Changing Pediatric Hospice and Palliative Care Through Medicaid Partnerships.

Since its inception in 2010, the Concurrent Care for Children Provision of the Affordable Care Act has enabled seriously ill pediatric patients and their families to access comprehensive, supportive hospice services while simultaneously receiving ongoing treatment-directed therapies. Although this groundbreaking federal legislation has resulted in improvements in care for vulnerable pediatric patients, the implementation of the law has varied from state to state through Medicaid programming. The pediatric professional community is called to consider how Medicaid services can more effectively be delivered by leveraging legislative mandates and collaborative relationships between clinicians, Medicaid administrators, and policy makers. In this article, we examine ways concurrent care has been executed in 3 different states and how key stakeholders in care for children with serious illness advocated to ensure effective implementation of the legislation. The lessons learned in working with state Medicaid programs are applicable to any advocacy issue impacting children and families .

Do Geographic Region, Pathologic Chronicity, and Hospital Affiliation Affect Access to Care Among Medicaid- and Privately Insured Foot and Ankle Surgery Patients?

OBJECTIVES: Studies have shown that patients enrolled in Medicaid have difficulty obtaining access to care compared with patients with private insurance. Whether variables such as geographic location, state expansion versus nonexpansion, and private versus academic affiliation affect access to care among foot and ankle surgery patients enrolled in Medicaid has not been previously established. The purpose of this study was to assess the differences in access to care between patients who are privately insured and those with Medicaid in need of foot and ankle consultation. Secondary objectives include assessment of whether access to care for foot and ankle patients with Medicaid differs between those with acute and chronic conditions, Medicaid expanded and unexpanded states, geographic regions within the United States, and academic versus private practices. METHODS: Twenty providers from each of five Medicaid-expanded and five nonexpanded states in different US geographic regions were randomly chosen via the American Orthopaedic Foot & Ankle Society directory. One investigator contacted each office requesting the earliest available appointment for their fictitious relative's acute Achilles tendon rupture or hallux valgus. Investigator insurance was stated to be Medicaid for half of the telephone calls and Blue Cross Blue Shield (BCBS) for the other half. Appointment success rate and average time to appointment were compared between private insurance and Medicaid. Results were further compared across geographic regions, between private and academic practices, and between urgent acute injury (Achilles rupture) and chronic nonurgent injury (hallux valgus). RESULTS: Appointments were successful for all 100 (100%) calls made with BCBS as the insurer, in comparison to 73 of 100 calls (73%) with Medicaid (P < 0.001). Both acute and chronic injury had significantly higher success rates with BCBS than Medicaid (P < 0.001). The appointment success rate was significantly lower with Medicaid than with BCBS (P ≤ 0.01) in all of the geographic regions. The success rate with Medicaid (66.7%) was significantly lower than with BCBS (100.0%, P < 0.001) for private practice offices, but not for academic practices. CONCLUSIONS: Patients with Medicaid experience fewer options when obtaining appointments for common nonemergent foot and ankle problems and may experience less difficulty scheduling appointments at academic rather than private institutions. The medical community should continue to seek and identify potential interventions which can improve access to orthopedic care for all patients and increase the visibility of practices that accept Medicaid.

Association Between Medicaid Expansion and Diagnosis and Management of Colon Cancer.

BACKGROUND: The Affordable Care Act facilitated improved insurance coverage for states that expanded Medicaid coverage, but the impact on cancer outcomes is unclear. This study compared changes in the diagnosis and management of colon cancer in states that did and did not participate in Medicaid expansion. STUDY DESIGN: Using a quasi-experimental difference-in-differences (DID) approach, we analyzed Medicaid and uninsured patients in the National Cancer Data Base during 2 time periods: pre (2011-2012) and post expansion (2015-2016). Patients in non-expansion states were compared with those in January 2014 expansion states with regard to changes in patient and facility characteristics, cancer staging, treatment decisions, and surgical outcomes. RESULTS: Along with increased Medicaid coverage (DID = 20.27; p < 0.001), patients in expansion states had an increase in stage I diagnoses (DID = 2.97; p = 0.035), distance traveled (miles, DID = 6.67; p = 0.005), and treatment at integrated network programs (DID = 2.67; p = 0.045). More early-stage patients were treated within 30 days (DID = 7.24; p = 0.035) and more stage IV patients received palliative care (DID = 5.01; p = 0.048). Among surgical patients, Medicaid expansion correlated with fewer urgent cases (< 7 days, DID = -5.88; p = 0.008) and more minimally invasive surgery (DID = 5.00; p = 0.022). There were no observed differences in postoperative outcomes or adjuvant chemotherapy. CONCLUSIONS: Medicaid expansion correlated with earlier diagnosis, enhanced access, and improved surgical care for colon cancer patients. These findings highlight the importance of improving health insurance coverage and can help guide future policy efforts.

Association of Mandatory Bundled Payments for Joint Replacement With Postacute Care Outcomes Among Medicare and Medicaid Dual Eligible Patients.

IMPORTANCE: The Medicare comprehensive care for joint replacement (CJR) model, a mandatory bundled payment program started in April 2016 for hospitals in randomly selected metropolitan statistical areas (MSAs), may help reduce postacute care (PAC) use and episode costs, but its impact on disparities between Medicaid and non-Medicaid beneficiaries is unknown. OBJECTIVE: To determine effects of the CJR program on differences (or disparities) in PAC use and outcomes by Medicare-Medicaid dual eligibility status. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study of 2013-2017, based on difference-in-differences (DID) analyses on Medicare data for 1,239,452 Medicare-only patients, 57,452 dual eligibles with full Medicaid benefits, and 50,189 dual eligibles with partial Medicaid benefits who underwent hip or knee surgery in hospitals of 75 CJR MSAs and 121 control MSAs. MAIN OUTCOME MEASURES: Risk-adjusted differences in rates of institutional PAC [skilled nursing facility (SNF), inpatient rehabilitation, or long-term hospital care] use and readmissions; and for the subgroup of patients discharged to SNF, risk-adjusted differences in SNF length of stay, payments, and quality measured by star ratings, rate of successful discharge to community, and rate of transition to long-stay nursing home resident. RESULTS: The CJR program was associated with reduced institutional PAC use and readmissions for patients in all 3 groups. For example, it was associated with reductions in 90-day readmission rate by 1.8 percentage point [DID estimate=-1.8; 95% confidence interval (CI), -2.6 to -0.9; P<0.001] for Medicare-only patients, by 1.6 percentage points (DID estimate=-1.6; 95% CI, -3.1 to -0.1; P=0.04) for full-benefit dual eligibles, and by 2.0 percentage points (DID estimate=-2.0; 95% CI, -3.6 to -0.4; P=0.01) for partial-benefit dual eligibles. These CJR-associated effects did not differ between dual eligibles (differences in above DID estimates=0.2; 95% CI, -1.4 to 1.7; P=0.81 for full-benefit patients; and -0.3; 95% CI, -1.9 to 1.3; P=0.74 for partial-benefit patients) and Medicare-only patients. Among patients discharged to SNF, the CJR program showed no effect on successful community discharge, transition to long-term care, or their persistent disparities. CONCLUSIONS: The CJR program did not help reduce persistent disparities in readmissions or SNF-specific outcomes related to Medicare-Medicaid dual eligibility, likely due to its lack of financial incentives for reduced disparities and improved SNF outcomes.

Unintended Consequences of Health Care Reform: Impact of Changes in Payor Mix on Patient Safety Indicators.

OBJECTIVE: To evaluate the impact of the Affordable Care Act's Medicaid expansion on patient safety metrics at the hospital level by expansion status, across varying levels of safety-net burden, and over time. SUMMARY BACKGROUND DATA: Medicaid expansion has raised concerns over the influx of additional medically and socially complex populations on hospital systems. Whether increases in Medicaid and uninsured payor mix impact hospital performance metrics remains largely unknown. We sought to evaluate the effects of expansion on Centers for Medicare and Medicaid Services-endorsed Patient Safety Indicators (PSI-90). METHODS: Three hundred fifty-eight hospitals were identified using State Inpatient Databases (2012-2015) from 3 expansions (KY, MD, NJ) and 2 nonexpansion (FL, NC) states. PSI-90 scores were calculated using Agency for Healthcare Research and Quality modules. Hospital Medicaid and uninsured patients were categorized into safety-net burden (SNB) quartiles. Hospital-level, multivariate linear regression was performed to measure the effects of expansion and change in SNB on PSI-90. RESULTS: PSI-90 decreased (safety improved) over time across all hospitals (-5.2%), with comparable reductions in expansion versus nonexpansion states (-5.9% vs -4.7%, respectively; P = 0.441) and across high SNB hospitals within expansion versus nonexpansion states (-3.9% vs -5.2%, P = 0.639). Pre-ACA SNB quartile did not predict changes in PSI-90 post-ACA. However, when hospitals increased their SNB by 5%, they incurred significantly more safety events in expansion relative to nonexpansion states (+1.87% vs -14.0%, P = 0.013). CONCLUSIONS: Despite overall improvement in patient safety, increased SNB was associated with increased safety events in expansion states. Accordingly, Centers for Medicare and Medicaid Services measures may unintentionally penalize hospitals with increased SNB following Medicaid expansion.

Association of Medicaid Expansion Under the Affordable Care Act With Breast Cancer Stage at Diagnosis.

Importance: The expansion of Medicaid sought to fill gaps in insurance coverage among low-income Americans. Although coverage has improved, little is known about the relationship between Medicaid expansion and breast cancer stage at diagnosis. Objective: To review the association of Medicaid expansion with breast cancer stage at diagnosis and the disparities associated with insurance status, age, and race/ethnicity. Design, Setting, and Participants: This cohort study used data from the National Cancer Database to characterize the relationship between breast cancer stage and race/ethnicity, age, and insurance status. Data from 2007 to 2016 were obtained, and breast cancer stage trends were assessed. Additionally, preexpansion years (2012-2013) were compared with postexpansion years (2015-2016) to assess Medicaid expansion in 2014. Data were analyzed from August 12, 2019, to January 19, 2020. The cohort included a total of 1 796 902 patients with primary breast cancer who had private insurance, Medicare, or Medicaid or were uninsured across 45 states. Main Outcomes and Measures: Percent change of uninsured patients with breast cancer and stage at diagnosis, stratified by insurance status, race/ethnicity, age, and state. Results: This study included a total of 1 796 902 women. Between 2012 and 2016, 71 235 (4.0%) were uninsured or had Medicaid. Among all races/ethnicities, in expansion states, there was a reduction in uninsured patients from 22.6% (4771 of 21 127) to 13.5% (2999 of 22 150) (P < .001), and in nonexpansion states, there was a reduction from 36.5% (5431 of 14 870) to 35.6% (4663 of 13 088) (P = .12). Across all races, there was a reduction in advanced-stage disease from 21.8% (4603 of 21 127) to 19.3% (4280 of 22 150) (P < .001) in expansion states compared with 24.2% (3604 of 14 870) to 23.5% (3072 of 13 088) (P = .14) in nonexpansion states. In African American patients, incidence of advanced disease decreased from 24.6% (1017 of 4136) to 21.6% (920 of 4259) (P < .001) in expansion states and remained at approximately 27% (27.4% [1220 of 4453] to 27.5% [1078 of 3924]; P = .94) in nonexpansion states. Further analysis suggested that the improvement was associated with a reduction in stage 3 diagnoses. Conclusions and Relevance: In this cohort study, expansion of Medicaid was associated with a reduced number of uninsured patients and a reduced incidence of advanced-stage breast cancer. African American patients and patients younger than 50 years experienced particular benefit. These data suggest that increasing access to health care resources may alter the distribution of breast cancer stage at diagnosis.

The Affordable Care Act's Medicaid Expansion and Impact Along the Cancer-Care Continuum: A Systematic Review.

BACKGROUND: Health reform and the merits of Medicaid expansion remain at the top of the legislative agenda, with growing evidence suggesting an impact on cancer care and outcomes. A systematic review was undertaken to assess the association between Medicaid expansion and the goals of the Patient Protection and Affordable Care Act in the context of cancer care. The purpose of this article is to summarize the currently published literature and to determine the effects of Medicaid expansion on outcomes during points along the cancer care continuum. METHODS: A systematic search for relevant studies was performed in the PubMed/MEDLINE, EMBASE, Scopus, and Cochrane databases. Three independent observers used an abstraction form to code outcomes and perform a quality and risk of bias assessment using predefined criteria. RESULTS: A total of 48 studies were identified. The most common outcomes assessed were the impact of Medicaid expansion on insurance coverage (23.4% of studies), followed by evaluation of racial and/or socioeconomic disparities (17.4%) and access to screening (14.5%). Medicaid expansion was associated with increases in coverage for cancer patients and survivors as well as reduced racial- and income-related disparities. CONCLUSIONS: Medicaid expansion has led to improved access to insurance coverage among cancer patients and survivors, particularly among low-income and minority populations. This review highlights important gaps in the existing oncology literature, including a lack of studies evaluating changes in treatment and access to end-of-life care following implementation of expansion.

First-year implementation of mailed FIT colorectal cancer screening programs in two Medicaid/Medicare health insurance plans: qualitative learnings from health plan quality improvement staff and leaders.

BACKGROUND: Colorectal cancer screening rates remain low, especially among certain racial and ethnic groups and the uninsured and Medicaid insured. Clinics and health care systems have adopted population-based mailed fecal immunochemical testing (FIT) programs to increase screening, and now health insurance plans are beginning to implement mailed FIT programs. We report on challenges to and successes of mailed FIT programs during their first year of implementation in two health plans serving Medicaid and dual eligible Medicaid/Medicare enrollees. METHODS: This qualitative descriptive study gathered data through in-depth interviews with staff and leaders at each health plan (n = 10). The Consolidated Framework for Implementation Research, field notes from program planning meetings between the research team and the health plans, and internal research team debriefs informed interview guide development. Qualitative research staff used Atlas.ti to code the health plan interviews and develop summary themes through an iterative content analysis approach. RESULTS: We identified first-year implementation challenges in five thematic areas: 1) program design, 2) vendor experience, 3) engagement/communication, 4) reaction/satisfaction of stakeholders, and 5) processing/returning of mailed kits. Commonly experienced challenges by both health plans related to the time-consuming nature of the programs to set up, and complexities and delays in working with vendors. We found implementation successes in the same five thematic areas as well as four additional areas of: 1) leadership support, 2) compatibility with the health plan, 3) broader impacts, and 4) collaboration with researchers. Commonly experienced successes included the ability to adapt the mailed FIT program to the individual health plan culture and needs, and the synchronicity between the programs and their organizational missions and goals. CONCLUSIONS: Both health plans successfully adapted mailed FIT programs to their own culture and resources and used their strong quality management resources to maximize success in overcoming the time demands of setting up the program and working with their vendors. Mailed FIT programs administered by health plans, especially those serving Medicaid- and dual eligible Medicaid/Medicare-insured populations, may be an important resource to support closing gaps in colorectal cancer screening among traditionally underserved populations.

Association Between the Maryland Medicaid Behavioral Health Home Program and Cancer Screening in People With Serious Mental Illness.

OBJECTIVE: This study evaluated the association of the Maryland Medicaid behavioral health home (BHH) integrated care program with cancer screening. METHODS: Using administrative claims data from October 2012 to September 2016, the authors measured cancer screening among 12,176 adults in Maryland's psychiatric rehabilitation program who were eligible for cervical (N=6,811), breast (N=1,658), and colorectal (N=3,430) cancer screening. Marginal structural modeling was used to examine the association between receipt of annual cancer screening and whether participants had ever enrolled in a BHH (enrolled: N=3,298, 27%; not enrolled: N=8,878, 73%). RESULTS: Relative to nonenrollment, BHH enrollment was associated with increased screening for cervical and breast cancer but not for colorectal cancer. Predicted annual rates remained low, even in BHHs. CONCLUSIONS: Despite estimates of improvements in cervical and breast cancer screening after BHH implementation, cancer screening rates remained suboptimal. Broader cancer screening interventions are needed to improve cancer screening for people with mental illness.

Association of Affordable Care Act-related Medicaid expansion with variation in utilization of surgical services.

BACKGROUND: We aim to understand how Medicaid expansion under the ACA has affected utilization of surgical services. METHODS: The State Inpatient Databases were used to compare utilization of a broad array of surgical procedures among nonelderly adults (aged 19-64 years) in a multistate population that experienced ACA-related Medicaid expansion to one that did not. We performed a difference-in-differences (DID) analysis to determine the effect of Medicaid expansion on utilization of surgical services from 2012 to 2014. RESULTS: There were 259,061 cases identified in the Medicaid expansion population and 261,269 in the control population. In the expansion group, there was a smaller decrease in utilization - by a margin of 21.68 cases per 100,000 individuals (p < 0.001). Percent of surgical patients covered by Medicaid increased among the expansion group from 12.00% to 15.48% (DID = 3.93%; p < 0.001). CONCLUSIONS: Year one of Medicaid expansion under the ACA was associated with a modest but statistically significant difference in utilization of surgical services as well as an increase in percent of surgery patients covered by Medicaid.

Association of Medicaid Expansion Under the Affordable Care Act With Stage at Diagnosis and Time to Treatment Initiation for Patients With Head and Neck Squamous Cell Carcinoma.

Importance: Medicaid expansions as part of the Patient Protection and Affordable Care Act (ACA) are associated with decreases in the percentage of uninsured patients who have received a new diagnosis of cancer. Little is known about the association of Medicaid expansions with stage at diagnosis and time to treatment initiation (TTI) for patients with head and neck squamous cell carcinoma (HNSCC). Objective: To determine the association of Medicaid expansions as part of the ACA with stage at diagnosis and TTI for patients with HNSCC. Design, Setting, and Participants: A retrospective cohort study was conducted at Commission on Cancer-accredited facilities among 90 789 patients identified from the National Cancer Database aged 18 to 64 years with HNSCC that was diagnosed during the period from January 1, 2010, to December 31, 2016. Statistical analysis was conducted from February 18 to November 8, 2019. Main Outcomes and Measures: Outcome measures included health insurance coverage, stage at diagnosis, and TTI. Absolute percentage change in health insurance coverage, crude and adjusted difference in differences (DD) in absolute percentage change in coverage, stage at diagnosis, and TTI before (2010-2013) and after (2014-2016) ACA implementation were calculated for Medicaid expansion and nonexpansion states. Results: Of the 90 789 nonelderly adults with newly diagnosed HNSCC (mean [SD] age, 54.7 [7.0] years), 70 907 (78.1%) were men, 72 911 (80.3%) were non-Hispanic white, 52 142 (57.4%) were between 55 and 64 years of age, and 54 940 (60.5%) resided in states with an ACA Medicaid expansion. Compared with nonexpansion states, the percentage of patients with HNSCC with Medicaid increased more in expansion states after the implementation of the ACA (adjusted DD, 4.6 percentage points [95% CI, 3.7-5.4 percentage points]). The percentage of patients with localized disease (American Joint Committee on Cancer stage I-II) at diagnosis increased in expansion states compared with nonexpansion states for the overall cohort (adjusted DD, 2.3 percentage points [95% CI, 1.1-3.5 percentage points]) and for the subset of patients with nonoropharyngeal HNSCC (adjusted DD, 3.4 percentage points [95% CI, 1.5-5.2 percentage points]). The mean TTI did not differ between expansion and nonexpansion states for the cohort (adjusted DD, -12.7 percentage points [95% CI, -27.4 to 4.2 percentage points]) but improved for patients with nonoropharyngeal HNSCC (adjusted DD, -26.5 percentage points [95% CI, -49.6 to -3.4 percentage points]). Conclusions and Relevance: This study suggests that Medicaid expansions were associated with a greater increase in the percentage of patients with HNSCC with Medicaid coverage, an increase in the percentage of patients with localized disease at diagnosis for the overall cohort of patients with HNSCC, and improved TTI for patients with nonoropharyngeal HNSCC.

The impact of the affordable care act (ACA) Medicaid Expansion on access to minimally invasive surgical care.

INTRODUCTION: This study aims to evaluate the effect of the ACA Medicaid expansion on the utilization of minimally invasive (MIS) approaches to common general surgical procedures. METHODS: We queried five Healthcare Cost and Utilization Project State Inpatient Databases to evaluate rates of utilization and costs of MIS and open approaches pre and post Medicaid expansion. RESULTS: 117,241 patients met the inclusion criteria. Following the enactment of the ACA, use of both laparoscopic gastric bypass (IRR 1.08; 95% CI: [1.02, 1.15]) and Nissen fundoplication (IRR 1.17; 95% CI [1.09, 1.26]) increased in Medicaid patients treated in expansion states than in those treated in non-expansion states. Simultaneously, the costs reported for self-pay patients increased in expansion states more than in non-expansion states (+$1669; 95% CI [$655, $2682]). CONCLUSIONS: Medicaid expansion was associated with increased rates of utilization of MIS approaches to several surgical procedures and a shifting of costs toward patients who were self-insured.

Disparities in access to cancer surgery after Medicaid expansion.

INTRODUCTION: The Affordable Care Act (ACA) expanded Medicaid eligibility to persons with income up to 138% of the federal poverty line. We investigated how Medicaid expansion (ME) impacted the access to cancer-specific surgical care in the US. METHODS: We used a nationwide population-based database (SEER) to identify patients with the 8 most prevalent cancers between 2007 and 2015. Adjusted difference-in-differences (DiD) and multivariate regression were used for statistical analysis. RESULTS: A total of 1,008,074 patients were included. Patients post-ME were diagnosed at an earlier stage (pre-ME, 27.6%; post-ME, 31.1%; P < 0.001), and lack of insurance coverage decreased from 5.5% to 2.6% (P < 0.001). Lower-SES population had improved access to surgical care (attributable benefit +3.18%; P < 0.001). ME was an independent predictor of access-to-surgery (OR, 1.45; P < 0.001), whereas African-American and Hispanic race were negative predictive factors. CONCLUSION: After ME, the population without insurance coverage decreased. This was associated with earlier cancer diagnosis and improved access to surgery in patients from economically disadvantaged communities.

Prevalence of Screening for Food Insecurity, Housing Instability, Utility Needs, Transportation Needs, and Interpersonal Violence by US Physician Practices and Hospitals.

Importance: Social needs, including food, housing, utilities, transportation, and experience with interpersonal violence, are linked to health outcomes. Identifying patients with unmet social needs is a necessary first step to addressing these needs, yet little is known about the prevalence of screening. Objective: To characterize screening for social needs by physician practices and hospitals. Design, Setting, and Participants: Cross-sectional survey analyses of responses by physician practices and hospitals to the 2017-2018 National Survey of Healthcare Organizations and Systems. Responses were collected from survey participants from June 16, 2017, to August 17, 2018. Exposures: Organizational characteristics, including participation in delivery and payment reform. Main Outcomes and Measures: Self-report of screening patients for food insecurity, housing instability, utility needs, transportation needs, and experience with interpersonal violence. Results: Among 4976 physician practices, 2333 responded, a response rate of 46.9%. Among hospitals, 757 of 1628 (46.5%) responded. After eliminating responses because of ineligibility, 2190 physician practices and 739 hospitals remained. Screening for all 5 social needs was reported by 24.4% (95% CI, 20.0%-28.7%) of hospitals and 15.6% (95% CI, 13.4%-17.9%) of practices, whereas 33.3% (95% CI, 30.5%-36.2%) of practices and 8.0% (95% CI, 5.8%-11.0%) of hospitals reported no screening. Screening for interpersonal violence was most common (practices: 56.4%; 95% CI, 53.3%-2 59.4%; hospitals: 75.0%; 95% CI, 70.1%-79.3%), and screening for utility needs was least common (practices: 23.1%; 95% CI, 20.6%-26.0%; hospitals: 35.5%; 95% CI, 30.0%-41.0%) among both hospitals and practices. Among practices, federally qualified health centers (yes: 29.7%; 95% CI, 21.5%-37.8% vs no: 9.4%; 95% CI, 7.2%-11.6%; P < .001), bundled payment participants (yes: 21.4%; 95% CI, 17.1%-25.8% vs no: 10.7%; 95% CI, 7.9%-13.4%; P < .001), primary care improvement models (yes: 19.6%; 95% CI, 16.5%-22.6% vs no: 9.6%; 95% CI, 6.0%-13.1%; P < .001), and Medicaid accountable care organizations (yes: 21.8%; 95% CI, 17.4%-26.2% vs no: 11.2%; 95% CI, 8.6%-13.7%; P < .001) had higher rates of screening for all needs. Practices in Medicaid expansion states (yes: 17.7%; 95% CI, 14.8%-20.7% vs no: 11.4%; 95% CI, 8.1%-14.6%; P = .007) and those with more Medicaid revenue (highest tertile: 17.1%; 95% CI, 11.4%-22.7% vs lowest tertile: 9.0%; 95% CI, 6.1%-11.8%; P = .02) were more likely to screen. Academic medical centers were more likely than other hospitals to screen (49.5%; 95% CI, 34.6%-64.4% vs 23.0%; 95% CI, 18.5%-27.5%; P < .001). Conclusions and Relevance: This study's findings suggest that few US physician practices and hospitals screen patients for all 5 key social needs associated with health outcomes. Practices that serve disadvantaged patients report higher screening rates. The role of physicians and hospitals in meeting patients' social needs is likely to increase as more take on accountability for cost under payment reform. Physicians and hospitals may need additional resources to screen for or address patients' social needs.

Impact of Medicaid Expansion of the Affordable Care on the Outcomes of Lower Extremity Bypass for Patients With Peripheral Artery Disease in the Vascular Quality Initiative Database.

OBJECTIVE: The aim of this study was to evaluate changes in the utilization and outcomes of surgery after Medicaid Expansion (ME) for patients with peripheral artery disease (PAD). SUMMARY BACKGROUND DATA: Recent studies have demonstrated increased insurance coverage and improved care with the Affordable Care Act's (ACA) state expansion of Medicaid. METHODS: Infrainguinal bypass procedures performed due to occlusive pathology in the Vascular Quality Initiative database between 2010 and 2017 were included. Primary outcomes including postoperative mortality and major adverse limb events (MALE) at 1-year of follow-up were analyzed using interrupted time-series analysis (ITS). RESULTS: Out of 26,446 infrainguinal bypass procedures, 13,955 (52.8%) were included in this analysis. ME states witnessed an annual decrease in infrainguinal surgery for acute ischemia [annual change in post vs pre-ME period (95% confidence interval): -4.3% (-7.5% to -1.0%), P = 0.02] and an increase in revascularization for claudication [3.7% (1.7%-5.6%), P = 0.01]. Among nonacute cases, elective procedures increased in ME states [3.9% (0.1%-7.7%), P = 0.05] along with a significant annual decrease in in-hospital mortality [-0.4% (-0.8 to -0.02), P = 0.04) and MALE at 1 year of follow up [-9.0% (-20.3 to 2.3), P = 0.09]. These results were statistically significant after comparing them with the annual trend changes in states which did not adopt ME. CONCLUSIONS: The adoption of ME in 2014 was associated with significant increase in the use of infrainguinal bypass for nonsevere and elective cases, along with improved in-hospital mortality and MALE at 1 year. Longer follow-up is needed to evaluate the impact of ME on other aspects of care and longer term outcomes of PAD patients.

Early Term Delivery and Breastfeeding Outcomes.

OBJECTIVE: Higher rates of adverse outcomes have been reported for early term (37 0 to 38 6 weeks) versus full term (≥ 39 0 weeks) infants, but differences in breastfeeding outcomes have not been systematically evaluated. This study examined breastfeeding initiation and exclusivity in early and full term infants in a large US based sample. METHODS: This secondary analysis included 743 geographically- and racially-diverse women from the Measurement of Maternal Stress Study cohort, and 295 women from a quality assessment at a hospital-based clinic in Evanston, IL. Only subjects delivering ≥ 37 weeks were included. Initiation of breastfeeding (IBF) and exclusive breastfeeding (EBF) were assessed via electronic medical record review after discharge. Associations of IBF and EBF with early and full term delivery were assessed via univariate and multivariate logistic regression. RESULTS: Among 872 women eligible for inclusion, 85.7% IBF and 44.0% EBF. Early term delivery was not associated with any difference in frequency of IBF (p = 0.43), but was associated with significantly lower odds of EBF (unadjusted OR 0.61, 95% CI 0.466, 0.803, p < 0.001). This association remained significant (adjusted OR 0.694, 95% CI 0.515, 0.935, p = 0.016) after adjusting for maternal diabetes, hypertensive disorders of pregnancy, cesarean delivery, maternal age, race/ethnicity, parity, Medicaid status, NICU admission, current smoking, and delivery hospital. CONCLUSIONS FOR PRACTICE: Despite comparable breastfeeding initiation frequencies, early term infants were significantly less likely to be exclusively breastfed compared to full term infants. These data suggest that women with early term infants may benefit from counseling regarding the potential for breastfeeding difficulties as well as additional breastfeeding support after delivery.

Engaging Beneficiaries In Medicaid Programs That Incentivize Health-Promoting Behaviors.

Medicaid programs are increasingly adopting incentive programs to improve health behaviors among beneficiaries. There is limited evidence on what incentives are being offered to Medicaid beneficiaries, how programs are engaging beneficiaries, and how programs are evaluated. In 2017-18 we synthesized available information on these programs and interviewed eighty policy stakeholders to identify the rationale behind key program design decisions and stakeholders' recommendations for beneficiary engagement and program evaluation. Key underlying program rationales included improving the use of preventive services and promoting personal responsibility. Beneficiary engagement strategies emphasized meeting members where they are and offering prizes or services customized for certain groups. Stakeholders recommended collaborating with external evaluators to design and conduct robust evaluations of incentive programs. Finally, stakeholders recommended aligning beneficiary incentives with provider incentives and other payment reforms through the use of common meaningful measures to streamline program evaluation.

Evaluating the early impact of Medicaid expansion on trends in diagnosis and treatment of benign gallbladder disease in Kentucky.

BACKGROUND: In January 2014, Kentucky expanded Medicaid coverage in an effort to improve access to healthcare. This study evaluated the early impact of Medicaid expansion on diagnosis and treatment of benign gallbladder disease in Kentucky. METHODS: Administrative claims data were queried for patients undergoing cholecystectomy for benign gallbladder disease between 2011 and 2015. Demographic, procedure, and outcome variables from 2011 to 2013 (PRE) and 2014-2015 (POST) were compared. RESULTS: After Medicaid expansion, patients were more likely to have their operation performed as an outpatient (80.0% vs. 78.2%, p < 0.001). A significant trend was noted toward a shorter hospital stay (p < 0.001) among inpatients. For both inpatients and outpatients, a significant shift was noted toward increased hospital charges (p < 0.001). CONCLUSIONS: The expansion of Kentucky Medicaid in 2014 has been associated with an increase in outpatient cholecystectomy, shorter hospital stays for inpatients, and increased hospital charges for both inpatients and outpatients. Increased charges for all procedures may represent a mechanism for hospitals to offset the cost of providing global care for more patients.