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Journal of General Internal Medicine Nov 2023On July 1, 2021, North Carolina's Medicaid Transformation mandatorily switched 1.6 million Medicaid beneficiaries from fee-for-service to managed care plans. We examined...
INTRODUCTION
On July 1, 2021, North Carolina's Medicaid Transformation mandatorily switched 1.6 million Medicaid beneficiaries from fee-for-service to managed care plans. We examined the early enrollee experience in terms of engagement in plan selection, provider continuity, use of primary care visits, and assistance with social needs.
METHODS
Using electronic health records (EHR) covering pre- and post-transition periods (1/1/2019-5/31/2022) from the largest provider network in western North Carolina, we identified all children and adults under age 65 with continuous Medicaid or private coverage. We conducted primary surveys of a random sample of Medicaid-covered enrollees and obtained self-reported rates of engagement in plan selection, continuity of provider access, and receipt of social need assistance. We used comparative interrupted time series models to estimate the relative change in primary care visits associated with the transition.
RESULTS
Our EHR-based study cohorts included 4859 Medicaid and 5137 privately insured enrollees, with 398 Medicaid enrollees in the primary surveys. We found that 77.3% of survey participants reported that the managed care plan they were on was not chosen but automatically assigned to them, 13.1% reported insufficient information about the transition, and 19.2% reported lacking assistance with plan choice. We found that 5.9% were assigned to a different primary care provider. Over 29% reported not receiving any additional social need assistance. The transition was associated with a 7.1% reduction (95% CI, -11.5 to -2.7%) in the volume of primary care visits among Medicaid enrollees relative to privately insured enrollees.
CONCLUSIONS
Medicaid enrollees in North Carolina may have had limited awareness and engagement in the transition process and experienced a reduction in primary care visits. As the state's transition process gains a foothold, future policy needs to improve enrollee engagement and develop evidence on healthcare utilization and patient outcomes.
Topics: Child; Adult; United States; Humans; Aged; Medicaid; North Carolina; Managed Care Programs; Fee-for-Service Plans; Surveys and Questionnaires
PubMed: 37488369
DOI: 10.1007/s11606-023-08319-9 -
Administration and Policy in Mental... Sep 2023Therapeutic foster care (TFC) is a service for children with high behavioral health needs that has shown promise to prevent entry into more restrictive and expensive...
Therapeutic foster care (TFC) is a service for children with high behavioral health needs that has shown promise to prevent entry into more restrictive and expensive care settings. The purpose of this study was to compare Medicaid expenditures associated with TFC with Medicaid expenditures associated with an enhanced higher-rate service called Intensive Alternative Family Treatment (IAFT). We conducted a secondary analysis of Medicaid claims in North Carolina among children entering care in 2018-2019. Using propensity score analysis with difference-in-difference estimation, we compared monthly Medicaid expenditures before and after initiating TFC and IAFT (N = 5472 person-months). Youth entering IAFT had higher expenditures prior to treatment than those entering TFC. Both standard TFC and IAFT were associated with a downward trend in expenditures following treatment initiation. Both TFC and IAFT reverse a trend of increasing Medicaid costs prior to care among children with high behavioral health needs.
Topics: Child; Adolescent; United States; Humans; Health Expenditures; Medicaid; North Carolina; Costs and Cost Analysis; Foster Home Care
PubMed: 37160645
DOI: 10.1007/s10488-023-01270-1 -
Translational Behavioral Medicine Apr 2024Most early maternal deaths are preventable, with many occurring within the first year postpartum (we use the terms "maternal" and "mother" broadly to include all...
Most early maternal deaths are preventable, with many occurring within the first year postpartum (we use the terms "maternal" and "mother" broadly to include all individuals who experience pregnancy or postpartum and frame our recognition of need and policy recommendations in gender-neutral terms. To acknowledge limitations inherent in existing policy and the composition of samples in prior research, we use the term "women" when applicable). Black, Hispanic, and Native American individuals are at the most significant risk of pregnancy-related death. They are more commonly covered by Medicaid, highlighting likely contributions of structural racism and consequent social inequities. State-level length and eligibility requirements for postpartum Medicaid vary considerably. Federal policy requires 60 days of Medicaid continuation postpartum, risking healthcare coverage loss during a critical period of heightened morbidity and mortality risk. This policy position paper aims to outline urgent risks to maternal health, detail existing federal and state-level efforts, summarize proposed legislation addressing the issue, and offer policy recommendations for legislative consideration and future study. A team of maternal health researchers and clinicians reviewed and summarized recent research and current policy pertaining to postpartum Medicaid continuation coverage, proposing policy solutions to address this critical issue. Multiple legislative avenues currently exist to support and advance relevant policy to improve and sustain maternal health for those receiving Medicaid during pregnancy, including legislation aligned with the Biden-Harris Maternal Health Blueprint, state-focused options via the American Rescue Plan of 2021 (Public Law 117-2), and recently proposed acts (HR3407, S1542) which were last reintroduced in 2021. Recommendations include (i) reintroducing previously considered legislation requiring states to provide 12 months of continuous postpartum coverage, regardless of pregnancy outcome, and (ii) enacting a revised, permanent federal mandate equalizing Medicaid eligibility across states to ensure consistent access to postpartum healthcare offerings nationwide.
Topics: Humans; Medicaid; United States; Female; Postpartum Period; Pregnancy; Child Health; Maternal Health; Health Policy
PubMed: 38417096
DOI: 10.1093/tbm/ibae007 -
Medical Care Research and Review : MCRR Aug 2023This study asks: Does the empirical evidence support the conclusion that for-profit (FP) hospitals are more productive or efficient than private not-for-profit (NFP)... (Review)
Review
This study asks: Does the empirical evidence support the conclusion that for-profit (FP) hospitals are more productive or efficient than private not-for-profit (NFP) hospitals or non-federal public (PUB) hospitals? Alternative theories of NFP behavior are described. Our review of individual empirical hospital studies of quality, service mix, community benefit, and cost/efficiency in the United States published since 2000 indicates that no systematic difference exists in cost/efficiency, provision of uncompensated care, and quality of care. But FPs are more likely to provide profitable services, higher service intensity, have lower shares of uninsured and Medicaid patients, and are more responsive to external financial incentives. That FP hospitals are not more efficient runs counter to property rights theory, but their relative responsiveness to financial incentives supports it. There is little evidence that FP market presence changes NFP behaviors. Observed differences between FP and NFP hospitals are mostly a "little deal."
Topics: Humans; United States; Hospitals, Voluntary; Ownership; Medically Uninsured; Uncompensated Care; Medicaid; Hospitals, Public
PubMed: 36637023
DOI: 10.1177/10775587221142268 -
Journal of the American Geriatrics... Oct 2023Although older adults prefer to age at home, Medicaid has a longstanding institutional bias in funding long-term services and supports (LTSS). Some states have resisted...
BACKGROUND
Although older adults prefer to age at home, Medicaid has a longstanding institutional bias in funding long-term services and supports (LTSS). Some states have resisted expanding Medicaid funding for home- and community-based services (HCBS) due to budgetary concerns related to the so-called "woodwork" effect whereby individuals enroll on Medicaid to access HCBS.
METHODS
To examine the implications associated with state Medicaid HCBS expansion, we obtained state-year data for 1999-2017 from various sources. We estimated difference-in-differences regressions comparing outcomes in states that expanded Medicaid HCBS aggressively versus those that expanded less aggressively, controlling for several covariates. We examined a range of outcomes including Medicaid enrollment, nursing home census, Medicaid institutional LTSS spending, total Medicaid LTSS spending, and Medicaid HCBS waiver enrollment. We measured HCBS expansion by the total share of state Medicaid LTSS spending for aged and disabled persons devoted to HCBS.
RESULTS
HCBS expansion was not associated with increased Medicaid enrollment among individuals ages 65 and older. A 1% increase in HCBS spending was associated with reductions in the state nursing home population of 47.1 residents (95% confidence interval [CI]: -80.5, -13.8) and institutional Medicaid LTSS spending of $7.3 million (95% CI: -$12.1M, -$2.4M). A $1 increase in HCBS spending was associated with $0.74 increase (95% CI: $0.57, $0.91) in total LTSS spending, suggesting each dollar directed to HCBS was offset by $0.26 savings from decreased nursing home use. Increased HCBS waiver spending was associated with more older adults receiving LTSS at a lower cost per beneficiary served relative to the nursing home setting.
CONCLUSIONS
We did not find evidence of a woodwork effect in those states that expanded Medicaid HCBS more aggressively, as measured by age 65 and older Medicaid enrollment. However, they did experience Medicaid savings from reduced nursing home use, suggesting states that expand Medicaid HCBS are able to use these additional dollars to serve more LTSS recipients.
Topics: United States; Humans; Aged; Medicaid; Home Care Services; Community Health Services; Long-Term Care; Health Expenditures; Nursing Homes
PubMed: 37326313
DOI: 10.1111/jgs.18478 -
Pediatric Blood & Cancer May 2024Medicaid-associated disparities in childhood and adolescent (pediatric) cancer diagnosis stage and survival have been reported. However, a key limitation of prior...
BACKGROUND
Medicaid-associated disparities in childhood and adolescent (pediatric) cancer diagnosis stage and survival have been reported. However, a key limitation of prior studies is the assessment of health insurance at a single time point. To evaluate Medicaid-associated disparities more robustly, we used Surveillance, Epidemiology, and End Results (SEER)-Medicaid linked data to examine diagnosis stage and survival disparities in those (i) Medicaid-enrolled and (ii) with discontinuous and continuous Medicaid enrollment.
METHODS
SEER-Medicaid linked data from 2006 to 2013 were obtained on cases diagnosed from 0 to 19 years. Medicaid enrollment was classified as enrolled versus not enrolled, with further classifications as continuous when enrolled 6 months before through 6 months after diagnosis, and discontinuous when not enrolled continuously for this period. We used multinomial logistic and Cox proportional hazards regression models to determine associations between enrollment measures, diagnosis stage, and cancer death adjusted for covariates.
RESULTS
Among 21,502 cases, a higher odds of distant stage diagnoses were observed in association with Medicaid enrollment (odds ratio [OR] = 1.56, 95% confidence interval [CI]: 1.48-1.65), with the highest odds for discontinuous enrollment (OR = 2.0, 95% CI: 1.86-2.15). Among 30,654 cases, any Medicaid enrollment, continuous enrollment, and discontinuous enrollment were associated with 1.68 (95% CI: 1.35-2.10), 1.66 (95% CI: 1.35-2.05), and 1.89 (95% CI: 1.54-2.33) times higher hazards of cancer death versus no enrollment, respectively.
CONCLUSIONS
Medicaid enrollment, particularly discontinuous enrollment, is associated with a higher distant stage diagnosis odds and risk of death. This study supports the critical need for consistent health insurance coverage in children and adolescents.
Topics: Adolescent; United States; Humans; Child; Medicaid; Neoplasms; Insurance, Health; Neoplasm Staging; Proportional Hazards Models; Insurance Coverage
PubMed: 38235939
DOI: 10.1002/pbc.30861 -
Frontiers in Public Health 2023This study examined the effect of Medicaid expansion in Oregon on duration of Medicaid enrollment and outpatient care utilization for low-income individuals during the...
OBJECTIVE
This study examined the effect of Medicaid expansion in Oregon on duration of Medicaid enrollment and outpatient care utilization for low-income individuals during the postpartum period.
METHODS
We linked Oregon birth certificates, Medicaid enrollment files, and claims to identify postpartum individuals ( = 73,669) who gave birth between 2011 and 2015. We created one pre-Medicaid expansion (2011-2012) and two post-expansion (2014-2015) cohorts (i.e., previously covered and newly covered by Medicaid). We used ordinary least squares and negative binomial regression models to examine changes in postpartum coverage duration and number of outpatient visits within a year of delivery for the post-expansion cohorts compared to the pre-expansion cohort. We examined monthly and overall changes in outpatient utilization during 0-2 months, 3-6 months, and 7-12 months after delivery.
RESULTS
Postpartum coverage duration increased by 3.14 months and 2.78 months for the post-Medicaid expansion previously enrolled and newly enrolled cohorts ( < 0.001), respectively. Overall outpatient care utilization increased by 0.06, 0.19, and 0.34 visits per person for the previously covered cohort and 0.12, 0.13, and 0.26 visits per person for newly covered cohort during 0-2 months, 3-6 months, and 7-12 months, respectively. Monthly change in utilization increased by 0.006 (0-2 months) and 0.004 (3-6 months) visits per person for post-Medicaid previously enrolled cohort and decreased by 0.003 (0-2 months) and 0.02 (7-12 months) visits per person among newly enrolled cohort.
CONCLUSION
Medicaid expansion increased insurance coverage duration and outpatient care utilization during postpartum period in Oregon, potentially contributing to reductions in pregnancy-related mortality and morbidities among birthing individuals.
Topics: Female; Humans; Pregnancy; Ambulatory Care; Health Services Accessibility; Medicaid; Oregon; Patient Protection and Affordable Care Act; Postpartum Period; United States
PubMed: 37469686
DOI: 10.3389/fpubh.2023.1025399 -
Health Services Research Oct 2023To examine indirect spillover effects of Affordable Care Act (ACA) Medicaid expansions to working-age adults on health care coverage, spending, and utilization by older...
OBJECTIVE
To examine indirect spillover effects of Affordable Care Act (ACA) Medicaid expansions to working-age adults on health care coverage, spending, and utilization by older low-income Medicare beneficiaries.
DATA SOURCES
2010-2018 Health and Retirement Study survey data linked to annual Medicare beneficiary summary files.
STUDY DESIGN
We estimated individual-level difference-in-differences models of total spending for inpatient, institutional outpatient, physician/professional provider services; inpatient stays, outpatient visits, physician visits; and Medicaid and Part A and B Medicare coverage. We compared changes in outcomes before and after Medicaid expansion in expansion versus nonexpansion states.
DATA COLLECTION/EXTRACTION METHODS
The sample included low-income respondents aged 69 and older with linked Medicare data, enrolled in full-year traditional Medicare, and residing in the community.
PRINCIPAL FINDINGS
ACA Medicaid expansion was associated with a 9.8 percentage point increase in Medicaid coverage (95% CI: 0.020-0.176), a 4.4 percentage point increase in having any institutional outpatient spending (95% CI: 0.005-0.083), and a positive but statistically insignificant 2.4 percentage point change in Part B enrollment (95% CI: -0.003 to 0.050, p = 0.079).
CONCLUSIONS
ACA Medicaid expansion was associated with more institutional outpatient spending among older low-income Medicare beneficiaries. Increased care costs should be weighed against potential benefits from increased realized access to care.
Topics: Adult; Humans; Aged; United States; Medicaid; Medicare; Patient Protection and Affordable Care Act; Poverty; Health Services Accessibility; Insurance Coverage
PubMed: 37011907
DOI: 10.1111/1475-6773.14155 -
Medical Care Research and Review : MCRR Aug 2023Provider networks in Medicaid Managed Care (MMC) play a crucial role in ensuring access to buprenorphine, a highly effective treatment for opioid use disorder. Using a...
Provider networks in Medicaid Managed Care (MMC) play a crucial role in ensuring access to buprenorphine, a highly effective treatment for opioid use disorder. Using a difference-in-differences approach that compares network breadth across provider specialties and market segments within the same state, we investigated the association between three Medicaid policies and the breadth of MMC networks for buprenorphine prescribers: Medicaid expansion, substance use disorder (SUD) network adequacy criteria, and SUD carveouts. We found that both Medicaid expansion and SUD network adequacy criteria were associated with substantially increased breadth in buprenorphine-prescriber networks in MMC. In both cases, we found that the associations were largely driven by increases in the network breadth of primary care physician prescribers. Our findings suggest that Medicaid expansion and SUD network adequacy criteria may be effective strategies at states' disposal to improve access to buprenorphine.
Topics: United States; Humans; Buprenorphine; Medicaid; Opioid-Related Disorders; Policy; Opiate Substitution Treatment
PubMed: 37083043
DOI: 10.1177/10775587231167514 -
PloS One 2024Pregnant beneficiaries in the two primary Medicaid eligibility categories, traditional Medicaid and pregnancy Medicaid, have differing access to care especially in the...
OBJECTIVES
Pregnant beneficiaries in the two primary Medicaid eligibility categories, traditional Medicaid and pregnancy Medicaid, have differing access to care especially in the preconception and postpartum periods. Pregnancy Medicaid has higher income limits for eligibility than traditional Medicaid but only provides coverage during and for a limited time period after pregnancy. Our objective was to determine the association between type of Medicaid (traditional Medicaid and pregnancy Medicaid) on receipt of outpatient care during the perinatal period.
METHODS
This retrospective cohort study compared outpatient visits using linked birth certificate and Medicaid claims from all Medicaid births in Oregon and South Carolina from 2014 through 2019. Pregnancy Medicaid ended 60 days postpartum during the study. Our primary outcome was average number of outpatient visits per 100 beneficiaries each month during three perinatal time points: preconceputally (three months prior to conception), prenatally (9 months prior to birthdate) and postpartum (from birth to 12 months).
RESULTS
Among 105,808 Medicaid-covered births in Oregon and 141,385 births in South Carolina, pregnancy Medicaid was the most prevelant categorical eligibility. Traditional Medicaid recipients had a higher average number of preconception, prenatal and postpartum visits as compared to those in pregnancy Medicaid.
DISCUSSION
In South Carolina, those using traditional Medicaid had 450% more preconception visits and 70% more postpartum visits compared with pregnancy Medicaid. In Oregon, those using traditional Medicaid had 200% more preconception visits and 29% more postpartum visits than individuals using pregnancy Medicaid. Lack of coverage in both the preconception and postpartum period deprive women of adequate opportunities to access health care or contraception. Changes to pregnancy Medicaid, including extended postpartum coverage through the American Rescue Plan Act of 2021, may facilitate better continuity of care.
Topics: Pregnancy; United States; Female; Humans; Medicaid; Retrospective Studies; Prenatal Care; Postpartum Period; Contraception
PubMed: 38568923
DOI: 10.1371/journal.pone.0299818