Pregnancy Medicaid Improvements in a Nonexpansion State After the Affordable Care Act.

One-half of women in the United States use Medicaid during pregnancy. Women living in states that did not expand Medicaid under the Patient Protection and Affordable Care Act (ACA) are at risk of losing coverage post partum. We analyzed Medicaid claims and vital statistics for the state of North Carolina for the period 2011 to 2017. North Carolina did not expand Medicaid but did alter Medicaid enrollment to meet ACA requirements. After implementation, enrollment in full Medicaid during pregnancy almost doubled, and enrollment in Medicaid for pregnant women decreased. Full Medicaid offers more comprehensive coverage and does not expire at 60 days post partum, allowing for access to crucial preventive health services including contraception and primary care.

Assessment of the Cost-Effectiveness of a Brief Video Intervention for Sexually Transmitted Disease Prevention.

BACKGROUND: Cost-effective, scalable interventions are needed to address high rates of sexually transmitted diseases (STDs) in the United States. Safe in the City, a 23-minute video intervention designed for STD clinic waiting rooms, effectively reduced new infections among STD clinic clients. A cost-effectiveness analysis of this type of intervention could inform whether it should be replicated. METHODS: The cost-effectiveness of a brief video intervention was calculated under a baseline scenario in which this type of intervention was expanded to a larger patient population. Alternative scenarios included expanding the intervention over a longer period or to more clinics, including HIV prevention benefits, and operating the intervention part time. Program costs, net costs per STD case averted, and the discounted net cost of the intervention were calculated from a health sector perspective across the scenarios. Monte Carlo simulations were used to calculate 95% confidence intervals surrounding the cost-effectiveness measures. RESULTS: The net cost per case averted was $75 in the baseline scenario. The net cost of the intervention was $108,015, and most of the alternative scenarios found that the intervention was cost saving compared with usual care. CONCLUSIONS: Single session, video-based interventions can be highly cost effective when implemented at scale. Updated video-based interventions that account for the changing STD landscape in the United States could play an important role in addressing the recent increases in infections.

Evaluating the effect of Medicaid expansion on access to preventive reproductive care for women in Oregon.

We evaluated the effect of the Affordable Care Act (ACA) Medicaid expansion on receipt of preventive reproductive services for women in Oregon. First, we compared service receipt among continuing Medicaid enrollees pre- and post-ACA. We then compared receipt among new post-ACA Medicaid enrollees to receipt by continuing enrollees after ACA implementation. Using Medicaid enrollment and claims data, we identified well-woman visits, contraceptive counseling, contraceptive services, sexually transmitted infection (STI) screening, and cervical cancer screening among women ages 15-44 in years when not pregnant. For pre-ACA enrollees, we assessed pre-ACA receipt in 2011-2013 (n = 83,719) and post-ACA receipt in 2014-2016 (n = 103,225). For post-ACA enrollees we similarly assessed post-ACA service receipt (n = 73,945) and compared this to service receipt by pre-ACA enrollees during 2014-2016. We estimated logistic regression models to compare service receipt over time and between enrollment groups. Among pre-ACA enrollees we found lower receipt of all services post-ACA. Adjusted declines ranged from 7.0 percentage points (95% CI: -7.5, -6.4) for cervical cancer screening to 0.4 percentage points [-0.6, -0.2] for STI screening. In 2014-2016, post-ACA enrollees differed significantly from pre-ACA enrollees in receipt of all services, but all differences were <2 percentage points. Despite small declines in receipt of several preventive reproductive services among prior enrollees, the ACA resulted in Medicaid financing of these services for a large number of newly enrolled low-income women in Oregon, which may eventually lead to population-level improvements in reproductive health. These findings among women in Oregon could inform Medicaid coverage efforts in other states.

The influence of healthcare financing on cardiovascular disease prevention in people living with HIV.

BACKGROUND: People living with HIV are diagnosed with age-related chronic health conditions, including cardiovascular disease, at higher than expected rates. Medical management of these chronic health conditions frequently occur in HIV specialty clinics by providers trained in general internal medicine, family medicine, or infectious disease. In recent years, changes in the healthcare financing for people living with HIV in the U.S. has been dynamic due to changes in the Affordable Care Act. There is little evidence examining how healthcare financing characteristics shape primary and secondary cardiovascular disease prevention among people living with HIV. Our objective was to examine the perspectives of people living with HIV and their healthcare providers on how healthcare financing influences cardiovascular disease prevention. METHODS: As part of the EXTRA-CVD study, we conducted in-depth, semi-structured interviews with 51 people living with HIV and 34 multidisciplinary healthcare providers and at three U.S. HIV clinics in Ohio and North Carolina from October 2018 to March 2019. Thematic analysis using Template Analysis techniques was used to examine healthcare financing barriers and enablers of cardiovascular disease prevention in people living with HIV. RESULTS: Three themes emerged across sites and disciplines (1): healthcare payers substantially shape preventative cardiovascular care in HIV clinics (2); physician compensation tied to relative value units disincentivizes cardiovascular disease prevention efforts by HIV providers; and (3) grant-based services enable tailored cardiovascular disease prevention, but sustainability is limited by sponsor priorities. CONCLUSIONS: With HIV now a chronic disease, there is a growing need for HIV-specific cardiovascular disease prevention; however, healthcare financing complicates effective delivery of this preventative care. It is important to understand the effects of evolving payer models on patient and healthcare provider behavior. Additional systematic investigation of these models will help HIV specialty clinics implement cardiovascular disease prevention within a dynamic reimbursement landscape. TRIAL REGISTRATION: Clinical Trial Registration Number: NCT03643705 .

Community Pharmacy Engagement in Diabetes Prevention: Key Informant Interviews with Pharmacy Executives.

INTRODUCTION: Even though evidence-based diabetes prevention interventions exist, more than 1 in 3 Americans have prediabetes; the use of pharmacies has been explored as a way to reach and care for this population. The objective of this study was to analyze factors that influence adoption of type 2 diabetes prevention programs by community pharmacies. METHODS: We conducted 21 semistructured interviews in 2018 with decision makers from 11 independent pharmacies in 6 US states and the District of Columbia and from 10 chain pharmacies operating in 1 state, multiple states, and nationwide. We identified participants by using purposive sampling. We used qualitative methods to analyze data and conducted interviews until we reached saturation. RESULTS: Multiple themes emerged: 1) initiation of services is more likely if initial financial support is received; 2) patient demand for services, actual or perceived, is paramount; 3) diabetes prevention services often fit within the existing operations of a pharmacy and allow maximum use of resources; 4) customer loyalty is a clearly articulated advantage against competition; and 5) engagement in diabetes prevention affirms an expanded role and the value of pharmacies to serve communities. CONCLUSION: Pharmacies are well situated to deliver diabetes prevention programs to communities. Although considerable opportunity exists for pharmacies to address diabetes prevention, more could be done to reduce barriers to their use.

Investment in child and adolescent health and development: key messages from Disease Control Priorities, 3rd Edition.

The realisation of human potential for development requires age-specific investment throughout the 8000 days of childhood and adolescence. Focus on the first 1000 days is an essential but insufficient investment. Intervention is also required in three later phases: the middle childhood growth and consolidation phase (5-9 years), when infection and malnutrition constrain growth, and mortality is higher than previously recognised; the adolescent growth spurt (10-14 years), when substantial changes place commensurate demands on good diet and health; and the adolescent phase of growth and consolidation (15-19 years), when new responses are needed to support brain maturation, intense social engagement, and emotional control. Two cost-efficient packages, one delivered through schools and one focusing on later adolescence, would provide phase-specific support across the life cycle, securing the gains of investment in the first 1000 days, enabling substantial catch-up from early growth failure, and leveraging improved learning from concomitant education investments.

A Brief History of the Prevention and Public Health Fund: Implications for Public Health Advocates.

The nation's first broad-based, mandatory investment in public health and prevention, the Prevention and Public Health Fund (the Fund), has had a brief and controversial history. Advocates for the Fund have had to defend it from both Democratic and Republican threats, including being used as an offset for administration priorities, and from congressional efforts to repeal and replace the Patient Protection and Affordable Care Act. Lessons learned from efforts to sustain the Fund are instructive in addressing current and future challenges faced by advocates for public health programs and prevention policies.

Effectiveness of Medicare cost-sharing elimination for Cancer screening on utilization.

BACKGROUND: The Patient Protection and Affordable Care Act (ACA) eliminated the cost-sharing requirement for several preventive cancer screenings. This study examined the cancer screening utilization of mammogram, Pap smear and colonoscopy in Medicare fee-for-service (FFS) under the ACA. METHODS: The primary data were the 2007-2013 Medicare Current Beneficiary Survey linked to FFS claims. The effect of the cost-sharing removal on the probability of receiving a preventive cancer screening test was estimated using a logistic regression, separately for each screening test, adjusting for the complex survey design. The model was also separately estimated for different socioeconomic and race/ethnic groups. The study sample included beneficiaries with Part B coverage for the entire calendar year, excluding beneficiaries in Medicaid or Medicare Advantage plans. Beneficiaries with a claims-documented or self-reported history of targeted cancers, who were likely to have diagnostic tests or have surveillance screenings were excluded. The screening measures were constructed separately following Medicare coverage and U.S. Preventive Services Task Force (USPSTF) recommendations. We measured the screening utilization outcome drawing from claims data, as well as using the self-reported survey data. RESULTS: After the cost-sharing removal policy, we found no statistically significant difference in a beneficiary's probability of receiving a colonoscopy (transition period: OR = 1.08, 95% CI = 0.90-1.29; post-policy period: OR = 1.08, 95% CI = 0.83-1.42), a mammogram (transition period: OR = 1.03, 95% CI = 0.91-1.17; post-policy period: OR = 1.07, 95% CI = 0.88-1.30), or a biennial Pap smear (transition period: OR = 0.87, 95% CI = 0.69-1.09; post-policy period: OR = 0.72, 95% CI = 0.51-1.03) in claims-based measures following Medicare coverage. Similarly, we found null effects of the policy change on utilization of colonoscopy among enrollees 50-75 years old, biennial mammograms by women 50-74, and triennial Pap smear tests among women 21-65 in claims-based measures according to USPSTF. The findings from survey-based measures were consistent with the estimates from claims-based measures, except that the use of Pap smear declined since 2011. Further, the policy change did not increase utilization in patients with disadvantaged socioeconomic characteristics. Yet the disparate patterns in adjusted screening rates by socioeconomic status and race/ethnicity persisted over time. CONCLUSIONS: Removing out-of-pocket costs for screenings did not provide enough incentives to increase the screening rates among Medicare beneficiaries.

Integrating Retention Rates into Economic Analyses of Prevention Interventions.

Evidence-based prevention interventions hold great promise for enhancing the well-being of individuals, families, and society. As these interventions are implemented in new contexts and at wider scales, policymakers and private sector organizations are increasingly interested in understanding the economic returns that programs produce through reductions of burden on public service systems, such as criminal justice and human services. Thus, it is important to ensure that economic models account for factors, such as retention, which are important when interventions are implemented in real-world contexts with selective populations and voluntary participation. Yet the field of prevention has provided little guidance to help researchers and policymakers analyze the economics of interventions so that estimates reflect the impact of implementation factors on intervention cost-effectiveness. This paper discusses the role retention plays in the economic efficiency of interventions when the prevention of child maltreatment is the primary motivation for funding these programs. We present a conceptual model to serve as a guide for explicit inclusion of retention rates when calculating cost estimates to be used in cost-effectiveness analysis. A case study is presented, demonstrating the variability in estimates dependent on the definition of retention and the estimated retention rate. The results underscore the importance of improving our understanding of factors underlying and related to retention, such as engagement, which may improve the precision of cost and cost-effectiveness analysis in applied settings.

Preventive visit among older adults with Medicare's introduction of Annual Wellness Visit: Closing gaps in underutilization.

Preventive visit rates are low among older adults in the United States. We evaluated changes in preventive visit utilization with Medicare's introduction of Annual Wellness Visits (AWVs) in 2011. We further assessed how coverage expansion differentially affected older adults who were previously underutilizing the service. The study included Medicare beneficiaries aged 65 to 85 from a mixed-payer multispecialty outpatient healthcare organization in northern California between 2007 and 2016. Data from the electronic health records were used, and the unit of analysis was patient-year (N = 456,281). Multivariable logistic regression models were used to assess determinants of "any preventive visit" use. Prior to the AWV coverage (2007-2010), Medicare beneficiaries who were older, with serious chronic conditions, and with a fee-for-services (FFS) plan underutilized preventive visits such that odds ratio (OR) for age groups (vs. age 65-69) ranges from 0.826 (age 70-74) to 0.522 (age 80-85); for Charlson comorbidity index (CCI) (vs. 0 CCI) ranges from 0.77 (1 CCI) to 0.65 (≥2 CCI); and for FFS (vs. HMO) is 0.236. With the Medicare coverage (2011-2016), the age-based gap reduced substantially, but the difference persisted, e.g., OR for age 80-85 (vs. 65-69) is 0.628, and FFS (vs. HMO) beneficiaries still have far lower odds of using a preventive visit (OR = 0.278). The gap based on comorbidity was not reduced. Medicare's coverage expansion facilitated the use of preventive visit particularly for older adults with more advanced age or with FFS, thereby reducing disparities in preventive visit use.

A systematic review of economic evaluations of local authority commissioned preventative public health interventions in overweight and obesity, physical inactivity, alcohol and illicit drugs use and smoking cessation in the United Kingdom.

Background: Since 2013, local authorities in England have been responsible for commissioning preventative public health interventions. The aim of this systematic review was to support commissioning by collating published data on economic evaluations and modelling of local authority commissioned public health preventative interventions in the UK. Methods: Following the PRISMA protocol, we searched for economic evaluations of preventative intervention studies in four different areas: overweight and obesity, physical inactivity, alcohol and illicit drugs use and smoking cessation. The systematic review identified studies between January 1994 and February 2015, using five databases. We synthesized the studies to identify the key methods and examined results of the economic evaluations. Results: The majority of the evaluations related to cost-effectiveness, rather than cost-benefit analyses or cost-utility analyses. These analyses found preventative interventions to be cost effective, though the context of the interventions differed between the studies. Conclusions: Preventative public health interventions in general are cost-effective. There is a need for further studies to support justification of continued and/or increased funding for public health interventions. There is much variation between the types of economically evaluated preventative interventions in our review. Broader studies incorporating different contexts may help support funding for local authority-sponsored public health initiatives.

The Protecting Strong African American Families Program: a Randomized Controlled Trial with Rural African American Couples.

This study presents results from a randomized controlled trial of the Protecting Strong African American Families (ProSAAF) program, a family-centered intervention designed to promote strong couple, coparenting, and parent-child relationships in two-parent African American families. A total of 346 African American couples with an early adolescent child participated; all families lived in rural, low-income communities in the southern USA. Intent-to-treat growth curve analyses involving three waves and spanning 17 months indicated that ProSAAF participants, compared with control participants, reported greater improvements in relationship communication, confidence, satisfaction, partner support, coparenting, and parenting. More than 80% of the couples attended all six of the in-home, facilitator-led sessions; costs to implement the program averaged $1739 per family. The findings inform the ongoing debate surrounding prevention programs for low-income and ethnic minority couples.

Stillbirths: ending preventable deaths by 2030.

Efforts to achieve the new worldwide goals for maternal and child survival will also prevent stillbirth and improve health and developmental outcomes. However, the number of annual stillbirths remains unchanged since 2011 and is unacceptably high: an estimated 2.6 million in 2015. Failure to consistently include global targets or indicators for stillbirth in post-2015 initiatives shows that stillbirths are hidden in the worldwide agenda. This Series paper summarises findings from previous papers in this Series, presents new analyses, and proposes specific criteria for successful integration of stillbirths into post-2015 initiatives for women's and children's health. Five priority areas to change the stillbirth trend include intentional leadership; increased voice, especially of women; implementation of integrated interventions with commensurate investment; indicators to measure effect of interventions and especially to monitor progress; and investigation into crucial knowledge gaps. The post-2015 agenda represents opportunities for all stakeholders to act together to end all preventable deaths, including stillbirths.

The effect of economic development on population health: a review of the empirical evidence.

Background: Economic growth is considered an important determinant of population health. Sources of data: Relevant studies investigating the effect of economic growth on health outcomes were identified from Google Scholar and PubMed searches in economics and medical journals. Areas of agreement: Additional resources generated through economic growth are potentially useful for improving population health. Areas of controversy: The empirical evidence on the aggregate effect of economic growth on population health is rather mixed and inconclusive. Growing points: The causal pathways from economic growth to population health are crucial and failure or success in completing the pathways explains differences in empirical findings. Areas timely for developing research: Future research should investigate how additional resources can more effectively reach those in need and how additional resources can be used more efficiently. It is particularly relevant to understand why preventive health care in developing countries is very price elastic whereas curative health care is very health inelastic and how this understanding can inform public health policy.

Why Early Prevention of Childhood Obesity Is More Than a Medical Concern: A Health Economic Approach.

BACKGROUND: Childhood overweight and obesity are a non-deniable health concern with increasing economic attention. SUMMARY: International studies provide robust evidence about substantial lifetime excess costs due to childhood obesity, thereby underscoring the urgent need to implement potent obesity prevention programs in early childhood. Fortunately, this is happening more and more, as evidenced by the increase in well-conducted interventions. Nevertheless, an important piece of the puzzle is often missing, that is, health economic evaluations. There are 3 main reasons for this: an insufficient number of economic approaches which consider the complexity of childhood obesity, a lack of (significant) long-term effect sizes of an intervention, and inadequate planning of health economic evaluations in the design phase of an intervention. Key Messages: It is advisable to involve health economists during the design phase of an intervention. Equally necessary is the development of a tailored toolbox for efficient data acquisition.

Valuing Our Communities: Ethical Considerations for Economic Evaluation of Community-Based Prevention.

Restricted public budgets and increasing efforts to link the impact of community interventions to public savings have increased the use of economic evaluation. While this type of evaluation can be important for program planning, it also raises important ethical issues about how we value the time of local stakeholders who support community interventions. In particular, researchers navigate issues of scientific accuracy, institutional inequality, and research utility in their pursuit of even basic cost estimates. We provide an example of how we confronted these issues when estimating the costs of a large-scale community-based intervention. Principles for valuing community members' time and conducting economic evaluations of community programs are discussed.

Genomics is changing personal healthcare and medicine: the dawn of iPH (individualized preventive healthcare).

This opinion piece focuses on the convergence of information technology (IT) in the form of personal monitors, especially smart phones and possibly also smart watches, individual genomic information and preventive healthcare and medicine. This may benefit each one of us not only individually but also society as a whole through iPH (individualized preventive healthcare). This shift driven by genomic and other technologies may well also change the relationship between patient and physician by empowering the former but giving him/her also much more individual responsibility.

Randomised trial of two nicotine patch protocols distributed through a state quitline.

BACKGROUND: Most telephone quitlines provide free nicotine replacement therapy (NRT). An 8-week course is recommended, but few users complete it. Information is needed to help quitlines distribute NRT cost-effectively. DESIGN: Randomised two-group trial. SETTING/PARTICIPANTS: Colorado QuitLine callers who smoked 16-20 cigarettes per day at enrolment and who were eligible for and agreed to receive free NRT. INTERVENTION: Provision of 4-week versus 8-week NRT supply; the 8-week supply was shipped in halves and required participants to request the second half (split-shipment protocol). Enrolment occurred during March 2010-February 2011, follow-up concluded in November 2011, and analysis was performed in 2012. MAIN OUTCOME MEASURES: Point abstinence (7 and 30 day) and prolonged abstinence (6 month) from tobacco use. RESULTS: Overall, 1495 study participants were enrolled and 57.7% completed follow-up. Abstinence rates did not differ significantly between study conditions: 13.8% versus 12.4% in 4-week versus 8-week arms, respectively, (30-day point abstinence, non-respondents treated as smokers). NRT duration was similar in both groups, due in part to purchase of additional patches in the 4-week group. About one-third of the 8-week group requested the full 8-week supply and had higher abstinence rates. Cost per quit was lower in the 4-week (compared to 8-week) group. CONCLUSIONS: A randomised trial did not find worse cessation outcomes among quitline users who received half the minimum recommended course of NRT, but offering the full recommended course using a split-shipment protocol may be reasonably cost-effective and supportive of NRT adherers. TRIAL REGISTRATION NUMBER: NCT01889771.

Communicating the Value of the Preventive Health and Health Services Block Grant.

The Preventive Health and Health Services (PHHS) Block Grant (Block Grant) continues to offer public health leadership a major lever to promote health and ensure the delivery of essential public health services. This column describes reasons why public health leaders must maintain strong participation in defining and communicating the collective and localized benefits of this flexible funding program for prevention.

Funding of community-based interventions for HIV prevention.

Since the start of the HIV epidemic, community responses have been at the forefront of the response. Following the extraordinary expansion of global resources, the funding of community responses rose to reach at least US$690 million per year in the period 2005-2009. Since then, many civil society organisations (CSOs) have reported a drop in funding. Yet, the need for strong community responses is even more urgent, as shown by their role in reaching the Joint United Nations Programme on HIV/AIDS (UNAIDS) Fast-Track targets. In the case of antiretroviral treatment, interventions need to be adopted by most people at risk of HIV in order to have a substantial effect on the prevention of HIV at the population level. This paper reviews the published literature on community responses, funding and effectiveness. Additional funding is certainly needed to increase the coverage of community-based interventions (CBIs), but current evidence on their effectiveness is extremely mixed, which does not provide clear guidance to policy makers. This is especially an issue for adolescent girls and young women in Eastern and Southern Africa, who face extremely high infection risk, but the biomedical prevention tools that have been proven effective for the general population still remain pilot projects for this group. Research is especially needed to isolate the factors affecting the likelihood that interventions targeting this group are consistently successful. Such work could be focused on the community organisations that are currently involved in delivering gender-sensitive interventions.