Translating Policy to Practice: An Association Between Medicare Access and Children's Health Insurance Program Reauthorization Act Implementation and Palliative Care Consultations and Perioperative Mortality in Critical Care.

OBJECTIVES: To evaluate the 30-day postoperative mortality and palliative care consultations in patients that underwent surgical procedures in the United States before and after Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) implementation. DESIGN: Retrospective, Observational cohort study. SETTING: Secondary data were collected from the U.S. National Inpatient Sample, the largest hospital database in the country. The time span was from 2011 to 2019. PATIENTS: Adult patients that electively underwent 1 of 19 major procedures. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was cumulative postoperative mortality in two study cohorts. The secondary outcome was palliative care use. We identified 4,900,451 patients and categorized them into two study cohorts: PreM: 2011-2014 ( n = 2,103,836) and PostM: 2016-2019 ( n = 2,796,615). Regression discontinuity estimates and multivariate analysis were used. Across all procedures, 149,372 patients (7.1%) and 156,610 patients (5%) died within 30 days of their index procedures in the PreM and PostM cohorts, respectively. There was no statistically significant increase in mortality rates around postoperative day (POD) 30 (POD 26-30 vs 31-35) for both cohorts. More patients had inpatient palliative consultations during POD 31-60 compared with POD 1-30 in PreM (8,533 of 2,081,207 patients [0.4%] vs 1,118 of 22,629 patients [4.9%]) and PostM (18,915 of 2,791,712 patients [0.7%] vs 417 of 4,903 patients [8.5%]). Patients were more likely to receive palliative care consultations during POD 31-60 compared with POD 1-30 in both the PreM (odds ratio [OR] 5.31; 95% CI, 2.22-8.68; p < 0.001) and the PostM (OR 7.84; 95% CI, 4.83-9.10; p < 0.001) cohorts. CONCLUSIONS: We did not observe an increase in postoperative mortality after POD 30 before or after MACRA implementation. However, palliative care use markedly increased after POD 30. These findings should be considered hypothesis-generating because of several confounders.

Preventive Care: Improving Health of Medicare, Medicaid, and Children's Health Insurance Program Patients Through Access to Fresh Fruit and Vegetables.

Diet is the number one risk factor for deaths in the United States. Members of marginalized and impoverished communities particularly struggle to afford nutritious food. Poor diets result in health disparities along socio-economic, age, racial, ethnic, indigenous, rural, and urban lines. Despite the ever-growing social and financial burden of diet-related chronic diseases, the U.S. has failed to invest in health care-related dietary policy. This Article proposes produce prescriptions as a national dietary preventive medicine program through Medicare, Medicaid, and the Children's Health Insurance Program (CHIP).Recently, nonprofits, governments, and health care providers have designed innovative produce prescription programs to combat diet-related chronic diseases. In these programs, clinical providers can prescribe subsidized fruit and vegetables to patients. Produce prescriptions empower patients by making dietary change affordable and by motivating patients to improve their health. Numerous studies, pilot projects, and local programs demonstrate that produce prescriptions can improve health care outcomes for individuals from diverse communities. Most at-risk members of our society receive health coverage through Medicare, Medicaid, or CHIP. This Article analyzes how to scale up produce prescriptions within these programs using law and policy.

Sexually Transmitted Infection/HIV Testing Among Medicaid/Children's Health Insurance Program-Insured Enrollees Aged 15 to 60 Years Who Were Diagnosed With High-Risk Sexual Behaviors With Their Opposite-Sex or Same-Sex Partners.

BACKGROUND: There is a lack of information on high-risk sexual behaviors (HRSB) related to gender of sex partner and associated sexually transmitted infection (STI)/HIV testing among Medicaid enrollees. METHODS: We used the 2016 Centers for Medicare & Medicaid Services Medicaid claims data to identify enrollees aged 15 to 60 years with HRSB by International Classification of Disease, Tenth Revision codes (Z72.51, Z72.52, and Z72.53). Enrollees diagnosed with HRSB were classified into 2 groups:(1) with same-sex partners and (2) with opposite-sex partners. The date when the initial diagnosis for HRSB was documented was used to define as the index date. We assessed chlamydia, gonorrhea, syphilis, and HIV testing on the index date, in the 6-month period before and after the index date (excluded the index date). HIV testing was limited to enrollees without documented HIV infection. RESULTS: Of 50 million Medicaid enrollees aged 15 to 60 years, 1.2% were identified as enrollees with HRSB in 2016. Of those enrollees with HRSB, 2.7% were enrollees with same-sex partners and 0.71% had documented HIV infection. Chlamydia, gonorrhea, syphilis, and HIV testing rates were 82.4%, 81.9%, 33.2%, and 44.3%, respectively, at the index date. The chlamydia testing rate was ≥90% among enrollees who resided in the West compared with 53% to 61% across other regions. HIV testing was more likely among males and among those with same-sex partners. Sexually transmitted infection/HIV testing was <30% in the 6-month periods before and after the index date. CONCLUSIONS: Among Medicaid enrollees with HRSB, STI/HIV testing varied regionally. Many enrollees were not tested for STI/HIV at the index visit in which they were identified as HRSB.

The Impact of Sociodemographic and Hospital Factors on Length of Stay Before and After Pyloromyotomy.

BACKGROUND: The aim of the study was to determine whether racial or ethnic and insurance disparities exist in pre- and post-operative length of stay (LOS) in patients with hypertrophic pyloric stenosis (HPS). MATERIALS AND METHODS: The Healthcare Cost and Utilization Project Kid's Inpatient Database database (years 2006, 2009, and 2012) was analyzed for patients aged <1 y with HPS with a primary procedure of pyloromyotomy. Multivariate logistic regression was performed to determine the association between race or ethnicity and insurance status with the primary outcomes of prolonged pre- and post-operative LOS (defined as >1 d). Odds ratios (ORs) and 95% confidence intervals (CIs) were tabulated using SPSS v24. RESULTS: A total of 13,706 cases were identified: 8503 (62%) non-Hispanic whites, 3143 (23%) Hispanics, 1007 (7%) non-Hispanic blacks (NHB), and 1053 (8%) non-Hispanic other race or ethnicity. NHB and Hispanics were 45% and 37%, respectively, more likely to have prolonged preoperative LOS compared with non-Hispanic whites (OR = 1.45, 95% CI: 1.19-1.77; OR = 1.37, 95% CI: 1.18-1.60, respectively). Children with public insurance had 21% increased odds of increased preoperative LOS (OR = 1.21, 95% CI: 1.06-1.38). All minority groups had increased odds of postoperative LOS (NHB OR 1.36, 95% CI: 1.17-1.54; Hispanic OR 1.14, 95% CI: 1.03-1.26; NHO OR 1.31, 95% CI: 1.15-1.51). CONCLUSIONS: We conclude that NHB, Hispanics, and other race or ethnicity were more likely to have prolonged pre- and post-operative LOS. In addition, children with public insurance were more likely to have prolonged preoperative LOS. Further work is needed to better characterize and eliminate disparities in the management and outcomes of children with HPS.

State Approaches to Funding Home and Community-Based Mental Health Care for Non-Medicaid Youth: Alternatives to Medicaid Waivers.

Home and Community-Based Services (HCBS) Medicaid waivers for children increase the availability of public funding for HCBS by waiving or expanding the means tests for parents' income, basing child eligibility for Medicaid coverage primarily on clinical need. But many states provide mechanisms apart from HCBS waivers to increase coverage for youth with significant mental health needs. Through interviews with public mental health officials from 37 states, this study identifies and explains non-waiver funding strategies for HCBS services for otherwise ineligible youth. Results demonstrate that states expand Medicaid-eligibility through CHIP or use state general revenue funds to pay for medically necessary HCBS for non-Medicaid youth.

Supply-side effects from public insurance expansions: Evidence from physician labor markets.

Medicaid and the Child Health Insurance Programs (CHIP) are key sources of coverage for U.S. children. Established in 1997, CHIP allocated $40 billion of federal funds across the first 10 years but continued support required reauthorization. After 2 failed attempts in Congress, CHIP was finally reauthorized and significantly expanded in 2009. Although much is known about the demand-side policy effects, much less is understood about the policy's impact on providers. In this paper, we leverage a unique physician dataset to examine if and how pediatricians responded to the expansion of the public insurance program. We find that newly trained pediatricians are 8 percentage points more likely to subspecialize and as much as 17 percentage points more likely to enter private practice after the law passed. There is also suggestive evidence of greater private practice growth in more rural locations. The sharp supply-side changes that we observe indicate that expanding public insurance can have important spillover effects on provider training and practice choices.

After The Demonstration: What States Sustained After the End of Federal Grants to Improve Children's Health Care Quality.

Introduction Under the CHIPRA Quality Demonstration Grant Program, CMS awarded $100 million through 10 grants that 18 state Medicaid agencies implemented between 2010 and 2015. The program's legislatively-mandated purpose was to evaluate promising ideas for improving the quality of children's health care provided through Medicaid and CHIP. As part of the program's multifaceted evaluation, this study examined the extent to which states sustained key program activities after the demonstration ended. Methods We identified 115 potentially sustainable elements within states' CHIPRA demonstrations and analyzed data from grantee reports and key informant interviews to assess sustainment outcomes and key influential factors. We also assessed sustainment of the projects' intellectual capital. Results 56% of potentially sustainable elements were sustained. Sustainment varied by topic area: Elements related to quality measure reporting and practice facilitation were more likely to be sustained than others, such as parent advisors. Broad contextual factors, the state's Medicaid environment, implementation partners' resources, and characteristics of the demonstration itself all shaped sustainment outcomes. Discussion Assessing sustainment of key elements of states' CHIPRA quality demonstration projects provides insight into the fates of the "promising ideas" that the grant program was designed to examine. As a result of the federal government's investment in this grant program, many demonstration states are in a strong position to extend and spread specific strategies for improving the quality of care for children in Medicaid and CHIP. Our findings provide insights for policymakers and providers working to improve the quality of health care for low income children.

Oral Health Coverage Options for Pregnant Adults and Adolescents.

Oral health care is a necessary and critical component of health care for pregnant women, but its importance is often overlooked by clinicians. Pregnant women who are low-income also find it particularly difficult to access care. This analytic essay summarizes oral health coverage for pregnant women under various types of health insurance coverage, including Medicaid, the Children's Health Insurance Program, and coverage options available under the Affordable Care Act. We hope this information will help clinicians better understand the importance of oral health care during pregnancy and the range of coverage options that may be available to their patients.

Perspectives on Implementing Quality Improvement Collaboratives Effectively: Qualitative Findings from the CHIPRA Quality Demonstration Grant Program.

BACKGROUND: The most frequently pursued intervention in the $100 million, 18-state Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) quality demonstration (2010-2015) was quality improvement collaboratives, which 12 states offered to more than 300 primary care practices. A study was conducted to identify which aspects of these collaboratives were viewed by organizers and participants as working well and which were not. METHODS: Some 223 interviews were conducted in these states near the end of their collaboratives. Interview notes were coded and analyzed to identify trends. RESULTS: Aspects of collaboratives that interviewees valued were aimed at attracting participation, maintaining engagement, or facilitating learning. To attract participants, interviewees recommended offering maintenance-of-certification credits, aligning content with existing financial incentives, hiring a knowledgeable collaborative organizer of the same medical specialty as participants, and having national experts speak at meetings. Positively viewed approaches for maintaining engagement included meeting one-on-one with practices to articulate participation expectations in advance, tying disbursal of stipends to meeting participation expectations, and soliciting feedback and making mid-course adjustments. To facilitate learning, interviewees liked learning from other practices, interactive exercises, practical handouts, and meeting face-to-face with new referral partners. CONCLUSION: Prior studies have tended to focus on strategies to maintain engagement. The interviewees valued these features but also valued aspects of collaboratives that attracted participants in the first place and facilitated learning after participants were actively engaged. The findings suggest that a wider array of features may be important when developing or evaluating collaboratives. Collaborative organizers may benefit from incorporating the recommended collaborative features into their own collaboratives.

The Medicare Access and CHIP Reauthorization Act: Implications for Nephrology.

In response to rising Medicare costs, Congress passed the Medicare Access and Children's Health Insurance Program Reauthorization Act in 2015. The law fundamentally changes the way that health care providers are reimbursed by implementing a pay for performance system that rewards providers for high-value health care. As of the beginning of 2017, providers will be evaluated on quality and in later years, cost as well. High-quality, cost-efficient providers will receive bonuses in reimbursement, and low-quality, expensive providers will be penalized financially. The Centers for Medicare and Medicaid Services will evaluate provider costs through episodes of care, which are currently in development, and alternative payment models. Although dialysis-specific alternative payment models have already been implemented, current models do not address the transition of patients from CKD to ESRD, a particularly vulnerable time for patients. Nephrology providers have an opportunity to develop cost-efficient ways to care for patients during these transitions. Efforts like these, if successful, will help ensure that Medicare remains solvent in coming years.

Medicare, Medicaid, and Children's Health Insurance Programs: Announcement of the Extension of Temporary Moratoria on Enrollment of Part B Non-Emergency Ground Ambulance Suppliers and Home Health Agencies in Designated Geographic Locations. Extension of temporary moratoria.

This document announces the extension of statewide temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance providers and suppliers and Medicare home health agencies and branch locations in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey, as applicable, to prevent and combat fraud, waste, and abuse. This extension also applies to the enrollment of new non- emergency ground ambulance suppliers and home health agencies and branch locations in Medicaid and the Children's Health Insurance Program in those states.

Medicare, Medicaid, and Children's Health Insurance Programs: Announcement of Revisions to the Provider Enrollment Moratoria Access Waiver Demonstration for Part B Non-Emergency Ground Ambulance Suppliers and Home Health Agencies in Moratoria-Designated Geographic Locations. Revisions of the waiver demonstration.

This document announces revisions to the Provider Enrollment Moratoria Access Waiver Demonstration (PEWD) for Part B Non-Emergency Ground Ambulance Suppliers and Home Health Agencies. The demonstration was implemented in accordance with section 402(a)(1)(J) of the Social Security Amendments of 1967 and, as revised, gives CMS the authority to grant waivers to the statewide enrollment moratoria on a case-by-case basis in response to access to care issues and previously denied enrollment applications because of statewide moratoria implementation, and to subject providers and suppliers enrolling via such waivers to heightened screening, oversight, and investigations.

Addressing Children's Mental Health.

(1) Untreated mental disorders and mental illness in children can lead to costly outcomes such as school dropout, substance use and suicide. (2) Half of lifetime cases of mental illness begin by age 14 and 75 percent of all lifetime cases present by age 24. (3) Early intervention and access to treatment may decrease the financial and health burdens associated with mental illness.

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.

Children Covered by Medicaid/State Children's Health Insurance Program More Likely to Use Emergency Departments for Food Allergies.

BACKGROUND: Food allergies (FAs) occur in 4% to 8% of children in the United States, and emergency department (ED) visits account for up to 20% of their costs. In 2010, the National Institute of Allergy and Infectious Diseases established diagnostic criteria and management practices for FAs, and recognition and treatment of FAs for pediatric ED practitioners has been described. OBJECTIVE: This study identified trends and factors related to ED visits for pediatric FAs in the United States from 2001 to 2010. It was hypothesized that FAs increased and that differences existed in ED utilization based on age, insurance status, and geography. Low concordance with treatment guidelines for FAs was expected. METHODS: Multivariate logistic regression, using National Hospital Ambulatory Medical Care Survey data, estimated factors associated with ED visits and treatment of FAs and nonspecific allergic reactions. Trends and treatment patters used weighted frequencies to account for the complex 4-stage probability survey design. RESULTS: An estimated 239,303 (95% confidence interval [CI], 180,322-298,284) children visited the ED for FAs, demonstrating a significant rate increase during the period (53.08, P < 0.001). Logistic regression showed that the odds of ED visits for FAs were significantly associated with Medicaid/State Children's Health Insurance Program insurance (OR, 1.65 [95% CI, 1.01-2.69], P = 0.04), adolescents (OR, 1.92 [95% CI, 1.10-3.35], P = 0.02), and boys (OR, 1.55 [95% CI, 1.03-2.35], P = 0.04). Treatment with epinephrine for anaphylaxis diagnoses occurred in 57.4% of visits (95% CI, 42.3%-66.8%). CONCLUSIONS: Medicaid/State Children's Health Insurance Program-insured pediatric patients had higher odds of visiting ED for recognized FAs and nonspecific allergic reactions and higher odds of receiving epinephrine than privately insured children.

Medicaid/CHIP Program; Medicaid Program and Children's Health Insurance Program (CHIP); Changes to the Medicaid Eligibility Quality Control and Payment Error Rate Measurement Programs in Response to the Affordable Care Act. Final rule.

This final rule updates the Medicaid Eligibility Quality Control (MEQC) and Payment Error Rate Measurement (PERM) programs based on the changes to Medicaid and the Children's Health Insurance Program (CHIP) eligibility under the Patient Protection and Affordable Care Act. This rule also implements various other improvements to the PERM program.