STI Testing among Medicaid Enrollees Initiating PrEP for HIV Prevention in Six Southern States.

OBJECTIVES: The purpose of this study was to measure sexually transmitted infection (STI) testing among Medicaid enrollees initiating preexposure prophylaxis (PrEP) to prevent human immunodeficiency virus. Secondary data are in the form of Medicaid enrollment and claims data in six states in the US South. METHODS: Research partnerships in six states in the US South developed a distributed research network to accomplish study aims. Each state identified all first-time PrEP users in fiscal year 2017-2018 (combined N = 990) and measured the presence of STI testing for chlamydia, syphilis, and gonorrhea through 2019. Each state calculated the percentage of individuals with at least one STI test during 3-, 6-, and 12-month follow-up periods. RESULTS: The proportion of first-time PrEP users that received an STI test varied by state: 37% to 67% of all of the individuals in each state who initiated PrEP received a test within the first 6 months of PrEP treatment and 50% to 77% received a test within the first 12 months. CONCLUSIONS: Although the Centers for Disease Control and Prevention recommends STI testing at least every 6 months for PrEP users, our analysis of Medicaid data suggests that STI testing occurs less frequently than recommended in populations at elevated risk of syphilis, gonorrhea, and chlamydia.

Trends in blood transfusion, hydroxyurea use, and iron overload among children with sickle cell disease enrolled in Medicaid, 2004-2019.

BACKGROUND: There have been significant changes in clinical guidelines for sickle cell disease (SCD) over the past two decades, including updated indications for hydroxyurea, transfusions, and iron overload management. In practice however, there are few studies that examine SCD care utilization over time. METHODS: We conducted a serial cross-sectional cohort study of pediatric SCD patients from 2004 to 2019 using Georgia Medicaid claims data. For each year, we reported receipt of any transfusion, chronic transfusion, or three or more filled hydroxyurea prescriptions. For children receiving chronic transfusion (six or more annual transfusions), we evaluated iron overload diagnosis, monitoring, and chelation use. Among children with sickle cell anemia (SCA), we examined rates of transfusions and hydroxyurea use. The Cochran-Armitage test was used to assess trend. RESULTS: There were 5316 unique children 2-18 years old with SCD enrolled in Georgia Medicaid from 2004 to 2019. Children receiving any transfusion increased from 2004 to 2010, then stabilized. In SCA patients, chronic transfusions initially increased from 2004 to 2010, then stabilized from 2010 to 2019. For chronically transfused children, monitoring of iron burden and filled chelator prescriptions both increased significantly. Hydroxyurea use in SCA patients increased from 12% to 37%, with increases noted within each age group, most notably from 21% to 60% in the 13-18-year-old cohort. CONCLUSION: We demonstrated changes in SCD care utilization over time, including increased hydroxyurea use, changes in transfusion rates, and increased attention to iron overload management. While trends in clinical management do follow updates in treatment guidelines, there is still delayed and suboptimal uptake of guideline recommendations in pediatric SCD patients.

Prenatal Syphilis Screening Among Medicaid Enrollees in 6 Southern States.

INTRODUCTION: The rates of syphilis among pregnant women and infants have increased in recent years, particularly in the U.S. South. Although state policies require prenatal syphilis testing, recent screening rates comparable across Southern states are not known. The purpose of this study is to measure syphilis screening among Medicaid enrollees with delivery in states in the U.S. South. METHODS: A total of 6 state-university research partnerships in the U.S. South developed a distributed research network to analyze Medicaid claims data using a common analytic approach for enrollees with delivery in fiscal years 2017-2018 and 2018-2019 (combined N=504,943). In 2020-2021, each state calculated the percentage of enrollees with delivery with a syphilis screen test during the first trimester, third trimester, and at any point during pregnancy. Percentages for those with first-trimester enrollment were compared with the percentages of those who enrolled in Medicaid later in pregnancy. RESULTS: Prenatal syphilis screening during pregnancy ranged from 56% to 91%. Screening was higher among those enrolled in Medicaid during the first trimester than in those enrolled later in pregnancy. CONCLUSIONS: Despite state laws requiring syphilis screening during pregnancy, screening was much lower than 100%, and states varied in syphilis screening rates among Medicaid enrollees. Findings indicate that access to Medicaid in the first trimester is associated with higher rates of syphilis screening and that efforts to improve access to screening in practice settings are needed.

Student-Perceived School Climate Is Associated With ADHD Medication Treatment Among Adolescents in Medicaid.

OBJECTIVE: The objective of this study was to evaluate the relationship between school climate and ADHD medication treatment among adolescents in Medicaid in Georgia. METHOD: School climate and Medicaid claims data were aggregated for 159 GA counties. County-level school climate percentile and medicated ADHD prevalence were calculated. The t tests and regression models evaluated the relationship between school climate, medicated ADHD, and demographics, weighted by county population. Poorer 2008 school climate (<25th percentile) was regressed on 2011 medicated ADHD prevalence, controlling for potential confounders. RESULTS: The prevalence of medicated ADHD was 7.8% among Medicaid-enrolled GA adolescents. The average county-level prevalence of medicated ADHD was 10.0% ( SD = 2.9%). Poorer school climate was associated with lower rates of medicated ADHD ( p < .0001); along with demographics, these factors accounted for 50% of the county variation in medicated ADHD. CONCLUSION: School climate is associated with medicated ADHD among adolescents in Medicaid. Additional research may reveal whether high medicated ADHD may reflect a lack of access to non-pharmacological therapies in some communities.

Caring by Numbers: Evaluation of Inconsistencies and Incompleteness in the Reporting of Racial and Ethnic Data.

Significant health disparities throughout the lifespan have long been evident within the American, non-White population. These differences include increased incidence of infant mortality, childhood hospitalization, diabetes, mental and behavioral health problems, cardiovascular disease, and late-stage cancer diagnoses. These types of disparities could be addressed by identifying those individuals at greatest risk for chronic disease or higher mortality rates and improving their health literacy and access to care. However, this is only possible if health management organizations and care providers have accurate racial and ethnic information. As an initial step at better understanding the problem, a survey of demographic data for Ohio Medicaid beneficiaries was conducted. The results of the study revealed inconsistencies and omissions in reported race and ethnicity for nearly 10% of records received from the state. This trend was most evident among older adults and those joining under the Affordable Care Act's Medicaid Expansion. Collectively, these results suggest that the first step in correcting health disparities may be to ensure that accurate information is available about the target population.

Do High Fidelity Wraparound Services for Youth with Serious Emotional Disturbances Save Money in the Long-Term?

BACKGROUND: Treating youth with serious emotional disturbances (SED) is expensive often requiring institutional care. A significant amount of recent federal and state funding has been dedicated to expanding home and community-based services for these youth as an alternative to institutional care. High Fidelity Wraparound (Wrap) is an evolving, evidence-informed practice to help sustain community-based placements for youth with an SED through the use of intensive, customized care coordination among parents, multiple child-serving agencies, and providers. While there is growing evidence on the benefits of Wrap, few studies have examined health care spending associated with Wrap participation and none have examined spending patterns after the completion of Wrap. Merging health care spending data from multiple agencies and programs allows for a more complete picture of the health care costs of treating these youth in a system-of-care framework. AIMS OF STUDY: (i) To compare overall health care spending for youth who transitioned from institutional care into Wrap (the treatment group) versus youth not receiving Wrap (the control group) and (ii) to compare changes in health care spending, overall and by category, for both groups before (the pre-period) and after (the post-period) Wrap participation. METHODS: The treatment group (N=161) is matched to the control group (N=324) temporally based on the month the youth entered institutional care. Both total health care spending and spending by category are compared for each group pre- and post-Wrap participation. The post-period includes the time in which the youth was receiving Wrap services and one year afterwards to capture long-term cost impacts. RESULTS: In the year before Wrap participation, the treatment group averaged USD 8,433 in monthly health care spending versus USD 4,599 for the control group. Wrap participation led to an additional reduction of USD 1,130 in monthly health care spending as compared to the control group in the post-period. For youth participating in Wrap, these spending reductions were the result of decreases in mental health inpatient spending and general outpatient spending. DISCUSSION: Youth participating in Wrap had much higher average monthly costs than youth in the control group for the year prior to entering Wrap, suggesting that the intervention targeted youth with the highest mental health utilization and likely more complex needs. While both groups experienced reductions in spending, the treatment group experienced larger absolute reductions, but smaller relative reductions associated with participation. These differences were driven mainly by reductions in mental health inpatient spending. Larger reductions in general outpatient spending for the treatment group suggest spillover benefits in terms of physical health care spending. Further analysis is needed to assess how these spending changes impacted health outcomes. IMPLICATIONS FOR HEALTH POLICIES: Wrap or similar programs may lead to reductions in health care spending. This is the first study to find evidence of longer-term spending reductions for up to a year after Wrap participation. IMPLICATIONS FOR FURTHER RESEARCH: Randomized trials or some other source of plausibly exogenous variation in Wrap participation is needed to further assess the causal impact of Wrap on health care spending, outcomes, or broader system-of-care spending.

Determining Adherence to Quality Indicators in Sickle Cell Anemia Using Multiple Data Sources.

INTRODUCTION: Advances in primary prophylaxis have resulted in improved outcomes for patients with sickle cell anemia (SCA; i.e., hemoglobin SS- and Sß(0)-thalassemia). Standard prophylactic measures include a first pneumococcal polysaccharide vaccine (PPV) and transcranial Doppler ultrasound (TCD) at age 2 years. Though efficacious, evidence suggests that delivery of these interventions is suboptimal. This study reports adherence to these measures and examines concordance across various data sources, using Registry and Surveillance for Hemoglobinopathies project data. METHODS: Retrospective database and SCA center chart review identified children with SCA aged 24-36 months between January 1, 2004, and December 31, 2008. PPV and TCD administration were determined through Medicaid and Children's Health Insurance Program administrative claims data, medical record review, and Georgia Registry of Immunization Transaction and Services. Analysis was conducted in 2015. RESULTS: A total of 125 children met inclusion criteria. Forty-five (36.0%) children had documentation of both interventions, whereas 19 (15.2%) had no documentation of either intervention. Sixty-one (48.8%) children obtained only one intervention. Of these, more were likely to have had PPV than TCD (77.0% vs 23.0%, respectively, p<0.001). Agreement between claims data and medical record review was moderate for PPV (κ=0.55) and substantial for TCD (κ=0.74). CONCLUSIONS: No single, reliable data source for tracking standard of care for children with SCA statewide was found. According to study data, prophylaxis measures were not universally implemented during the surveillance period. Further research is needed to adequately track changes over time, determine risk groups, and develop methods of evaluating important metrics.

Estimating premium sensitivity for children's public health insurance coverage: selection but no death spiral.

OBJECTIVE: To estimate the effect of premium increases on the probability that near-poor and moderate-income children disenroll from public coverage. DATA SOURCES: Enrollment, eligibility, and claims data for Georgia's PeachCare for Kids(™) (CHIP) program for multiple years. STUDY DESIGN: We exploited policy-induced variation in premiums generated by cross-sectional differences and changes over time in enrollee age, family size, and income to estimate the duration of enrollment as a function of the effective (per child) premium. We classify children as being of low, medium, or high illness severity. PRINCIPAL FINDINGS: A dollar increase in the per-child premium is associated with a slight increase in a typical child's monthly probability of exiting coverage from 7.70 to 7.83 percent. Children with low illness severity have a significantly higher monthly baseline probability of exiting than children with medium or high illness severity, but the enrollment response to premium increases is similar across all three groups. CONCLUSIONS: Success in achieving coverage gains through public programs is tempered by persistent problems in maintaining enrollment, which is modestly affected by premium increases. Retention is subject to adverse selection problems, but premium increases do not appear to significantly magnify the selection problem in this case.

Examining the potential of information technology to improve public insurance application processes: enrollee assessments from a concurrent mixed method analysis.

OBJECTIVE: To assess the perceived readiness of Medicaid and Children's Health Insurance Program (CHIP) enrollees to use information technologies (IT) in order to facilitate improvements in the application processes for these public insurance programs. METHODS: We conducted a concurrent mixed method study of Medicaid and CHIP enrollees in a southern state. We conducted focus groups to identify enrollee concerns regarding the current application process and their IT proficiency. Additionally, we surveyed beneficiaries via telephone about their access to and use of the Internet, and willingness to adopt IT-enabled processes. 2013 households completed the survey. We used χ(2) analysis for comparisons across different groups of respondents. RESULTS: A majority of enrollees will embrace IT-enabled enrollment, but a small yet significant group continues to lack access to facilitating technologies. Moreover, a segment of beneficiaries in the two programs continues to place a high value on personal interactions with program caseworkers. DISCUSSION: IT holds the promise of improving efficiency and reducing barriers for enrollees, but state and federal agencies managing public insurance programs need to ensure access to traditional processes and make caseworkers available to those who require and value such assistance, even after implementing IT-enabled processes. CONCLUSIONS: The use of IT-enabled processes is essential for effectively managing eligibility and enrollment determinations for public programs and private plans offered through state or federally operated exchanges. However, state and federal officials should be cognizant of the technological readiness of recipients and provide offline help to ensure broad participation in the insurance market.

Comparing preventive visits of children in foster care with other children in Medicaid.

OBJECTIVE: This study compared preventive medical and dental visits of Georgia children in foster care with other children enrolled in Medicaid to determine if utilization differed. METHODS: Two logistic regressions estimated the likelihood of an annual Health Check screening and the likelihood of at least one dental visit. RESULTS: Compared with children in foster care, children in the adoption assistance ([AOR] .37, 95% confidence interval [CI] = 0.35-0.40), SSI (AOR .37, 95% CI = 0.35-0.38) and low-income (AOR .40, 95% CI = 0.39-0.42) Medicaid categories were less likely to receive an annual Health Check screening. Children in adoption assistance were also less likely to have a dental visit during the study period. CONCLUSION: Policies require a Health Check visit upon placement into foster care and annual check-ups consistent with pediatric guidelines; we found more Early and Periodic Screening, Detection, and Treatment screenings for foster care children in Georgia than for other children receiving Medicaid.

Discontinuity of coverage for Medicaid and S-CHIP children at a transitional birthday.

RESEARCH OBJECTIVE: To investigate disenrollment from public insurance at the 6-year transitional birthday when eligibility for many children moves from Medicaid to State Children's Health Insurance Program (S-CHIP). DATA SOURCES: Data from Georgia's S-CHIP (PeachCare) and Medicaid programs from 2000 to 2002. STUDY DESIGN: The likelihood of dropping public coverage after the reference birthday is modeled for children turning age 6 compared with a control cohort of children turning age 9 controlling for demographic and geographic differences between enrollees. PRINCIPAL FINDINGS: Over 17 percent of 6-year-olds versus only 7 percent of the control cohort dropped coverage. After controlling for other factors (e.g., race/ethnicity, prior enrollment, and geographic region) having lower historical expenditures is predictive of dropping coverage among all children, although the unadjusted effect is stronger among children enrolled in PeachCare before their sixth birthday. Only 1 percent of Medicaid children who remained covered transitioned to PeachCare. CONCLUSIONS: Turnover at transitional birthdays identifies a common pathway for children into the ranks of the uninsured. Facilitating continuous enrollment would retain in the programs children with lower than average expenditures. This may be one of the more cost effective ways of reducing the number of uninsured children in Georgia.

Are State legislatures responding to public opinion when allocating funds for tobacco control programs?

This study explored the factors associated with state-level allocations to tobacco-control programs. The primary research question was whether public sentiment regarding tobacco control was a significant factor in the states' 2001 budget decisions. In addition to public opinion, several additional political and economic measures were considered. Significant associations were found between our outcome, state-level tobacco-control funding per capita, and key variables of interest including public opinion, amount of tobacco settlement received, the party affiliation of the governor, the state's smoking rate, excise tax revenue received, and whether the state was a major producer of tobacco. The findings from this study supported our hypothesis that states with citizens who favor more restrictive indoor air policies allocate more to tobacco control. Effective public education to change public opinion and the cultural norms surrounding smoking may affect political decisions and, in turn, increase funding for crucial public health programs.