Understanding Clinic and Community Member Experiences with Implementation of Evidence-Based Strategies for HPV Vaccination in Safety-Net Primary Care Settings.

HPV vaccination rates remain below target levels among adolescents in the United States, which is particularly concerning in safety-net populations with persistent disparities in HPV-associated cancer burden. Perspectives on evidence-based strategies (EBS) for HPV vaccination among key implementation participants, internal and external to clinics, can provide a better understanding of why these disparities persist. We conducted virtual interviews and focus groups, guided by the Practice Change Model, with clinic members (providers, clinic leaders, and clinic staff) and community members (advocates, parents, policy-level, and payers) in Los Angeles and New Jersey to understand common and divergent perspectives on and experiences with HPV vaccination in safety-net primary care settings. Fifty-eight interviews and seven focus groups were conducted (n = 65 total). Clinic members (clinic leaders n = 7, providers n = 12, and clinic staff n = 6) revealed conflicting HPV vaccine messaging, lack of shared motivation to reduce missed opportunities and improve workflows, and non-operability between clinic electronic health records and state immunization registries created barriers for implementing effective strategies. Community members (advocates n = 8, policy n = 11, payers n = 8, and parents n = 13) described lack of HPV vaccine prioritization among payers, a reliance on advocates to lead national agenda setting and facilitate local implementation, and opportunities to support and engage schools in HPV vaccine messaging and adolescents in HPV vaccine decision-making. Participants indicated the COVID-19 pandemic complicated prioritization of HPV vaccination but also created opportunities for change. These findings highlight design and selection criteria for identifying and implementing EBS (changing the intervention itself, or practice-level resources versus external motivators) that bring internal and external clinic partners together for targeted approaches that account for local needs in improving HPV vaccine uptake within safety-net settings.

Impact of a Provider Tele-mentoring Learning Model on the Care of Medicaid-enrolled Patients With Diabetes.

BACKGROUND: Project ECHO (Extension for Community Healthcare Outcomes), a tele-mentoring program for health care providers, has been shown to improve provider-reported outcomes, but there is insufficient research on patient-level outcomes. OBJECTIVES: To evaluate the impact of primary care provider (PCP) participation in Project ECHO on the care of Medicaid enrollees with diabetes. RESEARCH DESIGN: New Jersey Medicaid claims and encounter data and difference-in-differences models were used to compare utilization and spending between Medicaid patients seen by PCPs participating in a Project ECHO program to those of matched nonparticipating PCPs. SUBJECTS: A total of 1776 adult Medicaid beneficiaries (318 with diabetes), attributed to 25 participating PCPs; and 9126 total (1454 diabetic) beneficiaries attributed to 119 nonparticipating PCPs. MEASURES: Utilization and spending for total inpatient, diabetes-related inpatient, emergency department, primary care, and endocrinologist services; utilization of hemoglobin A1c tests, eye exams, and diabetes prescription medications among diabetics, and total Medicaid spending. RESULTS: Participation in Project ECHO was associated with decreases of 44.3% in inpatient admissions (P=0.001) and 61.9% in inpatient spending (P=0.021) among treatment relative to comparison patients. Signs of most other outcome estimates were consistent with hypothesized program effects but without statistical significance. Sensitivity analyses largely confirmed these findings. CONCLUSIONS: We find evidence that Project ECHO participation was associated with large and statistically significant reductions of inpatient hospitalization and spending. The study was observational and limited by a small sample of participating PCPs. This study demonstrates the feasibility and potential value of quasi-experimental evaluation of Project ECHO patient outcomes using claims data.

Differences in elective epilepsy monitoring unit admission rates by race/ethnicity and primary payer in New Jersey.

Elective admission to the epilepsy monitoring unit (EMU) is an essential service provided by epilepsy centers, particularly for those with drug-resistant epilepsy. Given previously characterized racial and socioeconomic healthcare disparities in the management of epilepsy, we sought to understand access and utilization of this service in New Jersey (NJ). We examined epilepsy hospitalizations in NJ between 2014 and 2016 using state inpatient and emergency department (ED) databases. We stratified admissions by race/ethnicity and primary payer and used these to estimate and compare (1) admission rates per capita in NJ, as well as (2) admission rates per number of ED visits for each group. Patients without insurance underwent elective EMU admission at the lowest rates across all racial/ethnic groups and payer types studied. Black patients with Medicaid and private insurance were admitted at disproportionately low rates relative to their number of ED visits. Hispanic/Latino and Asian/Pacific Islanders with private insurance, Hispanic/Latinos with Medicaid, and Asian/Pacific Islanders with Medicare were also admitted at low rates per capita within each respective payer category. Future studies should focus on addressing causal factors driving healthcare disparities in epilepsy, particularly for patients without adequate health insurance coverage and those who have been historically underserved by the healthcare system.

Patterns of chronic disease management and health outcomes in a population-based cohort of Black women with breast cancer.

PURPOSE: Diabetes and hypertension are two common comorbidities that affect breast cancer patients, particularly Black women. Disruption of chronic disease management during cancer treatment has been speculated. Therefore, this study examined the implementation of clinical practice guidelines and health outcomes for these comorbidities before and during cancer treatment. METHODS: We used a population-based, prospective cohort of Black women diagnosed with breast cancer (2012-2016) in New Jersey (n = 563). Chronic disease management for diabetes and hypertension was examined 12 months before and after breast cancer diagnosis and compared using McNemar's test for matched paired and paired t tests. RESULTS: Among this cohort, 18.1% had a co-diagnosis of diabetes and 47.2% had a co-diagnosis of hypertension. Implementation of clinical practice guidelines and health outcomes that differed in the 12 months before and after cancer diagnosis included lipid screening (64.5% before versus 50.0% after diagnosis; p = 0.004), glucose screening (72.7% versus 90.7%; p < 0.001), and blood pressure control < 140/90 mmHg (57.6% versus 71.5%; p = 0.004) among patients with hypertension-only. For patients with diabetes, eye and foot care were low (< 35%) and optimal HbA1c < 8.0% was achieved for less than 50% of patients in both time periods. CONCLUSION: Chronic disease management continued during cancer treatment; however, eye and foot exams for patients with diabetes and lipid screening for patients with hypertension-only were inadequate. Given that comorbidities may account for half of the Black-White breast cancer survival disparity, strategies are needed to improve chronic disease management during cancer, especially for Black women who bear a disproportionate burden of chronic diseases.

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.

Comorbidity Management in Black Women Diagnosed with Breast Cancer: the Role of Primary Care in Shared Care.

BACKGROUND: Black women are more likely to have comorbidity at breast cancer diagnosis compared with White women, which may account for half of the Black-White survivor disparity. Comprehensive disease management requires a coordinated team of healthcare professionals including primary care practitioners, but few studies have examined shared care in the management of comorbidities during cancer care, especially among racial/ethnic minorities. OBJECTIVE: To examine whether the type of medical team composition is associated with optimal clinical care management of comorbidities. DESIGN: We used the Women's Circle of Health Follow-up Study, a population-based cohort of Black women diagnosed with breast cancer. The likelihood of receiving optimal comorbidity management after breast cancer diagnosis was compared by type of medical team composition (shared care versus cancer specialists only) using binomial regression. PARTICIPANTS: Black women with a co-diagnosis of diabetes and/or hypertension at breast cancer diagnosis between 2012 and 2016 (N = 274). MAIN MEASURES: Outcome-optimal clinical care management of diabetes (i.e., A1C test, LDL-C test, and medical attention for nephropathy) and hypertension (i.e., lipid screening and prescription for hypertension medication). Main predictor-shared care, whether the patient received care from both a cancer specialist and a primary care provider and/or a medical specialist within the 12 months following a breast cancer diagnosis. KEY RESULTS: Primary care providers were the main providers involved in managing comorbidities and 90% of patients received shared care during breast cancer care. Only 54% had optimal comorbidity management. Patients with shared care were five times (aRR: 4.62; 95% CI: 1.66, 12.84) more likely to have optimal comorbidity management compared with patients who only saw cancer specialists. CONCLUSIONS: Suboptimal management of comorbidities during breast cancer care exists for Black women. However, our findings suggest that shared care is more beneficial at achieving optimal clinical care management for diabetes and hypertension than cancer specialists alone.

Medicaid Waivers and Tenancy Supports for Individuals Experiencing Homelessness: Implementation Challenges in Four States.

Policy Points Medicaid policymakers have a growing interest in addressing homelessness as a social determinant of health and driver of the potentially avoidable use of expensive medical services. Drawing on extensive document reviews and in-depth interviews in four early-adopter states, we examined the implementation of Medicaid's Section 1115 demonstration waivers to test strategies to finance tenancy support services for persons experiencing or at risk of homelessness. CONTEXT: The Affordable Care Act extended Medicaid eligibility to large numbers of individuals experiencing or at risk of homelessness. This legislative development and the growing recognition of homelessness as a significant social determinant of health have encouraged advocates and policymakers to seek new ways to use Medicaid to provide housing supports. METHODS: We conducted 28 semistructured interviews with 36 stakeholders in four states. The stakeholders were government administrators, health care providers, nonprofit housing staff, and consultants. We supplemented these interviews with extensive reviews of public documents, media accounts, think-tank reports, and published literature. We also conducted a systematic inductive qualitative analysis. FINDINGS: We identified seven challenges to the successful implementation of tenancy support demonstration projects: resolving the housing supply and NIMBY, removing silos between health care and homeless services providers, enrolling and retaining the target populations in Medicaid, contracting with and paying tenancy support providers, recruiting and retaining key workers, ensuring Medicaid's waiver durability, and reducing administrative crowd-out and waiver burden. CONCLUSIONS: Notwithstanding these challenges, three of the four states have made significant progress in launching their initiatives. At this point, the fourth state has delayed its start-up to consider alternatives to a Medicaid demonstration waiver to provide tenancy supports. The experience of the four states suggests lessons for Medicaid officials in other jurisdictions that are interested in pursuing tenancy support initiatives. Nevertheless, the limitations of tenancy support waiver programs suggest that federal policymakers should consider allowing states to more directly subsidize housing costs for those experiencing or at risk of homelessness as an optional Medicaid benefit.

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.

Using ICD-10 codes to identify elective epilepsy monitoring unit admissions from administrative billing data: A validation study.

Video-electroencephalogram (EEG) monitoring in the epilepsy monitoring unit (EMU) is essential for managing epilepsy and seizure mimics. Evaluation of care in the EMU would benefit from a validated code set capable of identifying EMU admissions from administrative databases comprised of large, diverse cohorts. We assessed the ability of code-based queries to parse EMU admissions from administrative billing records in a large academic medical center over a four-year period, 2016-2019. We applied prespecified queries for admissions coded as follows: 1) elective, 2) receiving video-EEG monitoring, and 3) including diagnoses typically required by major US healthcare payers for EMU admission. Sensitivity (Sn), specificity (Sp), and predictive value positive/negative (PVP, PVN) were determined. Two approaches were highly effective. Incorporating epilepsy, seizure, or seizure mimic codes as the admitting diagnosis (assigned at admission; Sn 96.3%, Sp 100.0%, PVP 98.3%, and PVN 100.0%) or the principal diagnosis (assigned after discharge; Sn 94.9%, Sp 100.0%, PVP 98.8%, and PVN 100.0%) identified elective adult EMU admissions with comparable reliability (p = 0.096). The addition of surgical procedure codes further separated EMU admissions for intracranial EEG monitoring. When applied to larger, more comprehensive datasets, these code-based queries should enhance our understanding of EMU utilization and access to care on a scalable basis.

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.

Informing the Design and Evaluation of Superuser Care Management Initiatives: Accounting for Regression-to-the-Mean.

BACKGROUND: Health care spending is concentrated among a small number of high-cost patients, and the popularity of initiatives to improve care and reduce cost among such "superusers" (SUs) is growing. However, SU costs decline naturally over time, even without intervention, a statistical phenomenon known as regression-to-the-mean (RTM). OBJECTIVES: We assess the magnitude of RTM in hospital costs for cohorts of hospital SUs identified on the basis of high inpatient (IP) or emergency department (ED) utilization. We further examine how cost and RTM are associated with patient characteristics including behavioral health (BH) problems, multiple chronic conditions, and indicators of vulnerability. STUDY DESIGN: Using longitudinally linked all-payer hospital billing data, we selected patient cohorts with ≥2 IP stays (IP SUs) or ≥6 ED visits (ED SUs) during a 6-month baseline period, and additional subgroups defined by combinations of IP and ED superuse. POPULATION STUDIED: A total of 289,060 NJ hospital IP and treat-and-release ED patients over 2009-2011. RESULTS: Hospital costs among IP and ED SUs declined 70% and 38%, respectively, over 8 quarters following the baseline period. The decrease occurs more quickly for IP SUs compared with ED SUs. Presence of BH problems was positively associated with costs among patients overall, but the relationship varied by SU cohort. CONCLUSIONS: Understanding patterns of RTM among SU populations is important for designing intervention strategies, as there is greater potential for savings among patients with more persistent costs (less RTM). Further, as many SU initiatives lack resources for rigorous evaluation, quantifying the extent of RTM is vital for interpreting program outcomes.

Reform of the Individual Insurance Market in New Jersey: Lessons for the Affordable Care Act.

The individual health insurance market has played a small but important role in providing coverage to those without access to group insurance or public programs. With implementation of the Affordable Care Act (ACA), the individual market has attained a more prominent role. However, achieving accessible and affordable coverage in this market is a long-standing challenge, in large part due to the threat of adverse risk selection. New Jersey pursued comprehensive reforms beginning in the 1990s to achieve a stable, accessible, and affordable individual market. We review how adverse risk selection can pose a challenge to achieving such objectives in the individual health insurance market. We follow this discussion by describing the experience of New Jersey through three rounds of legislative reform and through the first year of the implementation of the ACA coverage provisions. While the New Jersey reforms did not require individuals to purchase coverage, its experiences with direct and indirect market subsidies and regulations guiding plan design, issuance, and rating have important implications for how the ACA may achieve its coverage goals in the absence of the controversial individual purchase mandate.

Medicaid Long-Term Care: State Variation and the Intergovernmental Lobby.

Medicaid is vastly more important than Medicare or private insurance in funding long-term care (LTC). However, states vary tremendously in their commitment to Medicaid LTC. This article advances knowledge of the origins, nature, and implications of this variation. After examining the degree of variation in state spending on Medicaid LTC, we show how federal policy has over the past fifty years steadily increased state discretion to shape these services. This decentralization largely reflects the potency of the intergovernmental lobby-governors and other state officials-in influencing federal policy. While fueling state variation, the intergovernmental lobby has also provided valuable political support that has helped Medicaid grow and resist retrenchment. After considering policy options that could mitigate Medicaid LTC inequities rooted in state differences, we assess how the catalytic forces that have fueled growth in Medicaid LTC may be insufficient to protect the program from future erosion.

Prehospital transportation to therapeutic hypothermia centers and survival from out-of-hospital cardiac arrest.

BACKGROUND: Clinical trials supporting the use of therapeutic hypothermia (TH) in the treatment of out-of-hospital cardiac arrest (OHCA) are based on small patient samples and do not reflect the wide variation in patient selection, cooling methods, and other elements of post-arrest care that are used in everyday practice. This study provides a real world evaluation of the effectiveness of post-arrest care in TH centers during a time of growing TH dissemination in the state of New Jersey (NJ). METHODS: Using a linked database of prehospital, hospital, and mortality records for NJ in 2009-2010, we compared rates of neurologically intact survival at discharge and at 30 days for OHCA patients transported to TH centers (N = 2363) versus other hospitals (N = 2479). We used logistic regression to adjust for patient and hospital covariates. To account for potential endogeneity in prehospital transportation decisions, we used an instrumental variable (IV) based on differential distance to the nearest TH and non-TH hospitals. RESULTS: Patients taken to TH centers were older, more likely to have a witnessed arrest, more likely to receive defibrillation, and waited a shorter amount of time for initial EMS response. Also, TH hospitals were larger, more likely to be teaching facilities, and operated in a service area with a relatively lower poverty rate compared to hospitals statewide. A Stock-Yogo test confirmed the strength of our IV (F = 2349.91, p < 0.0001). Nevertheless, the data showed no evidence of endogenous transportation to TH centers related to in-hospital survival (Z = -0.08, p = 0.934) or 30-day survival (Z = 0.94, p = 0.349). In logistic regression models, treatment at a TH center was associated with greater odds of 30-day neurologically intact survival (OR = 1.70; 95% CI: 1.19 - 2.42) but not associated with the odds of neurologically intact survival to hospital discharge (OR = 0.90; 95% CI: 0.61 - 1.31). CONCLUSIONS: Post-arrest outcomes are more favorable at TH centers but these improved outcomes are not apparent until after hospital discharge. This finding may reflect superior care by TH centers in later stages of post-arrest treatment such as care provided in the intensive care unit, which has greater potential to affect longer term outcomes than initial treatment in the emergency department.

The fragmentation of hospital use among a cohort of high utilizers: implications for emerging care coordination strategies for patients with multiple chronic conditions.

BACKGROUND: Use of multiple hospitals by patients with multiple chronic conditions (MCC) may undermine emerging care coordination initiatives. OBJECTIVE: The aim of this study was to assess the prevalence and correlates of fragmented hospital use among high users with MCC and derive implications for care management. RESEARCH DESIGN: Using all-payer hospital billing data, we follow a 2-year cohort of patients with at least 2 inpatient stays, identifying those with MCC and calculating the percentage using multiple hospitals and applying multivariate Poisson regression to predict correlates of multiple hospital use. SUBJECTS: The subjects included in our study were New Jersey adults with at least 2 inpatient stays during a 24-month period between 2007 and 2010. RESULTS: Nearly 80% of the study cohort had ≥2 chronic conditions and >30% had fragmented hospital use. The probability of visiting multiple hospitals was positively associated with the number of chronic conditions present at admission, total number of admissions, lower hospital market concentration, and injury or behavioral health diagnoses. Over 40% of patients with ≥4 stays had multiple hospital use. CONCLUSIONS: Fragmentation of hospital care occurs frequently among high utilizers with MCC. Although multiple hospital use is not necessarily inappropriate, it may present barriers to effective care coordination for complex patients with MCC, leading to higher costs or worse outcomes. Leaders of innovative delivery reforms such as Accountable Care Organizations should monitor and coordinate care for multiple hospital users, especially those with MCC.

The New Jersey Medicaid ACO Demonstration Project: seeking opportunities for better care and lower costs among complex low-income patients.

A small but growing number of states are turning to accountable care concepts to improve their Medicaid programs. In 2011 New Jersey enacted the Medicaid Accountable Care Organization (ACO) Demonstration Project to offer local provider coalitions the opportunity to share any savings they generate. Impetus came from initiatives in Camden that aim to reduce costs through improved care coordination among hospital high users and that have received considerable media attention and substantial federal and private grant support. Though broadly similar to Medicare and commercial ACOs, the New Jersey demonstration addresses the unique concerns faced by Medicaid populations. Using hospital all-payer billing data, we estimate savings from care improvement efforts among inpatient and emergency department high users in thirteen communities that are candidates for participation in the New Jersey demonstration. We also examine their characteristics to inform Medicaid accountable care strategies. We find substantial variation in the share of high-user hospital patients across the study communities and high rates of avoidable use and costs among these patients. The potential savings among Medicaid enrollees are considerable, particularly if Medicaid ACOs can develop ways to successfully address the high burden of chronic illness and behavioral health conditions prevalent in the prospective demonstration communities.

The Camden Coalition Care Management Program Improved Intermediate Care Coordination: A Randomized Controlled Trial.

When a randomized evaluation finds null results, it is important to understand why. We investigated two very different explanations for the finding from a randomized evaluation that the Camden Coalition's influential care management program-which targeted high-use, high-need patients in Camden, New Jersey-did not reduce hospital readmissions. One explanation is that the program's underlying theory of change was not right, meaning that intensive care coordination may have been insufficient to change patient outcomes. Another explanation is a failure of implementation, suggesting that the program may have failed to achieve its goals but could have succeeded if it had been implemented with greater fidelity. To test these two explanations, we linked study participants to Medicaid data, which covered 561 (70 percent) of the original 800 participants, to examine the program's impact on facilitating postdischarge ambulatory care-a key element of care coordination. We found that the program increased ambulatory visits by 15 percentage points after fourteen days postdischarge, driven by an increase in primary care; these effects persisted through 365 days. These results suggest that care coordination alone may be insufficient to reduce readmissions for patients with high rates of hospital admissions and medically and socially complex conditions.

States' commitment to Medicaid before the Affordable Care Act: trends and implications.

Medicaid insures more than 65 million low-income people, and the Affordable Care Act of 2010 gives states the option to enroll millions more. Historical trends in state Medicaid effort possess important implications for health policy going forward. Nearly all states steadily ratcheted up their Medicaid effort in the period from 1992 to 2009, holding out promise that most will sustain their programs and ultimately participate in the expansion authorized by the Affordable Care Act. But the growth in Medicaid over this period did not appreciably curtail vast geographic disparities in program benefits that threaten to undermine the goals of health reform.