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JAMA Network Open Aug 2023Despite momentum for pediatric value-based payment models, little is known about tailoring design elements to account for the unique needs and utilization patterns of...
IMPORTANCE
Despite momentum for pediatric value-based payment models, little is known about tailoring design elements to account for the unique needs and utilization patterns of children and young adults.
OBJECTIVE
To simulate attribution to a hypothetical pediatric accountable care organization (ACO) and describe baseline demographic characteristics, expenditures, and utilization patterns over the subsequent year.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective cohort study used Medicaid claims data for children and young adults aged 1 to 20 years enrolled in North Carolina Medicaid at any time during 2017. Children and young adults receiving at least 50% of their primary care at a large academic medical center (AMC) in 2017 were attributed to the ACO. Data were analyzed from April 2020 to March 2021.
MAIN OUTCOMES AND MEASURES
Primary outcomes were total cost of care and care utilization during the 2018 performance year.
RESULTS
Among 930 266 children and young adults (377 233 children [40.6%] aged 6-12 years; 470 612 [50.6%] female) enrolled in Medicare in North Carolina in 2017, 27 290 children and young adults were attributed to the ACO. A total of 12 306 Black non-Hispanic children and young adults (45.1%), 6308 Hispanic or Latinx children and young adults (23.1%), and 6531 White non-Hispanic children and young adults (23.9%) were included. Most attributed individuals (23 133 individuals [84.7%]) had at least 1 claim in the performance year. The median (IQR) total cost of care in 2018 was $347 ($107-$1123); 272 individuals (1.0%) accounted for nearly half of total costs. Compared with children and young adults in the lowest-cost quartile, those in the highest-cost quartile were more likely to have complex medical conditions (399 individuals [6.9%] vs 3442 individuals [59.5%]) and to live farther from the AMC (median [IQR distance, 6.0 [4.6-20.3] miles vs 13.9 [4.6-30.9] miles). Total cost of care was accrued in home (43%), outpatient specialty (19%), inpatient (14%) and primary (8%) care. More than half of attributed children and young adults received care outside of the ACO; the median (IQR) cost for leaked care was $349 ($130-$1326). The costliest leaked encounters included inpatient, ancillary, and home health care, while the most frequently leaked encounters included behavioral health, emergency, and primary care.
CONCLUSIONS AND RELEVANCE
This cohort study found that while most children attributed to the hypothetical Medicaid pediatric ACO lived locally with few health care encounters, a small group of children with medical complexity traveled long distances for care and used frequent and costly home-based and outpatient specialty care. Leaked care was substantial for all attributed children, with the cost of leaked care being higher than the total cost of care. These pediatric-specific clinical and utilization profiles have implications for future pediatric ACO design choices related to attribution, accounting for children with high costs, and strategies to address leaked care.
Topics: Child; Humans; Aged; Female; United States; Male; Medicaid; Accountable Care Organizations; Medicare; North Carolina; Cohort Studies; Retrospective Studies
PubMed: 37540515
DOI: 10.1001/jamanetworkopen.2023.27264 -
Journal of the Academy of Nutrition and... May 2024
Topics: Humans; Motivation; Diet; Food; Food Assistance; Food Supply
PubMed: 38052306
DOI: 10.1016/j.jand.2023.11.023 -
American Journal of Public Health Dec 2023Enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is suboptimal, particularly for eligible children aged 1 to 4 years. We...
Enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is suboptimal, particularly for eligible children aged 1 to 4 years. We used converged data from key informants from October 2021 to January 2023 to understand the barriers to and opportunities for WIC utilization and the role of the health care provider in links to WIC. Families and WIC staff identified gaps in provider knowledge and an expressed need for improved collaboration between health providers and WIC. (. 2023;113(S3):S220-S223. https://doi.org/10.2105/AJPH.2023.307443).
Topics: Infant; Child; Humans; Female; Food Assistance; Nutritional Status
PubMed: 38118102
DOI: 10.2105/AJPH.2023.307443 -
Psychiatric Services (Washington, D.C.) Aug 2023Dual Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage (MA) plan for individuals who have both Medicare and Medicaid coverage. The authors compared...
OBJECTIVE
Dual Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage (MA) plan for individuals who have both Medicare and Medicaid coverage. The authors compared the breadths of psychiatrist and nonpsychiatrist provider networks in D-SNPs and other MA plans.
METHODS
MA plan provider network data were merged with plan service areas and a nationwide provider database to form a data set with 843 observations on networks subclassified by state and network type (D-SNP or other MA) covering 42 U.S. states and Washington, D.C. Network breadth measured the in-network fraction of clinically active Medicare-accepting psychiatrists and other physician providers in the plans' service areas in each state. Regression analyses were used to compare psychiatrist and nonpsychiatrist network breadth and psychiatrist-nonpsychiatrist breadth differences between D-SNPs and other MA plans, after adjustment for state-level differences.
RESULTS
Mean psychiatrist network breadth was 0.319 in D-SNPs and 0.299 in other MA plans, and nonpsychiatrist network breadth was 0.346 in D-SNPs and 0.358 in other MA plans. Psychiatrist networks were narrower than nonpsychiatrist networks (0.303 vs. 0.355, p<0.001), but mean psychiatrist network breadth did not differ between D-SNPs and other MA plans. In regression analyses, the psychiatrist-nonpsychiatrist breadth difference was smaller in D-SNPs (-0.031) than in other MA plans (-0.060) (p0.002).
CONCLUSIONS
Psychiatrist provider networks in a nationwide sample of D-SNPs had similar breadth as psychiatrist networks used in other MA plans. Special provider network adequacy requirements for psychiatrists in D-SNP networks may be worthy of further consideration given D-SNPs' disproportionate enrollment of adults with serious mental illness who have dual Medicare-Medicaid insurance coverage.
Topics: Aged; Humans; United States; Medicare Part C; Medicaid; Physicians; Psychiatry; Insurance Coverage
PubMed: 36789608
DOI: 10.1176/appi.ps.20220239 -
JCO Oncology Practice Jan 2024Oral anticancer drugs (OACDs) have become increasingly prevalent over the past decade. OACD prescriptions require coordination between payers and providers, which can...
PURPOSE
Oral anticancer drugs (OACDs) have become increasingly prevalent over the past decade. OACD prescriptions require coordination between payers and providers, which can delay drug receipt. We examined the association between insurance type, pursuit of copayment assistance, pursuit of prior authorization (PA), and time to receipt (TTR) for new OACD prescriptions.
METHODS
We prospectively collected data on new OACD prescriptions for adult oncology patients from January 1, 2018, to December 31, 2019, including demographic and clinical characteristics, insurance type, and pursuit of PA and copayment assistance. TTR was defined as the number of days from prescription to OACD receipt. We summarized TTR using cumulative incidence and compared TTR by insurance type, pursuit of copayment assistance, and PA activity using the log-rank test.
RESULTS
Our cohort of 1,024 patients was 53% male, and 40% were younger than 65. Twenty-six percent had commercial insurance only, 16% had Medicaid only, and 59% had Medicare with or without additional insurance. Eighty-six percent of prescriptions were successfully received. Across all prescriptions, 69% involved PA activity, and 21% involved the copayment assistance process. In unadjusted analyses, prescriptions involving the copayment assistance process had longer TTR compared with those not involving assistance (log-rank value = .005) and OACDs covered by Medicare/commercial insurance had a longer TTR compared with Medicaid (log-rank value = .006). The PA process was not associated with TTR (log-rank value = .124).
CONCLUSION
The process for obtaining OACDs is complex. The copayment assistance process and Medicare/commercial insurance are associated with delayed TTR. New policies are needed to reduce time to OACD receipt.
Topics: Aged; Adult; Humans; Male; United States; Female; Medicare; Prior Authorization; Antineoplastic Agents; Medicaid; Neoplasms
PubMed: 38033273
DOI: 10.1200/OP.23.00205 -
Health Services Research Aug 2023To test whether differences in hospital interoperability are related to the extent to which hospitals treat groups that have been economically and socially marginalized.
OBJECTIVE
To test whether differences in hospital interoperability are related to the extent to which hospitals treat groups that have been economically and socially marginalized.
DATA SOURCES AND STUDY SETTING
Data on 2393 non-federal acute care hospitals in the United States from the American Hospital Association Information Technology Supplement fielded in 2021, the 2019 Medicare Cost Report, and the 2019 Social Deprivation Index.
STUDY DESIGN
Cross-sectional analysis.
DATA COLLECTION/EXTRACTION METHODS
We identified five proxy measures related to marginalization and assessed the relationship between those measures and the likelihood that hospitals engaged in all four domains of interoperable information exchange and participated in national interoperability networks in cross-sectional analysis.
PRINCIPAL FINDINGS
In unadjusted analysis, hospitals that treated patients from zip codes with high social deprivation were 33% less likely to engage in interoperable exchange (Relative Risk = 0.67, 95% CI: 0.58-0.76) and 24% less likely to participate in a national network than all other hospitals (RR = 0.76; 95% CI: 0.66-0.87). Critical Access Hospitals (CAH) were 24 percent less likely to engage in interoperable exchange (RR = 0.76; 95% CI: 0.69-0.83) but not less likely to participate in a national network (RR = 0.97; 95% CI: 0.88-1.06). No difference was detected for 2 measures (high Disproportionate Share Hospital percentage and Medicaid case mix) while 1 was associated with a greater likelihood to engage (high uncompensated care burden). The association between social deprivation and interoperable exchange persisted in an analysis examining metropolitan and rural areas separately and in adjusted analyses accounting for hospital characteristics.
CONCLUSIONS
Hospitals that treat patients from areas with high social deprivation were less likely to engage in interoperable exchange than other hospitals, but other measures were not associated with lower interoperability. The use of area deprivation data may be important to monitor and address hospital clinical data interoperability disparities to avoid related health care disparities.
Topics: Aged; Humans; United States; Cross-Sectional Studies; Medicare; Hospitals; Uncompensated Care; Medicaid
PubMed: 37219368
DOI: 10.1111/1475-6773.14165 -
Family Practice Management Jan 2024
Topics: Aged; United States; Humans; Medicare; Physicians, Family
PubMed: 38194303
DOI: No ID Found -
Community Dentistry and Oral... Feb 2024Exemption from paying dental care costs among recipients of public assistance contributes to universal health care coverage. Although this system might reduce the...
OBJECTIVES
Exemption from paying dental care costs among recipients of public assistance contributes to universal health care coverage. Although this system might reduce the financial barriers to dental care among patients, there are still several other barriers for public assistance recipients. Therefore, this study examined whether receiving public assistance was associated with a higher prevalence of dental visits for any reason, treatment and prevention.
METHODS
Data were obtained from 16 366 respondents from the 2019 wave of a nationwide cohort study on older adults in Japan. Poisson regression analyses with robust error variance were used to examine the associations between receiving public assistance and dental visits, adjusting for number of teeth, dental pain, periodontal conditions, age, sex, number of family members, education, equivalent household income, working status, instrumental activities of daily living, medical conditions, depressive symptoms, instrumental support and geographical variations.
RESULTS
More than half of the non-recipients of public assistance visited a dentist for some reason in the past 6 months. Meanwhile, only 37% of the recipients visited a dentist. In addition, almost half of the non-recipients had treatment visits, while only 34% of the recipients visited. Furthermore, 46% of the non-recipients had dental visits for prevention, while 32% of the recipients had preventive visits. In the fully adjusted models, compared to non-recipients, public assistance recipients were 24% (Prevalence Ratio [PR]: 0.76, 95% Confidence Intervals [CI]: 0.64, 0.90), 23% (PR: 0.77, 95% CI: 0.65, 0.92) and 21% (PR: 0.79, 95% CI: 0.65, 0.95) less likely to have dental visits for any reason, treatment, and prevention, respectively.
CONCLUSIONS
Although recipients were exempted from dental treatment fees, receiving public assistance was associated with a lower prevalence of dental visits for any reason, treatment and prevention. Future studies should identify the barriers to accessing dental care among public assistance recipients to improve dental visits.
Topics: Humans; Aged; Japan; Prevalence; Activities of Daily Living; Cohort Studies; Public Assistance
PubMed: 37555616
DOI: 10.1111/cdoe.12902 -
JAMA Feb 2024
Topics: Humans; Health Personnel; Medicaid; United States; Patient Protection and Affordable Care Act
PubMed: 38411657
DOI: 10.1001/jama.2023.27155 -
JAMA Surgery Apr 2024
Topics: Humans; United States; Insurance, Health; Medicaid; Health Services Accessibility; Insurance Coverage
PubMed: 38324305
DOI: 10.1001/jamasurg.2023.7536