Health Services Use Among Children With Prenatal Substance Exposure or Neonatal Abstinence Syndrome.

OBJECTIVE: Infants with prenatal substance exposure or neonatal abstinence syndrome (NAS) use health services more often than other children; however, little is known about their use of mental health services and psychotropic medication. METHODS: The sample (N=1,004,085) consisted of infants born in 2016 in 38 states who were followed through the fifth year of life and enrolled each year in Medicaid or the Children's Health Insurance Program. Infants with prenatal substance exposure or NAS were identified with ICD-10 diagnosis codes; procedure and revenue codes documented their service use. RESULTS: Rates of any mental health visit and of psychotropic medication use were higher among infants with prenatal substance exposure or NAS compared with infants without either condition; these patterns persisted during most years of the 5-year study. CONCLUSIONS: Infants' elevated mental health services use through their first 5 years of life highlights the importance of early screening and subsequent engagement in school-based mental health interventions.

Prenatal Substance Exposure and Neonatal Abstinence Syndrome: State Estimates from the 2016-2020 Transformed Medicaid Statistical Information System.

INTRODUCTION: Estimating Neonatal Abstinence Syndrome (NAS) and prenatal substance exposure rates in Medicaid can help target program efforts to improve access to services. METHODS: The data for this study was extracted from the 2016-2020 Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) Research Identifiable Files (RIF) and included infants born between January 1, 2016 and December 31, 2020 with a either a NAS diagnosis or prenatal substance exposure. RESULTS: Between 2016 and 2020, the estimated national rate of NAS experienced a 18% decline, while the estimated national rate of prenatal substance exposure experienced a 3.6% increase. At the state level in 2020, the NAS rate ranged from 3.2 per 1000 births (Hawaii) to 68.0 per 1000 births (West Virginia). Between 2016 and 2020, 28 states experienced a decline in NAS births and 20 states had an increase in NAS rates. In 2020, the lowest prenatal substance exposure rate was observed in New Jersey (9.9 per 1000 births) and the highest in West Virginia (88.1 per 1000 births). Between 2016 and 2020, 38 states experienced an increase in the rate of prenatal substance exposure and 10 states experienced a decline. DISCUSSION: Estimated rate of NAS has declined nationally, but rate of prenatal substance exposure has increased, with considerable state-level variation. The reported increase in prenatal substance exposure in the majority of US states (38) suggest that substances other than opioids are influencing this trend. Medicaid-led initiatives can be used to identify women with substance use and connect them to services.

What is already known about the topic? Neonatal Abstinence Syndrome (NAS) and prenatal substance exposure are significant risk factors for poor neurodevelopmental and mental health outcomes in early childhood. NAS birth rates have been increasing in the US since 2000 and the majority of NAS births are covered by Medicaid.What this article adds? This article estimates national and state-level prenatal substance exposure and NAS rates among Medicaid-covered infants born between 2016-2020 using data from the Transformed Medicaid Statistical Information System. This is the first study using post-2017 data to estimate national NAS rates. The findings can inform future federal and state policy efforts to improve access to screening, diagnosis and treatment among pregnant women with substance use disorder and infants with NAS.

Implementing a Whole Health Model in a Community Mental Health Center: Impact on Service Utilization and Expenditures.

OBJECTIVE: This study examined whether implementing a whole health care model in a community mental health center reduced the use of acute care services and total Medicare expenditures. The whole health care model embedded monitoring of overall health and wellness education within the center's outpatient mental and substance use disorder treatment services, and it improved care coordination with primary care providers. METHODS: This study used fee-for-service Medicare administrative claims and enrollment data for June 2009 through July 2015 for the intervention (N=846) and matched comparison group (N=2,643) to estimate a difference-in-differences model. RESULTS: For the first two-and-a-half years of the program, Medicare expenditures decreased by $266 per month on average for each enrolled beneficiary in the intervention group relative to the comparison group (p<.01). Intervention clients had .02 fewer hospitalizations, .03 fewer emergency department (ED) visits, and .13 fewer office visits per month relative to the comparison group (p<.05 for all estimates). CONCLUSIONS: Overall, the whole health model reduced Medicare expenditures, ED visits, and hospitalization rates. These results may be due in part to the availability of more comprehensive medical data and staff's improved awareness of client's overall health needs. There was a lag between initial program implementation and the program's substantial impact on health expenditures. This lag may be attributed to the substantial transformation and time needed for staff to adapt to the program.

Early Experiences Engaging Patients Through Patient and Family Advisory Councils.

Primary care practices are increasingly asked to engage patients in improving care delivery. We report early experiences with Patient and Family Advisory Councils (PFACs) from interviews of patients and practice staff in the Comprehensive Primary Care initiative, and identify ways to improve PFACs. Patients and practice staff report PFACs help practices elicit patient feedback and, in response, improve care delivery. Nonetheless, there are areas for refinement, including recruiting more diverse patients, providing an orientation to members, overcoming reticence of some patients to raise issues, and increasing transparency by sharing progress with PFAC members and patients in the practice more generally.

Associations between practice-reported medical homeness and health care utilization among publicly insured children.

BACKGROUND: The patient-centered medical home (PCMH) is widely promoted as a model to improve the quality of primary care and lead to more efficient use of health care services. Few studies have examined the relationship between PCMH implementation at the practice level and health care utilization by children. Existing studies show mixed results. METHODS: Using practice-reported PCMH assessments and Medicaid claims from child-serving practices in 3 states participating in the Children's Health Insurance Program Reauthorization Act of 2009 Quality Demonstration Grant Program, this study estimates the association between medical homeness (tertiles) and receipt of well-child care and nonurgent, preventable, or avoidable emergency department (ED) use. Multilevel logistic regression models are estimated on data from 32 practices in Illinois (IL) completing the National Committee for Quality Assurance's (NCQA) medical home self-assessment and 32 practices in North Carolina (NC) and South Carolina (SC) completing the Medical Home Index (MHI) or Medical Home Index-Revised Short Form (MHI-RSF). RESULTS: Medical homeness was not associated with receipt of age-appropriate well-child visits in either sample. Associations between nonurgent, preventable, or avoidable ED visits and medical homeness varied. No association was seen among practices in NC and SC that completed the MHI/MHI-RSF. Children in practices in IL with the highest tertile NCQA self-assessment scores were less likely to have a nonurgent, preventable, or avoidable ED visit than children in practices with low (odds ratio 0.65; 95% confidence interval 0.47-0.92; P < .05) and marginally less likely to have such a visit compared with children in practices with medium tertile scores (odds ratio 0.72, 95% confidence interval 0.52-1.01; P = .06). CONCLUSIONS: Higher levels of medical homeness may be associated with lower nonurgent, preventable, or avoidable ED use by publicly insured children. Robust longitudinal studies using multiple measures of medical homeness are needed to confirm this observation.

Health Care Utilization among Children Enrolled in Medicaid and CHIP via Express Lane Eligibility.

OBJECTIVE: To assess health care utilization among children enrolled in Medicaid and CHIP via Express Lane Eligibility (ELE). DATA SOURCES/STUDY SETTING: Enrollment, claims, and encounter data for children enrolled in Medicaid or CHIP in Alabama, Iowa, Louisiana, and New Jersey during 2009-2012. STUDY DESIGN: We compared health care utilization among children enrolled via ELE and nondisabled children who enrolled through standard pathways in each state. We used a two-step estimation approach, examining the likelihood of utilization and then the volume and cost of services among users. Regression adjustment corrected for demographic differences. PRINCIPAL FINDINGS: Most ELE and comparison group children used services within a year of enrollment and accessed a variety of services, including outpatient care, prescription drugs, and dental and vision care. ELE enrollees were somewhat less likely to use each service type, and those who used services often did so less intensively compared to other enrollees in their state. CONCLUSIONS: Health care use patterns suggest that ELE enrollees are aware of their coverage; enrollees accessed and repeatedly used services covered by public health insurance. However, states considering this policy may expect that remaining eligible but uninsured children may be less expensive to cover than existing beneficiaries.

Toward understanding EHR use in small physician practices.

This article presents insights into the use of electronic health records (EHRs) by small physician practices participating in a CMS pay-for-performance demonstration. Site visits to four States reveal slow movement toward improved EHR use. Factors facilitating use of EHRs include customization of EHR products and being owned by a larger organization. Factors limiting use of EHRs include system limitations, cost, and lack of strong incentives to improve. Practices in one State were moving more vigorously toward improved EHR use than those in the other States. Many practices also increased use of medical assistants after implementing EHRs.

State variation in out-of-home Medicaid mental health services for children and youth: an examination of residential treatment and inpatient hospital services.

This research investigated state variation in the use of out-of-home mental health services among children and youth enrolled in Medicaid during 2003. Medicaid claims from three states were used to describe the demographic and diagnostic characteristics of children and youth under age 22 who received mental health services in general hospitals, psychiatric hospitals, psychiatric residential treatment facilities, and other residential treatment settings and to examine their lengths of stay, repeat stays, and expenditures. Depending on the state, 6-13% of children and youth with a mental health diagnosis received out-of-home services during the year; 37-58% of these children and youth had more than one out-of-home stay. Out-of-home mental health services accounted for 21-75% of Medicaid mental health expenditures for children and youth, depending on the state. States varied considerably in lengths of stay and per beneficiary expenditures for out-of-home care. Although some similarities in out-of-home care were found across states, substantial state variation in out-of-home care warrants further research in the context of state service systems and Medicaid policies.

Temporal trends in anti-diabetes drug use in TRICARE following safety warnings in 2007 about rosiglitazone.

PURPOSE: To describe utilization patterns for anti-diabetes medications among a cohort of diabetes patients in the Military Health System (MHS) before and after warnings about rosiglitazone issued in May 2007. METHODS: We used segmented regression analysis to compare changes in the level and trend of rosiglitazone utilization and use of other anti-diabetes therapies in the period prior to the drug warnings (between April 2006 and May 2007) and the period after the warnings were issued (between October 2007 and May 2008). RESULTS: The level and trend of rosiglitazone use changed after the highly publicized warnings. The number of prescriptions filled fell by almost 7000 after the warning (p < 0.001). The number of prescriptions filled for pioglitazone, sulfonylureas, and other diabetes drugs increased significantly after the warnings (p < 0.05 in all models). Overall, the level and trend of filled prescriptions per month for all anti-diabetic drugs did not significantly change after the warnings. CONCLUSIONS: Utilization patterns changed in response to warnings about rosiglitazone. While overall utilization of anti-diabetic drugs did not change, further study is needed to determine the associated health outcomes.