Impact of a Provider Tele-mentoring Learning Model on the Care of Medicaid-enrolled Patients With Diabetes.

BACKGROUND: Project ECHO (Extension for Community Healthcare Outcomes), a tele-mentoring program for health care providers, has been shown to improve provider-reported outcomes, but there is insufficient research on patient-level outcomes. OBJECTIVES: To evaluate the impact of primary care provider (PCP) participation in Project ECHO on the care of Medicaid enrollees with diabetes. RESEARCH DESIGN: New Jersey Medicaid claims and encounter data and difference-in-differences models were used to compare utilization and spending between Medicaid patients seen by PCPs participating in a Project ECHO program to those of matched nonparticipating PCPs. SUBJECTS: A total of 1776 adult Medicaid beneficiaries (318 with diabetes), attributed to 25 participating PCPs; and 9126 total (1454 diabetic) beneficiaries attributed to 119 nonparticipating PCPs. MEASURES: Utilization and spending for total inpatient, diabetes-related inpatient, emergency department, primary care, and endocrinologist services; utilization of hemoglobin A1c tests, eye exams, and diabetes prescription medications among diabetics, and total Medicaid spending. RESULTS: Participation in Project ECHO was associated with decreases of 44.3% in inpatient admissions (P=0.001) and 61.9% in inpatient spending (P=0.021) among treatment relative to comparison patients. Signs of most other outcome estimates were consistent with hypothesized program effects but without statistical significance. Sensitivity analyses largely confirmed these findings. CONCLUSIONS: We find evidence that Project ECHO participation was associated with large and statistically significant reductions of inpatient hospitalization and spending. The study was observational and limited by a small sample of participating PCPs. This study demonstrates the feasibility and potential value of quasi-experimental evaluation of Project ECHO patient outcomes using claims data.

Medicaid Waivers and Tenancy Supports for Individuals Experiencing Homelessness: Implementation Challenges in Four States.

Policy Points Medicaid policymakers have a growing interest in addressing homelessness as a social determinant of health and driver of the potentially avoidable use of expensive medical services. Drawing on extensive document reviews and in-depth interviews in four early-adopter states, we examined the implementation of Medicaid's Section 1115 demonstration waivers to test strategies to finance tenancy support services for persons experiencing or at risk of homelessness. CONTEXT: The Affordable Care Act extended Medicaid eligibility to large numbers of individuals experiencing or at risk of homelessness. This legislative development and the growing recognition of homelessness as a significant social determinant of health have encouraged advocates and policymakers to seek new ways to use Medicaid to provide housing supports. METHODS: We conducted 28 semistructured interviews with 36 stakeholders in four states. The stakeholders were government administrators, health care providers, nonprofit housing staff, and consultants. We supplemented these interviews with extensive reviews of public documents, media accounts, think-tank reports, and published literature. We also conducted a systematic inductive qualitative analysis. FINDINGS: We identified seven challenges to the successful implementation of tenancy support demonstration projects: resolving the housing supply and NIMBY, removing silos between health care and homeless services providers, enrolling and retaining the target populations in Medicaid, contracting with and paying tenancy support providers, recruiting and retaining key workers, ensuring Medicaid's waiver durability, and reducing administrative crowd-out and waiver burden. CONCLUSIONS: Notwithstanding these challenges, three of the four states have made significant progress in launching their initiatives. At this point, the fourth state has delayed its start-up to consider alternatives to a Medicaid demonstration waiver to provide tenancy supports. The experience of the four states suggests lessons for Medicaid officials in other jurisdictions that are interested in pursuing tenancy support initiatives. Nevertheless, the limitations of tenancy support waiver programs suggest that federal policymakers should consider allowing states to more directly subsidize housing costs for those experiencing or at risk of homelessness as an optional Medicaid benefit.

Medicaid DSRIP in New Jersey: Trade-offs between Broad Hospital Participation and Safety Net Viability.

The Delivery System Reform Incentive Payment (DSRIP) program, an increasingly utilized payment strategy to foster population health management by hospitals and outpatient providers, may sometimes generate financial and operational hardships for safety net hospitals (SNHs). The authors utilized a hospital survey and stakeholder interviews to examine impacts of the New Jersey DSRIP program, particularly focusing on its participatory structure that extended eligibility to all hospitals, and specific effects on SNHs. They found that the New Jersey DSRIP fulfilled its primary objective of conditioning receipt of Medicaid supplementary payments on quality and reporting of care by hospitals. It also provided an impetus to ongoing hospital-directed initiatives and introduced new areas of focus, including behavioral health and obesity. However, stakeholders reported that program implementation was not sensitive to specific constraints, priorities, and resource needs of SNHs. Some of the policies relating to outpatient partnerships, reporting of quality metrics, and monitoring low-income populations were perceived to have placed disproportionate burdens on SNHs. Despite appearing to meet its primary goals, the New Jersey DSRIP experience reveals a critical need to be responsive to problems faced by SNHs so as to limit their short-term transition costs and maintain financial viability for serving their patient populations.

Medicaid Long-Term Care: State Variation and the Intergovernmental Lobby.

Medicaid is vastly more important than Medicare or private insurance in funding long-term care (LTC). However, states vary tremendously in their commitment to Medicaid LTC. This article advances knowledge of the origins, nature, and implications of this variation. After examining the degree of variation in state spending on Medicaid LTC, we show how federal policy has over the past fifty years steadily increased state discretion to shape these services. This decentralization largely reflects the potency of the intergovernmental lobby-governors and other state officials-in influencing federal policy. While fueling state variation, the intergovernmental lobby has also provided valuable political support that has helped Medicaid grow and resist retrenchment. After considering policy options that could mitigate Medicaid LTC inequities rooted in state differences, we assess how the catalytic forces that have fueled growth in Medicaid LTC may be insufficient to protect the program from future erosion.

Nurse Delegation in Home Care: Research Guiding Policy Change.

The current study evaluated nurse delegation in home care, a pilot program introduced in 2007 in New Jersey to promote home care options for consumers needing assistance with medical/nursing tasks. Findings on readiness for the program, barriers and facilitating factors, experience with the program, and recommendations are summarized and presented. Methods included surveys and interviews with participants in nurse delegation, observations of planning and implementation meetings, and review meeting minutes. Major findings were no negative outcomes for consumers, improvements in quality of life and quality of care for consumers, high readiness and increasing satisfaction with experience in delegation, perception of nurse delegation in home care as a valued option, and the challenges of ensuring adequate staffing. Subsequent changes in regulation in New Jersey are underway, translating this research into policy. [Journal of Gerontological Nursing, 42(9), 7-15.].

States' commitment to Medicaid before the Affordable Care Act: trends and implications.

Medicaid insures more than 65 million low-income people, and the Affordable Care Act of 2010 gives states the option to enroll millions more. Historical trends in state Medicaid effort possess important implications for health policy going forward. Nearly all states steadily ratcheted up their Medicaid effort in the period from 1992 to 2009, holding out promise that most will sustain their programs and ultimately participate in the expansion authorized by the Affordable Care Act. But the growth in Medicaid over this period did not appreciably curtail vast geographic disparities in program benefits that threaten to undermine the goals of health reform.