Long-Term Stability of Coverage Among Michigan Medicaid Beneficiaries : A Cohort Study.

BACKGROUND: Medicaid, the primary source of insurance coverage for disadvantaged Americans, was originally designed as a temporary safety-net program. No studies have used long-run data to assess the recent use of the program by beneficiaries. OBJECTIVE: To assess patterns of short- and long-term enrollment among beneficiaries, using a 10-year longitudinal panel of Michigan Medicaid eligibility data. DESIGN: Primary analyses assessing trends in Medicaid enrollment among cohorts of existing and new beneficiaries. SETTING: Administrative records from Michigan Medicaid for the period 2011 to 2020. PARTICIPANTS: 3.97 million Medicaid beneficiaries. MEASUREMENTS: Short- and long-term enrollment in the program. RESULTS: The sample includes 3.97 million unique beneficiaries enrolled at some point between 2011 and 2020. Among a cohort of 1.23 million beneficiaries enrolled in 2011, over half (53%) were also enrolled in Medicaid in June 2020, spending, on average, two-thirds of that period (67%) on Medicaid. These beneficiaries, however, experienced substantial lapses in coverage, as only 25% were continuously enrolled throughout the period. Enrollment was less stable when assessed from the perspective of newly enrolled beneficiaries, of whom only 37% remained enrolled at the end of the study period. LIMITATION: Primary estimates from a single state. CONCLUSION: For many beneficiaries, Medicaid has served as their primary source of coverage for at least a decade. This pattern would justify increasing investments in the program to improve long-term health outcomes. PRIMARY FUNDING SOURCE: Self-funded.

Disparities in Health Care Spending and Utilization Among Black and White Medicaid Enrollees.

Importance: Administrative records indicate that more than half of the 80 million Medicaid enrollees identify as belonging to a racial and ethnic minority group. Despite this, disparities within the Medicaid program remain understudied. For example, we know of no studies examining racial differences in Medicaid spending, a potential measure of how equitably state resources are allocated. Objectives: To examine whether and to what extent there are differences in health care spending and utilization between Black and White enrollees in Medicaid. Design Setting and Participants: This cross-sectional study used calendar year 2016 administrative data from 3 state Medicaid programs and included 1 966 689 Black and White Medicaid enrollees. Analyses were performed between January 28, 2021, and October 18, 2021. Exposures: Self-reported race. Main Outcomes and Measures: Rates and racial differences in health care spending and utilization (including Healthcare Effectiveness Data and Information Set [HEDIS] access measures). Results: Of 1 966 689 Medicaid adults and children (mean [SD] age, 20.3 [17.1] years; 1 119 136 [56.9%] female), 867 183 (44.1%) self-identified as non-Hispanic Black and 1 099 506 (55.9%) self-identified as non-Hispanic White. Results were adjusted for age, sex, Medicaid eligibility category, zip code, health status, and usual source of care. On average, annual spending on Black adult (19 years or older) Medicaid enrollees was $317 (95% CI, $259-$375) lower than White enrollees, a 6% difference. Among children (18 years or younger), annual spending on Black enrollees was $256 (14%) lower (95% CI, $222-$290). Adult Black enrollees also had 19.3 (95% CI, 16.78-21.84), or 4%, fewer primary care encounters per 100 enrollees per year compared with White enrollees. Among children, the differences in primary care utilization were larger: Black enrollees had 90.1 (95% CI, 88.2-91.8) fewer primary care encounters per 100 enrollees per year compared with White enrollees, a 23% difference. Black enrollees had lower utilization of most other services, including high-value prescription drugs, but higher emergency department use and rates of HEDIS preventive screenings. Conclusions and Relevance: In this cross-sectional study of US Medicaid enrollees in 3 states, Black enrollees generated lower spending and used fewer services, including primary care and recommended care for acute and chronic conditions, but had substantially higher emergency department use. While Black enrollees had higher rates of HEDIS preventive screenings, ensuring equitable access to all services in Medicaid must remain a national priority.

In Medicaid Managed Care Networks, Care Is Highly Concentrated Among A Small Percentage Of Physicians.

States have increasingly outsourced the provision of Medicaid services to private managed care plans. To ensure that plans maintain access to care, many states set network adequacy standards that require plans to contract with a minimum number of physicians. In this study we used data from the period 2015-17 for four states to assess the level of Medicaid participation among physicians listed in the provider network directories of each managed care plan. We found that about one-third of outpatient primary care and specialist physicians contracted with Medicaid managed care plans in our sample saw fewer than ten Medicaid beneficiaries in a year. Care was highly concentrated: 25 percent of primary care physicians provided 86 percent of the care, and 25 percent of specialists, on average, provided 75 percent of the care. Our findings suggest that current network adequacy standards might not reflect actual access; new methods are needed that account for beneficiaries' preferences and physicians' willingness to serve Medicaid patients.

Residual Confounding in Health Plan Performance Assessments: Evidence From Randomization in Medicaid.

BACKGROUND: Risk adjustment is used widely in payment systems and performance assessments, but the extent to which it distinguishes plan or provider effects from confounding due to patient differences is typically unknown. OBJECTIVE: To assess the degree to which risk-adjusted measures of health plan performance adequately adjust for the variation across plans that arises because of differences in patient characteristics (residual confounding). DESIGN: Comparison between plan performance estimates based on enrollees who made plan choices (observational population) and estimates based on enrollees assigned to plans (randomized population). SETTING: Natural experiment in which more than two thirds of a state's Medicaid population in 1 region was randomly assigned to 1 of 5 plans. PARTICIPANTS: 137 933 enrollees in 2013 to 2014, of whom 31.1% selected a plan and 68.9% were randomly assigned to 1 of the same 5 plans. MEASUREMENTS: Annual total spending (that is, payments to providers), primary care use, dental care use, and avoidable emergency department visits, all scored as plan-specific deviations from the "average" plan performance within each population. RESULTS: Enrollee characteristics were appreciably imbalanced across plans in the observational population, as expected, but were not in the randomized population. Annual total spending varied across plans more in the observational population (SD, $147 per enrollee) than in the randomized population (SD, $70 per enrollee) after accounting for baseline differences in the observational and randomized populations and for differences across plans. On average, a plan's spending score (its deviation from the "average" performance) in the observational population differed from its score in the randomized population by $67 per enrollee in absolute value (95% CI, $38 to $123), or 4.2% of mean spending per enrollee (P = 0.009, rejecting the null hypothesis that this difference would be expected from sampling error). The difference was reduced modestly by risk adjustment to $62 per enrollee (P = 0.012). Residual confounding was similarly substantial for most other performance measures. Further adjustment for social factors did not materially change estimates. LIMITATION: Potential heterogeneity in plan effects between the 2 populations. CONCLUSION: Residual confounding in risk-adjusted performance assessments can be substantial and should caution policymakers against assuming that risk adjustment isolates real differences in plan performance. PRIMARY FUNDING SOURCE: Arnold Ventures.

Characterization of US Hospital Advertising and Association With Hospital Performance, 2008-2016.

Importance: Hospital advertising has been touted as a tool to improve consumer decision-making, but little is known about its association with objective measures of hospital quality. Objective: To document recent trends in hospital advertising in the US and examine the association between concurrent measures of hospital advertising and quality. Design, Setting, and Participants: Retrospective cross-sectional study of all general acute care hospitals operating in the US between January 2008 and December 2016. Data were analyzed from December 6, 2019, to July 15, 2020. Exposure: Annualized advertising spending for each hospital as measured by a market research firm. Main Outcomes and Measures: Four composites of hospital performance from the Centers for Medicare & Medicaid Services Hospital Compare database were used: risk-standardized mortality rate, risk-standardized readmission rate, Consumer Assessment of Healthcare Providers & Systems (CAHPS) Overall Patient Experience Rating (scale of 1-5; higher scores indicate a more positive patient experience rating), and overall 5-star rating. Linear models adjusted for hospital bed size, hospital revenue, and geographic census region. Results: The study sample included, on average, 4569 general acute care hospitals per year between 2008 and 2016. During this time, approximately half of acute care hospitals (2239 of 4569 [49%]) advertised their services to consumers and spent a total of $3.39 billion. Relative to hospitals that never advertised, advertising hospitals were more likely to be nonprofit facilities (mean [SD], 66% [47%] vs 51% [50%]; P < .001), had larger bed sizes (mean [SD], 234.3 [210.7] beds vs 84.8 [110.6] beds; P < .001), and had higher net incomes (mean [SD], $17 800 000 [$49 000 000] vs $134 099 [$51 600 000]; P < .001). There was no observed association between hospital advertising and performance. For example, hospitals that advertised had a mean (SD) CAHPS 5-star rating of 3.2 (0.9) stars compared with 3.3 (1.0) stars among hospitals that did not advertise, an insignificant difference (P = .92). We observed no difference in performance between advertising and nonadvertising hospitals in 30-day readmission rates (mean [SD], 15.5% [0.8%] vs 15.6% [1.0%]; P = .25), mortality rates (mean [SD], 12.7% [4.0%] vs 12.0% [4.1%]; P = .46), and overall 5-star hospital ratings (mean [SD], 3.1 [0.8] stars vs 3.0 [0.9] stars; P = .50). A significant difference was observed in adjusted mortality rates across terciles of advertising spending, with lower mortality rates for the hospitals with higher ad spending (2016, mean [SD] mortality composite for hospitals in the highest tercile, 11.2% [4.2%] vs hospitals in the middle tercile, 12.0% [3.8%], and for hospitals in the lowest tercile, 12.7% [4.1%]; P = .003). Conclusions and Relevance: The results of this cross-sectional study suggest that the amount hospitals spent on direct-to-consumer advertising was not associated with publicly reported measures of hospital quality; instead, hospital advertising spending was higher for financially stable hospitals with higher net incomes.

Evaluation of the Association Between Medicare Eligibility and Excess Deaths During the COVID-19 Pandemic in the US.

This cross-sectional regression discontinuity analysis compares deaths slightly younger and older than 65 years to examine the relationship between access to health insurance coverage and COVID-19 mortality.

Association of Provider Performance with Changes in Insurance Networks.

BACKGROUND: Medicaid managed care plans change provider networks frequently, yet there is no evidence about the performance of exiting providers relative to those that remain. OBJECTIVES: To investigate the association between provider cost and quality and network exit. DESIGN: Observational study with provider network directory data linked to administrative claims from managed care plans in Tennessee's Medicaid program during the period 2010-2016. PARTICIPANTS: 1,966,022 recipients assigned to 9593 unique providers. MAIN MEASURES: Exposures were risk-adjusted total costs of care and nine measures from the Healthcare Effectiveness Data and Information Set (HEDIS) were used to construct a composite annual indicators of provider performance on quality. Outcome was provider exit from a Medicaid managed care plan. Differences in quality and cost between providers that exited and remained in managed care networks were estimated using a propensity score model to match exiting to nonexiting providers. KEY RESULTS: Over our study period, we found that 21% of participating providers exited at least one of the Medicaid managed care plans in Tennessee. As compared with providers that remained in networks, those that exited performed 3.8 percentage points [95% CI, 2.3, 5.3] worse on quality as measured by a composite of the nine HEDIS quality metrics. However, 22% of exiting providers performed above average in quality and cost and only 29% of exiting providers had lower than average quality scores and higher than average costs. Overall, exiting providers had lower aggregate costs in terms of the annual unadjusted cost of care per-member-month - $21.57 [95% CI, - $41.02, - $2.13], though difference in annual risk-adjusted cost per-member-month was nonsignificant. CONCLUSIONS: Providers exiting Medicaid managed care plans appear to have lower quality scores in the year prior to their exit than the providers who remain in network. Our study did not show that managed care plans disproportionately drop high-cost providers.

Comparison of Office-Based Physician Participation in Medicaid Managed Care and Health Insurance Exchange Plans in the Same US Geographic Markets.

Importance: Several recent policy proposals have sought to expand the role of Medicaid in providing health insurance for low-income Americans, but there is little recent information on how physician participation in Medicaid compares with alternative forms of coverage for low-income Americans. Objective: To compare the number of office-based physicians included in Medicaid managed care and health insurance exchange plans that operate in the same geographic markets. Design, Setting, and Participants: This cross-sectional study used administrative data from physician network directories and survey data from office-based physicians for Kansas, Nebraska, New York, Tennessee, and Washington. The number of participants totaled 67 057 office-based physicians in the 5 sample states. Data were collected and analyzed from May 2018 to June 2019. Exposures: Physician participation in a Medicaid managed care or health insurance exchange plan network. Main Outcomes and Measures: The percentage of office-based physicians in a county who indicated during a phone survey that they participated in Medicaid; the percentage of office-based physicians in a county who participated in each Medicaid managed care and health insurance exchange plan network; and the percentage of office-based physicians in a county who participated in at least 1 Medicaid managed care plan or, separately, at least 1 health insurance exchange plan. Results: Of the 67 057 office-based physicians in our sample, 49 983 reported in a telephone survey that they accepted Medicaid. This survey-based measure undercounted the percentage of physicians participating in Medicaid by 5.2% (95% CI, 2.3%-8.1%; P < .001) relative to a measure based on physician network directories. Medicaid managed care physician networks covered a median (interquartile range) of 63.4% (48.0%-81.3%) of office-based physicians compared with health insurance exchange physician networks, which covered 51.0% (31.0%-70.5%). In adjusted analyses, Medicaid managed care plans covered 6.2% (95% CI, 3.2%-9.3%, P < .001) more office-based physicians than health insurance exchange plans operating in the same counties. In the states where the same insurers participated in both markets (New York, Tennessee, Washington), the Medicaid managed care physician networks were 6.5% (95% CI, 3.2%-9.8%, P < .001) larger than the health insurance exchange networks offered by the same insurer. Conclusions and Relevance: In this cross-sectional study of physician network data, Medicaid managed care physician networks included more office-based physicians than the physician networks of health insurance exchange plans operating in the same geographic markets. This suggests that Medicaid remains a viable option for expanding coverage in the United States.