A Comprehensive Review of State Vision Screening Mandates for Schoolchildren in the United States.

SIGNIFICANCE: Methods and frequency of vision screenings for school-aged children vary widely by state, and there has been no recent comparative analysis of state requirements. This analysis underscores the need for developing evidence-based criteria for vision screening in school-aged children across the United States. PURPOSE: The purpose of this study was to conduct an updated comprehensive analysis of vision screening requirements for school-aged children in the United States. METHODS: State laws pertaining to school-aged vision screening were obtained for each state. Additional information was obtained from each state's Department of Health and Education, through their websites or departmental representatives. A descriptive analysis was performed for states with data available. RESULTS: Forty-one states require vision screening for school-aged children to be conducted directly in schools or in the community. Screening is more commonly required in elementary school (n = 41) than in middle (n = 30) or high school (n = 19). Distance acuity is the most commonly required test (n = 41), followed by color vision (n = 11) and near vision (n = 10). Six states require a vision screening annually or every 2 years. CONCLUSIONS: Although most states require vision screening for some school-aged children, there is marked variation in screening methods and criteria, where the screening occurs, and grade levels that are screened. This lack of standardization and wide variation in state regulations point to a need for the development of evidence-based criteria for vision screening programs for school-aged children.

Home- and Community-Based Provider Preparation for Pennsylvania's Managed Long-term Services and Supports.

As Pennsylvania implements its managed long-term services and supports program, we explore how home- and community-based providers are preparing for and perceiving the transition through an online survey. We summarize responses and conduct chi-square analysis to measure differences between select provider groups. Despite high levels of uncertainty about program impact, over 84% of respondents plan to participate. We found that providers in the first implementation phase had more strategic and operational discussions with MCOs than the other two phases (p < .03). As program rollout continues, we anticipate changes in MCO-provider conversation frequency and topics based upon implementation zone.

The Role of Health Extension in Practice Transformation and Community Health Improvement: Lessons From 5 Case Studies.

Passage of the Patient Protection and Affordable Care Act triggered 2 successive grant initiatives from the Agency for Healthcare Research and Quality, allowing for the evolution of health extension models among 20 states, not limited to support for in-clinic primary care practice transformation, but also including a broader concept incorporating technical assistance for practices and their communities to address social determinants of health. Five states stand out in stretching the boundaries of health extension: New Mexico, Oklahoma, Oregon, Colorado, and Washington. Their stories reveal lessons learned regarding the successes and challenges, including the importance of building sustained relationships with practices and community coalitions; of documenting success in broad terms as well as achieving diverse outcomes of meaning to different stakeholders; of understanding that health extension is a function that can be carried out by an individual or group depending on resources; and of being prepared for political struggles over "turf" and ownership of extension. All states saw the need for long-term, sustained fundraising beyond grants in an environment expecting a short-term return on investment, and they were challenged operating in a shifting health system landscape where the creativity and personal relationships built with small primary care practices was hindered when these practices were purchased by larger health delivery systems.

Cost-effectiveness of option B+ in prevention of mother-to-child transmission of HIV in Yunnan Province, China.

BACKGROUND: Although Option B+ may be more costly than Options B, it may provide additional health benefits that are currently unclear in Yunnan province. We created deterministic models to estimate the cost-effectiveness of Option B+. METHODS: Data were used in two deterministic models simulating a cohort of 2000 HIV+ pregnant women. A decision tree model simulated the number of averted infants infections and QALY acquired for infants in the PMTCT period for Options B and B+. The minimum cost was calculated. A Markov decision model simulated the number of maternal life year gained and serodiscordant partner infections averted in the ten years after PMTCT for Option B or B+. ICER per life year gained was calculated. Deterministic sensitivity analyses were conducted. RESULTS: If fully implemented, Option B and Option B+ averted 1016.85 infections and acquired 588,01.02 QALYs.The cost of Option B was US$1,229,338.47, the cost of Option B+ was 1,176,128.63. However, when Options B and B+ were compared over ten years, Option B+ not only improved mothers'ten-year survival from 69.7 to 89.2%, saving more than 3890 life-years, but also averted 3068 HIV infections between serodiscordant partners. Option B+ yielded a favourable ICER of $32.99per QALY acquired in infants and $5149per life year gained in mothers. A 1% MTCT rate, a 90% coverage rate and a 20-year horizon could decrease the ICER per QALY acquired in children and LY gained in mothers. CONCLUSIONS: Option B+ is a cost-effective treatment for comprehensive HIV prevention for infants and serodiscordant partners and life-long treatment for mothers in Yunnan province, China. Option B+ could be implemented in Yunnan province, especially as the goals of elimination mother-to-child transmission of HIV and "90-90-90" achieved, Option B+ would be more attractive.

Changes in health care spending and quality 4 years into global payment.

BACKGROUND: Spending and quality under global budgets remain unknown beyond 2 years. We evaluated spending and quality measures during the first 4 years of the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC). METHODS: We compared spending and quality among enrollees whose physician organizations entered the AQC from 2009 through 2012 with those among persons in control states. We studied spending changes according to year, category of service, site of care, experience managing risk contracts, and price versus utilization. We evaluated process and outcome quality. RESULTS: In the 2009 AQC cohort, medical spending on claims grew an average of $62.21 per enrollee per quarter less than it did in the control cohort over the 4-year period (P<0.001). This amount is equivalent to a 6.8% savings when calculated as a proportion of the average post-AQC spending level in the 2009 AQC cohort. Analogously, the 2010, 2011, and 2012 cohorts had average savings of 8.8% (P<0.001), 9.1% (P<0.001), and 5.8% (P=0.04), respectively, by the end of 2012. Claims savings were concentrated in the outpatient-facility setting and in procedures, imaging, and tests, explained by both reduced prices and reduced utilization. Claims savings were exceeded by incentive payments to providers during the period from 2009 through 2011 but exceeded incentive payments in 2012, generating net savings. Improvements in quality among AQC cohorts generally exceeded those seen elsewhere in New England and nationally. CONCLUSIONS: As compared with similar populations in other states, Massachusetts AQC enrollees had lower spending growth and generally greater quality improvements after 4 years. Although other factors in Massachusetts may have contributed, particularly in the later part of the study period, global budget contracts with quality incentives may encourage changes in practice patterns that help reduce spending and improve quality. (Funded by the Commonwealth Fund and others.).

Association Between Health Plan Exit From Medicaid Managed Care and Quality of Care, 2006-2014.

Importance: State Medicaid programs have increasingly contracted with insurers to provide medical care services for enrollees (Medicaid managed care plans). Insurers that provide these plans can exit Medicaid programs each year, with unclear effects on quality of care and health care experiences. Objective: To determine the frequency and interstate variation of health plan exit from Medicaid managed care and evaluate the relationship between health plan exit and market-level quality. Design, Setting, and Participants: Retrospective cohort of all comprehensive Medicaid managed care plans (N = 390) during the interval 2006-2014. Exposures: Plan exit, defined as the withdrawal of a managed care plan from a state's Medicaid program. Main Outcomes and Measures: Eight measures from the Healthcare Effectiveness Data and Information Set were used to construct 3 composite indicators of quality (preventive care, chronic disease care management, and maternity care). Four measures from the Consumer Assessment of Healthcare Providers and Systems were combined into a composite indicator of patient experience, reflecting the proportion of beneficiaries rating experiences as 8 or above on a 0-to-10-point scale. Outcome data were available for 248 plans (68% of plans operating prior to 2014, representing 78% of beneficiaries). Results: Of the 366 comprehensive Medicaid managed care plans operating prior to 2014, 106 exited Medicaid. These exiting plans enrolled 4 848 310 Medicaid beneficiaries, with a mean of 606 039 beneficiaries affected by plan exits annually. Six states had a mean of greater than 10% of Medicaid managed care recipients enrolled in plans that exited, whereas 10 states experienced no plan exits. Plans that exited from a state's Medicaid market performed significantly worse prior to exiting than those that remained in terms of preventive care (57.5% vs 60.4%; difference, 2.9% [95% CI, 0.3% to 5.5%]), maternity care (69.7% vs 73.6%; difference, 3.8% [95% CI, 1.7% to 6.0%]), and patient experience (73.5% vs 74.8%; difference, 1.3% [95% CI, 0.6% to 1.9%]). There was no significant difference between exiting and nonexiting plans for the quality of chronic disease care management (76.2% vs 77.1%; difference, 1.0% [95% CI, -2.1% to 4.0%]). There was also no significant change in overall market performance before and after the exit of a plan: 0.7-percentage point improvement in preventive care quality (95% CI, -4.9 to 6.3); 0.2-percentage point improvement in chronic disease care management quality (95% CI, -5.8 to 6.2); 0.7-percentage point decrease in maternity care quality (95% CI, -6.4 to 5.0]); and a 0.6-percentage point improvement in patient experience ratings (95% CI, -3.9 to 5.1). Medicaid beneficiaries enrolled in exiting plans had access to coverage for a higher-quality plan, with 78% of plans in the same county having higher quality for preventive care, 71.1% for chronic disease management, 65.5% for maternity care, and 80.8% for patient experience. Conclusions and Relevance: Between 2006 and 2014, health plan exit from the US Medicaid program was frequent. Plans that exited generally had lower quality ratings than those that remained, and the exits were not associated with significant overall changes in quality or patient experience in the plans in the Medicaid market.

Quality Varies Across Health Insurance Marketplace Pricing Regions.

BACKGROUND: Although consumers purchasing health plans in the new Health Insurance Marketplace will be provided information on the cost and quality of participating health plans, it is unclear whether the state-wide plan quality averages that will be reported will accurately represent quality at the pricing region level where care will be received. OBJECTIVES: To evaluate whether currently reported state-wide health plan quality scores accurately represent quality within pricing regions established for the Health Insurance Marketplace. RESEARCH DESIGN: Observational, historical cohort study using health plan administrative and pharmacy data. SUBJECTS: A total of 5.2 million members enrolled in the preferred provider organization health plans of 1 large commercial California insurer in 2012. MEASURES: State-wide and pricing region performance on each of the 17 Healthcare Effectiveness Data and Information Set (HEDIS) measures. RESULTS: Across the 17 measures assessed in each of the 19 pricing regions, scores were statistically different (P<0.05) than the overall plan rate for 176 (54%). Variations in scores across regions were observed for each measure ranging from 6.4-percentage points for engagement in treatment for people with dependence of alcohol or other drugs to 47.2-percentage points for appropriate testing for pharyngitis among children. CONCLUSIONS: Quality scores in California vary greatly across geographic regions. Statewide averages may misrepresent the quality of care that consumers are likely to receive within a geographic area making difficult assessments about the value of the health care.

Basic health program: state administration of basic health programs; eligibility and enrollment in standard health plans; essential health benefits in standard health plans; performance standards for basic health programs; premium and cost sharing for basic health programs; federal funding process; trust fund and financial integrity. Final rule.

This final rule establishes the Basic Health Program (BHP), as required by section 1331 of the Affordable Care Act. The BHP provides states the flexibility to establish a health benefits coverage program for low-income individuals who would otherwise be eligible to purchase coverage through the Affordable Insurance Exchange (Exchange, also called Health Insurance Marketplace). The BHP complements and coordinates with enrollment in a QHP through the Exchange, as well as with enrollment in Medicaid and the Children's Health Insurance Program (CHIP). This final rule also sets forth a framework for BHP eligibility and enrollment, benefits, delivery of health care services, transfer of funds to participating states, and federal oversight. Additionally, this final rule amends another rule issued by the Secretary of the Department of Health and Human Services (Secretary) in order to clarify the applicability of that rule to the BHP.

Designing Vermont's pay-for-population health system.

Vermont is developing a health care system that could offer a unique opportunity to test a new model for improving population health. Four lines of development converged for the system: 1) a published challenge to create a pay-for-population health system, 2) comprehensive state health reform legislation, 3) the Institute for Healthcare Improvement Triple Aim project, and 4) the concept of the accountable care organization (ACO). In phase 1 of pilot testing, 3 communities serving 10% of the population are using the system, which is based on the enhanced medical home model. Planning is under way for phase 2 of the pilot, ACOs that use incentives based on the Triple Aim goals. Vermont has created a conceptual framework for a community health system and identified some of the practical issues involved in implementing this framework. This article summarizes the design and implementation of the enhanced medical home pilots and the results of a feasibility study for the ACO pilots. It describes how one state is using a systematic approach to health care reform to overcome some of the implementation barriers to a pay-for-population health system. Vermont will continue to provide a statewide laboratory for a pay-for-population health system.

Support of nursing homes in infection management varies by US State Departments of Health.

BACKGROUND: In many countries, healthcare-associated infections (HAIs) are problematic in long-term aged care living facilities. In the United States (US), HAIs occur frequently in nursing homes (NHs). Identifying effective practices for state Departments of Health (DOHs) to help NHs improve infection prevention and control and reduce HAIs is necessary. AIM: As a first step, the objective was to systematically examine and catalogue the variations in state intentions and activities related to HAI prevention in NHs. METHODS: An environmental scan of state DOH websites, HAI plans, and HAI state infographics was conducted. Data were collected on 16 items across three domains: (1) intentions to reduce HAIs in NHs, (2) actions to reduce HAIs in NHs, and (3) website usability. FINDINGS: State infection control support for NHs varied widely. Most states (92%) mentioned NHs in their HAI plans and 76% included NHs in their infographic. Half has an HAI prevention advisory council, while one-third had a state HAI prevention collaborative. Only 57% of HAI plans that mentioned NHs included training materials on HAI reduction. The most common training available was on antibiotic stewardship. CONCLUSION: Many US states have room for improvement in the support they provide NHs regarding infection prevention and control. Specific areas of improvement include: (1) increased provision of training materials on HAI reduction, (2) focusing training materials on common HAIs, and (3) NH engagement in collaboratives aimed at HAI reduction. More research is needed linking DOH activities to resident outcomes.

Association of Medicaid-Focused or Commercial Medicaid Managed Care Plan Type With Outpatient and Acute Care.

Importance: Enrollment in Medicaid managed care plans has increased rapidly, particularly in national commercial insurance plans. Whether the type of managed care plan is associated with the use of health services for Medicaid beneficiaries is unknown. Objective: To compare the use of outpatient and acute care between Medicaid enrollees randomly assigned to a national commercial managed care plan or a local Medicaid-focused managed care plan. Design, Setting, and Participants: This natural experiment of a cohort of Medicaid enrollees randomly assigned to 2 managed care plans in a Northeastern US state was conducted from June 30, 2009, to June 30, 2013. Statistical analysis was performed from September 1, 2019, to August 30, 2020. Interventions: Assignment to a Medicaid-focused insurance plan or a commercial managed care plan. Main Outcomes and Measures: Outpatient visits, emergency department visits, and total inpatient and ambulatory care-sensitive hospitalizations. Results: A total of 8010 patients were included in the analysis: 4737 were assigned to a Medicaid-focused plan (2795 female [59.0%]; mean [SD] age, 17.8 [3.2] years) and 3273 to a commercial managed care plan (1915 female [58.5%]; mean [SD] age, 17.9 [3.3] years). Those randomly assigned to the Medicaid-focused plan had a mean (SD) of 6.67 (9.18) annual outpatient visits per person, and those assigned to the commercial plan had a mean (SD) of 8.36 (11.77) annual outpatient visits per person (adjusted absolute difference, 1.72 [95% CI, 1.31-2.13]; 22% relative difference). The increased use of outpatient visits in the commercial plan was associated with an increase in specialty care visits (mean [SD], 2.34 [6.31] visits in Medicaid-focused plan vs 3.75 [9.32] visits in commerical plan; adjusted absolute difference, 1.43 visits [95% CI, 1.25-1.56 visits]; 61% relative difference). Mean (SD) annual emergency department visits were 0.49 (1.39) per person in the Medicaid-focused plan and 0.51 (1.40) in the commercial plan (adjusted absolute difference, 0.02 [95% CI, -0.02 to 0.05]). Mean (SD) annual inpatient admissions were 0.067 (0.45) per person in the Medicaid-focused plan and 0.069 (0.53) in the commercial plan (adjusted absolute difference, 0.003 [95% CI, -0.01 to 0.02]). Plan assignment was not significantly associated with ambulatory care-sensitive admissions. Results were consistent in instrumental variables analyses that accounted for disenrollment and switching. Conclusions and Relevance: Compared with Medicaid managed care enrollees assigned to a Medicaid-focused plan, those assigned to a commercial plan had more outpatient visits, particularly for specialty care, but had similar rates of emergency department visits and hospitalizations. These findings suggest that the type of managed care plan may be associated with health services use and spending among Medicaid beneficiaries and that random assignment may help states understand how well different plans perform for enrollees.

Cardiac surgeons and the quality movement: the Michigan experience.

The Michigan Society of Thoracic and Cardiovascular Surgeons created a voluntary quality collaborative with all the cardiac surgeons in the state and all hospitals doing adult cardiac surgery. Utilizing this collaborative over the last 3 years and creating a unique relationship with a payor, an approach to processes and outcomes has produced improvements in the quality of care for cardiac patients in the state of Michigan.

Quality Measures for Managing Prescription of Antipsychotic Medication Among Youths: Factors Associated With Health Plan Performance.

OBJECTIVE: This study examined the performance of health plans on two HEDIS measures: metabolic monitoring of children and adolescents prescribed an antipsychotic and use of first-line psychosocial care for children and adolescents prescribed an antipsychotic for a nonindicated use. Plan characteristics and other contextual factors that may be associated with health plan performance were examined to identify potential strategies for improving care. METHODS: The study population included 279 commercial and 169 Medicaid health plans that voluntarily submitted data for care provided in 2016. Bivariate associations between performance on the two measures and each plan characteristic (eligible population size, region, profit status, model type, and operating in a state with legislation on prior authorization for antipsychotics) were examined. Main-effects multivariable linear regression models were used to examine the combined association of plan characteristics with each measure. RESULTS: Performance rates on both measures were comparable for commercial and Medicaid plans. Among commercial plans, not-for-profit plans outperformed for-profit plans on both measures. Commercial and Medicaid plans in the North performed significantly better on the metabolic monitoring measure. Commercial plans in the South and Medicaid plans in the West performed significantly worse on the first-line psychosocial care measure. Plans operating in states requiring prior authorization performed significantly better on the metabolic monitoring measure. CONCLUSIONS: This study identified key plan characteristics and other contextual factors associated with health plan performance on quality measures related to pediatric antipsychotic prescribing. Findings suggest that quality measures, in conjunction with policies such as prior authorization, can encourage better care delivery to vulnerable populations.

The states' role in national health reform.

The respective roles of states and the federal government in health reform is a defining feature of any proposal. Heterogeneity among states implies the need for different approaches in different places, but a possible consequence is variation in results and outcomes around the nation.

[Primary health care and urban dynamics in large cities in São Paulo State, Brazil]. / Atenção básica e dinâmica urbana nos grandes municípios paulistas, Brasil.

The Baseline Studies on the Project for Expansion and Consolidation of the Family Health Strategy created primary health care indicators and models for the 62 municipalities with more than 100,000 inhabitants in São Paulo State, Brazil, and identified varying patterns for these indicators and models in relation to different urban dynamics in the State. The studies showed the need to reflect on health in relation to urban land use. The main objective was to gain a better understanding of how urban dynamics influence the health system's profile, organization, and operation, based on which it was possible to extract some hypotheses and discussions regarding how urbanization in São Paulo State creates challenges for the expansion and consolidation of primary health care and the Family Health Program in these municipalities.

[Family development index: a comparative analysis in 21 municipalities in Rio de Janeiro State, Brazil]. / Indice de desenvolvimento da família: uma análise comparativa em 21 municípios do Estado do Rio de Janeiro, Brasil.

This article presents an adaptation of the family development index, with a detailed description of the results of its application in 21 municipalities in the State of Rio de Janeiro, Brazil, in 2000. The research is part of the Baseline Study on the Project for Expansion and Consolidation of the Family Health Strategy and was proposed as an instrument for monitoring and analyzing the municipal reality in the context of a family-centered public policy. The results show a serious-to-severe situation for families in the State of Rio de Janeiro. The most critical dimensions relate to inequalities in results, availability of resources, and labor market access, in addition to a key aspect involving inequality of opportunities, namely access to knowledge. The most vulnerable groups consist of families headed by individuals over 65 years of age and families headed by women.

[Health records: evaluation of patient health charts in primary care, Rio de Janeiro, Brazil]. / Registros em saúde: avaliação da qualidade do prontuário do paciente na atenção básica, Rio de Janeiro, Brasil.

With the purpose of contributing to the evaluation of primary care, a study was conducted based on the quality of patients' health charts, considering the records for care provided in 4 municipalities with more than 100 thousand inhabitants each in the State of Rio de Janeiro, Brazil, in 2004. This was a cross-sectional study based on primary data collected from direct consultation of patient charts. A two-stage, probabilistic cluster sample was selected from primary care facilities and consultations/patient charts. We checked the completeness of attributes pertaining to the identification of users receiving care and the characteristics of the care itself (weight, blood pressure, Pap tests, and blood glucose) on the charts of women over 19 years of age with hypertension and/or diabetes. User identification showed a low presence of social attributes, and only half of the charts had recorded the opening date. Records of process characteristics in care provided to women with hypertension and diabetes failed to conform to Brazilian Ministry of Health guidelines. Analysis of completeness suggests dubious quality in the continuity of the care provided and difficulties in management practice for primary care and implementation of the Family Health Strategy.

Public reporting of quality information on Medicaid health plans.

Transparency through public reporting of quality data is key to achieving the Institute of Medicine's (IOM) vision for 21st century health care. This article reviews the status of States' voluntary public reporting of Medicaid managed care (MMC) quality data, and analyzes these data. Twenty-one States, including 17 of the 20 largest managed care States, have made plan-level data publicly available online, although the data are sometimes thin, with few measures reported, hard-to-access, and old. We conclude that CMS could better leverage the power of public reporting for quality improvement (QI) by increasing the visibility of health plan employer data and information set (HEDISV) data that States already collect.