-
JAMA Health Forum Dec 2023Hospice care enhances quality of life for people with terminal illness and is most beneficial with longer length of stay (LOS). Most hospice research focuses on the...
IMPORTANCE
Hospice care enhances quality of life for people with terminal illness and is most beneficial with longer length of stay (LOS). Most hospice research focuses on the Medicare-insured population. Little is known about hospice use for the racially and ethnically diverse, low-income Medicaid population.
OBJECTIVE
To compare hospice use and hospice LOS by race and ethnicity among Medicaid-only individuals and those with dual eligibility for Medicare and Medicaid (duals) in the Connecticut Medicaid program who died over a 4-year period.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective population-based cohort study used Medicaid and traditional Medicare enrollment and claims data for 2015 to 2020. The study included Connecticut Medicaid recipients with at least 1 of 5 most common hospice diagnoses who died from 2017 to 2020.
EXPOSURE
Race and ethnicity.
MAIN OUTCOMES AND MEASURES
Hospice use (yes/no) and hospice LOS (1-7 days vs ≥8 days.) Covariates included sex, age, and nursing facility stay within 60 days of death.
RESULTS
Overall, 2407 and 23 857 duals were included. Medicaid-only decedents were younger (13.8% ≥85 vs 52.5%), more likely to be male (50.6% vs 36.4%), more racially and ethnically diverse (48.7% non-Hispanic White vs 79.9%), and less likely to have a nursing facility stay (34.9% vs 56.1%). Race and ethnicity were significantly associated with hospice use and LOS in both populations: non-Hispanic Black and Hispanic decedents had lower odds of using hospice than non-Hispanic White decedents, and Hispanic decedents had higher odds of a short LOS. In both populations, older age and female sex were also associated with more hospice use. For duals only, higher age was associated with lower odds of short LOS. For decedents with nursing facility stays, compared with those without, Medicaid-only decedents had higher odds of using hospice (odds ratio [OR], 1.49; 95% CI, 1.24-1.78); duals had lower odds (OR, 0.60; 95% CI, 0.57-0.63). Compared with decedents without nursing facility stays, duals with a nursing facility stay had higher odds of short LOS (OR, 2.63; 95% CI, 2.43-2.85).
CONCLUSIONS AND RELEVANCE
Findings raise concerns about equity and timing of access to hospice for Hispanic and non-Hispanic Black individuals in these understudied Medicaid populations. Knowledge about, access to, and acceptance of hospice may be lacking for these low-income individuals. Further research is needed to understand barriers to and facilitators of hospice use for people with nursing facility stays.
Topics: Aged; Humans; Male; Female; United States; Hospice Care; Hospices; Medicaid; Medicare; Retrospective Studies; Cohort Studies; Quality of Life
PubMed: 38064239
DOI: 10.1001/jamahealthforum.2023.4240 -
JAMA Health Forum Jun 2024States resumed Medicaid eligibility redeterminations, which had been paused during the COVID-19 public health emergency, in 2023. This unwinding of the pandemic...
IMPORTANCE
States resumed Medicaid eligibility redeterminations, which had been paused during the COVID-19 public health emergency, in 2023. This unwinding of the pandemic continuous coverage provision raised concerns about the extent to which beneficiaries would lose Medicaid coverage and how that would affect access to care.
OBJECTIVE
To assess early changes in insurance and access to care during Medicaid unwinding among individuals with low incomes in 4 Southern states.
DESIGN, SETTING, AND PARTICIPANTS
This multimodal survey was conducted in Arkansas, Kentucky, Louisiana, and Texas from September to November 2023, used random-digit dialing and probabilistic address-based sampling, and included US citizens aged 19 to 64 years reporting 2022 incomes at or less than 138% of the federal poverty level.
EXPOSURE
Medicaid enrollment at any point since March 2020, when continuous coverage began.
MAIN OUTCOMES AND MEASURES
Self-reported disenrollment from Medicaid, insurance at the time of interview, and self-reported access to care. Using multivariate logistic regression, factors associated with Medicaid loss were evaluated. Access and affordability of care among respondents who exited Medicaid vs those who remained enrolled were compared, after multivariate adjustment.
RESULTS
The sample contained 2210 adults (1282 women [58.0%]; 505 Black non-Hispanic individuals [22.9%], 393 Hispanic individuals [17.8%], and 1133 White non-Hispanic individuals [51.3%]) with 2022 household incomes less than 138% of the federal poverty line. On a survey-weighted basis, 1564 (70.8%) reported that they and/or a dependent child of theirs had Medicaid at some point since March 2020. Among adult respondents who had Medicaid, 179 (12.5%) were no longer enrolled in Medicaid at the time of the survey, with state estimates ranging from 7.0% (n = 19) in Kentucky to 16.2% (n = 82) in Arkansas. Fewer children who had Medicaid lost coverage (42 [5.4%]). Among adult respondents who left Medicaid since 2020 and reported coverage status at time of interview, 47.8% (n = 80) were uninsured, 27.0% (n = 45) had employer-sponsored insurance, and the remainder had other coverage as of fall 2023. Disenrollment was higher among younger adults, employed individuals, and rural residents but lower among non-Hispanic Black respondents (compared with non-Hispanic White respondents) and among those receiving Supplemental Nutrition Assistance Program benefits. Losing Medicaid was significantly associated with delaying care due to cost and worsening affordability of care.
CONCLUSIONS AND RELEVANCE
The results of this survey study indicated that 6 months into unwinding, 1 in 8 Medicaid beneficiaries reported exiting the program, with wide state variation. Roughly half who lost Medicaid coverage became uninsured. Among those moving to new coverage, many experienced coverage gaps. Adults exiting Medicaid reported more challenges accessing care than respondents who remained enrolled.
Topics: Humans; Medicaid; United States; Health Services Accessibility; Adult; Female; Male; Insurance Coverage; Middle Aged; COVID-19; Poverty; Young Adult; Arkansas
PubMed: 38943683
DOI: 10.1001/jamahealthforum.2024.2193 -
Dental Clinics of North America Jan 2024The one provider anesthesia model used in oral and maxillofacial surgery (OMS) practices has been a subject of debate due to concerns about patient safety, inadequate... (Review)
Review
The one provider anesthesia model used in oral and maxillofacial surgery (OMS) practices has been a subject of debate due to concerns about patient safety, inadequate attention, and mortality and morbidity rates. Historically, OMS specialists have made significant contributions to modern anesthesia; however, recent changes in Centers for Medicare and Medicaid Services have led to increased scrutiny of the OMS anesthesia model. Proponents argue that the model is safe and effective, thanks to well-trained Dental Anesthesia Assistants and OMS surgeons' extensive experience in dental anesthesia cases.
Topics: Aged; Humans; United States; Medicare; Surgery, Oral; Anesthesia; Medicaid; Patient Safety
PubMed: 37951639
DOI: 10.1016/j.cden.2023.07.006 -
The Journal of Mental Health Policy and... Dec 2023In the US, much of the research into new intervention and delivery models for behavioral health care is funded by research institutes and foundations, typically through... (Review)
Review
BACKGROUND
In the US, much of the research into new intervention and delivery models for behavioral health care is funded by research institutes and foundations, typically through grants to develop and test the new interventions. The original grant funding is typically time-limited. This implies that eventually communities, clinicians, and others must find resources to replace the grant funding -otherwise the innovation will not be adopted. Diffusion is challenged by the continued dominance in the US of fee-for-service reimbursement, especially for behavioral health care.
AIMS
To understand the financial challenges to disseminating innovative behavioral health delivery models posed by fee-for-service reimbursement, and to explore alternative payment models that promise to accelerate adoption by better addressing need for flexibility and sustainability.
METHODS
We review US experience with three specific novel delivery models that emerged in recent years. The models are: collaborative care model for depression (CoCM), outpatient based opioid treatment (OBOT), and the certified community behavioral health clinic (CCBHC) model. These examples were selected as illustrating some common themes and some different issues affecting diffusion. For each model, we discuss its core components; evidence on its effectiveness and cost-effectiveness; how its dissemination was funded; how providers are paid; and what has been the uptake so far.
RESULTS
The collaborative care model has existed for longest, but has been slow to disseminate, due in part to a lack of billing codes for key components until recently. The OBOT model faced that problem, and also (until recently) a regulatory requirement requiring physicians to obtain federal waivers in order to prescribe buprenorphine. Similarly, the CCBHC model includes previously nonbillable services, but it appears to be diffusing more successfully than some other innovations, due in part to the approach taken by funders.
DISCUSSION
A common challenge for all three models has been their inclusion of services that were not (initially) reimbursable in a fee-for-service system. However, even establishing new procedure codes may not be enough to give providers the flexibility needed to implement these models, unless payers also implement alternative payment models.
IMPLICATIONS FOR HEALTH CARE PROVISION AND USE
For providers who receive time-limited grant funding to implement these novel delivery models, one key lesson is the need to start early on planning how services will be sustained after the grant ends.
IMPLICATIONS FOR HEALTH POLICY
For research funders (e.g., federal agencies), it is clearly important to speed up the process of obtaining coverage for each novel delivery model, including the development of new billable service codes, and to plan for this as early as possible. Funders also need to collaborate with providers early in the grant period on sustainability planning for the post-grant environment. For payers, a key lesson is the need to fold novel models into stable existing funding streams such as Medicaid and commercial insurance coverage, rather than leaving them at the mercy of revolving time-limited grants, and to provide pathways for contracting for innovations under new payment models.
IMPLICATIONS FOR FURTHER RESEARCH
For researchers, a key recommendation would be to pay greater attention to the payment environment when designing new delivery models and interventions.
Topics: United States; Humans; Fee-for-Service Plans; Medicaid; Ambulatory Care Facilities
PubMed: 38113385
DOI: No ID Found -
Journal of Environmental Management Feb 2024Understanding the dynamics between public disaster assistance, disaster damages, and social vulnerability at county-level is crucial for designing effective disaster...
Understanding the dynamics between public disaster assistance, disaster damages, and social vulnerability at county-level is crucial for designing effective disaster mitigation strategies. This study utilized the Local Bivariate Moran Index (LBMI) and geographically weighted regression (GWR) models to examine spatial patterns and relationships between disaster damages, social vulnerability, and public disaster assistance in contiguous US counties from 2001 to 2021. LBMI results reveal that public disaster assistance has predominantly been directed towards post-disaster recovery efforts, with a particular focus on coastal communities affected by major declared disasters. However, the distributions of public assistance and individual housing assistance, which are the two primary sources of public disaster assistance, do not adequately cover physically and socially vulnerable communities. The distribution of pre-disaster risk mitigation also falls short of sufficiently covering vulnerable communities. Results further indicate the complex interactions between different categories of natural disasters and public assistances. The GWR model results demonstrate spatial variations in predicting each category of public disaster assistance. These findings indicate the need to address disparities in accessing public disaster assistance in the US, and advocate for more equitable disaster mitigation strategies.
Topics: Social Vulnerability; Disasters; Housing; Public Assistance
PubMed: 38048707
DOI: 10.1016/j.jenvman.2023.119690 -
The Milbank Quarterly Dec 2023Policy Points Little attention to date has been directed at examining how the long-term services and supports (LTSS) environmental context affects the health and...
UNLABELLED
Policy Points Little attention to date has been directed at examining how the long-term services and supports (LTSS) environmental context affects the health and well-being of older adults with disabilities. We develop a conceptual framework identifying environmental domains that contribute to LTSS use, care quality, and care experiences. We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain; increased neighborhood social and economic deprivation are highly associated with experiencing adverse consequences due to unmet need, whereas availability and generosity of the health care and social services delivery environment are inversely associated with participation restrictions in valued activities. Policies targeting local and state-level LTSS-relevant environmental characteristics stand to improve the health and well-being of older adults with disabilities, particularly as it relates to adverse consequences due to unmet need and participation restrictions.
CONTEXT
Long-term services and supports (LTSS) in the United States are characterized by their patchwork and unequal nature. The lack of generalizable person-reported information on LTSS care experiences connected to place of community residence has obscured our understanding of inequities and factors that may attenuate them.
METHODS
We advance a conceptual framework of LTSS-relevant environmental domains, drawing on newly available data linkages from the 2015 National Health and Aging Trends Study to connect person-reported care experiences with public use spatial data. We assess relationships between LTSS-relevant environmental characteristic domains and person-reported care adverse consequences due to unmet need, participation restrictions, and subjective well-being for 2,411 older adults with disabilities and for key population subgroups by race, dementia, and Medicaid enrollment status.
FINDINGS
We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain. Measures of neighborhood social and economic deprivation (e.g., poverty, public assistance, social cohesion) are highly associated with experiencing adverse consequences due to unmet care needs. Measures of the health care and social services delivery environment (e.g., Medicaid Home and Community-Based Service Generosity, managed LTSS [MLTSS] presence, average direct care worker wage, availability of paid family leave) are inversely associated with experiencing participation restrictions in valued activities. Select measures of the built and natural environment (e.g., housing affordability) are associated with participation restrictions and lower subjective well-being. Observed relationships between measures of LTSS-relevant environmental characteristics and care experiences were generally held in directionality but were attenuated for key subpopulations.
CONCLUSIONS
We present a framework and analyses describing the variable relationships between LTSS-relevant environmental factors and person-reported care experiences. LTSS-relevant environmental characteristics are differentially relevant to the care experiences of older adults with disabilities. Greater attention should be devoted to strengthening state- and community-based policies and practices that support aging in place.
Topics: Humans; United States; Aged; Long-Term Care; Independent Living; Disabled Persons; Medicaid; Health Services Needs and Demand
PubMed: 37503792
DOI: 10.1111/1468-0009.12664 -
JAMA Health Forum Aug 2023Better evidence is needed on whether Medicare Advantage (MA) plans can control the use of postacute care services while achieving excellent outcomes.
IMPORTANCE
Better evidence is needed on whether Medicare Advantage (MA) plans can control the use of postacute care services while achieving excellent outcomes.
OBJECTIVE
To compare self-reported use of postacute care services and outcomes among traditional Medicare (TM) beneficiaries and MA enrollees.
DESIGN, SETTING, AND PARTICIPANTS
This cohort study used data from the National Health and Aging Trends Study (NHATS) with linked Medicare enrollment data from 2015 to 2017. Participants were community-dwelling MA or TM beneficiaries 70 years and older; those with dual Medicare and Medicaid eligibility were also identified. Analyses were conducted from May 2022 to February 2023 and were weighted to account for the complex survey design.
EXPOSURES
Enrollment in MA and dual eligibility for Medicare and Medicaid.
MAIN OUTCOMES AND MEASURES
Postacute care service use including site of use, duration, primary indication, and whether participants met their goals or experienced improved functional status during or after services.
RESULTS
Included in the analysis were 2357 Medicare beneficiaries who used postacute care. Of these beneficiaries, 815 (32.6%; 62.0% were females [weighted percentages]) had MA and 1542 (67.4%; 59.5% were females [weighted percentages]) had TM. Enrollees in MA reported using postacute care services across all NHATS survey rounds: between 16.2% (95% CI, 14.3%-18.4%) and 17.7% (95% CI, 15.4%-20.4%) of MA enrollees reported using postacute care services each round, vs 22.4% (95% CI, 20.9%-24.1%) to 24.1% (95% CI, 21.8%-26.6%) of TM beneficiaries (P for all rounds <.002). Enrollees in MA reported less functional improvement during postacute care use (63.1% [95% CI, 59.2%-66.8%] vs 71.7% [95% CI, 68.9%-74.3%], P < .001). Among beneficiaries who ended postacute service use, fewer MA enrollees than TM enrollees reported that they met their goals (70.5% [95% CI, 65.1%-75.3%] vs 76.2% [95% CI, 73.1%-79.1%]; P = .053) or had improved functional status (43.9% [95% CI, 38.9%-49.1%] vs 46.0% [95% CI, 42.5%-49.5%]; P = .42), but differences were not statistically significant. Differences in postacute care use and functional improvement were not statistically significant between MA and TM enrollees with dual eligibility.
CONCLUSIONS AND RELEVANCE
In this cohort study of Medicare beneficiaries, we found that MA enrollees overall used less postacute care services than their TM counterparts. Among users of postacute care services, MA enrollees reported less favorable outcomes compared with TM enrollees. These findings highlight the importance of assessing patient-reported outcomes, especially as MA and other payment models seek to reduce inefficient use of postacute care services.
Topics: United States; Female; Aged; Humans; Male; Medicare Part C; Cohort Studies; Subacute Care; Medicaid; Aging
PubMed: 37594745
DOI: 10.1001/jamahealthforum.2023.2517 -
Nursing Philosophy : An International... Oct 2023Canadian nursing practice has been profoundly influenced by the legalization of medical assistance in dying in 2016, requiring that nurses navigate new and sometimes...
Canadian nursing practice has been profoundly influenced by the legalization of medical assistance in dying in 2016, requiring that nurses navigate new and sometimes highly challenging experiences. Findings from our longitudinal studies of nurses' experiences suggest that these include deep emotional responses to medical assistance in dying, an urgency in orchestrating the perfect death, and a high degree of relational impact, both professionally and personally. Here we propose a theoretical explanation for these experiences based upon a relational ontology. Drawing upon the work of Wildman, we understand a relational ontology to be one in which relationships are more fundamentally central than the conceptual entities that provide the context to practice. It is in a relationship that conceptual entities, and their affiliated values, are created and recreated. Seen as causal, relationships have ontological status, with important implications for how we consider the concepts of death, suffering, and time in this context. From a conceptual perspective, suffering is primarily self-defined based upon personal histories, time reflects the potential remaining until death, and death is primarily biological and amoral, although social discourses of a good and bad death surround the death trajectory. However, within a relational ontology of medical assistance in dying, these understandings shift. Death becomes primarily social rather than biological, suffering is shared, and time until death is now clearly delimited. Accordingly, nurses assume a profound responsibility for influencing outcomes that are authentically person-centered. These understandings provide important insights into nurses' experiences, enabling us to recognize the causal effects, both intended and unintended, of nurses' relational practices amidst the complexities of assisted death. Drawing on such a perspective, we find implications for how we provide spaces for nurses to reflect on, and have conversations about, their experiences with some of the greatest mysteries of life-death, suffering, and time.
Topics: Humans; Canada; Suicide, Assisted; Medical Assistance
PubMed: 37032463
DOI: 10.1111/nup.12438 -
Frontiers in Public Health 2023Purchasing produce at farmers markets represents one method by which individuals can purchase and have access to healthful and seasonal fruits. Despite the extension of...
INTRODUCTION
Purchasing produce at farmers markets represents one method by which individuals can purchase and have access to healthful and seasonal fruits. Despite the extension of nutrition assistance programs to local farmers markets, fruit and vegetables consumption has remained below the recommended guidelines, specifically in rural geographical locations.
STATEMENT OF PURPOSE
The purpose of the study was to explore the aspects of the Link Up Illinois Double Value SNAP Nutrition Incentives Program (DVCP) and its effects on food selection at rural farmers markets for individuals enrolled in nutrition assistance programs.
METHODS/APPROACH
The current study uses a qualitative methodology in order to uncover barriers local health departments and farmers markets face to implementing the DVCP in their communities and to discover the perspectives of low-income individuals who utilize the DVCP. This paper explores the organizational and community member perceptions of the DVCP and its administration. Semi-structured interviews and one focus group were conducted with health educators from county health departments, DVCP stakeholders, farmers market managers, local farmers, and residents who used the DVCP. A purposeful sampling method was used, intentionally selecting individuals with lived experiences of the research objective. Data were analyzed using a three-cycle coding process, then categorized into overarching themes until thematic saturation was reached.
RESULTS
There were a total of 19 individuals who participated in the study. Five themes and four subthemes emerged from data analysis, including organizational capacity, exposure to the DVCP, purchasing power, DVCP advancements, and values.
CONCLUSION/IMPLICATIONS
These findings contextualize the facilitators and barriers of multiple stakeholders when implementing nutrition assistance programs at farmers markets. Other similar "double value" programs can utilize these lessons when seeking to increase participation of underrepresented populations at local farmers markets.
Topics: Humans; Food Supply; Vegetables; Fruit; Food Assistance; Illinois
PubMed: 37483939
DOI: 10.3389/fpubh.2023.1125069 -
American Journal of Surgery Oct 2023This study highlights the implications of surgical disparities on health care spending. The strengths of this study include pinning down the potential etiologies of how...
This study highlights the implications of surgical disparities on health care spending. The strengths of this study include pinning down the potential etiologies of how surgical disparities contribute to excessive spending. Prior studies have focused primarily on individual social factors, yet this study takes into consideration the financial implications of disparities from multiple levels. Black patients face more challenges in cancer care in part due to late stage presentation and diagnosis, as well as increased exposure to risk factors that place them under a disproportionate burden of disease and risk of post-operative complications. We commend the authors for broaching this rarely discussed and costly combination of minority race and dual eligibility contributing to a "multiple hit" phenomenon that our most vulnerable patients face.
Topics: Aged; Humans; United States; Medicare; Patients; Healthcare Disparities
PubMed: 37500300
DOI: 10.1016/j.amjsurg.2023.07.021