Geographic Variation in Medicaid Acceptance Across Michigan Primary Care Practices in the Era of the Affordable Care Act.

Coverage and access have improved under the Affordable Care Act, yet it is unclear whether recent gains have reached those regions within states that were most in need of improved access to care. We examined geographic variation in Medicaid acceptance among Michigan primary care practices before and after Medicaid expansion in the state, using data from a simulated patient study of primary care practices. We used logistic regression analysis with time indicators to assess regional changes in Medicaid acceptance over time. Geographic regions with lower baseline (<50%) Medicaid acceptance had significant increases in Medicaid acceptance at 4 and 8 months post-expansion, while regions with higher baseline (≥50%) Medicaid acceptance did not experience significant changes in Medicaid acceptance. As state Medicaid expansions continue to be implemented across the country, policy makers should consider the local dynamics of incentives for provider participation in Medicaid.

A multi-stakeholder evaluation of the Baltimore City virtual supermarket program.

BACKGROUND: Increasing access to healthy foods and beverages in disadvantaged communities is a public health priority due to alarmingly high rates of obesity. The Virtual Supermarket Program (VSP) is a Baltimore City Health Department program that uses online grocery ordering to deliver food to low-income neighborhoods. This study evaluates stakeholder preferences and barriers of program implementation. METHODS: This study assessed the feasibility, sustainability and efficacy of the VSP by surveying 93 customers and interviewing 14 programmatic stakeholders who had recently used the VSP or been involved with program design and implementation. RESULTS: We identified the following themes: The VSP addressed transportation barriers and food availability. The VSP impacted customers and the city by including improving food purchasing behavior, creating a food justice "brand for the city", and fostering a sense of community. Customers appreciated using Supplemental Nutrition Assistance Program (SNAP) benefits to pay for groceries, but policy changes are needed allow online processing of SNAP benefits. CONCLUSIONS: This evaluation summarizes lessons learned and serves as a guide to other public health leaders interested in developing similar programs. Provisions in the U.S. Department of Agriculture (USDA) Farm Bill 2014 allow for select grocers to pilot online transactions with SNAP benefits. If these pilots are efficacious, the VSP model could be easily disseminated.

Culturally Targeted Strategies for Diabetes Prevention in Minority Population.

Purpose The purpose of this study is to (a) assess the effectiveness of culturally tailored diabetes prevention interventions in minority populations and (b) develop a novel framework to characterize 4 key domains of culturally tailored interventions. Prevention strategies specifically tailored to the culture of ethnic minority patients may help reduce the incidence of diabetes. Methods We searched PubMed, EMBASE, and CINAHL for English-language, randomized controlled trials (RCTs) or quasi-experimental (QE) trials testing culturally tailored interventions to prevent diabetes in minority populations. Two reviewers independently extracted data and assessed risk of bias. Inductive thematic analysis was used to develop a framework with 4 domains (FiLLM: Facilitating [ie, delivering] Interventions Through Language, Location, and Message). The framework was used to assess the overall effectiveness of culturally tailored interventions. Results Thirty-four trials met eligibility criteria. Twelve studies were RCTs, and 22 were QE trials. Twenty-five out of 34 studies (74%) that used cultural tailoring demonstrated significantly improved A1C, fasting glucose, and/or weight loss. Of the 25 successful interventions, 21 (84%) incorporated at least 3 culturally targeted domains. Seven studies used all 4 domains and were all successful. The least utilized domain was delivery (4/34) of the intervention's key educational message. Conclusions Culturally tailoring interventions across the 4 domains of facilitators, language, location, and messaging can be effective in improving risk factors for progression to diabetes among ethnic minority groups. Future studies should evaluate how specific tailoring approaches work compared to usual care as well as comparative effectiveness of each tailoring domain.

Medicaid Administrator Experiences with the Implementation of Immediate Postpartum Long-Acting Reversible Contraception.

OBJECTIVE: This study sought to understand state Medicaid agencies' experiences with implementing payment for long-acting reversible contraception devices inserted immediately postpartum. METHODS: We conducted semistructured telephone interviews with Medicaid representatives from 15 agencies that have specific payment methodology for immediate postpartum long-acting reversible contraception (IPLARC). Interviews investigated agency experiences with IPLARC policy implementation. Interviews were audio-recorded and professionally transcribed. We analyzed data thematically using qualitative content analysis principles. RESULTS: Described implementation experiences fell into three major categories: 1) payer preparedness regarding payment challenges, 2) health care system awareness, attitudes, and readiness to implement IPLARC policy in clinical settings, and 3) ongoing practice improvement. Within the category of payer preparedness, major emergent themes included Medicaid's need to ensure efficient claims processing, maintain appropriate reimbursement rates, and alleviate perceived provider mistrust about payment. With respect to health care systems, themes emerged around raising clinician awareness of IPLARC coverage, managing provider misconceptions about IPLARC, and addressing gaps in provider IPLARC insertion expertise. Regarding practice improvement, a salient theme emerged around the limitations of Medicaid to engage in ongoing clinical implementation and evaluation efforts. CONCLUSIONS: These findings suggest a multistakeholder implementation framework that can guide the growing number of Medicaid agencies newly implementing IPLARC policy. As more Medicaid programs remove reimbursement barriers to IPLARC, clinicians and hospital administrators have a crucial opportunity to address clinical barriers to IPLARC and ensure real-time access among beneficiaries who desire this safe and effective approach to contraception.

Internet-Delivered Cognitive Behavioral Therapy to Treat Insomnia: A Systematic Review and Meta-Analysis.

BACKGROUND: Insomnia is of major public health importance. While cognitive behavioral therapy is beneficial, in-person treatment is often unavailable. We assessed the effectiveness of internet-delivered cognitive behavioral therapy for insomnia. OBJECTIVES: The primary objectives were to determine whether online cognitive behavioral therapy for insomnia could improve sleep efficiency and reduce the severity of insomnia in adults. Secondary outcomes included sleep quality, total sleep time, time in bed, sleep onset latency, wake time after sleep onset, and number of nocturnal awakenings. DATA SOURCES: We searched PubMed/MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, PsycInfo, Cochrane Library, Embase, and the Web of Science for randomized trials. METHODS: Studies were eligible if they were randomized controlled trials in adults that reported application of cognitive behavioral therapy for insomnia via internet delivery. Mean differences in improvement in sleep measures were calculated using the Hartung-Knapp-Sidik-Jonkman method for random effects meta-analysis. RESULTS: We found 15 trials, all utilizing a pretest-posttest randomized control group design. Sleep efficiency was 72% at baseline and improved by 7.2% (95% CI: 5.1%, 9.3%; p<0.001) with internet-delivered cognitive behavioral therapy versus control. Internet-delivered cognitive behavioral therapy resulted in a decrease in the insomnia severity index by 4.3 points (95% CI: -7.1, -1.5; p = 0.017) compared to control. Total sleep time averaged 5.7 hours at baseline and increased by 20 minutes with internet-delivered therapy versus control (95% CI: 9, 31; p = 0.004). The severity of depression decreased by 2.3 points (95% CI: -2.9, -1.7; p = 0.013) in individuals who received internet-delivered cognitive behavioral therapy compared to control. Improvements in sleep efficiency, the insomnia severity index and depression scores with internet-delivered cognitive behavioral therapy were maintained from 4 to 48 weeks after post-treatment assessment. There were no statistically significant differences between sleep efficiency, total sleep time, and insomnia severity index for internet-delivered versus in-person therapy with a trained therapist. CONCLUSION: In conclusion, internet-delivered cognitive behavioral therapy is effective in improving sleep in adults with insomnia. Efforts should be made to educate the public and expand access to this therapy. Registration Number, Prospero: CRD42015017622.

Characterization of Medicaid policy for immediate postpartum contraception.

OBJECTIVE: Long-acting reversible contraception (LARC) is safe, effective and cost-saving when provided immediately postpartum but currently underutilized due to nonreimbursement by Medicaid and other insurers. The objectives of this study were to (a) determine which state Medicaid agencies provide specific reimbursement for immediate postpartum LARC and (b) identify modifiable policy-level barriers and facilitators of immediate postpartum LARC access. STUDY DESIGN: We conducted semistructured telephone interviews with representatives of 40 Medicaid agencies to characterize payment methodology for immediate postpartum LARC. We coded transcripts using grounded theory and content analysis principles. RESULTS: Three categories of immediate postpartum LARC payment methodology emerged: state Medicaid agency (a) provides separate or increased bundled payment (n=15), (b) is considering providing enhanced payment (n=9) or (c) is not considering enhanced payment (n=16). Two major themes emerged related to Medicaid decision-making about immediate postpartum LARC coverage: (a) Health effects: States with payment for immediate postpartum LARC frequently cited improved maternal/child health outcomes as motivating their reimbursements. Conversely, states without payment expressed misinformation about LARC's clinical effects and lack of advocacy from local providers about clinical need for this service. (b) Financial implications: States providing payment emphasized overall cost savings. Conversely, states without reimbursement expressed concern about immediate budget constraints and potential adverse impact on existing global payment methodology for inpatient care. CONCLUSIONS: Many states have recently provided Medicaid coverage of immediate postpartum LARC, and several other states are considering such coverage. Addressing misinformation about clinical effects and concerns about cost-effectiveness of immediate postpartum LARC may promote adoption of immediate postpartum LARC reimbursement in Medicaid agencies currently without it. IMPLICATIONS: Medicaid policy for reimbursement of immediate postpartum LARC is evolving rapidly across the US. Our findings suggest several concrete strategies to remove policy-level barriers and promote facilitators of immediate postpartum LARC.