Prevalence and Correlates of Unmet Medical and Social Needs in Virginia's Medicaid Managed Long Term Services and Supports Program.

BACKGROUND: Medicaid Long Term Services and Support (LTSS) programs serve individuals with complex medical and social needs. Increasingly, state Medicaid programs are contracting with managed care organizations to administer LTSS programs. OBJECTIVES: Understand the prevalence of and risk factors for unmet medical and social needs among a sample of patients within a Medicaid managed LTSS program. METHODS: We surveyed a cross-sectional random sample of 798 community-residing individuals over 21 in Virginia who were served by the state Medicaid managed LTSS program. Outcomes of interest include 3 distinct medical needs: medical appointments, medical transportation, and prescriptions; 4 distinct social needs: housing security, food security, utility bills, and nonmedical transportation, and composite measures of unmet social and medical needs. RESULTS: We found that 12.5% of our sample had any unmet medical need, while far more (62.2%) of our sample had any unmet social needs, with food insecurity being the most common. We found that members of color had almost 2 times the odds of having both unmet social and medical needs [social: adjusted odds ratio (aOR): 2.21; 95% confidence Interval (CI): (1.59, 3.09); medical aOR: 2.25 ; 95% CI: (1.34, 3.8)]. CONCLUSION: Medicaid members may not be fully realizing the potential of LTSS programs and would benefit from both Medicaid agency and managed care organizations' strategies aimed at addressing social drivers of health. To achieve health equity for LTSS members of color, Medicaid agencies may consider policies specifically targeting racial disparities.

Patient experiences with outpatient opioid use disorder treatment before and during COVID-19: results from a survey of Medicaid members.

Background: Payers are increasingly interested in quality improvement for opioid use disorder (OUD) treatment, including incorporating patient experiences. Medicaid is the largest payer for OUD treatment, yet we know little about the treatment benefits Medicaid members report, how these vary across members, or changed with the COVID-19 pandemic.Objective: To examine Medicaid members' report of outpatient treatment benefits, employment, and housing outcomes before and during the pandemic.Methods: A representative sample of 1,032 Virginia Medicaid members (52% women) receiving OUD treatment completed a survey of treatment benefits, health status and social needs. A reported treatment benefit index was created based on seven self-reported items. Multivariable linear regression models, pooled and stratified by time (pre-COVID-19/COVID-19), assessed member characteristics associated with reported treatment benefit, employment and housing outcomes.Results: Members reported strong treatment benefit (mean: 21.8 [SD: 5.9] out of 28 points) and improvements in employment (2.4 [1.3] out of 5) and housing (2.8 [1.2] out of 5). After adjustment, mental distress (regression coefficient: -3.00 [95% CI:-3.97;-2.03]), polysubstance use (-1.25 [-1.99;-0.51]), and food insecurity (-1.00 [-1.71;-0.29]), were associated with decreased benefits from treatment. During COVID-19, justice-involved individuals reported decreased benefits (-2.17 [-3.54; -0.80]) compared to before the pandemic (-0.09 [-1.4-;1.24] p < .05).Conclusions: Medicaid members receiving outpatient OUD treatment reported positive treatment benefits, and housing and employment outcomes. However, those with comorbid health and social conditions often benefited the least. As payers move toward quality improvement and value-based purchasing initiatives, collecting and integrating patient reported outcomes into quality metrics is critical.

Associations Between Patient-Reported Experiences with Opioid Use Disorder Treatment and Unmet Treatment Needs and Discontinuation Among Virginia Medicaid Members.

BACKGROUND: Many payers, including Medicaid, the largest payer of opioid use disorder (OUD) treatment, are pursuing treatment-related quality improvement initiatives. Yet, how patient-reported experiences with OUD treatment relate to patient-centered outcomes remains poorly understood. AIM: To examine associations between Medicaid members' OUD treatment experiences, outpatient treatment settings, demographic and social factors, and members' self-report of unmet needs during treatment and treatment discontinuation. METHODS: A sample of Virginia Medicaid members aged 21 years or older with OUD diagnoses who received outpatient OUD treatment completed a mail survey between January 2020 and August 2021 (n = 1042, weighted n = 9244). A treatment experience index was constructed from responses to four items from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) relating to feelings of involvement, safety, and respect and having treatment explained in an understandable way; two additional CAHPS items: "given options for treatment" and "able to refuse treatment" were also assessed. Weighted imputed logistic regressions tested adjusted associations between members' treatment experiences, demographic and social factors, and two outcomes capturing unmet needs during treatment and treatment discontinuation. RESULTS: More positive scores on the treatment experiences index were associated with lower adjusted odds of reporting unmet needs during treatment (aOR: 0.52, 95% CI: 0.41-0.66) and discontinuation (aOR: 0.63, 95% CI: 0.47-0.79). Respondents with serious psychological distress had higher odds of reporting unmet needs during treatment (aOR: 1.69 95% CI: 1.14-2.51) and discontinuation (aOR: 1.84, 95% CI: 1.21-2.82), as did individuals with housing insecurity (unmet needs: (aOR: 1.65, 95% CI: 1.11-2.44); treatment discontinuation: (aOR: 1.56, 95% CI: 1.04-2.36)). CONCLUSION: Using a first-of-its-kind survey of Medicaid members with OUD, we found that members who had more positive treatment experiences were less likely to report unmet treatment needs and discontinue treatment. Care approaches focused on improving patient experience are critical to delivering effective, high-quality OUD treatment.

Income Disparities in the Prevalence, Severity, and Costs of Co-occurring Chronic and Behavioral Health Conditions.

BACKGROUND: Behavioral health problems usually co-occur along with physical health problems, resulting in higher health care costs. These co-occurring conditions are likely to be more prevalent and serious among low income patients, affecting both the quality and costs of care. OBJECTIVE: To examine the prevalence, severity, and health care costs of co-occurring chronic and behavioral health conditions among low income people compared with higher income people. METHODS: Analysis of the 2011-2014 Medical Expenditure Panel Survey. Sample includes 146,000 persons aged 18-64 years. Regression analysis was used to examine how the combination of behavioral health conditions and chronic health conditions is associated with health care expenditures, and how this association differs by family income. RESULTS: (1) Comorbid behavioral health problems are more prevalent and serious among low income people with chronic conditions compared with higher income people; (2) among patients with co-occurring chronic and behavioral problems, average annual spending is greater among the low income patients ($9472) compared with high income patients ($7457); (3) higher costs among low income patients with co-occurring conditions reflects their poorer mental and physical health, relative to higher income patients. CONCLUSIONS: For many low income people, comorbid behavioral problems need to be understood in the social context in which they live. Simply screening low income people for behavioral health problems may not be sufficient unless there is greater understanding of the mechanisms that both cause and exacerbate chronic and behavioral health problems in the low income population.

Closing the Medicare Doughnut Hole: Changes in Prescription Drug Utilization and Out-of-Pocket Spending Among Medicare Beneficiaries With Part D Coverage After the Affordable Care Act.

BACKGROUND: The Affordable Care Act (ACA) include provisions that reduce beneficiaries' cost sharing and eventually closes the coverage gap-known as the "doughnut hole"-that was originally part of Medicare prescription drug coverage implemented in 2006. OBJECTIVES: This study examines changes in overall prescription drug utilization and out-of-pocket spending as well as by manufacturer type (brand vs. generic), through 2013 as a result of the doughnut hole provisions of the ACA. MATERIALS AND METHODS: This analysis is based on data from Medical Expenditure Panel Survey and the sample for this analysis includes all individuals 55 years of age and older. A difference-in-differences methodology was adopted to measure changes in drug utilization and out-of-pocket spending among both the treatment group and the comparison group after the ACA. RESULTS: The findings from this study suggest that overall out-of-pocket spending significantly decreased after closing the coverage gap, mainly because of a significant reduction in out-of-pocket spending on brand-name drugs. Conversely, the results show that generic drug utilization increased after closing the coverage gap. As expected, the effects were considerably larger for people who fell into the doughnut hole. CONCLUSIONS: The ACA doughnut hole provisions likely contributed to a reduction in out-of-pocket spending for prescription drugs for part D beneficiaries, especially for people who fell into the doughnut hole.

Changes in Emergency Department Utilization After Early Medicaid Expansion in California.

BACKGROUND: Medicaid expansions aim to improve access to primary care, which could reduce nonemergent (NE) use of the emergency department (ED). In contrast, Medicaid enrollees use the ED more than other groups, including the uninsured. Thus, the expected impact of Medicaid expansion on ED use is unclear. OBJECTIVES: To estimate changes in total and NE ED visits as a result of California's early Medicaid expansion under the Affordable Care Act. In addition to overall changes in the number of visits, changes by payer and safety net hospital status are examined. METHODS: We used a quasi-experimental approach to examine changes in ED utilization, comparing California expansion counties to comparison counties from California and 2 other states in the same region that did not implement Medicaid expansion during the study period. RESULTS: Regression estimates show no significant change in total number of ED visits following expansion. Medicaid visits increased by 145 visits per hospital-quarter in the first year following expansion and 242 visits subsequent to the first year, whereas visits among uninsured patients decreased by 129 visits per hospital-quarter in the first year and 175 visits in subsequent years, driven by changes at safety net hospitals. We also observe an increase in NE visits per hospital-quarter paid for by Medicaid, and a significant decrease in uninsured NE visits. CONCLUSIONS: Medicaid expansions in California were associated with increases in ED visits paid for by Medicaid and declines in uninsured visits. Expansion was also associated with changes in NE visits among Medicaid enrollees and the uninsured.

Beneficiary Experience of Care by Level of Integration in Dual Eligible Special Needs Plans.

Importance: Dual Eligible Special Needs Plans (D-SNPs) are private managed care plans designed to promote Medicare and Medicaid integration for full-benefit, dually eligible beneficiaries. Currently, the highest level of D-SNP integration occurs in plans with exclusively aligned enrollment (EAE). Objective: To compare patient experience of care, out-of-pocket spending, and satisfaction among dually enrolled Medicaid beneficiaries in D-SNPs with EAE, those in D-SNPs without EAE, and those with traditional Medicare. Design, Setting, and Participants: This cross-sectional study included respondents to a mail survey fielded to a stratified random sample of full-benefit, community-dwelling, dual-eligible Medicaid beneficiaries who qualified for receipt of home and community-based services in the Virginia Medicaid Commonwealth Coordinated Care Plus program between March and October 2022. Exposure: Enrollment in a D-SNP with EAE or a D-SNP without EAE vs traditional Medicare. Main Outcomes and Measures: The main outcomes were self-reported measures of access and delays in receiving plan approvals, out-of-pocket spending, and satisfaction with health plans' customer service and choice of primary care and specialist physicians. Results: Of 7200 surveys sent, 2226 were completed (response rate, 30.9%). The analytic sample consisted of 1913 Medicaid beneficiaries with nonmissing data on covariates (mean [SD] age, 70.8 [15.6] years; 1367 [71.5%] female). Of these, 583 (30.5%) were enrolled in D-SNPs with EAE, 757 (39.6%) in D-SNPs without EAE, and 573 (30.0%) in traditional Medicare. Compared with respondents enrolled in D-SNPs without EAE, those in D-SNPs with the highest level of integration (EAE) were 6.77 percentage points (95% CI, 8.81-12.66 percentage points) more likely to report being treated with courtesy and respect and 5.83 percentage points (95% CI, 0.21-11.46 percentage points) more likely to know who to call when they had a health problem. No statistically significant differences were found between members in either type of D-SNP and between those in D-SNPs and traditional Medicare in terms of their difficulty accessing care, delays in care, and satisfaction with care coordination and physician choice. Conclusions and Relevance: This cross-sectional study found some benefits of integrating administrative processes under Medicare and Medicaid but suggests that care coordination and access improvements under full integration require additional time and/or efforts to achieve.

Virginia Medicaid Expansion: New Members Report Reduced Financial Concerns During The COVID-19 Pandemic.

Medicaid is a critical antipoverty program. Since the Affordable Care Act expanded Medicaid eligibility, millions of newly eligible people have enrolled, creating positive financial improvements for low-income families. We examined the association of Virginia's 2019 Medicaid expansion and changes in health care-related and non-health-care-related financial needs among newly eligible Medicaid enrollees. Our unique survey collected responses between December 2018 and April 2019 from newly enrolled members reporting on experiences in the year before enrollment and between July 2020 and May 2021 from members reporting on experiences one year after enrollment. The follow-up period coincided with the COVID-19 pandemic. Medicaid enrollment was associated with decreases in concern about all financial needs assessed: housing, food, monthly bills, credit card and loan payments, and health care costs. These reductions were broadly similar across demographic subgroups and across the months of the pandemic that overlapped with the follow-up period. We add to the evidence that Medicaid expansion is a social safety-net policy that could improve equity among low-income families, potentially encouraging states that have yet to expand to do so.

Hospital Use Declines After Implementation Of Virginia Medicaid's Addiction And Recovery Treatment Services.

Medicaid programs responded to the opioid crisis by expanding treatment coverage and reforming delivery systems. We assessed whether Virginia's Addiction and Recovery Treatment Services (ARTS) program, implemented in April 2017, influenced emergency department and inpatient use. Using claims for January 2016-June 2018 and difference-in-differences models, we compared beneficiaries with opioid use disorder before and after ARTS implementation to beneficiaries with no substance use disorder. After program implementation, the likelihood of having an emergency department visit in a quarter declined by 9.4 percentage points (a 21.1 percent relative decrease) among beneficiaries with opioid use disorder, compared to 0.9 percentage points among beneficiaries with no substance use disorder. Similarly, the likelihood of having an inpatient hospitalization declined among beneficiaries with opioid use disorder. In contrast to other states, Virginia has a new Medicaid expansion population whose beneficiaries enter a delivery system in which reforms of the addiction treatment system are well under way.

High medical cost burdens, patient trust, and perceived quality of care.

BACKGROUND: The financial burden of medical care expenses is increasing for American families. However, the association between high medical cost burdens and patient trust in physicians is not known. OBJECTIVE: To examine the association between high medical cost burdens and self-reported measures of patient trust and perceived quality of care. METHODS: Cross-sectional household survey based on random-digit dialing and conducted largely by telephone, supplemented by in-person interviews of households with no telephones. The sample for this analysis includes 32,210 adults who reported having a physician as their regular source of care. Measures of patient trust include overall trust, confidence in being referred to a specialist, and belief that the physician uses more services than necessary. Perceived quality measures include thoroughness of exam, ability to listen, and ability to explain. RESULTS: In adjusted analyses, persons with high medical cost burdens had greater odds of lacking trust in their physician to put their needs above all else (OR = 1.43, CI = 1.19, 1.73), not referring them to specialists (OR = 1.39, CI = 1.22, 1.58), and performing unnecessary tests (OR = 1.42, CI = 1.20, 1.62). Patients with high medical cost burdens also had more negative assessments of the thoroughness of care they receive from their physician (OR = 1.26, CI = 1.02, 1.56). The association of high medical cost burdens with patient trust and perceived quality of care was greatest for privately insured persons. CONCLUSION: The rising cost of medical care threatens a vital aspect of the effective delivery of medical care-patient trust in their physician and continuity of care. Exposing patients to more of the costs could lead to greater skepticism and less trust of physicians' decision-making, thereby making health-care delivery less effective.

Patient experiences with coordination of care: the benefit of continuity and primary care physician as referral source.

BACKGROUND: Coordination across a patient's health needs and providers is important to improving the quality of care. OBJECTIVES: (1) Describe the extent to which adults report that their care is coordinated between their primary care physician (PCP) and specialists and (2) determine whether visit continuity with one's PCP and the PCP as the referral source for specialist visits are associated with higher coordination ratings. DESIGN: Cross-sectional study of the 2007 Health Tracking Household Survey. PARTICIPANTS: A total of 3,436 adults with a PCP and one or more visits to a specialist in the past 12 months. MEASUREMENTS: Coordination measures were patient perceptions of (1) how informed and up to date the PCP was about specialist care received, (2) whether the PCP talked with the patient about what happened at the recent specialist visit and (3) how well different doctors caring for a patient's chronic condition work together to manage that care. RESULTS: Less than half of respondents (46%) reported that their PCP always seemed informed about specialist care received. Visit continuity with the PCP was associated with better coordination of specialist care. For example, 62% of patients who usually see the same PCP reported that their PCP discussed with them what happened at their recent specialist visit vs. 48% of those who do not usually see the same PCP (adjusted percentages, p < 0.0001). When a patient's recent specialist visit was based on PCP referral (vs. self-referral or some other source), 50% reported that the PCP was informed and up to date about specialist care received (vs. 35%, p < 0.0001), and 66% reported that their PCP discussed with them what happened at their recent specialist visit (vs. 47%, p < 0.0001). CONCLUSIONS: Facilitating visit continuity between the patient and PCP, and encouraging the use of the PCP as the referral source would likely enhance care coordination.

Chronic burdens: the persistently high out-of-pocket health care expenses faced by many Americans with chronic conditions.

Using data from the 2001-2005 Medical Expenditure Panel Survey, this study shows that nearly 40 percent of nonelderly adults with three or more chronic conditions had out-of-pocket expenses and premiums exceeding 5 percent of income for two consecutive years, compared with 20 percent of people who had a single chronic condition and 14 percent who had no chronic conditions. Prescription drug spending accounts for over half of the out-of-pocket spending by individuals who have multiple chronic conditions and who have had persistently high financial burdens that last two years or more. The prevalence of persons with persistently high financial burdens is likely to increase in the future, because of expected increases in prescription drug costs as well as chronic disease prevalence.

Identifying affordable sources of medical care among uninsured persons.

OBJECTIVE: To examine the effects of policy, health system, and sociodemographic characteristics on the likelihood that uninsured persons pay a lower price at their regular source of care, or that they are aware of lower priced providers in their community. DATA SOURCES: The 2003 Community Tracking Study household survey, a nationally representative sample of the U.S. population and 60 randomly selected communities. STUDY DESIGN: The survey asked uninsured persons if they paid full or reduced cost at their usual source of medical care, or if they were aware of providers in their community that charge less for uninsured people. We use binomial and multinomial logistic regression analysis to examine the effects of various policy, health system, and sociodemographic characteristics on use and awareness of lower priced providers. We focus especially on the effects of safety-net capacity, measured by safety-net hospitals, community health centers, physicians' charity care, and Community Access Program (CAP) grants. PRINCIPAL FINDINGS: Less than half of the uninsured (47.5 percent) reported that they used or were aware of a lower priced provider in their community. Multivariate regression analysis shows that greater safety-net capacity is associated with a higher likelihood of having a lower priced provider as the regular source of care and greater awareness of lower priced providers. Lower incomes and racial/ethnic minorities also had a higher likelihood of having a lower priced provider, although health status did not have statistically significant effects. CONCLUSION: Although increased safety-net capacity may lead to more uninsured having a lower priced provider, many uninsured who live near safety-net providers are not aware of their presence. Greater outreach designed to increase awareness may be needed in order to increase the effectiveness of safety-net providers in improving access to care for the uninsured.

Overburdened and overwhelmed: the struggles of communities with high medical cost burdens.

The number of people with potentially high medical cost burdens varies widely across the nation, reflecting differences in the number of people who lack health insurance coverage and people who have coverage but nevertheless have high costs relative to their income. To address this problem, many states are undertaking expansions of insurance coverage, but federal support will be critical, particularly in states with large numbers of low-income residents.

Predicting high-cost privately insured patients based on self-reported health and utilization data.

OBJECTIVES: To examine how well self-reported data on health, health behaviors, and healthcare utilization by a sample of privately insured patients predict whether they will incur high healthcare costs the following year. STUDY DESIGN: A 2012 mail survey of autoworkers from Chrysler, Ford, and General Motors, with 3983 survey respondents linked to their health insurance claims data for 2012 and 2013. METHODS: High healthcare costs are defined as being in the 75th percentile or higher of healthcare expenditures. Models that include combinations of claims-based measures of expenditures and morbidity and self-reported measures of health, health behaviors, and healthcare utilization are compared. RESULTS: Claims-based measures of healthcare costs and comorbidity for 2012 were strong predictors of whether a patient would incur high healthcare costs in 2013 (C statistic = 0.78). Self-reported measures of chronic conditions, health status, health behaviors, and hospital use are also good predictors of high healthcare costs. However, even the most comprehensive model that included self-reported measures was not as accurate in predicting high healthcare costs (C statistic = 0.73). CONCLUSIONS: Efficient targeting of high-cost patients is crucial to the success of innovative care delivery models that attempt to lower costs and improve quality of care through more intensive care management of patients. The results of this study show that in the absence of claims data on prior use and expenditures, patient-reported measures of health status and prior healthcare use are reasonable predictors of future healthcare costs for a privately insured population.

Medicaid/SCHIP cuts and hospital emergency department use.

This paper uses data from the 2000-01 and 2003 Community Tracking Study household surveys to examine how decreases in enrollment in Medicaid and the State Children's Health Insurance Program (SCHIP) and increases in the number of uninsured people would affect the volume and distribution of emergency department (ED) use among low-income people. A decrease in Medicaid/SCHIP enrollment would lead to an increase in ED visits by the uninsured but little change in overall ED volume. The results suggest that cost containment efforts that reduce eligibility and enrollment will achieve cost savings largely by reducing access and shifting costs away from Medicaid/SCHIP.

Medicaid cost containment and access to prescription drugs.

States have been intensifying their efforts to control rising prescription drug costs in their Medicaid programs. This study examines the effects of five Medicaid cost containment policies on enrollees' perceptions of their ability to get prescription drugs. The results show that enrollees in states that have implemented all or almost all of these five policies have greater problems getting prescription drugs than enrollees in other states encounter. In terms of specific policies, prior authorization and mandatory generic substitutions had the largest effects on access to prescription drugs.

The effects of medicaid reimbursement on the access to care of medicaid enrollees: a community perspective.

Previous research has not found a strong association between Medicaid reimbursement levels and enrollees' access to medical care, even though higher fees increase the acceptance of Medicaid patients by physicians. This study shows that high Medicaid acceptance rates by physicians in a community are more important than fee levels per se in affecting enrollees' access to medical care. Although high fee levels increase the probability that individual physicians will accept Medicaid patients, high fee levels do not necessarily lead to high levels of physician Medicaid acceptance in an area. Numerous other physician practice, health system, and community characteristics also affect Medicaid acceptance. The effects of Medicaid fees on Medicaid acceptance are substantially lower in areas with high Medicaid managed care penetration and for physicians who practice in institutional settings. The results suggest that a broad range of factors need to be considered to increase access to physicians for Medicaid enrollees.

The share of people with high medical costs increased prior to implementation of the Affordable Care Act.

The percentage of Americans with high medical cost burdens--those who spend more than 10 percent of their family income on out-of-pocket expenses for health care--increased to 19.2 percent in 2011, after having stabilized at 18.2 percent during the Great Recession of 2007-09. The increase was driven primarily by growth in premium expenses in 2009-11 for people with employer-sponsored coverage. Out-of-pocket spending on health services, especially for prescription drugs, continued to decrease between 2007-09 and 2011. Medical cost burdens were highest for income groups most likely to benefit from the Affordable Care Act's coverage expansions, including people with private insurance coverage. Those who purchased nongroup coverage before the implementation of the health insurance Marketplaces in 2014 spent an especially high proportion of their income on health care, and over half of these people will qualify for premium subsidies in the Marketplaces. Federal subsidies will substantially reduce medical cost burdens for many people who do not obtain health insurance through their employers.

Many Medicaid Beneficiaries Receive Care Consistent With Attributes Of Patient-Centered Medical Homes.

The patient-centered medical home (PCMH) is being embraced as a way to improve access to and quality of care and to control health care costs. However, it is not known what proportion of the Medicaid population receives care from practices that incorporate PCMH goals. Nationally representative data for 2008-12 indicate that the majority of Medicaid beneficiaries with no other coverage who reported having a usual source of care described it as consistent with at least three of five key PCMH attributes: serving multiple health needs, ease of phone contact, extended office hours, coordination of prescriptions, and shared decision making. Younger, healthier, and higher-income Medicaid beneficiaries tended to report care sources with multiple attributes, compared to the older, sicker, and lower-income beneficiaries, who may be more likely to benefit from access to such care. Most attributes were associated with higher perceived quality of care and greater access, although the findings regarding health care expenditures were inconclusive. Challenges to widespread adoption of PCMH principles in Medicaid programs include targeting delivery of care consistent with those principles to high-need, high-cost populations and ensuring an adequate supply of usual sources of primary care.