EMS Information System, Area Health Resource, and Center for Medicare & Medicaid Provider of Service files (2010-2016). Study Design: We examined the effects of rural hospital closures on EMS transport times for emergent 9-1-1 calls in rural areas using a pre-post, retrospective cohort study with the matched comparison group using difference-in-difference and quantile regression models. Principal Findings: Closures increased mean EMS transport times by 2.6 minutes (P =.09) and total activation time by 7.2 minutes (P =.02), but had no effect on mean response times. We also found closures had heterogeneous effects across the distribution of EMS times, with shorter response times, longer transport times, and median total activation times experiencing larger effects. Conclusions: Rural hospital closures increased mean transport and total activation times with varying effects across the distribution of EMS response, transport, and total times. These findings illuminate potential barriers to accessing timely emergency services due to closures. KEYWORDS barriers to access, emergency medical services, hospital closures, prehospital emergency care, rural, 1 | INTRODUCTION Rural hospitals provide critically needed services to local communities but have historically struggled to maintain financial viability. (1-4) From 2013 to 2017, 64 rural hospitals have closed, [...]

Objective: To estimate Prenatal Care Coordination's (PNCC) effect on birth outcomes for Wisconsin Medicaid-covered deliveries. Data Source: A longitudinal cohort of linked Wisconsin birth records (2008-2012), Medicaid claims, and state-administered social services. Study Design: We defined PNCC treatment dichotomously (none vs. any) and by service level (none vs. assessment/care plan only vs. service uptake). Outcomes were birthweight (grams), low birthweight ( Data Collection/Extraction Methods: We identified 136 224 Medicaid-paid deliveries, of which 33 073 (24.3 percent) linked to any PNCC claim and 22 563 (16.6 per-cent) linked to claims for PNCC service uptake. Principal Findings: Sibling fixed effects models--which best adjust for unobserved confounding and treatment selection--produced the largest estimates for all outcomes. For example, in these models, PNCC service uptake was associated with a 1.3 percentage point (14 percent) reduction and a 1.8 percentage point (17 percent) reduction in the probabilities of low birthweight and preterm birth, respectively (all P < .05). Conclusions: PNCC's modest but significant improvement of birth outcomes should motivate stronger PNCC outreach and implementation of similar programs elsewhere. KEYWORDS care coordination, Medicaid, prenatal, 1 | INTRODUCTION Adverse birth outcomes remain a critical public health problem. (1-3) Low birthweight and preterm infants are at risk of neonatal and post-neonatal mortality and a host of [...]