Persistent Disparities in Access to Elective Colorectal Cancer Surgery After Medicaid Expansion Under the Affordable Care Act: A Multistate Evaluation.

BACKGROUND: Despite their higher incidence of colorectal cancer, ethnoracial minority and low-income patients have reduced access to elective colorectal cancer surgery. Although the Affordable Care Act's Medicaid expansion increased screening of colonoscopies, its effect on disparities in elective colorectal cancer surgery remains unknown. OBJECTIVE: This study assessed the effects of Medicaid expansion on elective colorectal cancer surgery rates overall and by race-ethnicity and income. DESIGN: Using the 2012 to 2015 State Inpatient Databases, a retrospective cohort study was conducted. SETTINGS: State Inpatient Databases from 3 expansion states (Maryland, New Jersey, and Kentucky) and 2 nonexpansion states (Florida and North Carolina) were used. PATIENTS: This study examined 22,304 adult patients aged 18 to 64 years who underwent colorectal cancer surgery. MAIN OUTCOME MEASURES: Using interrupted time series analysis, the effect of Medicaid expansion on the odds of elective colorectal cancer surgery was assessed. RESULTS: Elective vs nonelective surgery rates remained unchanged overall (70.2% vs 70.7%, p = 0.63) and in ethnoracial minorities in expansion states (whites from 72.8% to 73.8% pre to post, p = 0.40 and non-white from 64.0% to 63.1% pre to post, p = 0.67). There was an instantaneous increase in odds of elective surgery in expansion vs nonexpansion states at policy implementation (adjusted OR 1.37; 95% CI, 1.05-1.79; p = 0.02), but it subsequently decreased (combined adjusted OR 0.95; 95% CI, 0.92-0.99; p = 0.03). Elective surgery rates were also unchanged among ethnoracial minorities (instantaneous changes in expansion states, combined effect 1.06; pre-trend 1.01 vs post-trend 0.98) and low-income persons in expansion states (pre-trend 1.03 vs post-trend 0.97) (for all, p > 0.1). LIMITATIONS: The study was limited to 5 states. Although patients may have increased access to cancer screening services and surgery after expansion, the State Inpatient Databases only provide information on patients who underwent surgery. CONCLUSIONS: Despite gains in screening, Medicaid expansion was not associated with reductions in known ethnoracial or income-based disparities in elective colorectal cancer surgery rates. Expanding access to colorectal cancer surgery for underserved populations likely requires attention to provider and health system factors contributing to persistent disparities. See Video Abstract at http://links.lww.com/DCR/C217 . DISPARIDADES PERSISTENTES EN EL ACCESO A LA CIRUGA ELECTIVA DEL CNCER COLORRECTAL DESPUS DE LA EXPANSIN DE MEDICAID EN VIRTUD DE LA LEY DEL CUIDADO DE SALUD A BAJO PRECIO UNA EVALUACIN MULTIESTATAL: ANTECEDENTES: A pesar de su mayor incidencia de cáncer colorrectal, los pacientes de minorías etnoraciales y de bajos ingresos tienen un acceso reducido a la cirugía electiva de cáncer colorrectal. Aunque la expansión de Medicaid de la Ley del Cuidado de Salud a Bajo Precio aumentó las colonoscopias de detección, aún se desconoce su efecto sobre las disparidades en la cirugía electiva de cáncer colorrectal.OBJETIVO: Este estudio evaluó los efectos de la expansión de Medicaid en las tasas de cirugía electiva de cáncer colorrectal en general y por raza, etnia e ingresos.DISEÑO: Utilizando las bases de datos estatales de pacientes hospitalizados de 2012-2015, se realizó un estudio de cohorte retrospectivo.CONFIGURACIÓN: Se utilizaron bases de datos estatales de pacientes hospitalizados de tres estados en expansión (Maryland, Nueva Jersey, Kentucky) y dos estados sin expansión (Florida, Carolina del Norte).PACIENTES: Este estudio examinó a 22,304 pacientes adultos de 18 a 64 años que se sometieron a cirugía de cáncer colorrectal.RESULTADO PRINCIPAL: Mediante el análisis de series de tiempo interrumpido, se evaluó el efecto de la expansión de Medicaid en las probabilidades de cirugía electiva de cáncer colorrectal.RESULTADOS: Las tasas de cirugía electiva frente a no electiva permanecieron sin cambios en general (70,2% frente a 70,7%, p = 0,63) y en las minorías etnoraciales en los estados de expansión (blancos del 72,8% al 73,8 % antes y después, p = 0,40 y no blancos del 64,0% al 63,1% pre a post, p = 0,67). Hubo un aumento instantáneo en las probabilidades de cirugía electiva en los estados de expansión frente a los de no expansión en la implementación de la política (OR ajustado 1,37, IC del 95%, 1,05-1,79, p = 0,02), pero disminuyó posteriormente (OR ajustado combinado 0,95, 95% IC, 0,92-0,99, p = 0,03). Las tasas de cirugía electiva también se mantuvieron sin cambios entre las minorías etnoraciales (cambios instantáneos en los estados de expansión, efecto combinado 1,06; antes de la tendencia 1,01 frente a la postendencia 0,98) y las personas de bajos ingresos en los estados de expansión (antes de la tendencia 1,03 frente a la postendencia 0,97; para todos, p > 0,1).LIMITACIONES: El estudio se limitó a cinco estados. Si bien los pacientes pueden tener un mayor acceso a los servicios de detección de cáncer y la expansión posterior a la cirugía, la base de datos de pacientes hospitalizados del estado solo brinda información sobre los pacientes que se sometieron a cirugía.CONCLUSIONES: A pesar de los avances en la detección, la expansión de Medicaid no se asoció con reducciones en las disparidades etnoraciales o basadas en los ingresos conocidas en las tasas de cirugía electiva de cáncer colorrectal. Ampliar el acceso a la cirugía del cáncer colorrectal para las poblaciones desatendidas probablemente requiera atención a los factores del proveedor y del sistema de salud que contribuyen a las disparidades persistentes. Consulte el Video Resumen en http://links.lww.com/DCR/C217 . (Traducción-Dr. Yesenia.Rojas-Khalil ).

Health, social, and economic characteristics of patients enrolled in a COVID-19 recovery program.

At least one in five people who recovered from acute COVID-19 have persistent clinical symptoms, however little is known about the impact on quality-of-life (QOL), socio-economic characteristics, fatigue, work and productivity. We present a cross-sectional descriptive characterization of the clinical symptoms, QOL, socioeconomic characteristics, fatigue, work and productivity of a cohort of patients enrolled in the MedStar COVID Recovery Program (MSCRP). Our participants include people with mental and physical symptoms following recovery from acute COVID-19 and enrolled in MSCRP, which is designed to provide comprehensive multidisciplinary care and aid in recovery. Participants completed medical questionnaires and the PROMIS-29, Fatigue Severity Scale, Work and Productivity Impairment Questionnaire, and Social Determinants of Health surveys. Participants (n = 267, mean age 47.6 years, 23.2% hospitalized for COVID-19) showed impaired QOL across all domains assessed with greatest impairment in physical functioning (mean 39.1 ± 7.4) and fatigue (mean 60.6 ±. 9.7). Housing or "the basics" were not afforded by 19% and food insecurity was reported in 14% of the cohort. Participants reported elevated fatigue (mean 4.7 ± 1.1) and impairment with activity, work productivity, and on the job effectiveness was reported in 63%, 61%, and 56% of participants, respectively. Patients with persistent mental and physical symptoms following initial illness report impairment in QOL, socioeconomic hardships, increased fatigue and decreased work and productivity. Our cohort highlights that even those who are not hospitalized and recover from less severe COVID-19 can have long-term impairment, therefore designing, implementing, and scaling programs to focus on mitigating impairment and restoring function are greatly needed.

Effects of Maryland's global budget revenue model on emergency department utilization and revisits.

BACKGROUND: In 2014, Maryland (MD) implemented a "global budget revenue" (GBR) program that prospectively sets hospital budgets. This program introduced incentives for hospitals to tightly control volume and meet budget targets. We examine GBR's effects on emergency department (ED) visits, admissions, and returns. METHODS: We performed an interrupted time-series analysis with difference-in-differences comparisons using 2012 to 2015 Healthcare Cost Utilization and Project data from MD, New York (NY), and New Jersey (NJ). We examined GBR's effects on ED visits/1,000 population, admissions from the ED, and ED returns at 72 h and 9 days. We also examined rates of admission, intensive care unit (ICU) stay, and in-hospital mortality among returns. To evaluate racial/ethnic and payer outcome disparities among ED returns, we performed a triple differences analysis. RESULTS: ED visits decreased with GBR adoption in MD relative to NY and NJ, by five and six visits/1,000 population, respectively. ED admissions declined relative to NY and NJ, by 0.6% and 1.8%, respectively. There was also a post-GBR decline in ED returns by 0.7%. Admissions among returns declined by 2%, while ICU and in-hospital mortality among returns remained relatively stable. ED return outcomes varied by racial/ethnic and payer group. Non-Hispanic Whites and non-Hispanic Blacks experienced a similar decline in returns, while returns remained unchanged among Hispanics/Latinos, widening the disparity gap. Payer group disparities between privately insured and Medicare, Medicaid, and uninsured individuals improved, with the disparity reduction most pronounced among the uninsured. CONCLUSIONS: GBR adoption was associated with lower ED utilization and admissions. ED returns and admissions among returns also decreased, while mortality and ICU stays among returns remained stable, suggesting that GBR has not led to adverse patient outcomes from fewer admissions. However, changes in ED return disparities varied by subgroup, indicating that improvements in care transitions may be uneven across patient populations.

ACA Medicaid expansion reduced disparities in use of high-volume hospitals for pancreatic surgery.

BACKGROUND: Early evaluation of the Affordable Care Act's Medicaid expansion demonstrated persistent disparities among Medicaid beneficiaries in use of high-volume hospitals for pancreatic surgery. Longer-term effects of expansion remain unknown. This study evaluated the impact of expansion on the use of high-volume hospitals for pancreatic surgery among Medicaid and uninsured patients. METHODS: State inpatient databases (2012-2017), the American Hospital Association Annual Survey Database, and the Area Resource File from the Health Resources and Services Administration, were used to examine 8,264 non-elderly adults who underwent pancreatic surgery in nine expansion and two non-expansion states. High-volume hospitals were defined as performing 20 or more resections/year. Linear probability triple differences models measured pre- and post-Affordable Care Act utilization rates of pancreatic surgery at high-volume hospitals among Medicaid and uninsured patients versus privately insured patients in expansion versus non-expansion states. RESULTS: The Affordable Care Act's expansion was associated with increased rates of utilization of high-volume hospitals for pancreatic surgery by Medicaid and uninsured patients (48% vs 55.4%, P = .047) relative to privately insured patients in expansion states (triple difference estimate +11.7%, P = .022). A pre-Affordable Care Act gap in use of high-volume hospitals among Medicaid and uninsured patients in expansion states versus non-expansion states (48% vs 77%, P < .0001) was reduced by 15.1% (P = .001) post Affordable Care Act. A pre Affordable Care Act gap between expansion versus non-expansion states was larger for Medicaid and uninsured patients relative to privately insured patients by 24.9% (P < .0001) and was reduced by 11.7% (P = .022) post Affordable Care Act. Rates among privately insured patients remained unchanged. CONCLUSION: Medicaid expansion was associated with greater utilization of high-volume hospitals for pancreatic surgery among Medicaid and uninsured patients. These findings are informative to non-expansion states considering expansion. Future studies should target understanding referral mechanism post-expansion.

Effects of Permanent Supportive Housing on Health Care Utilization and Spending Among New Jersey Medicaid Enrollees Experiencing Homelessness.

BACKGROUND: Permanent supportive housing (PSH) programs have the potential to improve health and reduce Medicaid expenditures for beneficiaries experiencing homelessness. However, most research on PSH has been limited to small samples of narrowly defined populations. OBJECTIVE: To evaluate the effects of PSH on Medicaid enrollees across New Jersey. RESEARCH DESIGN: Linked data from the Medicaid Management Information System and the Homeless Management Information System were used to compare PSH-placed Medicaid enrollees with a matched sample of other Medicaid enrollees experiencing homelessness. Comparisons of Medicaid-financed health care utilization and spending measures were made in a difference-in-differences framework 6 quarters before and after PSH placement. SUBJECTS: A total of 1442 Medicaid beneficiaries enrolled in PSH and 6064 Medicaid-enrolled homeless individuals not in PSH in 2013-2014. RESULTS: PSH placement is associated with a 14.3% reduction in emergency department visits (P<0.001) and a 25.2% reduction in associated spending (P<0.001). PSH also appears to reduce inpatient utilization and increase pharmacy spending with neutral effects on primary care visits and total costs of care (TCOC). CONCLUSIONS: Placement in PSH is associated with lower hospital utilization and spending. No relationship was found, however, between PSH placement and TCOC, likely due to increased pharmacy spending in the PSH group. Greater access to prescription drugs may have improved the health of PSH-placed individuals in a way that reduced hospital episodes with neutral effects on TCOC.

Primary care for new vs established Medicaid enrollees.

OBJECTIVES: To understand changes in primary care (PC) utilization in Medicaid and the Children's Health Insurance Program (CHIP) 3 years after the Affordable Care Act (ACA). STUDY DESIGN: Secondary data analysis using Medicaid/CHIP paid claims and managed care encounters. METHODS: Pre-/post-ACA trends in total enrollment and PC visits among newly enrolled and established patients were analyzed in half-year increments from the first half of 2012 to the second half of 2016. RESULTS: After ACA expansion, there was a temporary surge in new Medicaid/CHIP enrollment (which included surges in pre-ACA eligibility categories) and slow, steady growth in total enrollment. The percentage of new enrollees completing a PC visit within 90, 180, and 365 days of enrollment fell markedly in the first half of 2014 and then rebounded to pre-ACA levels thereafter. Conversely, the percentage of new enrollees remaining enrolled at 90, 180, and 365 days spiked upward in the first half of 2014 and gradually fell thereafter. Among established enrollees, PC visits per person exhibited a downward trend throughout the post-ACA period, driven mostly by a decline in the percentage of individuals with any PC visits. CONCLUSIONS: The first 6 months of ACA implementation in New Jersey were marked by a surge in Medicaid/CHIP enrollment that extended beyond the ACA target population, greater enrollment retention, and apparent bottlenecks in PC delivery. After the initial surge, new enrollees used PC at rates at least as high as in the pre-ACA period, whereas established enrollees used PC at a declining rate throughout the post-ACA period. PC delivery for new enrollees may have limited the availability of services for some established enrollees.

Emergency department care coordination strategies and perceived impact under Maryland's hospital payment reforms.

BACKGROUND: Emergency department (ED) care coordination plays an important role in facilitating care transitions across settings. We studied ED care coordination processes and their perceived effectiveness in Maryland (MD) hospitals, which face strong incentives to reduce hospital-based care through global budgets. METHODS: We conducted a qualitative study using semi-structured interviews to examine ED care coordination processes and perceptions of effectiveness. Interviews were conducted from January through October 2019 across MD hospital-based EDs. Results were reviewed to assign analytic domains and identify emerging themes. Descriptive statistics of ED care coordination staffing and processes were also calculated. RESULTS: A total of 25 in-depth interviews across 18 different EDs were conducted with ED physician leadership (n = 14) and care coordination staff (CCS) (n = 11). Across all EDs, there was significant variation in the hours and types of CCS coverage and the number of initiatives implemented to improve care coordination. Participants perceived ED care coordination as effective in facilitating safer discharges and addressing social determinants of health; however, adequate access to outpatient providers was a significant barrier. The majority of ED physician leaders perceived MD's policy reform as having a mixed impact, with improved care transitions and overall patient care as benefits, but increased physician workloads and worsened ED throughput as negative effects. CONCLUSIONS: EDs have responded to the value-based care incentives of MD's global budgeting program with investments to enhance care coordination staffing and a variety of initiatives targeting specific patient populations. Although the observed care coordination initiatives were broadly perceived to produce positive results, MD's global budgeting policies were also perceived to produce barriers to optimizing ED care. Further research is needed to determine the association of the various strategies to improve ED care coordination with patient outcomes to inform practice leaders and policymakers on the efficacy of the various approaches.

Evidence That Changes in Community Food Environments Lead to Changes in Children's Weight: Results from a Longitudinal Prospective Cohort Study.

BACKGROUND: Strategies to improve the community food environment have been recommended for addressing childhood obesity, but evidence substantiating their effectiveness is limited. OBJECTIVE: Our aim was to examine the impact of changes in availability of key features of the community food environment, such as supermarkets, small grocery stores, convenience stores, upgraded convenience stores, pharmacies, and limited service restaurants, on changes in children's body mass index z scores (zBMIs). DESIGN: We conducted a longitudinal cohort study. PARTICIPANTS/SETTING: Two cohorts of 3- to 15-year-old children living in 4 low-income New Jersey cities were followed during 2- to 5-year periods from 2009 through 2017. Data on weight status were collected at 2 time points (T1 and T2) from each cohort; data on food outlets in the 4 cities and within a 1-mile buffer around each city were collected multiple times between T1 and T2. MAIN OUTCOME MEASURES: We measured change in children's zBMIs between T1 and T2. STATISTICAL ANALYSIS: Changes in the food environment were conceptualized as exposure to changes in counts of food outlets across varying proximities (0.25 mile, 0.5 mile, and 1.0 mile) around a child's home, over different lengths of time a child was exposed to these changes before T2 (12 months, 18 months, and 24 months). Multivariate models examined patterns in relationships between changes in zBMI and changes in the food environment. RESULTS: Increased zBMIs were observed in children with greater exposure to convenience stores over time, with a consistent pattern of significant associations across varying proximities and lengths of exposure. For example, exposure to an additional convenience store over 24 months within 1 mile of a child's home resulted in 11.7% higher odds (P = 0.007) of a child being in a higher zBMI change category at T2. Lower zBMIs were observed in children with increased exposure to small grocery stores selling an array of healthy items, with exposure to an additional small grocery store within 1 mile over 24 months, resulting in 37.3% lower odds (P < 0.05) of being in a higher zBMI change category at T2. No consistent patterns were observed for changes in exposure to supermarkets, limited service restaurants, or pharmacies. CONCLUSIONS: Increased availability of small grocery stores near children's homes may improve children's weight status, whereas increased availability of convenience stores is likely to be detrimental.

Who, What, Where: Demographics, Severity of Presentation, and Location of Treatment Drive Delivery of Diabetic Limb Reconstructive Services within the National Inpatient Sample.

BACKGROUND: Technical advances have been made in reconstructive diabetic limb salvage modalities. It is unknown whether these techniques are widely used. This study seeks to determine the role of patient- and hospital-level characteristics that affect use. METHODS: Admissions for diabetic lower extremity complications were identified in the 2012 to 2014 National Inpatient Sample using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The study cohort consisted of admitted patients receiving amputations, limb salvage without flap techniques, or advanced limb salvage with flap techniques. Multinomial regression analysis accounting for the complex survey design of the National Inpatient Sample was used to determine the independent contributions of factors expressed as marginal effects. RESULTS: The authors' study cohort represented 155,025 admissions nationally. White non-Hispanic patients had the highest proportion of reconstruction without and with flaps, whereas black patients had the lowest. Multinomial regression models revealed that controlling for nongas gangrene and critical limb ischemia, both of which have a much greater incidence in minorities, the effect of race against receipt of reconstructive modalities was attenuated. Access to urban teaching hospitals was the strongest protective factor against amputation (9 percent reduction; p < 0.01) and predictor of receiving limb salvage without flaps (5 percent increase; p < 0.01) and with flaps (3 percent increase; p < 0.01). CONCLUSIONS: This study identified multiple patient- and hospital-level factors associated with decreased access to the gamut of reconstructive limb salvage techniques. Disparity reduction will likely require a multifaceted strategy that addresses the severity of disease presentation seen in minorities and delivery system capabilities affecting access and use of reconstructive limb salvage procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Medicaid Utilization and Spending among Homeless Adults in New Jersey: Implications for Medicaid-Funded Tenancy Support Services.

Policy Points Large numbers of homeless adults gained Medicaid coverage under the Affordable Care Act, increasing policymaker interest in strategies to improve care and reduce avoidable hospital costs for homeless populations. Compared with nonhomeless adult Medicaid beneficiaries, homeless adult beneficiaries have higher levels of health care needs, due in part to mental health issues and substance use disorders. Homeless adults are also more likely to visit the emergency department or require inpatient admissions. Emergency care and inpatient admissions may sometimes be avoided when individuals have high-quality community-based care and healthful living conditions. Offering tenancy support services that help homeless adults achieve stable housing may therefore be a cost-effective strategy for improving the health of this vulnerable population while reducing spending on avoidable health care interventions. Medicaid beneficiaries with disabling health conditions and more extensive histories of homelessness experience the most potentially avoidable health care interventions and spending, with the greatest opportunity to offset the cost of offering tenancy support benefits. CONTEXT: Following Medicaid expansion under the Affordable Care Act, the number of homeless adults enrolled in Medicaid has increased. This has spurred interest in developing Medicaid-funded tenancy support services (TSS) for homeless populations as a way to reduce Medicaid spending on health care for these individuals. An emerging body of evidence suggests that such TSS can reduce avoidable health care spending. METHODS: Drawing on linked Homeless Management Information System and Medicaid claims and encounter data, this study describes the characteristics of homeless adults who could be eligible for Medicaid TSS in New Jersey and compares their Medicaid utilization and spending patterns to matched nonhomeless beneficiaries. FINDINGS: More than 8,400 adults in New Jersey were estimated to be eligible for Medicaid TSS benefits in 2016, including approximately 4,000 living in permanent supportive housing, 800 formally designated as chronically homeless according to federal guidelines, 1,300 who were likely eligible for the chronically homeless designation, and over 2,000 who were at risk of becoming chronically homeless. Homeless adults in our study were disproportionately between the ages of 30 and 64 years, male, and non-Hispanic blacks. The homeless adults we studied also tended to have very high burdens of mental health and substance use disorders, including opioid-related conditions. Medicaid spending for a homeless beneficiary who was potentially eligible for TSS was 10% ($1,362) to 27% ($5,727) more than spending for a nonhomeless Medicaid beneficiary matched on demographic and clinical characteristics. Hospital inpatient and emergency department utilization accounted for at least three-fourths of "excess" Medicaid spending among the homeless groups. CONCLUSIONS: A large group of high-need Medicaid beneficiaries could benefit from TSS, and Medicaid funding for TSS could reduce avoidable Medicaid utilization and spending.

The Policy and Practice Legacy of the New Jersey Medicaid ACO Demonstration Project.

The New Jersey Medicaid Accountable Care Organization (ACO) Demonstration was created with a unique combination of features regarding ACO geography, involvement of managed care organizations (MCOs), and shared savings parameters. Ultimately, the Demonstration did not lead to a sustainable accountable care financing model and shared savings were deemphasized. Instead, the ACOs evolved into community health coalitions focused on coordinating and enhancing a wide range of activities in partnership with state government, private health systems, community leaders, and MCOs. Currently, the state is developing policy parameters to reposition the ACOs as regional partners to implement state-directed population health initiatives.

Healthy Food Access in Low-Income High-Minority Communities: A Longitudinal Assessment-2009-2017.

Disparities in healthy food access are well documented in cross-sectional studies in communities across the United States. However, longitudinal studies examining changes in food environments within various neighborhood contexts are scarce. In a sample of 142 census tracts in four low-income, high-minority cities in New Jersey, United States, we examined the availability of different types of food stores by census tract characteristics over time (2009-2017). Outlets were classified as supermarkets, small grocery stores, convenience stores, and pharmacies using multiple sources of data and a rigorous protocol. Census tracts were categorized by median household income and race/ethnicity of the population each year. Significant declines were observed in convenience store prevalence in lower- and medium-income and majority black tracts (p for trend: 0.004, 0.031, and 0.006 respectively), while a slight increase was observed in the prevalence of supermarkets in medium-income tracts (p for trend: 0.059). The decline in prevalence of convenience stores in lower-income and minority neighborhoods is likely attributable to declining incomes in these already poor communities. Compared to non-Hispanic neighborhoods, Hispanic communities had a higher prevalence of small groceries and convenience stores. This higher prevalence of smaller stores, coupled with shopping practices of Hispanic consumers, suggests that efforts to upgrade smaller stores in Hispanic communities may be more sustainable.

Association of Medicaid enrollee characteristics and primary care utilization with cancer outcomes for the period spanning Medicaid expansion in New Jersey.

BACKGROUND: Cancer outcomes for Medicaid enrollees may be affected by patients' primary care (PC) utilization and complex Medicaid enrollment dynamics, which have recently changed for many states under the Affordable Care Act. METHODS: With New Jersey State Cancer Registry and linked Medicaid claims data, a retrospective cohort study was conducted for patients with incident breast, colorectal, or invasive cervical cancer (aged 21-64 years) diagnosed in 2012-2014. Associations of Medicaid enrollment factors and PC utilization with the stage at diagnosis and treatment delays were examined with multivariate logistic regression models. RESULTS: The study included 19,209 total cancer cases and 3253 linked Medicaid cases. Medicaid cases were more likely to be diagnosed at a late stage and to experience treatment delays in comparison with non-Medicaid cases. In adjusted analyses, Medicaid cases with 1 or more PC visits before the diagnosis had lower odds of a late-stage diagnosis (odds ratio, 0.47; 95% confidence interval, 0.33-0.67) in comparison with Medicaid cases with no outpatient visits. New enrollees (<6 months) and longer term enrollees in fee-for-service (FFS) Medicaid had greater odds of a late-stage diagnosis and treatment delays in comparison with those in Medicaid managed care. CONCLUSIONS: Medicaid patients with cancer diagnosed just before and in the initial year of eligibility expansion had worse outcomes than non-Medicaid cases. Poor outcomes were especially pronounced among new enrollees, those without outpatient visits before their diagnosis, and FFS enrollees. Targeted strategies to enhance care continuity, including access to PC providers before the diagnosis and a better understanding of pathways to cancer care upon Medicaid enrollment, are needed to improve outcomes in this population.

Spending Carveouts Substantially Improve the Accuracy of Performance Measurement in Shared Savings Arrangements: Findings From Simulation Analysis of Medicaid ACOs.

Accuracy of spending-based provider performance metrics is limited by random variation and components of spending that are uncontrollable by providers. Such components vary according to the care management focus and operational maturity of each provider group. This study uses data from New Jersey Medicaid accountable care organizations (ACOs) to examine how carving out uncontrollable components of spending affects the accuracy of performance measures in shared savings arrangements. Spending on injury care, custodial care in facilities (CCF), and amounts above $100 000 per patient are used as examples of potentially uncontrollable spending. Data from 7 applicant Medicaid ACOs are used to conduct Monte Carlo simulations examining the effects of carving out each type of uncontrollable spending under the assumption that controllable spending is reduced by 5%. The simulations show that failure to carve out uncontrollable injury care spending adds -3 to +1 percentage points of bias to the measurement of the true average savings rate (ASR) of 5% and can increase mean squared error (MSE) by a factor of up to 3. Failure to carve out uncontrollable CCF spending generates bias ranging from -4 to +9 percentage points and increases MSE by factors of 8 or more. Failure to carve out uncontrollable spending above $100 000 per person generates bias ranging from -5 to +5 percentage points and increases MSE by factors of 13 or more. Compared with the main modeling reported above, sensitivity analyses find even greater distortions in measured performance when uncontrollable spending is not carved out of the ASR calculation.

Mortality, Disenrollment, and Spending Persistence in Medicaid and CHIP.

BACKGROUND: Research on spending persistence has not focused on Medicaid and the Children's Health Insurance Program (Medicaid/CHIP), which includes a complex and growing population. OBJECTIVE OF THE STUDY: The objective of the study was to describe patterns of expenditure persistence, mortality, and disenrollment among nondually eligible Medicaid/CHIP enrollees and identify factors predicting these outcomes. RESEARCH DESIGN: The study is based on New Jersey Medicaid/CHIP claims data from 2011 to 2014. Descriptive and multinomial regression methods were used to characterize persistently extreme spenders, defined as those appearing in the top 1% of statewide spending every year, according to demographics, Medicaid/CHIP eligibility, nursing facility residence, patient risk scores, and clinical diagnostic categories measured in 2011. Similar analyses were done for persistently high spenders (ie, always in the top 10% but not always top 1%) as well as decedents, disenrollees, and moderate spenders (ie, at least 1 year outside of the top 10%). SUBJECTS: Nondually eligible NJ Medicaid/CHIP enrollees in 2011. RESULTS: One fourth of extreme spenders in 2011 remained in that category throughout 2011-2014. Almost all (89.3%) of the persistently extreme spenders were aged, blind, or disabled. Within the aged, blind, or disabled population, the strongest predictors of persistently extreme spending were diagnoses involving developmental disability, HIV/AIDS, central nervous system conditions, psychiatric disorders, type 1 diabetes, and renal conditions. Individuals in nursing facilities and those with very high risk scores were more likely to die or have persistently high spending than to have persistently extreme spending. CONCLUSIONS: The study highlights unique features of spending persistence within Medicaid/CHIP and provides methodological contributions to the broader persistence literature.

Monte Carlo Analysis of Payer and Provider Risks in Shared Savings Arrangements.

This article provides a thorough empirical analysis of random variation in shared savings arrangements. It uses claims data from seven provider coalitions that applied for certification to become Medicaid accountable care organizations (ACOs) in New Jersey to conduct Monte Carlo simulations under varying assumptions about true ACO savings. Among all the ACOs examined, the observed savings rate can be several percentage points higher or lower than the assumed true savings rate, leading to large probabilities of Type I and Type II error in determining the existence of savings. Although the effects of random variation are smaller for larger ACOs, the ACO-level coefficient of variation in health care spending also stands out as a highly relevant parameter. The risks of overpayment and underpayment can be minimized through modified specification of the savings measurement methodology. These findings have implications for the terms of shared savings arrangements negotiated between payers and providers.

Patterns of emergency department use for dental and oral health care: implications for dental and medical care coordination.

OBJECTIVES: To describe emergency department (ED) utilization for oral conditions (OCs) focusing on total volume, costs, repeat utilization, small area predictors, and implications for dental and medical care coordination. METHODS: Administrative and demographic data for New Jersey were used to identify users of the ED for OCs and a group of "high users," defined as individuals with four or more ED visits for OCs during 2008-2010. Cost-to-charge ratios were used to estimate costs, and linear regression models applied to zip codes were used to determine strongest predictors of small area variation in ED use for OCs. RESULTS: ED visits for OC generated $25.5 million in costs during 2008-2010. High users represented 4.2 percent of all users and 21.3 percent of ED visits for OCs. Almost all high users had a diagnosis of "dental disorder not otherwise specified," and tobacco use disorder was the most common comorbid medical condition. Young adults (ages 19-34), non-Hispanic blacks, and the medically uninsured were over-represented among high users. High users routinely spread their use across multiple hospitals (e.g., 40 percent of them visited three or more hospitals). Local dentist supply and ED use for other conditions were significant predictors of zip code-level ED use for OCs. CONCLUSIONS: Coordination of medical and dental treatment might improve health and reduce costs if targeted to high user populations. Health-care delivery reforms, such as accountable care organizations, could provide vehicles for achieving this coordination. Important challenges include fragmentation of ED visits across hospitals, adequacy of dentist supply, and broader reliance on the ED for health problems.

Impact of Medicare Part D on coverage, access, and disparities among new jersey seniors.

The authors used a population-based survey of New Jersey residents to assess outcomes associated with implementation of the Medicare Part D program. Between 2001 and 2009, there was a 24% increase in prescription drug coverage among elderly individuals, but also an increase in cost-related access problems. Compared with the pre-Part D period, seniors reporting access problems post-Part D were less likely to be uninsured and more likely to be publicly insured. Cost-related access disparities among elderly Blacks and Hispanics relative to elderly Whites persisted from 2001 to 2009, and were partly driven by ongoing disparities related to low income. Such cost-based access problems 3 years into implementation implies that they are not transitory and may reflect inadequate subsidy levels alongside the importance of physician advice about prescriptions in ensuring low-cost medication options for vulnerable patients. Finally, the findings, may also reflect success in enrolling high-need seniors into Part D.