Aligning research and practice: The role of academic-community partnerships for improving measurement and process.

OBJECTIVE: Community programs addressing social determinants of health are growing in prominence and are increasingly expected to provide metrics of success. Our objective is to assess the role of an academic-community partnership for a community health worker program targeting social and medical needs, and determine factors impacting its effectiveness. METHODS: We draw on a 4.5-year partnership that includes both quantitative and qualitative data collection and analysis. Quantitative data collection mechanisms evolved as a result of the partnership. Qualitative interviews were conducted with community health workers and leadership. RESULTS: To align medical and social support services in a sustainable and measurable manner, our academic-community partnership found that creating and maintaining a mutually beneficial space through small wins enabled us to then address larger problems and needs. Ongoing self-study and process evaluation allowed quick adjustments. Unique partnership elements such as having consistent funding and flexible timelines and objectives were essential. CONCLUSIONS: When integrating health and social services, academic-community partnerships create pathways for bidirectional learning than can quickly turn research into practice and support sustainability, especially when based on incrementally built trust and a history of small wins.

Economics of Using Telemedicine to Supplement Hospice Care in Rural Areas.

Background: Hospice care in rural areas is often characterized by provider shortages and vast geographical service areas to cover, making access to quality end-of-life care challenging. Telemedicine, broadly, is the utilization of interactive televideo (ITV) technology to provide health services over a distance. For over 25 years, telemedicine has been proposed as a solution to address access issues. In 2015, the University of Kansas Medical Center (Kansas City, Kansas) partnered with Hospice Services, Inc. (HSI) (Phillipsburg, Kansas), to augment traditional, face-to-face (FTF) hospice care with hospice care delivered through mobile tablets. Objective: This work examines the costs of TeleHospice (TH) (telemedicine use in hospice care) when compared with the costs of FTF hospice services. Design: Detailed administrative data from July 1, 2018, to December 31, 2018, were analyzed to estimate the costs of service after TH use was inculcated into routine practice. Results: his, which averages a daily census of 34 patients, conducted 257 calls, averaging 28 hours a month. The average time for a TH call was 18 and 17 minutes for nursing and medical director calls, respectively. Through various hospice functions, including administrative, patient, and nonpatient-related connections, HSI saved over $115,000 in staff travel time and mileage reimbursement. Administratively, by hosting their weekly 15-member interdisciplinary meeting through ITV, HSI saved $29,869 of staff travel time and mileage reimbursement. Conclusions: Our estimates indicate substantial cost saving potential with the use of TH services. Further research is needed to assess the effects of TH utilization on the experiences and subsequent cost of hospice care.

Where Is the Break-even Point for Community Health Workers? Using National Data and Local Programmatic Costs to Find the Break-even Point for a Metropolitan Community Health Worker Program.

BACKGROUND: Community health worker (CHW) programs take many forms and have been shown to be effective in improving health in several contexts. The extent to which they reduce unnecessary care is not firmly established. OBJECTIVES: This study estimates the number of hospitalizations and emergency department (ED) visits that would need to be avoided to recoup program costs for a CHW program that addressed both medical and social needs. RESEARCH DESIGN: A programmatic cost analysis is conducted using 6 different categories: personnel, training, transportation, equipment, facilities, and administrative costs. First, baseline costs are established for the current program and then estimate the number of avoided ED visits or hospitalizations needed to recoup program costs using national average health care estimates for different patient populations. MEASURES: Data on program costs are taken from administrative program records. Estimates of ED visit and hospitalization costs (or charges in some cases) are taken from the literature. RESULTS: To fully offset program costs, each CHW would need to work with their annual caseload of 150 participants to avoid almost 50 ED visits collectively. If CHW participants also avoided 2 hospitalizations, the number of avoided ED visits needed to offset costs reduces to about 34. CONCLUSIONS: Estimates of avoided visits needed to reach the break-even point are consistent with the literature. The analysis does not take other outcomes of the program from the clients' or workers' perspectives into account, so it is likely an upper bound on the number of avoided visits needed to be cost-effective.

Effect of the Affordable Care Act on Breastfeeding Outcomes.

OBJECTIVES: To assess how the 2012 Affordable Care Act (ACA) policy change, which required most private health insurance plans to cover lactation-support services and breastfeeding equipment (without cost-sharing), affected breastfeeding outcomes. METHODS: We used a regression-adjusted difference-in-differences approach with cross-sectional observational data from the US National Immunization Survey from 2008 to 2014 to estimate the effect of the ACA policy change on breastfeeding outcomes, including initiation, duration, and age at first formula feeding. The sample included children aged 19 to 23 months covered by private health insurance or Medicaid. RESULTS: The ACA policy change was associated with an increase in breastfeeding duration by 10% (0.57 months; P = .007) and duration of exclusive breastfeeding by 21% (0.74 months; P = .001) among the eligible population. Results indicate no significant effects on breastfeeding initiation and age at first formula feeding. CONCLUSIONS: Reducing barriers to receiving support services and breastfeeding equipment shows promise as part of a broader effort to encourage breastfeeding, particularly the duration of breastfeeding and the amount of time before formula supplementation.

Expanding Local Cancer Clinical Trial Options: Analysis of the Economic Impact of the Midwest Cancer Alliance in Kansas.

PURPOSE: Patients benefit from receiving cancer treatment closer to home when possible and at high-volume regional centers when specialized care is required. The purpose of this analysis was to estimate the economic impact of retaining more patients in-state for cancer clinical trials and care, which might offset some of the costs of establishing broader cancer trial and treatment networks. METHOD: Kansas Cancer Registry data were used to estimate the number of patients retained in-state for cancer care following the expansion of local cancer clinical trial options through the Midwest Cancer Alliance based at the University of Kansas Medical Center. The 2014 economic impact of this enhanced local clinical trial network was estimated in four parts: Medical spending was estimated on the basis of National Cancer Institute cost-of-care estimates. Household travel cost savings were estimated as the difference between in-state and out-of-state travel costs. Trial-related grant income was calculated from administrative records. Indirect and induced economic benefits to the state were estimated using an economic impact model. RESULTS: The authors estimated that the enhanced local cancer clinical trial network resulted in approximately $6.9 million in additional economic activity in the state in 2014, or $362,000 per patient retained in-state. This estimate includes $3.6 million in direct spending and $3.3 million in indirect economic activity. The enhanced trial network also resulted in 45 additional jobs. CONCLUSIONS: Retaining patients in-state for cancer care and clinical trial participation allows patients to remain closer to home for care and enhances the state economy.

Lessons from a Broad-based ACA Outreach Effort: Promises and Pitfalls.

The Marketplace Coverage Initiative (MCI) sought to expand awareness and ACA Marketplace enrollment in the greater Kansas City Area. The MCI was evaluated through interviews, surveys, and focus groups. Two main findings are particularly relevant for future Marketplace enrollment efforts. First, the link between contacting someone and actual enrollment is tenuous as follow-up is challenging. Outreach efforts that only track contacts, such as appointments and email addresses, lack information needed to assess enrollment. Linking outreach activities to enrollment outcomes leads us to a dramatically different conclusion about using big data and campaign-style tactics than evaluations of similar techniques such as that pioneered by Enroll America in 11 states. Second, there is a large chasm between the knowledge levels of the uninsured and the decisions they face on the Marketplace. Based on these findings, outreach efforts were redesigned for the 2014 open enrollment period to focus on smaller, community-driven projects.

Lactation Support Services and Breastfeeding Initiation: Evidence from the Affordable Care Act.

OBJECTIVE: Despite substantial evidence of the benefits of breastfeeding for both mothers and children, rates of sustained breastfeeding in the United States are quite low. This study examined whether mandated coverage of lactation support services under the Affordable Care Act (ACA) affects breastfeeding behavior. DATA SOURCE: We studied the census of U.S. births included in the National Vital Statistics System from 2009 to 2014. STUDY DESIGN: We used regression-adjusted difference-in-differences (DD) to examine changes in breastfeeding rates for privately insured mothers relative to those covered by Medicaid. We adjusted for several health and sociodemographic measures. We also examined the extent to which the effect varied across vulnerable populations-by race/ethnicity, maternal education, WIC status, and mode of delivery. PRINCIPAL FINDINGS: Results suggest that the ACA mandate increased the probability of breastfeeding initiation by 2.5 percentage points, which translates into about 47,000 more infants for whom breastfeeding was initiated in 2014. We find larger effects for black, less educated, and unmarried mothers. CONCLUSIONS: The Affordable Care Act-mandated coverage of lactation services increased breastfeeding initiation among privately insured mothers relative to mothers covered by Medicaid. The magnitude of the effect size varied with some evidence of certain groups being more likely to increase breastfeeding rates.

Indoor tobacco legislation is associated with fewer emergency department visits for asthma exacerbation in children.

BACKGROUND: During the past 3 decades, numerous cities and states have adopted laws that ban smoking in public indoor spaces. The rationale for these policies has been to protect nonsmokers from the adverse health effects of secondhand smoke. OBJECTIVE: To determine whether the implementation of indoor smoking legislation is associated with a decrease in emergency department visits for asthma in children. METHODS: This retrospective analysis used a natural experiment to estimate the impact of clean indoor air legislation on the rate of emergency department admissions for asthma exacerbation in children. Data were obtained from the Pediatric Health Information System. A Poisson regression was used for analyses and controlled for age, sex, race, payer source, seasonality, and secular trends. RESULTS: Asthma emergency department visits were captured from 20 hospitals in 14 different states plus the District of Columbia from July 2000 to January 2014 (n = 335,588). Indoor smoking legislation, pooled across all cities, was associated with a decreased rate of severe asthma exacerbation (adjusted rate ratio 0.83, 95% confidence interval 0.82-0.85, P < .0001). CONCLUSION: Indoor tobacco legislation is associated with a decrease in emergency department visits for asthma exacerbation. Such legislation should be considered in localities that remain without this legislation to protect the respiratory health of their children.

Impacts on Emergency Department Visits from Personal Responsibility Provisions: Evidence from West Virginia's Medicaid Redesign.

OBJECTIVE: To examine the impact of a 2007 redesign of West Virginia's Medicaid program, which included an incentive and "nudging" scheme intended to encourage better health care behaviors and reduce Emergency Department (ED) visits. DATA SOURCES: West Virginia Medicaid enrollment and claims data from 2005 to 2010. STUDY DESIGN: We utilized a "differences in differences" technique with individual and time fixed effects to assess the impact of redesign on ED visits. Starting in 2007, categorically eligible Medicaid beneficiaries were moved from traditional Medicaid to the new Mountain Health Choices (MHC) Program on a rolling basis, approximating a natural experiment. Members chose between a Basic plan, which was less generous than traditional Medicaid, or an Enhanced plan, which was more generous but required additional enrollment steps. DATA COLLECTION: Data were obtained from the West Virginia Bureau for Medical Services. PRINCIPAL FINDINGS: We found that contrary to intentions, the MHC program increased ED visits. Those who selected or defaulted into the Basic plan experienced increased overall and preventable ED visits, while those who selected the Enhanced plan experienced a slight reduction in preventable ED visits; the net effect was an increase in ED visits, as most individuals enrolled in the Basic plan.

Strategies for policy evaluation of health insurance marketplaces.

Millions of Americans have access to health insurance through new health insurance marketplaces. To serve the uninsured and underinsured populations, it is vital that key stakeholders put into place robust policy evaluation processes to capture data and provide timely feedback regarding exchange functions. This article lays a foundation for policy evaluation that includes health outcomes, economic outcomes, and consumer processes and perceptions. The evaluation methods outlined are easily adaptable to state, federal, and partnership marketplaces. The article provides a road map for insurance marketplace evaluation at any level and encourages a consistent approach that allows comparison across various marketplaces.

Opting to opt-in: policy choice, program expectations and results in West Virginia's Medicaid reform initiative.

Following the passage of the Federal Deficit Reduction Act in 2005, a few states, including West Virginia, redesigned their Medicaid programs to emphasize personal responsibility and consumer-driven health decisions. The West Virginia program was implemented in 2006 and was subsequently abandoned in 2010 due to changes in Federal laws and continuing criticism by advocacy groups whose expectations for enrollment in a wellness-based plan were not met. Using the results of a survey of the West Virginia members, the authors explore the public policy and implementation factors of this program. We argue that initial policy design relied on existing implementation mechanisms, while it needed specific tactics to address the novelty of the choice members were facing. With the passage of the Patient Protection and Affordable Care Act, the West Virginia results provide valuable insights for future health reform policy implementation, especially as they relate to consumer-directed health decision-making and the role of intermediaries who can play a role in assisting consumers in their choices.

Choice in public health insurance: evidence from West Virginia medicaid redesign.

This paper examines the factors that affect plan choice in a public health insurance program. West Virginia recently redesigned its state Medicaid program, offering members a choice between two plans--a basic plan and an enhanced plan. The latter plan includes more benefits, but requires additional agreements intended to lead patients to adopt healthier lifestyles. We use administrative claims records and survey data to examine plan choice. Our results yield convincing evidence that members with higher health care utilization patterns are more likely to enroll in the enhanced plan, but other factors such as education are also important.