Factors Associated with Early and Periodic Screening, Diagnostic, and Treatment Services in a Medicaid Managed Care Pediatric Population.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services is a Medicaid benefit for children that addresses their health problems before they become advanced, debilitating, and expensive. We conducted a retrospective cross-sectional analysis of pediatric beneficiaries (newborn to younger than 21 years) enrolled in a Medicaid managed care organization to examine the factors associated with EPSDT screening services completion. We obtained 2018 administrative claims data for beneficiaries continuously enrolled for a minimum of 90 days (n=156,108). Completion of EPSDT screening services among our Medicaid managed care beneficiaries was low. Those having more emergency department visits and hospitalizations, having family medicine practitioners as primary care physicians, belonging to the racial/ethnic group Asian/Pacific Islander/Hawaiian/Alaskan Native/Native American, and 18 to younger than 21 years age group were less likely than others to complete EPSDT services. Our results provide information on segments of pediatric beneficiaries that can be targeted to increase EPSDT screening services completion.

COVID-19 and social determinants of health: Medicaid managed care organizations' experiences with addressing member social needs.

BACKGROUND: The significant adverse social and economic impact of the COVID-19 pandemic has cast broader light on the importance of addressing social determinants of health (SDOH). Medicaid Managed Care Organizations (MMCOs) have increasingly taken on a leadership role in integrating medical and social services for Medicaid members. However, the experiences of MMCOs in addressing member social needs during the pandemic has not yet been examined. AIM: The purpose of this study was to describe MMCOs' experiences with addressing the social needs of Medicaid members during the COVID-19 pandemic. METHODS: The study was a qualitative study using data from 28 semi-structured interviews with representatives from 14 MMCOs, including state-specific markets of eight national and regional managed care organizations. Data were analyzed using thematic analysis. RESULTS: Four themes emerged: the impact of the pandemic, SDOH response efforts, an expanding definition of SDOH, and managed care beyond COVID-19. Specifically, participants discussed the impact of the pandemic on enrollees, communities, and healthcare delivery, and detailed their evolving efforts to address member nonmedical needs during the pandemic. They reported an increased demand for social services coupled with a significant retraction of community social service resources. To address these emerging social service gaps, participants described mounting a prompt and adaptable response that was facilitated by strong existing relationships with community partners. CONCLUSION: Among MMCOs, the COVID-19 pandemic has emphasized the importance of addressing member social needs, and the need for broader consideration of what constitutes SDOH from a healthcare delivery standpoint.

Nursing home care under Medicaid managed long-term services and supports.

OBJECTIVE: To measure the impact of Medicaid managed long-term services and supports (MLTSS) on nursing home (NH) quality and rebalancing. DATA SOURCES/STUDY SETTING: This study analyzes secondary data from annual NH recertification surveys and the minimum dataset (MDS) in three states that implemented MLTSS: Massachusetts (2001-2007), Kansas and Ohio (2011-2017). STUDY DESIGN: We utilized a difference-in-difference approach comparing NHs in border counties of states that implemented MLTSS with a control group of NHs in neighboring border counties in states that did not implement MLTSS. Sensitivity analyses included a triple-difference model (stratified by Medicaid payer mix) and a within-state comparison. We examined changes in six NH-level outcomes (percentage of low-care NH residents, facility occupancy, and four NH quality measures) after MLTSS implementation. DATA COLLECTION/EXTRACTION METHODS: For each state, all freestanding NHs in border counties were included, as were NHs in neighboring counties located in other states. Information on low-care residents was aggregated to the NH level from MDS data, then combined with Online Survey Certification and Reporting (OSCAR) and Certification and Survey Provider Enhanced Reporting (CASPER) data. PRINCIPAL FINDINGS: MLTSS had no statistically significant effects on NH quality outcomes in Massachusetts or Kansas. In Ohio, MLTSS led to an increase of 0.21 nursing hours per resident day [95% CI: 0.03, 0.40], and a decrease of 1.47 deficiencies [95% CI: -2.52, -0.42] and 9.38 deficiency points [95% CI: -18.53, -0.24] per certification survey. After MLTSS, occupancy decreased by 1.52 percentage points [95% CI: -2.92, -0.12] in Massachusetts, but increased by 3.17 percentage points [95% CI: 0.36, 5.99] in Ohio. We found no effect on low-care residents in any state. Findings were moderately sensitive to the choice of comparator group. CONCLUSION: The study provides little evidence that MLTSS reduces quality of care, occupancy, or the percentage of low-care residents in NHs.

Medication Use in the Management of Comorbidities Among Individuals With Autism Spectrum Disorder From a Large Nationwide Insurance Database.

Importance: Although there is no pharmacological treatment for autism spectrum disorder (ASD) itself, behavioral and pharmacological therapies have been used to address its symptoms and common comorbidities. A better understanding of the medications used to manage comorbid conditions in this growing population is critical; however, most previous efforts have been limited in size, duration, and lack of broad representation. Objective: To use a nationally representative database to uncover trends in the prevalence of co-occurring conditions and medication use in the management of symptoms and comorbidities over time among US individuals with ASD. Design, Setting, and Participants: This retrospective, population-based cohort study mined a nationwide, managed health plan claims database containing more than 86 million unique members. Data from January 1, 2014, to December 31, 2019, were used to analyze prescription frequency and diagnoses of comorbidities. A total of 26 722 individuals with ASD who had been prescribed at least 1 of 24 medications most commonly prescribed to treat ASD symptoms or comorbidities during the 6-year study period were included in the analysis. Exposures: Diagnosis codes for ASD based on International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. Main Outcomes and Measures: Quantitative estimates of prescription frequency for the 24 most commonly prescribed medications among the study cohort and the most common comorbidities associated with each medication in this population. Results: Among the 26 722 individuals with ASD included in the analysis (77.7% male; mean [SD] age, 14.45 [9.40] years), polypharmacy was common, ranging from 28.6% to 31.5%. Individuals' prescription regimens changed frequently within medication classes, rather than between classes. The prescription frequency of a specific medication varied considerably, depending on the coexisting diagnosis of a given comorbidity. Of the 24 medications assessed, 15 were associated with at least a 15% prevalence of a mood disorder, and 11 were associated with at least a 15% prevalence of attention-deficit/hyperactivity disorder. For patients taking antipsychotics, the 2 most common comorbidities were combined type attention-deficit/hyperactivity disorder (11.6%-17.8%) and anxiety disorder (13.1%-30.1%). Conclusions and Relevance: This study demonstrated considerable variability and transiency in the use of prescription medications by US clinicians to manage symptoms and comorbidities associated with ASD. These findings support the importance of early and ongoing surveillance of patients with ASD and co-occurring conditions and offer clinicians insight on the targeted therapies most commonly used to manage co-occurring conditions. Future research and policy efforts are critical to assess the extent to which pharmacological management of comorbidities affects quality of life and functioning in patients with ASD while continuing to optimize clinical guidelines, to ensure effective care for this growing population.

Impact of the 1115 behavioral health Medicaid waiver on adult Medicaid beneficiaries in New York State.

OBJECTIVE: To evaluate the impact of the Health and Recovery Plan (HARP), a capitated special needs Medicaid managed care product that fully integrates physical and behavioral health delivery systems in New York State. DATA SOURCES: 2013-2019 claims and encounters data on continuously enrolled individuals from the New York State Medicaid data system. STUDY DESIGN: We used a difference-in-difference approach with inverse probability of exposure weights to compare service use outcomes in individuals enrolled in the HARP versus HARP eligible comparison group in two regions, New York City (NYC) pre- (2013-2015) versus post- (2016-2018) intervention periods, and rest of the state (ROS) pre- (2014-2016) versus post- (2017-2019) intervention periods. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: HARPs were associated with a relative decrease in all-cause (RR = 0.78, 95% CI 0.68-0.90), behavioral health-related (RR = 0.76, 95% CI 0.60-0.96), and nonbehavioral-related (RR = 0.87, 95% CI 0.78-0.97) stays in the NYC region. In the ROS region, HARPs were associated with a relative decrease in all-cause (RR = 0.87, 95% CI 0.80-0.94) and behavioral health-related (RR = 0.80, 95% CI 0.70-0.91) stays. Regarding outpatient visits, the HARPs benefit package were associated with a relative increase in behavioral health (RR = 1.21, 95% CI 1.13-1.28) and nonbehavioral health (RR = 1.08, 95% CI 1.01-1.15) clinic visits in the NYC region. In the ROS region, the HARPs were associated with relative increases in behavioral health (RR = 1.47, 95% CI 1.32-1.64) and nonbehavioral health (RR = 1.17, 95% CI 1.11-1.25) clinic visits. CONCLUSIONS: Compared to patients with similar clinical needs, HARPs were associated with a relative increase in services used and led to a better engagement in the HARPs group regardless of the overall decline in services used pre- to postperiod.

Effects of forced disruption in Medicaid managed care on children with asthma.

OBJECTIVE: To evaluate the effect of a forced disruption to Medicaid managed care plans and provider networks on health utilization and outcomes for children with persistent asthma. DATA SOURCES: Medicaid managed care administrative claims data from 2013 to 2016, obtained from a southeastern state. STUDY DESIGN: A difference-in-difference analysis compared patients' outpatient, inpatient, and emergency department (ED) utilization and receipt of recommended services before and after implementation of a statewide redistribution of patients among nine managed care plans. DATA COLLECTION/EXTRACTION METHODS: Enrollment data for children with asthma were linked to the administrative claims. Children were included if they had a diagnosis of persistent asthma in 2013 and if they were enrolled continuously throughout 2014-2016. PRINCIPAL FINDINGS: Among the 28 537 children with asthma, 26% were forced to switch their managed care plan after the redistribution. Of these, 67% also switched their primary care provider (PCP). Relative to those who remained in their plan, disruption was associated with an additional 2.1 percentage-point decrease in the number of children who had an outpatient visit per quarter [95%CI -2.8, -1.3], from 71% to 66% (compared to plan stayers: 74% to 71%). Among children experiencing a change to their plan, there was overall a decrease in the proportion of children receiving an asthma-specific visit per quarter, but there was less of a decrease in children that also changed their PCP [1.6 percentage points, 95%CI 0.7, 2.5], from 9.7% to 8.3% (compared to those who did not switch their PCP: 12% to 8.6%). Indicators of asthma care quality and emergent care utilization were not significantly different between the two periods. CONCLUSIONS: While there was a decrease in the number of outpatient visits associated with forced disruption of Medicaid managed care plans for children with persistent asthma, there were no consistent associations with worse asthma quality performance or higher emergent health care utilization.

Plan Type and Opioid Prescriptions for Children in Medicaid.

BACKGROUND: Opioids are generally an inappropriate acute pain management strategy in children, particularly because of the risk for diversion and subsequent misuse and abuse. OBJECTIVES: To examine associations between Medicaid plan type [coordinated care organization (CCO), managed care (MC), fee-for-service (FFS)] and whether a child received an opioid prescription. RESEARCH DESIGN: Secondary analysis of Oregon Medicaid data (January 1, 2016 to December 31, 2017). SUBJECTS: Medicaid-enrolled children ages 0-17 (N=200,169). MEASURES: There were 2 outcomes: whether a child received an opioid prescription from (a) any health provider or (b) from a visit to the dentist. Predictor variables included Medicaid plan type, age, sex, race, and ethnicity. RESULTS: About 6.7% of children received an opioid from any health provider and 1.2% received an opioid from a dentist visit. Children in a CCO were significantly more likely than children in a MC (P<0.01) or FFS (P=0.02) plan to receive an opioid from any health provider. Children in a CCO were also significantly more likely than children in MC or FFS to receive an opioid from a dentist visit (P<0.01). CONCLUSIONS: Pediatric opioid prescriptions vary by plan type. Future efforts should identify reasons why Medicaid-enrolled children in a CCO plan are more likely to be prescribed opioids.

Characteristics and Outcomes of Mechanically Ventilated COVID-19 Patients-An Observational Cohort Study.

BACKGROUND: The United States currently has more confirmed cases of COVID-19 than any other country in the world. Given the variability in COVID-19 testing and prevention capability, identifying factors associated with mortality in patients requiring mechanical ventilation is critical. This study aimed to identify which demographics, comorbidities, markers of disease progression, and interventions are associated with 30-day mortality in COVID-19 patients requiring mechanical ventilation. METHODS: Adult patients with a confirmed diagnosis of COVID-19 admitted to one of the health system's intensive care units and requiring mechanical ventilation between March 9, 2020 and April 1, 2020, were included in this observational cohort study. We used Chi-Square and Mann-Whitney U tests to compare patient characteristics between deceased and living patients and multiple logistic regression to assess the association between independent variables and the likelihood of 30-day mortality. RESULTS: We included 85 patients, of which 20 died (23.5%) within 30 days of the first hospital admission. In the univariate analysis, deceased patients were more likely ≥60 years of age (p < 0.001), non-Hispanic (p = 0.026), and diagnosed with a solid malignant tumor (p = 0.003). Insurance status also differed between survivors and non-survivors (p = 0.019). Age ≥60 and malignancy had a 9.5-fold (95% confidence interval 1.4-62.3, p = 0.020) and 5.8-fold higher odds ratio (95% confidence interval 1.2-28.4, p = 0.032) for 30-day mortality after adjusted analysis using multivariable logistic regression, while other independent variables were no longer significant. CONCLUSIONS: In our observational cohort study of 85 mechanically ventilated COVID-19 patients, age, and a diagnosis of a solid malignant tumor were associated with 30-day mortality. Our findings validate concerns for the survival of elderly and cancer patients in the face of the COVID-19 pandemic in the United States, where testing capabilities and preventative measures have been inconsistent. Preventative efforts geared to patients at risk for intensive care unit mortality from COVID-19 should be explored.

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.

Fixed effects analysis of the incidence of cardiovascular outcomes under managed care following the managed care backlash.

ABSTRACTS: To examine the impact of increased managed care activity on 30-day readmission and mortality for acute myocardial infarctions and congestive heart failure in U.S. hospitals following the managed care backlash against managed care cost containment practices.The Centers for Medicare and Medicaid Services (CMS) Hospital Compare files, CMS Hospital Cost Report, CMS Medicare Advantage Enrollment files, and Health Resources and Services Administration Area Resource File data for the period 2008 to 2011 were used to construct the study sample. Multivariate fixed effects regression with robust standard errors, hospital fixed effects, and year fixed effects were used to estimate the impact of managed care penetration on adverse cardiovascular outcomes. Our primary outcome measures were readmission and mortality for patients discharged with acute myocardial infarction and congestive heart failure for acute, non-federal hospitals with emergency rooms. To examine effects of hospital ownership status, not-for-profit hospitals were compared to proprietary hospitals.The main analysis revealed that an increase in managed care penetration was associated with a decline in both 30-day readmission and mortality for acute myocardial infarction and congestive heart failure. In the hospital ownership analysis, only the acute myocardial infarction results for proprietary hospitals was statistically significant. All hospital types reported similar congestive heart failure trends as the full sample; however, proprietary hospitals reported greater declines in readmission and mortality.Increased managed care activity is associated with reductions in hospital readmission and mortality following the legislative and consumer backlash against managed care, with differential impacts across hospital ownership type. These finding highlights the important role of managed care in creating quality improvements in the delivery of care in the hospital setting.

The Economic Burden of Out-of-Pocket Expenses for Plastic Surgery Procedures.

BACKGROUND: Health insurance reimbursement structure has evolved, with patients becoming increasingly responsible for their health care costs through rising out-of-pocket expenses. High levels of cost sharing can lead to delays in access to care, influence treatment decisions, and cause financial distress for patients. METHODS: Patients undergoing the most common outpatient reconstructive plastic surgery operations were identified using Truven MarketScan databases from 2009 to 2017. Total cost of the surgery paid to the insurer and out-of-pocket expenses, including deductible, copayment, and coinsurance, were calculated. Multivariable generalized linear modeling with log link and gamma distribution was used to predict adjusted total and out-of-pocket expenses. All costs were inflation-adjusted to 2017 dollars. RESULTS: The authors evaluated 3,165,913 outpatient plastic and reconstructive surgical procedures between 2009 and 2017. From 2009 to 2017, total costs had a significant increase of 25 percent, and out-of-pocket expenses had a significant increase of 54 percent. Using generalized linear modeling, procedures performed in outpatient hospitals conferred an additional $1999 in total costs (95 percent CI, $1978 to $2020) and $259 in out-of-pocket expenses (95 percent CI, $254 to $264) compared with office procedures. Ambulatory surgical center procedures conferred an additional $1698 in total costs (95 percent CI, $1677 to $1718) and $279 in out-of-pocket expenses (95 percent CI, $273 to $285) compared with office procedures. CONCLUSIONS: For outpatient plastic surgery procedures, out-of-pocket expenses are increasing at a faster rate than total costs, which may have implications for access to care and timing of surgery. Providers should realize the increasing burden of out-of-pocket expenses and the effect of surgical location on patients' costs when possible.

Medicaid Managed Care's Effects on Costs, Access, and Quality: An Update.

Medicaid is integral to public health because it insures one in five Americans and half of the nation's births. Nearly two-thirds of all Medicaid recipients are currently enrolled in a health maintenance organization (HMO). Proponents of HMOs argue that they can lower costs while maintaining access and quality. We critically reviewed 32 studies on Medicaid managed care (2011-2019). Authors reported state-specific cost savings and instances of increased access or quality with implementation or redesign of Medicaid managed-care programs. Studies on high-risk populations (e.g., disabled) found improvements in quality specific to a state or a high-risk population. A unique model of managed care (i.e., the Oregon Health Plan) was associated with reduced costs and improved access and quality, but results varied by comparison state. New trends in the literature focused on analysis of auto-assignment algorithms, provider networks, and plan quality. More analysis of costs jointly with access/quality is needed, as is research on managing long-term care among elderly and disabled Medicaid recipients.

Associations Between Activities of Daily Living Independence and Mental Health Status Among Medicare Managed Care Patients.

BACKGROUND/OBJECTIVES: Although there is a strong cross-sectional association between dependence in activities of daily living (ADLs) and decreased mental health, it is largely unknown how the loss of specific ADLs, or the combination of ADLs, influences mental health outcomes. We examined the effect of ADL independence on mental health among participants in a large survey of Medicare managed care recipients. DESIGN/SETTING: Retrospective cohort study. PARTICIPANTS: A total of 104,716 participants in cohort 17 of the Medicare Health Outcomes Survey, who completed the baseline and follow-up surveys in 2014 and 2016. MEASUREMENTS: Linear regression models estimated the effects of loss of ADL independence on change in Mental Component Summary (MCS) score. RESULTS: In an adjusted model, loss of independence in eating, bathing, dressing, and toileting were associated with three- to four-point declines in MCS, suggesting meaningful worsening. In a model that also included all six ADLs, loss of independence in each ADL was associated with declines in MCS, with the largest effects for eating and bathing. MCS decreased by 1.3 per each additional summative loss of ADL independence (P < .001). CONCLUSION: Loss of ADL independence was associated with large declines in mental health, with personal care activities showing the largest effects. Additional research can help to characterize the causes of ADL loss, to explore how older adults cope with it, and to identify ways of maximizing resilience. J Am Geriatr Soc 68:1301-1306, 2020.

Top Evidentiary Gaps in Managed Care Pharmacy: A Research Agenda.

Research agendas play valuable roles in clearly identifying high-priority topics that reflect potential to improve health care quality. The purpose of this report is to present work completed by the Academy of Managed Care Pharmacy (AMCP) and AMCP Foundation Joint Research Committee. This committee set forth to develop a research agenda for our 2 organizations that focuses on critical evidence needs in managed care pharmacy. This document reviews results from 2 surveys that were conducted to better understand unmet research needs within managed care pharmacy and to inform professional efforts of managed care pharmacists. The first survey collected qualitative data from key opinion leaders (KOLs) regarding the top evidentiary gaps in managed care pharmacy and barriers to closing those gaps. The second survey was sent to AMCP members and AMCP Foundation stakeholders, used a mixed methods quantitative-qualitative design, and incorporated concepts from initial KOL responses. The key outcome from these proceedings is the research agenda, which identifies and prioritizes 4 evidentiary gaps in managed care pharmacy: (1) real-world evidence to inform managed care pharmacy decision making, (2) value-based models in managed care pharmacy to address total cost of care, (3) impact of benefit design or utilization management strategies on patient outcomes, and (4) impact of direct patient care services provided by managed care pharmacy on patient outcomes. The agenda was intended to be broad and will evolve over time. AMCP and the AMCP Foundation hope that this research agenda inspires the AMCP membership, researchers, and funding agencies to close these gaps in knowledge and understanding. DISCLOSURES: Chairs and members of the Joint Research Committee oversaw and conducted the work outlined in this report with the support of AMCP and the AMCP Foundation. No outside funding was received. Gembarski, Couto, Wilson, and Eichenbrenner declare no conflicts of interest, real or apparent, with any product or service mentioned in this report. Gembarski is employed by BCBS Michigan; Couto is employed by Cigna; Wilson is employed by HealthCore, a wholly owned subsidiary of Anthem; and Eichenbrenner is employed by the AMCP Foundation.

Access to and Engagement in Substance Use Disorder Treatment Over Time.

OBJECTIVE: This study evaluated whether access to and engagement in substance use disorder treatment has improved from 2010 to 2016. METHODS: Data submitted by commercial and Medicaid health plans, representing over 163 million beneficiaries from 2010 to 2016, were analyzed. RESULTS: For commercial plans, identification increased (from 1.0% to 1.6%, p<0.001), the initiation rate declined (from 41.9% to 33.7%, p<0.001), and the engagement rate also declined (from 15.8% to 12.1%, p<0.001). The decline in the initiation and engagement rates could not be explained by the increasing identification rates. For Medicaid plans, the identification rate increased (from 3.3% to 6.7%, p<0.001), and the initiation and engagement rates were unchanged. CONCLUSIONS: Although an increasing proportion of health plan members are being identified with substance use disorders, the majority of these individuals are not engaging in treatment.

Community Asthma Initiative: Cost Analyses using Claims Data from a Medicaid Managed Care Organization.

Objective: Use claims data to examine the cost benefit of the Community Asthma Initiative (CAI), a Boston area nurse-supervised community health worker (CHW) asthma home-visiting program. Methods: The reduction in asthma treatment costs was assessed using Massachusetts claims data from one Medicaid Managed Care Organization (MCO) in the north east that included all costs between January 1, 2011 and December 31, 2016. The data was used to determine asthma-related utilization cost reductions between 1 year pre- and 1, 2 and 3 years post-intervention. The cost reductions for 45 CAI patients and 45 cost-matched comparison patients were measured. Return on investment (ROI) was computed as the difference in cost reduction for CAI patients and a cost-matched comparison population divided by CAI program cost. Results: The excess reduction in per patient asthma-related utilization costs among CAI patients compared to the comparison population was $806 (p = 0.047), $1,253 (p = 0.01) and $1,549 (p = 0.005) between 1 year pre- and 1, 2 and 3 years post-intervention. These yielded adjusted ROI's of 0.31, 0.78 and 1.37 after 1, 2 and 3 years post-CAI intervention. Conclusions: The reduction in asthma utilization costs of a home visit program by nurse-supervised CHWs exceeds program costs. The findings support the business case for the provision of secondary prevention of home-based asthma services through reimbursement from payers or integration into Accountable Care Organizations (ACOs).

Impact of allergies on health-related quality of life in patients with asthma.

Objective: To estimate the health-related quality of life (HRQoL) and health utilities among asthma patients with and without comorbid allergies in a managed care population.Methods: This was a retrospective analysis of patient survey responses and pharmacy claims from the Observational Study of Asthma Control and Outcomes (OSACO). Patients ≥12 years-old with persistent asthma received four identical surveys between April-2011 and December-2012. The presence of allergy was identified by a positive response to a survey question about hay fever/seasonal allergies and ≥1 diagnosis-related ICD-9-CM code(s) for allergic conditions. HRQoL instruments included generic utility (EQ-5D-3L [including VAS]), asthma-specific utility (AQL-5D) and asthma-specific health status (Mini Asthma Quality of Life Questionnaire [MiniAQLQ]). Median regression was used for utility scores and Least Squares regression for MiniAQLQ, adjusting for sociodemographic characteristics and smoking.Results: Of the 2681 asthmatics who completed the first survey in the OSACO study, 971 had comorbid allergies. After adjusting for covariates, asthma patients with comorbid allergies had significantly lower MiniAQLQ scores than patients without allergies (-0.489 [95% CI -0.570, -0.409]; p < 0.01), with the greatest decrement/impairment observed for the environmental stimuli domain (-0.729 [95% CI -0.844, -0.613]; p < 0.01). Utility scores were also statistically significantly lower for asthma patients with comorbid allergies compared to those without allergies (EQ-5D, -0.031 [95% CI -0.047, -0.015]; AQL-5D, -0.036 [95% CI -0.042, -0.029]; p < 0.01 each).Conclusions: The presence of allergies with persistent asthma is associated with a significant deleterious impact on several different measures of HRQoL.

Costs of Severe Maternal Morbidity During Pregnancy in US Commercially Insured and Medicaid Populations: An Observational Study.

OBJECTIVE: To estimate the maternity-related cost of health care services in women with and without severe maternal morbidity (SMM). METHODS: Women with a live inpatient birth in the calendar year 2013 were identified in the MarketScan® Commercial and Medicaid health insurance claims databases. Costs were defined as the amounts paid by insurers plus out-of-pocket and third-party payments. Costs were calculated as total maternity-related costs and categorized as prenatal, delivery, and postpartum costs. SMM was identified using the CDC algorithm of 25 ICD-9 diagnostic and procedural codes. Variables associated with higher delivery costs were determined by multivariable linear regression analysis. RESULTS: A total of 750 women met the criteria for SMM in the Commercial population. The total, per-patient mean costs of care for women without and with SMM were $14,840 and $20,380, respectively. Delivery hospitalization costs were 76-77% of total mean costs for women without and with SMM. A total of 99 women met the criteria for SMM in the Medicaid population. The total, per-patient mean costs of care for women without and with SMM were $6894 and $10,134, respectively. Delivery costs were 71-72% of total costs. Variables independently predictive of increased delivery costs in both Commercial and Medicaid populations were delivery by cesarean section, multifetal gestation, gestational hypertension/preeclampsia, and obstetric infection. CONCLUSIONS: The occurrence of SMM was associated with an increase in maternity-related costs of 37% in the Commercial and 47% in the Medicaid population. Some of the factors associated with increased delivery hospitalization costs may be prevented.

Association of care management intensity with healthcare utilization in an all-condition care management program.

OBJECTIVES: To identify care needs among Medicaid and Medicare patients in an all-condition care management program involving case managers (CMs) and community health workers (CHWs), and to examine the relationship between intervention intensity and healthcare utilization. STUDY DESIGN: Retrospective longitudinal evaluation of managed care-hired CMs and CHWs based at 8 primary care sites participating in the Johns Hopkins Community Health Partnership (J-CHiP). METHODS: Patients at high risk for hospitalization were enrolled in J-CHiP. CMs provided care coordination and CHWs addressed barriers to care. Four program intensity categories were created: low CM-low CHW, low CM-high CHW, high CM-low CHW, and high CM-high CHW. We evaluated the adjusted relative risk (RR) of emergency department (ED) visits, hospitalizations, and 30-day hospital readmissions pre- and post enrollment in the program using CM documentation, electronic health record data, and insurance claims. RESULTS: Among 1408 Medicaid and 2196 Medicare patients, the predominant barriers to care were lack of transportation, unstable housing, medication payment, and healthy food access. Among Medicaid and Medicare patients, high CM-high CHW and high CM-low CHW intensities were associated with a higher adjusted risk of hospitalization and 30-day hospital readmission after program implementation compared with low CM-low CHW intensity. Among patients with low CM-high CHW intensity, Medicaid patients had a higher risk of readmission (RR, 1.47; P = .016) and Medicare patients had a higher risk of ED visit (RR, 1.33; P = .001) post program implementation. CONCLUSIONS: In this longitudinal evaluation of an all-condition, unstructured, managed care organization-led program, preprogram trajectories of healthcare utilization rates among patients increased rather than decreased after program implementation, especially among patients receiving the highest care management program intensity.

Implementing coordinated ambulatory cardiology care in southern Germany: a mixed-methods study.

BACKGROUND: In 2009 health insurers AOK and Bosch BKK introduced the "FacharztProgramm Kardiologie" - a program for coordinated ambulatory cardiology care in the German state of Baden-Württemberg. It aims for efficient, medical guideline-oriented cardiology care to reduce avoidable hospitalizations as well as costs of care. A high number of cardiologists participate and the program has served as blueprint for programs in other medical fields. With many prerequisites and conditions involved, its implementation cannot be expected to be self-directed. Still, only little data on the actual implementation exists. We aimed to determine to what extent medical specialists and cooperating general practitioners implemented the program, which components they adapted, and which contextual factors they deemed relevant. METHODS: We collected data from primary care practices of medical specialists and general practitioners within Baden-Württemberg. Qualitative data was obtained through structured telephone interviews with participating and non-participating medical specialists as well as general practitioners cooperating with the program and general practitioners not cooperating. Interviews were analyzed through content-structuring qualitative content analyses via MAXQDA. Quantitative data was obtained using anonymous written questionnaires completed by participating and non-participating medical specialists as well as general practitioners cooperating with the program. Analyses were performed using SPSS Statistics, mainly with regard to differences within and between groups of physicians. RESULTS: Most components of the program regarding medical care were well implemented. However, access to medical care was not completely as intended due to high numbers of patients participating in the program and prioritization by physicians. Procedures for communication and cooperation between medical specialists and general practitioners were only partially adhered to and standardized communication was not implemented. A range of regional and practice-related contextual factors influenced implementation and outcomes. CONCLUSIONS: Implementation of this program was mixed. Contextual factors posed individual challenges to participating physicians which can't be captured by an encompassing program. Both control mechanisms and tailoring of the program to medical care seem needed. TRIAL REGISTRATION: Though not a clinical study, we deemed registration appropriate to ensure transparency. The study has been registered as a non-interventional observation study at the German Clinical Trials Register under ID: DRKS00013070.