Effects of Global Budget Payments on Vulnerable Medicare Subpopulations in Maryland.

There is little evidence regarding population equity in alternative payment models (APMs). We aimed to determine whether one such APM, the Maryland All-Payer Model (MDAPM), had differential effects on subpopulations of vulnerable Medicare beneficiaries. We utilized Medicare fee-for-service claims for beneficiaries living in Maryland and 48 comparison hospital market areas between 2011 and 2018. We used doubly robust difference-in-difference-in-differences regression models to estimate the differential effects of MDAPM on Medicare beneficiaries by dual eligibility for Medicare and Medicaid, disability as original reason for Medicare entitlement, presence of multiple chronic conditions (MCC), race, and rural residency status. Dual, disabled, and beneficiaries with MCC had greater reductions in expenditures and utilization than their counterparts. Hospitals may have prioritized high-cost, high-need patients as they changed their care delivery practices. The percentage of hospital discharges with 14-day follow-up was significantly lower for disadvantaged subpopulations, including duals, disabled, and non-White.

Medicaid Accountable Care Organizations in Four States: Implementation and Early Impacts.

Policy Points Maine, Massachusetts, Minnesota, and Vermont leveraged State Innovation Model awards to implement Medicaid accountable care organizations (ACOs). Flexibility in model design, ability to build on existing reforms, provision of technical assistance to providers, and access to feedback data all facilitated ACO development. Challenges included sustainability of transformation efforts and the integration of health care and social service providers. Early estimates showed promising improvements in hospital-related utilization and Vermont was able to reduce or slow the growth of Medicaid costs. These states are sustaining Medicaid ACOs owing in part to provider support and early successes in generating shared savings. The states are modifying their ACOs to include greater accountability and financial risk. CONTEXT: As state Medicaid programs consider alternative payment models (APMs), many are choosing accountable care organizations (ACOs) as a way to improve health outcomes, coordinate care, and reduce expenditures. Four states (Maine, Massachusetts, Minnesota, and Vermont) leveraged State Innovation Model awards to create or expand Medicaid ACOs. METHODS: We used a mixed-methods design to assess achievements and challenges with ACO implementation and the impact of Medicaid ACOs on health care utilization, quality, and expenditures in three states. We integrated findings from key informant interviews, focus groups, document review, and difference-in-difference analyses using data from Medicaid claims and an all-payer claims database. FINDINGS: States built their Medicaid ACOs on existing health care reforms and infrastructure. Facilitators of implementation included allowing flexibility in design and implementation, targeting technical assistance, and making clinical, cost, and use data readily available to providers. Barriers included provider concerns about their ability to influence patient behavior, sustainability of provider practice transformation efforts when shared savings are reinvested into the health system and not shared with participating clinicians, and limited integration between health care and social service providers. Medicaid ACOs were associated with some improvements in use, quality, and expenditures, including statistically significant reductions in emergency department visits. Only Vermont's ACO demonstrated slower growth in total Medicaid expenditures. CONCLUSIONS: Four states demonstrated that adoption of ACOs for Medicaid beneficiaries was both possible and, for three states, associated with some improvements in care. States revised these models over time to address stakeholder concerns, increase provider participation, and enable some providers to accept financial risk for Medicaid patients. Lessons learned from these early efforts can inform the design and implementation of APMs in other Medicaid programs.

The effect of maternity care coordination services on utilization of postpartum contraceptive services.

OBJECTIVE: To examine whether maternity care coordination (MCC) services are associated with utilization of postpartum contraceptive services. METHODS: Using a random sample of 7120 live births, we analyzed administrative data to assess whether MCC services affected utilization of contraceptive services within 3months of delivery. Treatment groups were constructed as MCC during the prenatal period only (n=531), MCC in both the prenatal and postpartum periods (n=1723) and a non-MCC control group (n=4866). Inverse probability of treatment weights (IPTWs) were calculated and applied to balance baseline risk factors across groups. We used the IPTW linear probability model to estimate postpartum contraceptive service utilization, controlling for demographic, social, reproductive and medical home enrollment characteristics. RESULTS: At 3months postpartum, MCC participation was associated with a 19-percentage point higher level of utilization of postpartum contraceptive services among women who received both prenatal and postpartum care coordination services (p<.001), as compared with controls. Women who received only prenatal MCC services showed no difference in utilization of services at 3months postpartum from non-MCC controls. Sensitivity modeling showed the effect of MCC was independent of postpartum obstetrical care. Additionally, MCC had differential treatment effects across subpopulations based on maternal age, race, ethnicity and education; women who were white and did not have a medical home were more likely to benefit from MCC services in initiating postpartum contraceptives. CONCLUSIONS: MCC programs may be instrumental in increasing timely utilization of postpartum contraceptive services, but continuation of the intervention into the postpartum period is critical. IMPLICATION: MCC offered both prenatally and in the postpartum period appears to complement clinical care by increasing postpartum contraceptive service utilization. Providers should consider the potential added benefits of care coordination services in tandem with traditional obstetric care to increase postpartum contraceptive use and subsequently reduce short birth intervals.