The Patient Protection and Affordable Care Act and Pediatric Medical Clinicians' Application of Fluoride Varnish.

Importance: Fluoride varnish reduces children's tooth decay, yet few clinicians provide it. Most state Medicaid programs have covered this service during medical visits for children aged 1 to 5 years, but private insurers began covering it only in 2015 due to the Patient Protection and Affordable Care Act (ACA) mandate that they cover a set of recommended preventive services without cost-sharing. Evidence on clinicians' behavior change postmandate is limited. Objective: To examine monthly changes in fluoride varnish applications among pediatric clinicians following the ACA mandate. Design, Setting, and Participants: Using all-payer claims data from Massachusetts, this cohort study applied an interrupted time-series approach with linear regression models comparing changes in monthly clinician-level outcomes before and after the mandate. Participants included clinicians who billed at least 5 well-child visits for patients aged 1 to 5 years and were observed at least once premandate. Adjusted for clinician fixed effects, models were assessed overall and separately for clinicians categorized by their monthly share of well-child visits paid by private insurers before the mandate: mostly private (>66% of visits paid by private insurers), mostly public (<33% of visits paid by private insurers), or mixed (33%-66% of visits paid by private insurers) insurance types. Analysis was performed from June 1, 2022, to July 31, 2023. Exposure: Preenactment and postenactment of the ACA mandate for private insurers to cover fluoride varnish applications without cost-sharing. Main Outcomes and Measures: Clinician-month measures of whether fluoride varnish was provided during at least 1 well-child visit and the share of such visits, analyzed separately for clinicians who did and did not apply fluoride varnish premandate. Results: The sample included 2405 clinicians, with 107 841 clinician-months. Premandate, 10.48% of the visits included fluoride varnish applications. Two years postmandate, the likelihood of ever applying fluoride varnish was 13.64 (95% CI, 10.97-16.32) percentage points higher. For clinicians providing fluoride varnish premandate, the share of visits with fluoride varnish increased by 9.22 (95% CI, 5.41-13.02) percentage points. This increase was observed in clinicians who treated children with insurance that was mostly mixed and mostly private; no substantial change was observed among those treating children with mostly public insurance. Conclusions and Relevance: In this cohort study of pediatric primary care clinicians, an association between the ACA mandate and an increase in fluoride varnish application was observed, especially among clinicians primarily treating privately insured patients and those applying it premandate. However, application remains infrequent, suggesting persistent barriers.

Trends in Geographic Proximity to Substance Use Disorder Treatment.

INTRODUCTION: This study aims to assess the trends in the number and characteristics of substance use disorder (SUD) treatment facilities within the county of residence of adults aged 50+ years over time. METHODS: Using retrospective longitudinal data from the 1992-2018 Health and Retirement Study merged with the county-level data on all licensed treatment facilities in the country, linear mixed models were estimated to calculate geographic accessibility to SUD treatment, adjusted for person-level demographics, state-level controls, and calendar year-fixed effects. Analysis was conducted in 2022. RESULTS: Overall, older adults experienced a decline in the average number of SUD treatment facilities within their counties of residence from 4.80 per 100,000 residents (95% CI=4.69, 4.92) in 1992 to 4.50 (95% CI=4.35, 4.64) in 2018. However, the number accepting Medicare increased from 0.26 (95% CI=0.21, 0.30) in 1992 to 1.88 (95% CI=1.80, 1.96) facilities per 100,000 (42% of facilities); Medicaid increased from 0.20 (95% CI=0.13, 0.26) in 1992 to 3.50 (95% CI=3.39, 3.62) facilities per 100,000 (78% of facilities) in 2018. Older adults living in more rural areas experienced the most growth in SUD treatment facilities per capita in their counties but with less significant growth in facilities offering medication for opioid use disorder than those living in more urban areas. CONCLUSIONS: Despite increases in the number of SUD treatment facilities in rural areas, there has been less growth in nearby facilities offering evidence-based medication treatment for opioid use disorder.

The Long-term Value of Bariatric Surgery Interventions for American Adults With Type 2 Diabetes Mellitus.

BACKGROUND: Bariatric surgery can cause type 2 diabetes (diabetes) remission for individuals with comorbid obesity, yet utilization is <1%. Surgery eligibility is currently limited to body mass index (BMI) ≥35 kg/m 2 , though the American Diabetes Association recommends expansion to BMI ≥30 kg/m 2 . OBJECTIVE: We estimate the individual-level net social value benefits of diabetes remission through bariatric surgery and compare the population-level effects of expanding eligibility alone versus improving utilization for currently eligible individuals. METHODS: Using microsimulation, we quantified the net social value (difference in lifetime health/economic benefits and costs) of bariatric surgery-related diabetes remission for Americans with obesity and diabetes. We compared projected lifetime surgical outcomes to conventional management at individual and population levels for current utilization (1%) and eligibility (BMI ≥35 kg/m 2 ) and expansions of both (>1%, and BMI ≥30 kg/m 2 ). RESULTS: The per capita net social value of bariatric surgery-related diabetes remission was $264,670 (95% confidence interval: $234,527-294,814) under current and $227,114 (95% confidence interval: $205,300-248,928) under expanded eligibility, an 11.1% and 9.16% improvement over conventional management. Quality-adjusted life expectancy represented the largest gains (current: $194,706; expanded: $169,002); followed by earnings ($51,395 and $46,466), and medical savings ($41,769 and $34,866) balanced against the surgery cost ($23,200). Doubling surgical utilization for currently eligible patients provides higher population gains ($34.9B) than only expanding eligibility at current utilization ($29.0B). CONCLUSIONS: Diabetes remission following bariatric surgery improves healthy life expectancy and provides net social benefit despite high procedural costs. Per capita benefits appear greater among currently eligible individuals. Therefore, policies that increase utilization may produce larger societal value than expanding eligibility criteria alone.

How scheduling systems with automated appointment reminders improve health clinic efficiency.

Missed clinic appointments or no-shows burden health care systems through inefficient use of staff time and resources. Scheduling software with automatic appointment reminders shows promise to improve clinics' management through timely cancellations and re-scheduling, but at-scale evidence is missing. We study a nationwide text message appointment reminder program in Chile implemented at primary care clinics for patients with chronic disease. Using longitudinal clinic-level data, we find that the program did not change the number of visits by chronic patients eligible to receive the reminder but visits from other patients ineligible to receive reminders increased by 5.0% in the first year and 7.4% in the second. Clinics treating more chronic patients and those with a relatively younger patient population benefited more from the program. Scheduling systems with automatic appointment reminders were effective in increasing clinics' ability to care for more patients, likely due to timely cancellations and re-scheduling.

Associations of a National Tax on Non-Essential High Calorie Foods with Changes in Consumer Prices.

Several governments are considering taxes on non-essential energy-dense, high calorie foods (NEDF) to increase their prices and thereby encourage better diet and health. Alongside a tax on sugary drinks in January 2014, Mexico implemented such a tax: an 8 percent ad-valorem tax on NEDF, defined as those with energy density equal or larger than 275kcal/100g. We study the changes in the prices of taxed and tax-exempt foods following this tax both on average and by tax-eligible foods across store types and cities, using monthly price data between 2012 and 2016. We compare within-product price changes before and after the tax adjusting for product fixed effects, seasonality, and trends, and find that prices of taxed foods increased by 4.8 % on average, but differentially across foods. Prices of candies, cookies and packaged pastries increased by eight or more percent post-tax (vs pre-tax); prices of cakes, and savory snacks increased by less. Prices of fresh pastry and ready-to-eat cereal increased, but only in 2014. Prices of chocolate and pizza did not increase after the tax. For tax-exempt foods, no significant price changes were observed. Variability in price changes for taxed foods were observed by cities as well as by stores: increases were larger in supermarkets compared to smaller grocery stores on average and for most foods. Differences in how prices changed across foods, cities and stores have implications for who is likely to be affected by the tax and how tax effects on diet may vary due to the differential tax pass-through in addition to a heterogenous demand response to changed prices.

Nursing Home Antibiotic Stewardship Policy and Antibiotics Use: 2013-2017.

OBJECTIVES: Reducing inappropriate nursing home (NH) antibiotic usage by implementing stewardship programs is a national priority. Our aim is to evaluate the influence of antibiotic stewardship programs on antibiotic use rates in NHs over time. DESIGN: Retrospective, repeated cross-sectional analysis. SETTING AND PARTICIPANTS: Long-term residents not receiving hospice care in freestanding NHs that participated in 1 or both surveys in 2013 and 2017. METHODS: Survey data were merged with the Minimum Data Set and the Certification and Survey Provider Enhanced Reporting data. Our outcome was a binary indicator for antibiotic use. The main predictor was the NH antibiotic stewardship policy intensity. Using multivariate linear regression models adjusting for resident and facility characteristics that differed between the 2 years, we calculated antibiotic use rates in 2013 and 2017 for all residents, those with Alzheimer's disease, and those with any infection including urinary tract infections (UTIs). RESULTS: Our sample included 317,003 resident assessments from 2013 and 267,537 assessments from 2017, residing in 953 and 872 NHs, respectively. NH antibiotic stewardship policy intensity increased from 2013 to 2017 (P < .01) and among all NH residents, including those with Alzheimer's disease, antibiotic use rate decreased (P < .05), with 45% of the decline attributable to strengthening stewardship programs. For most residents, policy intensity was associated with decreased usage in residents with UTI. However, among Alzheimer's disease residents with a UTI, this association did not persist. CONCLUSIONS AND IMPLICATIONS: Although there was a decrease in antibiotic use in 2017, more time is needed to see the full impact of antibiotic stewardship policy into practice. Adjustments to programs that directly address barriers to implementation and appropriate UTI antibiotic use for residents with Alzheimer's disease are necessary to continue strengthening NH antibiotic stewardship and improve care.

Changes in Weight-Related Outcomes Among Adolescents Following Consumer Price Increases of Taxed Sugar-Sweetened Beverages.

Importance: Following the implementation of a tax on sugar-sweetened beverages (SSBs) in Mexico in 2014, SSB prices increased by about 10% on average, but differently across cities. It remains unclear how observed SSB price changes are associated with adolescent weight-related outcomes. Objective: To compare weight-related outcomes among adolescents living in cities with differential SSB price changes before and after the SSB tax was implemented in Mexico. Design, Setting, and Participants: Associations between differential SSB price changes and changes in weight-related outcomes were examined overall and by sex among 12 654 adolescents aged 10 to 18 years born between 1999 and 2002 living in 39 cities in Mexico. Multivariate regressions with individual fixed effects were applied on longitudinal individual-level yearly clinical data (height and weight) from 2012 to 2017 collected by the Instituto Mexicano del Seguro Social (IMSS) and merged with city-level SSB price data from 2011 to 2016 collected by the National Institute of Statistics and Geography (INEGI). Data were analyzed from July 2018 to July 2021. Exposures: Yearly city-level changes in SSB prices between 2011 and 2016. Main Outcomes and Measures: Age- and sex-specific body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) percentile and indicator for overweight or obesity if BMI was at or above the 85th percentile. Results: Before 2014, 46% of 12 654 adolescents (6850 girls and 5804 boys) included in this study had obesity or overweight. The mean (SD) age was 11.38 (1.08) years. Among girls, a 10% SSB price increase was associated with a 1.3 percentage point absolute decrease (95% CI, -2.19 to -0.36; P = .008) or a 3% relative decrease in overweight or obesity prevalence within 2 years of a price change. For girls with BMI at or above the 75th percentile pretax, this price increase was associated with a 0.59 lower BMI percentile (95% CI, -1.08 to -0.10; P = .02) or a 0.67% relative decrease. Improved outcomes for girls were observed in cities where price increases were greater than 10% after the tax. No such associations were observed for boys. Conclusions and Relevance: In this study, increased SSB prices were associated with decreased overweight or obesity prevalence among girls but not among boys. Improvements in outcomes were small, and mostly observed for girls with heavier weight and in cities where price increases after the tax were greater than 10%.

Bittersweet: How prices of sugar-rich foods contribute to the diet-related disease epidemic in Mexico.

I provide new evidence on how price changes of nutritionally similar foods, such as those rich in sugar or fats, change obesity and diet-related diseases in the context of Mexico between 1996-2010. I merge a bar-code level price dataset with product-specific nutritional composition to two datasets with health outcomes: state-level administrative and nationally representative individual-level panel data. Exploiting within-city variation in prices using fixed effects models, I show that decreased prices of sugar-rich foods increase obesity, type 2 diabetes, and hypertension prevalence; yet the prices of foods rich in other nutrients do not. Health responses to price changes are the largest for those abdominally obese or at the highest risk for chronic disease. The association between prices of sugary foods and chronic disease is meaningful: I estimate that in Mexico, price reductions of sugary foods explain roughly 15 percent of the rise in obesity and diabetes during the 15-year study period.

Advanced cognitive impairment among older nursing home residents.

BACKGROUND: Though work has been done studying nursing home (NH) residents with either advanced Alzheimer's disease (AD) or Alzheimer's disease related dementia (ADRD), none have distinguished between them; even though their clinical features affecting survival are different. In this study, we compared mortality risk factors and survival between NH residents with advanced AD and those with advanced ADRD. METHODS: This is a retrospective observational study, in which we examined a sample of 34,493 U.S. NH residents aged 65 and over in the Minimum Data Set (2011-2013). Incident assessment of advanced disease was defined as the first MDS assessment with severe cognitive impairment (Cognitive Functional Score equals to 4) and diagnoses of AD or ADRD. Demographics, functional limitations, and comorbidities were evaluated as mortality risk factors using Cox models. Survival was characterized with Kaplan-Maier functions. RESULTS: Of those with advanced cognitive impairment, 35 % had AD and 65 % ADRD. At the incident assessment of advanced disease, those with AD had better health compared to those with ADRD. Mortality risk factors were similar between groups (shortness of breath, difficulties eating, substantial weight-loss, diabetes mellitus, heart failure, chronic obstructive pulmonary disease, and pneumonia; all p < 0.01). However, stroke and difficulty with transfer (for women) were significant mortality risk factors only for those with advanced AD. Urinary tract infection, and hypertension (for women) only were mortality risk factors for those with advanced ADRD. Median survival was significantly shorter for the advanced ADRD group (194 days) compared to the advanced AD group (300 days). CONCLUSIONS: There were distinct mortality and survival patterns of NH residents with advanced AD and ADRD. This may help with care planning decisions regarding therapeutic and palliative care.

Association of Infection-Related Hospitalization With Cognitive Impairment Among Nursing Home Residents.

Importance: Hospitalizations for infections among nursing home (NH) residents remain common despite national initiatives to reduce them. Cognitive impairment, which markedly affects quality of life and caregiving needs, has been associated with hospitalizations, but the association between infection-related hospitalizations and long-term cognitive function among NH residents is unknown. Objective: To examine whether there are changes in cognitive function before vs after infection-related hospitalizations among NH residents. Design, Setting, and Participants: This cohort study used data from the Minimum Data Set 3.0 linked to Medicare hospitalization data from 2011 to 2017 for US nursing home residents aged 65 years or older who had experienced an infection-related hospitalization and had at least 2 quarterly Minimum Data Set assessments before and 4 or more after the infection-related hospitalization. Analyses were performed from September 1, 2019, to December 21, 2020. Exposure: Infection-related hospitalization lasting 1 to 14 days. Main Outcomes and Measures: Using an event study approach, associations between infection-related hospitalizations and quarterly changes in cognitive function among NH residents were examined overall and by sex, age, Alzheimer disease and related dementias (ADRD) diagnosis, and sepsis vs other infection-related diagnoses. Resident-level cognitive function was measured using the Cognitive Function Scale (CFS), with scores ranging from 1 (intact) to 4 (severe cognitive impairment). Results: Of the sample of 20 698 NH residents, 71.0% were women and 82.6% were non-Hispanic White individuals; the mean (SD) age at the time of transfer to the hospital was 82 (8.5) years. The mean CFS score was 2.17, and the prevalence of severe cognitive impairment (CFS score, 4) was 9.0%. During the first quarter after an infection-related hospitalization, residents experienced a mean increase of 0.06 points in CFS score (95% CI, 0.05-0.07 points; P < .001), or 3%. The increase in scores was greatest among residents aged 85 years or older vs younger residents by approximately 0.022 CFS points (95% CI, 0.004-0.040 points; P < .05). The prevalence of severe cognitive impairment increased by 1.6 percentage points (95% CI, 1.2-2.0 percentage points; P < .001), or 18%; the increases were observed among individuals with ADRD but not among those without it. After an infection-related hospitalization, cognition among residents who had experienced sepsis declined more than for residents who had not by about 0.02 CFS points (95% CI, 0.00-0.04 points; P < .05). All observed differences persisted without an accelerated rate of decline for at least 6 quarters after infection-related hospitalization. No differences were observed by sex. Conclusions and Relevance: In this cohort study, infection-related hospitalization was associated with immediate and persistent cognitive decline among nursing home residents, with the largest increase in CFS scores among older residents, those with ADRD, and those who had experienced sepsis. Identification of NH residents at risk of worsened cognition after an infection-related hospitalization may help to ensure that their care needs are addressed to prevent further cognitive decline.

Assessment of Coronavirus Disease 2019 Infection and Mortality Rates Among Nursing Homes With Different Proportions of Black Residents.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) has disproportionately impacted nursing homes (NHs) with large shares of Black residents. We examined the associations between the proportion of Black residents in NHs and COVID-19 infections and deaths, accounting for structural bias (operationalized as county-level factors) and stratifying by urbanicity/rurality. DESIGN: This was a cross-sectional observational cohort study using publicly available data from the LTCfocus, Centers for Disease Control and Prevention Long-Term Care Facility COVID-19 Module, and the NYTimes county-level COVID-19 database. Four multivariable linear regression models omitting and including facility characteristics, COVID-19 burden, and county-level fixed effects were estimated. SETTING AND PARTICIPANTS: In total, 11,587 US NHs that reported data on COVID-19 to the Centers for Disease Control and Prevention and had data in LTCfocus and NYTimes from January 20, 2020 through July 19, 2020. MEASURES: Proportion of Black residents in NHs (exposure); COVID-19 infections and deaths (main outcomes). RESULTS: The proportion of Black residents in NHs were as follows: none= 3639 (31.4%), <20% = 1020 (8.8%), 20%-49.9% = 1586 (13.7%), ≥50% = 681 (5.9%), not reported = 4661 (40.2%). NHs with any Black residents showed significantly more COVID-19 infections and deaths than NHs with no Black residents. There were 13.6 percentage points more infections and 3.5 percentage points more deaths in NHs with ≥50% Black residents than in NHs with no Black residents (P < .001). Although facility characteristics explained some of the differences found in multivariable analyses, county-level factors and rurality explained more of the differences. CONCLUSIONS AND IMPLICATIONS: It is likely that attributes of place, such as resources, services, and providers, important to equitable care and health outcomes are not readily available to counties where NHs have greater proportions of Black residents. Structural bias may underlie these inequities. It is imperative that support be provided to NHs that serve greater proportions of Black residents while considering the rurality of the NH setting.

The future of the elderly population health status: Filling a knowledge gap.

The aging process in OECD countries calls for a better understanding of the future disease prevalence, life expectancy (LE) and patterns of inequalities in health outcomes. In this paper we present the results obtained from several dynamic microsimulation models of the Future Elderly Model family for 12 OECD countries, with the aim of reproducing for the first time comparable long-term projections in individual health status across OECD countries. We provide projections of LE and prevalence of major chronic conditions and disabilities, overall, by gender and by education. We find that the prevalence of main chronic conditions in Europe is catching-up with the United States and significant heterogeneity in the evolution of gender and educational gradients. Our findings represent a contribution to support policymakers in designing and implementing effective interventions in the healthcare sector.

Does Integration of Palliative Care and Infection Management Reduce Hospital Transfers among Nursing Home Residents?

Background: An estimated 50% of nursing home (NH) residents experience hospital transfers in their last year of life, often due to infections. Hospital transfers due to infection are often of little clinical benefit to residents with advanced illness, for whom aggressive treatments are often ineffective and inconsistent with goals of care. Integration of palliative care and infection management (i.e., merging the goals of palliative care and infection management at end of life) may reduce hospital transfers for residents with advanced illness. Objectives: Evaluate the association between integration and (1) all-cause hospital transfers and (2) hospital transfers due to infection. Design: Cross-sectional observational study. Setting/Subjects: 143,223 U.S. NH residents, including 42,761 residents in the advanced stages of dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Measurement: Cross-sectional, nationally representative NH survey data (2017-2018) were combined with resident data from the Minimum Data Set 3.0 and Medicare inpatient data (2016-2017). NH surveys measured integration of palliative care and infection management using an index of 0-100. Logistic regression models were used to estimate the relationships between integration intensity (i.e., the degree to which NHs follow best practices for integration) and all-cause hospital transfer and transfer due to infection. Results: Among residents with advanced dementia, integration intensity was inversely associated with all-cause hospital transfer and transfer due to infection (p < 0.001). Among residents with advanced COPD, integration intensity was inversely associated with all-cause hospital transfer (p < 0.05) but not transfers due to infection. Among residents with advanced CHF, integration intensity was not associated with either outcome. Conclusions: NH policies aimed to promote integration of palliative care and infection management may reduce burdensome hospital transfers for residents with advanced dementia. For residents with advanced CHF and COPD, alternative strategies may be needed to promote best practices for infection management at end of life.

Trends in antibiotics use among long-term US nursing-home residents.

OBJECTIVES: Antibiotics are overly prescribed in nursing homes. Recent antibiotic stewardship efforts attempt to reduce inappropriate use. Our objective was to describe antibiotic use from 2012 to 2016 among nursing-home residents with various health conditions. DESIGN: Retrospective, repeated cross-sectional analysis. SETTING AND PARTICIPANTS: All long-term residents in a random 10% sample of national nursing homes: 2,092,809 assessments from 319,615 nursing-home residents in 1,562 nursing homes. MEASUREMENTS: We calculated a 1-day antibiotic prevalence using all annual and quarterly clinical assessments in the Minimum Data Set (MDS) from April 2012 through December 2016. We calculated prevalence of antibiotic use overall and within conditions of interest: Alzheimer's disease and related dementias (ADRD), advanced cognitive impairment (ACI), and infections likely to be treated with antibiotics. We applied logistic regressions with nursing-home cluster, robust standard errors to assess changes in conditions and antibiotic use 2012-2016. RESULTS: Overall, antibiotic use did not change (2012 vs 2016, adjusted odds ratio [AOR], 1.00; 95% CI, 0.97-1.03). Antibiotic use was higher in 2016 versus 2012 among assessments with any infection (AOR, 1.10; 95% CI, 1.04-1.16), urinary tract infection (AOR, 1.18; 95% CI, 1.12-1.25), and no infection (AOR, 1.13; 95% CI, 1.09-1.17). Results were similar by cognitive status. CONCLUSIONS: The increased proportion of assessments recording antibiotics but no infection may not be clinically appropriate. Higher antibiotic use among infected residents with advanced cognitive impairment is also concerning. Further efforts to understand mechanisms driving these trends and to promote antibiotic stewardship in nursing homes are warranted.

On the Value of the Umbilical Cord Blood Supply.

BACKGROUND: Several public cord blood banks are struggling financially, and the question remains as to whether additional allocations of funds to them are justified. OBJECTIVES: To estimate the social benefits of public cord blood bank inventory net of cord blood banks' operational costs. METHODS: We used publicly available data from the Health Resources and Service Administration on the number of annual cord blood transplants as well as the patient age distribution in 2010, and the survival estimates between 2008 and 2012 for the several diseases treated by cord blood transplantation. Data on aggregate annual costs to the cord blood industry for recruitment, processing, and storage were obtained from published work. We used estimated increases in life expectancy due to treatment using umbilical cord blood and value for life-years gained to estimate the social benefits of the public cord blood inventory annually. RESULTS: We found that the annual social benefits of between $500 million and $1.5 billion outweigh the current operational annual costs of running cord blood banks of $60 to $70 million by a significant margin. CONCLUSIONS: We estimated that the annual social benefit of having a cord blood system far outweighs its costs, by more than an order of magnitude. Thus, the social benefits of maintaining the US public cord blood banking system at the present time far outweigh the costs of collecting, storing, and distributing cord blood. This suggests that there is a potential justification for government intervention to align social benefits and costs. Nevertheless, simple fixes may produce unintended consequences, and so a careful design for subsidies is needed.

Associations Between the Patient Protection and Affordable Care Act Medicaid Primary Care Payment Increase and Physician Participation in Medicaid.

Importance: The Patient Protection and Affordable Care Act (ACA) increased 2013 to 2014 Medicaid payment rates for qualifying primary care physicians (PCPs) and services to higher Medicare payment levels, with the goal of improving primary care access for Medicaid enrollees. Objectives: To evaluate the payment increase policy and to assess whether it was associated with changes in Medicaid participation rates or Medicaid service volume among PCPs. Design, Setting, and Participants: This study used 2012 to 2015 IMS Health aggregated medical claims and encounter data from PCPs eligible for the payment increase practicing in all states except Alaska and Hawaii and included 20 723 PCPs with observations in each month from January 1, 2012, to December 31, 2015. Data are for professional services performed in ambulatory settings, including office, hospital outpatient department, and emergency department. Regression models were used to test whether outcomes differed in months subject to higher payment rates relative to months before the increase and after the expiration of the increase in some states. The models controlled for time-invariant physician characteristics and time-varying characteristics, such as Medicaid enrollment. Interaction terms were included to estimate differential associations in subgroups of states (eg, by Medicaid managed care penetration) and physicians (eg, by specialty). Main Outcomes and Measures: Physician-month records subject to higher Medicaid payment rates were flagged using state-specific implementation and end dates for the payment increase. Five outcomes were measured for each physician-month observation, including (1) an indicator for seeing any patients enrolled in Medicaid, (2) an indicator for seeing more than 5 patients enrolled in Medicaid, (3) the Medicaid share of total patients, (4) a count of new patient evaluation and management visits furnished to patients enrolled in Medicaid, and (5) a count of existing patient evaluation and management visits furnished to patients enrolled in Medicaid. Results: Among 20 723 PCPs, the payment increase had no association with PCP participation in Medicaid or Medicaid service volume. The estimated average marginal effects for all 5 outcomes were not statistically distinguishable from 0. This null result was robust to sensitivity analyses, including different time trend specifications and analyses focusing on the payment increase implementation and expiration time frames. Descriptively, the Medicaid share of patients increased by about 25% from 2012 to 2015, although the share did not increase differentially in states and months subject to higher payment rates. Conclusions and Relevance: The limited duration and design of the payment increase may have dampened its effectiveness. Future efforts to improve access through payment changes or other means can benefit from better understanding of the outcomes of this policy.

Developing a Strategic Program for Chilean Health Information Technology: Environmental Scan and Key Informant Interviews.

As part of an effort to assist Chile in developing a strategic program to foster the development of the health information technology (health IT) sector over the next five to ten years, this study assesses the current state of health IT adoption and implementation in Chile, as well as the challenges and opportunities facing the sector over the coming years. The authors conducted an environmental scan and ten key informant interviews and found that there are a number of successful health IT projects and strategies for further development currently underway in Chile, but that the successful projects are generally localized within specific health care providers and lack integration. These and other challenges suggest significant potential for the Ministry of Economy and other stakeholders to take specific actions designed to encourage further development of the health IT sector in Chile over the coming years. The next phase of this effort will use the results from this study to develop a roadmap for the Ministry of Economy to encourage health IT development in Chile over the short, medium, and long terms.