What Explains Inequalities in Telehealth Utilization Among North Carolina Medicaid Beneficiaries?

Background: Increased availability of telehealth can improve access to health care. However, there is evidence of persistent disparities in telehealth usage, as well as among people from minoritized racial and ethnic groups and rural residents. The objective of our work was to explore the degree to which disparities in telehealth use for behavioral health (BH) and musculoskeletal (MSK) related services during the COVID-19 pandemic are explained by observed beneficiary- and area-level characteristics. Methods: Using North Carolina Medicaid claims data of Medicaid beneficiaries with BH or MSK conditions, we apply nonlinear regression-based decomposition analysis-based models developed by Kitagawa, Oaxaca, and Blinder to determine which observed variables are associated with racial, ethnic, and rural inequalities in telehealth usage. Results: In the BH cohort, we found statistically significant differences in telehealth usage by race in the adult population, and by race, Hispanic ethnicity, and rurality in the pediatric population. In the MSK cohort, we found significant inequities by Hispanic ethnicity and rurality among adults, and by race and rurality among children. Inequalities in telehealth use between groups were small, ranging from 0.7 percentage points between urban and rural adults with MSK conditions to 3.8 percentage points between white adults and people of color among those with BH conditions. Overall, we found that racial and ethnic inequalities in telehealth use are not well explained by the observed variables in our data. Rural disparities in telehealth use are better explained by observed variables, particularly area-level broadband internet use. Conclusions: For inequalities between rural and urban residents, our analysis provides observational evidence that infrastructure such as broadband internet access is an important driver of differences in telehealth use. For racial and ethnic inequalities, the pathways may be more complex and difficult to measure, particularly when relying on administrative data sources in place of more detailed data on individual-level socioeconomic factors.

Building Equitable Mental Health Care for Latino Children: Perspectives from Providers and Communities.

BACKGROUND: The current pediatric mental health crisis has disproportionately impacted Latino youth in the United States (US), as demonstrated by their elevated risks of depression, substance use disorder, and anxiety. Despite this, research suggests Latino youth receive inequitable mental health services. OBJECTIVE: To understand best practices, challenges, and priorities in providing accessible and equitable mental health care for Latino youth from the perspectives of front-line mental health providers and Latino community members. METHODS: A bicultural, bilingual researcher conducted semi-structured interviews with 20 participants with expertise in Latino mental health. Topics included barriers and facilitators to mental health care access and cultural tailoring of treatment for Latino youth. Rapid qualitative analysis was used to identify themes. RESULTS: Four themes were identified: (1) Navigating immigration concerns and acculturation, practitioners should consider immigration-related concerns and be trained to address acculturation-related stressors respectfully; (2) Adapting to the cultural needs and strengths of the communities, cultural humility education can allow providers to engage with both the strengths and needs of Latino families; (3) Engaging Latino caregivers as partners, it is critical to engage with Latino caregivers' cultural perspectives on parenting and mental health collaboratively; and (4) Addressing systemic barriers to promote access, providers must recognize and attempt to alleviate the systemic barriers that limit families from seeking care. CONCLUSIONS: Participants identified several practical strategies to improve the provision of mental health services for Latino children. Future directions, policy and practice implications, and limitations are discussed.

Caregiver Perspectives on Barriers and Facilitators to Timely Well-Child Visits for Black Infants.

OBJECTIVES: Missed infant well-child visits (WCV) result in lost opportunities for critical preventive care. Black infants consistently receive less WCV care than other racial groups. We sought to understand barriers and facilitators to timely infant WCV for Black families in the context of COVID-19. METHODS: We conducted 21 semi-structured interviews with caregivers of Medicaid-insured Black children aged 15- to 24-months who attended six or fewer of eight recommended well-child visits within the first 15 months of life. Interviews focused on WCV value, barriers, and facilitators. After developing our initial coding structure through rapid qualitative analysis, we inductively derived the final codebook and themes through line-by-line content analysis. RESULTS: Caregivers attended a mean of 3.53 of eight infant visits. Structural (e.g., transportation) and psychological (e.g., maternal depression) barriers delayed Black infant WCV. Families most frequently valued monitoring development and addressing concerns. Caregivers perceived visits as less urgent when infants seemed healthy or more recently avoided visits due to fears around COVID-19. Long waits and feeling rushed/dismissed were linked to WCV delays; positive provider relationships encouraged WCV attendance. Most caregivers reported reluctance to vaccinate. Vaccine hesitancy contributed to delayed infant WCV. CONCLUSIONS: Caregivers described several factors that impacted WCV attendance for Black infants. Persistent structural and psychological barriers are compounded by perceptions that caregiver time is not respected and by notable vaccine hesitancy. To address these barriers, well-care can meet Black families in their communities, better address caregiver wellbeing, more efficiently use caregiver and provider time, and cultivate partnerships with Black caregivers.

Families Benefit After Utilization of a Clinic-Based Food Pantry Irrespective of Food Insecurity Experiences in a Pediatric Obesity Treatment Program.

PURPOSE: To evaluate the congruence between food insecurity screening outcome and clinic-based food pantry utilization and to examine caregiver reported comfort, motivation, and benefits of utilization. DESIGN: Mixed-methods study. SETTING: Academic pediatric obesity treatment clinic. SUBJECTS: Convenience sample of caregivers. INTERVENTION: Clinic-based food pantry offered irrespective of food insecurity screening outcome. MEASURES: Food insecurity screening (Hunger Vital Sign) and severity, self-rated caregiver health, willingness to disclose food insecurity and receive food, and food-related stress. ANALYSIS: Chi-square and t-tests were utilized to examine associations and descriptive analysis explored benefits. Rapid qualitative analysis was utilized to identify themes. RESULTS: Caregivers of 120 children were included (child mean age 11.8; 56.7% female, 67.6% Non-Hispanic Black), with 47 of 59 eligible completing follow-up surveys and 14 completing in-depth interviews. Approximately half (N = 30/59, 50.8%) of families utilizing the food pantry screened negative for food insecurity. Families utilizing the food pantry were more likely to report severe food insecurity (N = 23/59; 38.9%) compared to those declining (N = 3/61; 4.9%, P < .001). Caregivers accepting food were able to meet a child health goal (N = 30/47, 63.8%). Caregivers reported feeling comfortable receiving food (N = 13/14) and felt utilizing the food pantry led to consumption of healthier foods (N = 7/14). CONCLUSIONS: Families who screened both positive and negative for food insecurity utilized and benefited from a clinic-based food pantry. Clinics should consider strategies offering food resources to all families irrespective of screening outcome.

Investing in Child Health Through Alternative Payment Models: Lessons From North Carolina Integrated Care for Kids.

Pediatric value-based payment reform has been hindered by limited return on investment (ROI) for child-focused measures and the accrual of financial benefits to non-health care sectors. States participating in the federally-funded Integrated Care for Kids (InCK) models are required to design child-centered alternative payment models (APMs) for Medicaid-enrolled children. The North Carolina InCK pediatric APM launched in January 2023 and includes innovative measures focused on school readiness and social needs. We interviewed experts at NC Medicaid managed care organizations, NC Medicaid, and actuaries with pediatric value-based payment experience to assess the NC InCK APM design process and develop strategies for future child-focused value-based payment reform. Key principles emerging from conversations included: accounting for payer priorities and readiness to implement measures; impact of data uncertainty on investment in novel measures; misalignment of a short-term ROI framework with whole child health measures; and state levers like mandates and financial incentives to promote implementation.

Promoting Latinx health equity through community-engaged policy and practice reforms in North Carolina.

Introduction: The Latinx Advocacy Team & Interdisciplinary Network for COVID-19 (LATIN-19) is a unique multi-sector coalition formed early in the COVID-19 pandemic to address the multi-level health inequities faced by Latinx communities in North Carolina. Methods: We utilized the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework to conduct a directed content analysis of 58 LATIN-19 meeting minutes from April 2020 through October 2021. Application of the NIMHD Research Framework facilitated a comprehensive assessment of complex and multidimensional barriers and interventions contributing to Latinx health while centering on community voices and perspectives. Results: Community interventions focused on reducing language barriers and increasing community-level access to social supports while policy interventions focused on increasing services to slow the spread of COVID-19. Discussion: Our study adds to the literature by identifying community-based strategies to ensure the power of communities is accounted for in policy reforms that affect Latinx health outcomes across the U.S. Multisector coalitions, such as LATIN-19, can enable the improved understanding of underlying barriers and embed community priorities into policy solutions to address health inequities.

Analysis of North Carolina Medicaid Claims Data to Simulate a Pediatric Accountable Care Organization.

Importance: Despite momentum for pediatric value-based payment models, little is known about tailoring design elements to account for the unique needs and utilization patterns of children and young adults. Objective: To simulate attribution to a hypothetical pediatric accountable care organization (ACO) and describe baseline demographic characteristics, expenditures, and utilization patterns over the subsequent year. Design, Setting, and Participants: This retrospective cohort study used Medicaid claims data for children and young adults aged 1 to 20 years enrolled in North Carolina Medicaid at any time during 2017. Children and young adults receiving at least 50% of their primary care at a large academic medical center (AMC) in 2017 were attributed to the ACO. Data were analyzed from April 2020 to March 2021. Main Outcomes and Measures: Primary outcomes were total cost of care and care utilization during the 2018 performance year. Results: Among 930 266 children and young adults (377 233 children [40.6%] aged 6-12 years; 470 612 [50.6%] female) enrolled in Medicare in North Carolina in 2017, 27 290 children and young adults were attributed to the ACO. A total of 12 306 Black non-Hispanic children and young adults (45.1%), 6308 Hispanic or Latinx children and young adults (23.1%), and 6531 White non-Hispanic children and young adults (23.9%) were included. Most attributed individuals (23 133 individuals [84.7%]) had at least 1 claim in the performance year. The median (IQR) total cost of care in 2018 was $347 ($107-$1123); 272 individuals (1.0%) accounted for nearly half of total costs. Compared with children and young adults in the lowest-cost quartile, those in the highest-cost quartile were more likely to have complex medical conditions (399 individuals [6.9%] vs 3442 individuals [59.5%]) and to live farther from the AMC (median [IQR distance, 6.0 [4.6-20.3] miles vs 13.9 [4.6-30.9] miles). Total cost of care was accrued in home (43%), outpatient specialty (19%), inpatient (14%) and primary (8%) care. More than half of attributed children and young adults received care outside of the ACO; the median (IQR) cost for leaked care was $349 ($130-$1326). The costliest leaked encounters included inpatient, ancillary, and home health care, while the most frequently leaked encounters included behavioral health, emergency, and primary care. Conclusions and Relevance: This cohort study found that while most children attributed to the hypothetical Medicaid pediatric ACO lived locally with few health care encounters, a small group of children with medical complexity traveled long distances for care and used frequent and costly home-based and outpatient specialty care. Leaked care was substantial for all attributed children, with the cost of leaked care being higher than the total cost of care. These pediatric-specific clinical and utilization profiles have implications for future pediatric ACO design choices related to attribution, accounting for children with high costs, and strategies to address leaked care.

Food Insecurity Was Associated With Greater Family Health Care Expenditures In The US, 2016-17.

Food insecurity has been associated with the health care expenditures of individuals, but it can affect the entire family. Evaluating the relationship between food insecurity and family expenditures provides a better understanding of the financial implications of food insecurity interventions. Our primary objective was to evaluate the association between food insecurity in one year (2016) and family health care expenditures-for all members, for children only, and for adults only-in the next year (2017). We also evaluated whether this association varied across types of insurance coverage within families: all private, all public, or mixed (including uninsured). Using nationally representative data, we found that food-insecure families had 20 percent greater total health care expenditures than food-secure families, for an annual difference of $2,456. Food insecurity was associated with greater expenditures across all family insurance patterns, including the 19.1 percent of families with mixed coverage. Our findings suggest that in families with mixed coverage, positive impacts of food insecurity interventions on health care use may accrue to family members other than the targeted beneficiaries and those who have different insurance, benefiting the entire family but potentially discouraging investments on the part of any one payer.

Documentation Status and Self-Rated Physical Health Among Latinx Young Adult Immigrants: the Mediating Roles of Immigration and Healthcare Stress.

Previous research has demonstrated that undocumented Latinx immigrants in the USA report worse physical health outcomes than documented immigrants. Some studies suggest that immigration-related stress and healthcare related-stress may explain this relationship, but none have tested it empirically. The purpose of this study was to determine if immigration-related stress and healthcare-related stress in the USA explain the relationship between documentation status and physical health among Latinx immigrants in North Carolina. The conceptual model was tested utilizing baseline data from a longitudinal, observational, community-engaged research study of young adult (18-44 years) Latinx immigrants residing in North Carolina (N = 391). Structural equation modeling was used to determine relationships among documentation status, healthcare, and immigration stress in the past six months, and self-rated physical health. Goodness-of-fit measures indicated that data fit the model well (RMSEA = .008; CFI = 1.0; TLI = .999; SRMR = .02; CD = .157). Undocumented individuals were more likely to experience immigration stress than their documented counterparts ([Formula: see text] = - 0.37, p < 0.001). Both immigration stress ([Formula: see text] = - 0.22, p < 0.01) and healthcare stress ([Formula: see text] = - 0.14, p < 0.05) were negatively related to physical health. Additionally, immigration stress was positively related to healthcare stress ([Formula: see text] = 0.72, p < 0.001). Results demonstrate that documentation status is an important social determinant of health. Passage of inclusive immigration and healthcare policies may lessen the stress experienced by Latinx immigrants and subsequently improve physical health.

Assessment of Population-Level Disadvantage Indices to Inform Equitable Health Policy.

Policy Points The rapid uptake of disadvantage indices during the pandemic highlights investment in implementing tools that address health equity to inform policy. Existing indices differ in their design, including data elements, social determinants of health domains, and geographic unit of analysis. These differences can lead to stark discrepancies in place-based social risk scores depending on the index utilized. Disadvantage indices are useful tools for identifying geographic patterns of social risk; however, indiscriminate use of indices can have varied policy implications and unintentionally worsen equity. Implementers should consider which indices are suitable for specific communities, objectives, potential interventions, and outcomes of interest. CONTEXT: There has been unprecedented uptake of disadvantage indices such as the Centers for Disease Control and Prevention Social Vulnerability Index (SVI) to identify place-based patterns of social risk and guide equitable health policy during the COVID-19 pandemic. However, limited evidence around data elements, interoperability, and implementation leaves unanswered questions regarding the utility of indices to prioritize health equity. METHODS: We identified disadvantage indices that were (a) used three or more times from 2018 to 2021, (b) designed using national-level data, and (c) available at the census-tract or block-group level. We used a network visualization to compare social determinants of health (SDOH) domains across indices. We then used geospatial analyses to compare disadvantage profiles across indices and geographic areas. FINDINGS: We identified 14 indices. All incorporated data from public sources, with half using only American Community Survey data (n = 7) and the other half combining multiple sources (n = 7). Indices differed in geographic granularity, with county level (n = 5) and census-tract level (n = 5) being the most common. Most states used the SVI during the pandemic. The SVI, the Area Deprivation Index (ADI), the COVID-19 Community Vulnerability Index (CCVI), and the Child Opportunity Index (COI) met criteria for further analysis. Selected indices shared five indicators (income, poverty, English proficiency, no high school diploma, unemployment) but varied in other metrics and construction method. While mapping of social risk scores in Durham County, North Carolina; Cook County, Illinois; and Orleans Parish, Louisiana, showed differing patterns within the same locations depending on choice of disadvantage index, risk scores across indices showed moderate to high correlation (rs 0.7-1). However, spatial autocorrelation analyses revealed clustering, with discrepant distributions of social risk scores between different indices. CONCLUSIONS: Existing disadvantage indices use varied metrics to represent place-based social risk. Within the same geographic area, different indices can provide differences in social risk values and interpretations, potentially leading to varied public health or policy responses.

Integrated Health and Social Care in the United States: A Decade of Policy Progress.

INTRODUCTION: Over the last decade in the United States (US), the burden of chronic disease, health care costs, and fragmented care delivery have increased at alarming rates. To address these challenges, policymakers have prioritized new payment and delivery models to incentivize better integrated health and social services. POLICY PRACTICE: This paper outlines three major national and state policy initiatives to improve integrated health and social care over the last ten years in the US, with a focus on the Medicaid public insurance program for Americans with low incomes. Activities supported by these initiatives include screening patients for social risks in primary care clinics; building new cross-sector collaborations; financing social care with healthcare dollars; and sharing data across health, social and community services. Stakeholders from the private sector, including health systems and insurers, have partnered to advance and scale these initiatives. This paper describes the implementation and effectiveness of such efforts, and lessons learned from translating policy to practice. DISCUSSION AND CONCLUSION: National policies have catalyzed initiatives to test new integrated health and social care models, with the ultimate goal of improving population health and decreasing costs. Preliminary findings demonstrated the need for validated measures of social risk, engagement across levels of organizational leadership and frontline staff, and greater flexibility from national policymakers in order to align incentives across sectors.

The Health of Children in Immigrant Families: Key Drivers and Research Gaps Through an Equity Lens.

OBJECTIVE: The United States benefits economically and socially from the diverse skill-set and innovative contributions of immigrants. By applying a socioecological framework with an equity lens, we aim to provide an overview of the health of children in immigrant families (CIF) in the United States, identify gaps in related research, and suggest future areas of focus to advance health equity. METHODS: The literature review consisted of identifying academic and gray literature using a MeSH Database, Clinical Queries, and relevant keywords in 3 electronic databases (PubMed, Web of Science, and BrowZine). Search terms were selected with goals of: 1) conceptualizing a model of key drivers of health for CIF; 2) describing and classifying key drivers of health for CIF; and 3) identifying knowledge gaps. RESULTS: The initial search produced 1120 results which were screened for relevance using a meta-narrative approach. Of these, 224 papers were selected, categorized by topic, and reviewed in collaboration with the authors. Key topic areas included patient and family outcomes, institutional and community environments, the impact of public policy, and opportunities for research. Key inequities were identified in health outcomes; access to quality health care, housing, education, employment opportunities; immigration policies; and inclusion in and funding for research. Important resiliency factors for CIF included strong family connections and social networks. CONCLUSIONS: Broad structural inequities contribute to poor health outcomes among immigrant families. While resiliency factors exist, research on the impact of certain important drivers of health, such as structural and cultural racism, is missing regarding this population. More work is needed to inform the development and optimization of programs and policies aimed at improving outcomes for CIF. However, research should incorporate expertise from within immigrant communities. Finally, interventions to improve outcomes for CIF should be considered in the context of the socioecological model which informs the upstream and downstream drivers of health outcomes.

Medicaid Coverage Disruptions Among Children Enrolled in North Carolina Medicaid From 2016 to 2018.

Importance: Brief disruptions in insurance coverage among eligible participants are associated with poorer health outcomes for children. Objective: To describe factors associated with coverage disruptions among children enrolled in North Carolina Medicaid from 2016 to 2018 and estimate the outcome of preventing such disruptions on medical expenditures. Design Setting and Participants: This was a retrospective cohort study using North Carolina Medicaid claims data. All enrolled individuals were aged 1 to 20 years on January 1, 2016, and with 30 days of prior continuous enrollment. Children were observed from January 1, 2016, until December 31, 2018. Analyses were conducted from June 2020 through December 2020. Main Outcomes and Measures: Risk of Medicaid coverage disruptions of 1 to less than 12 months was assessed. Among children who disenrolled from Medicaid for 30 or more days, the risk of reenrollment within 1 to 6 months and 7 to 11 months was assessed. An inverse probability of censoring weights method was then used to estimate the outcome of an intervention to reduce coverage disruptions through preventing disenrollment on per member per month (PMPM) cost. Results: The study population included 831 173 Medicaid beneficiaries aged 1 to 5 years (23%), 6 to 17 years (68%), and 18 to 20 years (9%); 35% were Black, 44% were White, and 14% were Hispanic/Latinx. Among those with a first disenrollment (n = 214 401, 26%), the risk of reenrollment within 6 months and 7 to 11 months was 19% and 7%, respectively. Risk of coverage disruption was higher for Black children (hazard ratio [HR], 1.21; 95% CI, 1.18-1.24), children of other races (Asian, American Indian, Hawaiian or Pacific Islander, multiple races, or unreported; HR, 1.37; 95% CI, 1.33-1.40), and Latinx children (HR, 1.65; 95% CI, 1.60-1.70) compared with White children. Risk of coverage disruption was also higher for children with higher medical complexity (HR, 1.15; 95% CI, 1.12-1.19). The risk of coverage disruption was lower for children living in counties with the highest unemployment rates (HR, 0.89; 95% CI, 0.85-0.94), and comparisons between county-level measures of child poverty and graduation rates showed little or no difference. The estimated PMPM cost for the full population under a scenario in which all medical costs were included was $125.73. Estimated PMPM cost for the full cohort in a counterfactual scenario in which disenrollment was prevented was slightly lower ($122.14). Across all subgroups, estimated PMPM costs were modestly lower ($2-$8) in the scenario in which disenrollment was prevented. Conclusions and Relevance: In this cohort study, the risk of Medicaid coverage disruption was high, with many eligible children in historically marginalized communities continuing to experience unstable enrollment. In addition to improving health outcomes, preventing coverage gaps through policies that decrease disenrollment may also reduce Medicaid costs.

Health Care Use Among Latinx Children After 2017 Executive Actions on Immigration.

BACKGROUND: US immigration policy changes may affect health care use among Latinx children. We hypothesized that January 2017 restrictive immigration executive actions would lead to decreased health care use among Latinx children. METHODS: We used controlled interrupted time series to estimate the effect of executive actions on outpatient cancellation or no-show rates from October 2016 to March 2017 ("immigration action period") among Latinx children in 4 health care systems in North Carolina. We included control groups of (1) non-Latinx children and (2) Latinx children from the same period in the previous year ("control period") to account for natural trends such as seasonality. RESULTS: In the immigration action period, 114 627 children contributed 314 092 appointments. In the control period, 107 657 children contributed 295 993 appointments. Relative to the control period, there was an immediate 5.7% (95% confidence interval [CI]: 0.40%-10.9%) decrease in cancellation rates among all Latinx children, but no sustained change in trend of cancellations and no change in no-show rates after executive immigration actions. Among uninsured Latinx children, there was an immediate 12.7% (95% CI: 2.3%-23.1%) decrease in cancellations; however, cancellations then increased by 2.4% (95% CI: 0.89%-3.9%) per week after immigration actions, an absolute increase of 15.5 cancellations per 100 appointments made. CONCLUSIONS: There was a sustained increase in cancellations among uninsured Latinx children after immigration actions, suggesting decreased health care use among uninsured Latinx children. Continued monitoring of effects of immigration policy on child health is needed, along with measures to ensure that all children receive necessary health care.