The Impact of the Medicaid Reimbursement Bump on Influenza Vaccination Rates Among US Teens: Evidence from the National Immunization Survey-Teen 2011-2020.

BACKGROUND: Many adolescents do not receive basic preventive care such as influenza vaccinations. The Affordable Care Act (ACA) temporarily increased Medicaid reimbursements for primary care services, including vaccine administration, in 2013 to 2014. The objective of this study is to assess the impact of reimbursement increases on influenza vaccination rates among adolescents with Medicaid. METHODS: This repeated cross-sectional study used a difference-in-difference approach to compare changes in annual influenza vaccination rates for 20,884 adolescents 13 to 17 years old covered by Medicaid with adequate provider-reported data in 18 states with larger extended (>$5, 2013 to 2019) versus larger temporary (2013 to 2014 only) versus smaller reimbursement changes. We used linear probability models with individual-level random effects, adjusting for state and individual characteristics and annual time trends to assess the impact of a Medicaid vaccine administration reimbursement increase on annual influenza vaccination. RESULTS: Mean Medicaid reimbursements for vaccine administration doubled from 2011 to 2013 to 2014 (eg, from $11 to $22 for CPT 90460). States with smaller reimbursement changes had higher mean reimbursements and higher adjusted vaccination rates at baseline (2011) compared with states with larger temporary and extended reimbursement changes. The reimbursement change was not associated with increases in influenza vaccination rates. DISCUSSION: Influenza vaccination rates were low among adolescents with Medicaid throughout the study period, particularly in states with lower Medicaid reimbursement levels before the ACA. CONCLUSION: That reimbursement increases were not associated with higher vaccination rates suggests additional efforts are needed to improve influenza vaccination rates in this population.

Coverage Parity And Racial And Ethnic Disparities In Mental Health And Substance Use Care Among Medicare Beneficiaries.

Many older Americans do not receive needed care for mental health and substance use disorders (MHSUD), and there are substantial racial and ethnic disparities in receipt of this care across the lifespan. Medicare introduced cost-sharing parity for outpatient MHSUD care during the period 2010-14, reducing beneficiaries' out-of-pocket share of MHSUD spending from 50 percent to 20 percent. Among traditional Medicare beneficiaries ages sixty-five and older, we examined changes in MHSUD use and spending during the period 2008-18 for low-income beneficiaries with the cost-sharing reduction versus a control group of beneficiaries with free care throughout the study period among Black, Hispanic, Asian, and American Indian/Alaska Native versus White beneficiaries. Among older Medicare beneficiaries, overall use of MHSUD services increased during this period. For White beneficiaries, MHSUD cost-sharing parity was associated with an increased likelihood of having specialty MHSUD visits and medication use and a reduced likelihood of having unmonitored MHSUD medication use and MHSUD emergency department visits and hospitalizations. However, cost-sharing parity was associated with smaller or no gains in MHSUD services use for racial and ethnic minority beneficiaries compared with White beneficiaries, thus widening racial and ethnic disparities in MHSUD care.

Sexual Orientation and Gender Identity Data Reporting Among U.S. Health Centers.

INTRODUCTION: Sexual orientation and gender identity data collection is necessary to address health inequities. This study examines sexual orientation and gender identity data reporting among community health centers. METHODS: Using the 2016-2019 Uniform Data System for 1,381 community health centers, trends in reporting of sexual orientation and gender identity data were examined. Multivariable logistic regression was used to assess associations between community health center characteristics and whether sexual orientation and gender identity data were available for ≥75% of a community health center's patients in 2019. Data were analyzed in 2021. RESULTS: In 2016-2019, the percentage of community health centers with sexual orientation and gender identity data for ≥75% of patients increased from 14.9% to 53.0%. In 2019, community health centers were more likely to have this data for ≥75% of patients if they were in nonmetro counties (OR=1.48, 95% CI=1.04, 2.10 versus metro), were in the South (OR=2.27, 95% CI=1.57, 3.31) or West (OR=1.91, 95% CI=1.27, 2.88 versus the Northeast), and had more patients aged between 18 and 39 years (OR=1.04, 95% CI=1.02, 1.07), between 40 and 64 years (OR=1.04, 95% CI=1.02, 1.06 vs <18 years), or veterans (OR=1.10, 95% CI=1.01, 1.20). This was less likely among community health centers serving 10,000-20,000 patients (OR=0.70, 95% CI=0.52, 0.95) and >20,000 patients (OR=0.44, 95% CI=0.32, 0.61 vs <10,000) and community health centers with more patients of American Indian/Alaskan Native (OR=0.98, 95% CI=0.97, 0.99) or unknown race (OR=0.92, 95% CI=0.86, 0.97 versus White). CONCLUSIONS: Collection of sexual orientation and gender identity data by community health centers has increased substantially since 2016, although gaps remain.

Prevalence of Private and Public Health Insurance Among Transgender and Gender Diverse Adults.

BACKGROUND: Little is known about how health insurance payer types differ between transgender and gender diverse (TGD) people and cisgender people. Much of what is known about insurance coverage among TGD adults has been based on research from claims and electronic health record data, which excludes individuals who have not accessed gender-affirming care. Research designed to understand how TGD populations pay for health care to best inform care interventions and public insurance policies is lacking. OBJECTIVE: The objective of this study was to examine differences in the prevalence of public and private health insurance between transgender and cisgender adults. METHODS: Using data from the Behavioral Risk Factor Surveillance System, this study estimated prevalence of health insurance coverage among TGD and cisgender adults residing in 22 states that administered the Sexual Orientation and Gender Identity module and the Healthcare Access module from 2014 to 2019. This study estimated the odds of health insurance coverage (no insurance, private insurance, public insurance) among cisgender adults compared with TGD adults. RESULTS: TGD people had greater odds of being uninsured compared with cisgender women. Among nondisabled, nonelderly respondents, TGD adults had lower odds of having private insurance and higher odds of public insurance compared with cisgender men. Among respondents who were likely Medicaid-eligible, TGD respondents had lower odds of having public insurance and higher odds of being uninsured compared with cisgender women. CONCLUSION: These findings provide foundational information about the payer mix among TGD people and provide insight into barriers to health insurance that TGD adults may face.

Patterns of Mental Health Care Before Initiation of Telemental Health Services.

BACKGROUND: Use of telemental health has increased among rural Medicare beneficiaries, particularly among individuals with serious mental illness (SMI). Little is known about what leads to the initiation of telemental health. OBJECTIVE: To categorize the different patterns of mental health care use before initiation of telemental health services among individuals with SMI. METHODS: A cohort of rural beneficiaries with SMI (defined as schizophrenia/related psychotic disorders or bipolar disorder) with an index telemental health visit in 2010-2017 was built using claims for a 20% random sample of fee-for-service Medicare beneficiaries. The authors used latent class analysis to identify classes of mental health care use in the 6 months before the index telemental health visits. Across the classes, the authors also described characteristics of index and subsequent mental health visits. RESULTS: The cohort included 4930 rural Medicare beneficiaries with SMI. Three classes of mental health care use before initiation of telemental health were identified. The largest class (n=3066) had minimal use of primary care provider mental health care and the second largest class (n=1537) had minimal specialty mental health care. The smallest class (n=327) was characterized by recent hospitalization or emergency department care. In the overall cohort, index visits were frequently established visits and were often with specialty prescribers. CONCLUSIONS: Our findings highlight 3 distinct patterns of care before telemental health initiation, providing insight into the role that telemedicine may play in mental health care for rural Medicare beneficiaries with SMI. Overall, telemental health was most often used to maintain care with existing providers.

Transgender and gender diverse health education for future nurses: Students' knowledge and attitudes.

BACKGROUND: Compared to cisgender peers, transgender and gender diverse (TGD) people experience significant health disparities associated with discrimination and limited access to appropriate care in healthcare settings. Nurses represent the largest segment of the United States (US) healthcare workforce; however, US nursing programs only dedicate approximately 2.12 h to Lesbian, Gay, Bisexual, and TGD (LGBT)-related content. OBJECTIVES/DESIGN/SETTING/PARTICIPANTS: To fill the gap in TGD-related nursing education, the Transgender Curriculum Integration Project (TCIP) developed and integrated an evidence-based curriculum specific to TGD health into the pre-licensure accelerated Bachelor's in Nursing Science (BSN) program at Johns Hopkins School of Nursing. The purpose of this study was to assess the preliminary efficacy and feasibility (i.e., attrition, engagement, acceptability) of the TCIP in improving the TGD-related health knowledge and attitudes among a sample of pre-licensure nursing students. METHODS: TCIP utilized a self-administered online survey to assess students' knowledge and attitudes about TGD health prior to (time point 1) and following (time points 2 and 3) the integration of TGD-specific content into five nursing pre-licensure courses. Rank-based nonparametric testing using Kruskal-Wallis H and Mann-Whitney U were conducted to determine if there were statistically significant differences in responses between the three time points. Thematic content analysis was used to determine themes present among short answers. RESULTS: Findings indicate TGD-specific content improved student's gender sensitivity overtime, with improvements in self-reported skills in providing care for TGD people and knowledge of additional TGD-specific resources. However, gender sensitivity remains low among student's and students requested more TGD content suggesting room for further improvement. CONCLUSIONS: Findings support the efficacy of TCIP and highlight complexities of curricular change that can guide future curricular integration and evaluation in nursing programs nation-wide.

Association of Nondiscrimination Policies With Mental Health Among Gender Minority Individuals.

Importance: In the past decade, many states have implemented policies prohibiting private health insurers from discriminating based on gender identity. Policies banning discrimination have the potential to improve access to care and health outcomes among gender minority (ie, transgender and gender diverse) populations. Objective: To evaluate whether state-level nondiscrimination policies are associated with suicidality and inpatient mental health hospitalizations among privately insured gender minority individuals. Design, Setting, and Participants: In this cohort study, difference-in-differences analysis comparing changes in mental health outcomes among gender minority enrollees before and after states implemented nondiscrimination policies in 2009-2017 was conducted. A sample of gender minority children and adults was identified using gender minority-related diagnosis codes obtained from private health insurance claims. The present study was conducted from August 1, 2018, to September 1, 2019. Exposure: Living in states that implemented policies banning discrimination based on gender identity in 2013, 2014, 2015, and 2016. Main Outcomes and Measures: The primary outcome was suicidality. The secondary outcome was inpatient mental health hospitalization. Results: The study population included 28 980 unique gender minority enrollees (mean [SD] age, 26.5 [15] years) from 2009 to 2017. Relative to comparison states, suicidality decreased in the first year after policy implementation in the 2014 policy cohort (odds ratio [OR], 0.72; 95% CI, 0.58-0.90; P = .005), the 2015 policy cohort (OR, 0.50; 95% CI, 0.39-0.64; P < .001), and the 2016 policy cohort (OR, 0.61; 95% CI, 0.44-0.85; P = .004). This decrease persisted to the second postimplementation year for the 2014 policy cohort (OR, 0.48; 95% CI, 0.41-0.57; P < .001) but not for the 2015 policy cohort (OR, 0.81; 95% CI, 0.47-1.38; P = .43). The 2013 policy cohort experienced no significant change in suicidality after policy implementation in all 4 postimplementation years (2014: OR, 1.19; 95% CI, 0.85-1.67; P = .31; 2015: OR, 0.94; 95% CI, 0.73-1.20; P = .61; 2016: OR, 0.82; 95% CI, 0.65-1.03; P = .10; and 2017: OR, 1.29; 95% CI, 0.90-1.88; P = .18). Mental health hospitalization rates generally decreased or stayed the same for individuals living in policy states vs the comparison group. Conclusions and Relevance: Implementation of a state-level nondiscrimination policy appears to be associated with decreased or no changes in suicidality among gender minority individuals living in states that implemented these policies from 2013 to 2016. Given high rates of suicidality among gender minority individuals in the US, health insurance nondiscrimination policies may offer a mechanism for reducing barriers to care and mitigating discrimination.

Disparities in Suicidality by Gender Identity Among Medicare Beneficiaries.

INTRODUCTION: Suicidality is higher for gender minorities than the general population, yet little is known about suicidality in disabled or older adult gender minorities. METHODS: This study used 2009-2014 Medicare claims to identify people with gender identity-related diagnosis codes (disabled, n=6,678; older adult, n=2,018) and compared their prevalence of suicidality with a 5% random non-gender minority beneficiary sample (disabled, n=535,801; older adult, n=1,700,008). Correlates of suicidality were assessed (via chi-square) for each of the 4 participant groups separately, and then disparities within eligibility status (disabled or older adult) were assessed using logistic regression models, adjusting first for age and mental health chronic conditions and then additionally for Medicaid eligibility, race/ethnicity, or U.S. region (each separately). The primary hypotheses were that gender minority beneficiaries would have higher suicidality but that suicidality disparities would persist after adjusting for covariates. Data were analyzed between 2017 and 2019. RESULTS: Gender minority beneficiaries had higher unadjusted suicidality than non-gender minority beneficiaries in the disabled cohort (18.5% vs 7.1%, p<0.001). Significant suicidality predictors in all 4 groups included the following: age (except in older adult gender minorities), Medicaid eligibility, depression or behavioral health conditions, avoidable hospitalizations, and violence victimization. In age- and mental health-adjusted logistic regression models, gender minorities had higher odds of suicidality than non-gender minority beneficiaries (disabled, OR=1.95, p<0.0001; older adult, OR=2.10, p<0.0001). Disparities were not attenuated after adjusting for Medicaid eligibility, race/ethnicity, or region. CONCLUSIONS: Heightened suicidality among identified gender minority Medicare beneficiaries highlights a pressing need to identify and reduce barriers to wellness in this population.

Trends in Mental Health Care Use in Medicare from 2009 to 2014 by Gender Minority and Disability Status.

Purpose: This study examines trends in Medicare beneficiaries' mental health care use from 2009 to 2014 by gender minority and disability status. Methods: Using 2009 to 2014 Medicare claims, we modeled mental health care use (outpatient mental health care, inpatient mental health care, and psychotropic drugs) over time, adjusting for age and behavioral health diagnoses. We compared trends for gender minority beneficiaries (identified using diagnosis codes) to trends for a 5% random sample of other beneficiaries, stratified by original entitlement reason (age vs. disability). Results: Adjusted outpatient and inpatient mental health care use decreased and differences generally narrowed between gender minority and other beneficiaries over the study period. Among beneficiaries qualifying through disability, the gap in the number of outpatient and inpatient visits (among those with at least one visit in a given year) widened. Psychotropic drug use rose for all beneficiaries, but the proportion of gender minority beneficiaries in the aged cohort who had a psychotropic medication prescription rose faster than for other aged beneficiaries. Conclusions: Mental health care needs for Medicare beneficiaries may be met increasingly by using psychotropic medications rather than outpatient visits, and this pattern is more pronounced for identified gender minority (especially aged) beneficiaries. These trends may indicate a growing need for research and provider training in safe and effective psychotropic medication prescribing alongside gender-affirming treatments such as hormone therapy, especially for aged gender minority individuals who likely already experience polypharmacy.

Estimating the Health Status of Privately Insured Gender Minority Children and Adults.

Purpose: The purpose of this study was to characterize the health status of privately insured gender minority individuals. Methods: We created a diagnosis-based algorithm to identify gender minority children and adults in the 2009-2015 IBM® MarketScan® Commercial Database. We compared the age-adjusted health status among individuals with and without gender minority-related diagnosis codes. Results: The percentage of the privately insured population with gender minority-related diagnosis codes increased from 0.004% in 2009 to 0.026% in 2015. Age-adjusted analyses demonstrated that individuals with gender minority-related diagnosis codes were more likely to have diagnoses for mental health disorders (odds ratio [OR] = 8.5; 95% confidence interval [CI] = 8.1-9.0), substance use disorders (OR = 3.4; 95% CI = 2.9-3.9), and diabetes (OR = 1.4; 95% CI = 1.2-1.6), driven by high prevalence of these conditions among individuals younger than 18 years. Conclusions: Our findings highlight a markedly greater prevalence of mental health and substance use disorder diagnoses among privately insured gender minority individuals. These results establish a reference point for evaluating the impact of federal- and state-level policies that ban health insurance discrimination based on gender identity on the health and health care use of gender minority individuals.

Comparison of Approaches for Aggregating Quality Measures in Population-based Payment Models.

OBJECTIVE: To assess the impact of alternative methods of aggregating individual quality measures on Accountable Care Organization (ACO) overall scores. DATA SOURCE: 2014 quality scores for Medicare ACOs. STUDY DESIGN: We compare ACO overall scores derived using CMS' aggregation approach to those derived using alternative approaches to grouping and weighting measures. PRINCIPAL FINDINGS: Alternative grouping and weighting methods based on statistical criteria produced overall quality scores similar to those produced using CMS' approach (κ = 0.80 to 0.95). Scores derived from giving specific domains greater weight were less similar (κ = 0.51 to 0.93). CONCLUSIONS: How measures are grouped into domains and how these domains are weighted to generate overall scores can have important implications for ACO's shared savings payments.

Identifying Gender Minority Patients' Health And Health Care Needs In Administrative Claims Data.

Health care utilization patterns for gender minority Medicare beneficiaries (those who are transgender or gender nonbinary people) are largely unknown. We identified gender minority beneficiaries using a diagnosis-code algorithm and compared them to a 5 percent random sample of non-gender minority beneficiaries from the period 2009-14 in terms of mental health and chronic diseases, use of preventive and mental health care, hospitalizations, and emergency department (ED) visits. Gender minority beneficiaries experienced more disability and mental illness. When we adjusted for age and mental health, we found that they used more mental health care. And when we adjusted for age and chronic conditions, we found that they were more likely to be hospitalized and to visit the ED. There were several small but significant differences in preventive care use. Findings were similar for disabled and older cohorts. These findings underscore the need to capture gender identity in health data to better address this population's health needs.