Behavioral Health and the Comprehensive Primary Care (CPC) Initiative: findings from the 2014 CPC behavioral health survey.

BACKGROUND: Incorporating behavioral health care into patient centered medical homes is critical for improving patient health and care quality while reducing costs. Despite documented effectiveness of behavioral health integration (BHI) in primary care settings, implementation is limited outside of large health systems. We conducted a survey of BHI in primary care practices participating in the Comprehensive Primary Care (CPC) initiative, a four-year multi-payer initiative of the Centers for Medicare and Medicaid Services (CMS). We sought to explore associations between practice characteristics and the extent of BHI to illuminate possible factors influencing successful implementation. METHOD: We fielded a survey that addressed six substantive domains (integrated space, training, access, communication and coordination, treatment planning, and available resources) and five behavioral health conditions (depression, anxiety, pain, alcohol use disorder, and cognitive function). Descriptive statistics compared BHI survey respondents to all CPC practices, documented the availability of behavioral health providers, and primary care and behavioral health provider communication. Bivariate relationships compared provider and practice characteristics and domain scores. RESULTS: One hundred sixty-one of 188 eligible primary care practices completed the survey (86% response rate). Scores indicated basic to good baseline implementation of BHI in all domains, with lowest scores on communication and coordination and highest scores for depression. Higher scores were associated with: having any behavioral health provider, multispecialty practice, patient-centered medical home designation, and having any communication between behavioral health and primary care providers. CONCLUSIONS: This study provides useful data on opportunities and challenges of scaling BHI integration linked to primary care transformation. Payment reform models such as CPC can assist in BHI promotion and development.

Physician visits and colorectal cancer testing among Medicare enrollees in North Carolina and South Carolina, 2005.

INTRODUCTION: Many Medicare enrollees do not receive colorectal cancer tests at recommended intervals despite having Medicare screening coverage. Little is known about the physician visits of Medicare enrollees who are untested. Our study objective was to evaluate physician visits of enrollees who lack appropriate testing to identify opportunities to increase colorectal cancer testing. METHODS: We used North Carolina and South Carolina Medicare data to compare type and frequency of physician visits for Medicare enrollees with and without a colorectal cancer test in 2005. Type of physician visit was defined by the physician specialty as primary care, mixed specialty (more than 1 specialty, 1 of which was primary care), and nonprimary care. We used multivariate modeling to assess the influence of type and frequency of physician visits on colorectal cancer testing. RESULTS: Approximately half (46.5%) of enrollees lacked appropriate colorectal cancer testing. Among the untested group, 19.8% had no physician visits in 2005. Enrollees with primary care visits were more likely to be tested than those without a primary care visit. Many enrollees who had primary care visits remained untested. Enrollees with visits to all physician types had a greater likelihood of having colorectal cancer testing. CONCLUSION: We identified 3 categories of Medicare enrollees without appropriate colorectal cancer testing: those with no visits, those who see primary care physicians only, and those with multiple visits to physicians with primary and nonprimary care specialties. Different strategies are needed for each category to increase colorectal cancer testing in the Medicare population.

Colorectal cancer screening barriers and facilitators in older persons.

BACKGROUND: This systematic review identifies factors that are most consistently mentioned as either barriers to or facilitators of colorectal cancer (CRC) screening in older persons. METHODS: A systematic literature search (1995-2008) was conducted to identify studies that reported barriers to or facilitators of CRC screening uptake, compliance or adherence specifically for older persons (> or = 65 years). Information on study characteristics and barriers and facilitators related to subjects; healthcare providers; policies; and screening tests were then abstracted and analyzed. RESULTS: Eighty-three studies met the eligibility criteria. Low level of education, African American race, Hispanic ethnicity, and female gender were the most frequently reported barriers, whereas being married or living with a partner was the most frequently reported facilitator. The most cited barrier related to healthcare providers was lack of screening recommendation by a physician; having a usual source of care was a commonly reported facilitator. Lack of health insurance, and dual coverage with Medicare and Medicaid were the most frequently reported barriers, whereas Medicare's coverage of screening colonoscopy was consistently reported as a facilitator. CONCLUSIONS: Barriers to, and facilitators of, CRC screening among older persons are reported. Particular attention should be paid to modifiable factors that could become the focus of interventions aimed at increasing CRC screening participation in older persons.

Trends in colorectal cancer test use in the medicare population, 1998-2005.

BACKGROUND: Colorectal cancer (CRC) screening has been covered under the Medicare program since 1998. No prior study has addressed the question of the completeness of CRC screening in the entire Medicare cohort. METHODS: In 2008, CRC test-use rates were analyzed for the national fee-for-service Medicare population using Medicare enrollment and claims data from 1998 through 2005. Annual test-use rates were calculated for fecal occult blood testing, sigmoidoscopy, barium enema, and colonoscopy for each year by the demographic characteristics of enrollees. A current-in-Medicare rate was calculated to assess the percentage of enrollees with CRC testing according to recommended intervals. RESULTS: Colonoscopy rates have increased every year since the introduction of CRC screening coverage. Test-use rates for all other test modalities have steadily decreased. The percentage of Medicare enrollees receiving appropriate tests has slowly increased. In 2005, 47% of enrollees aged >or=65 years and 33% of enrollees aged 50-64 years had claims indicating that they had been tested according to recommended intervals. CONCLUSIONS: CRC test-use rates in the Medicare population are low. Disparities are apparent by age, race/ethnicity, gender, disability, income, and geographic residence. Much work remains to be done to increase testing to acceptable levels.

The effectiveness of covering smoking cessation services for medicare beneficiaries.

OBJECTIVE: To examine whether reimbursement for Provider Counseling, Pharmacotherapies, and a telephone Quitline increase smoking cessation relative to Usual Care. STUDY DESIGN: Randomized comparison trial testing the effectiveness of four smoking cessation benefits. SETTING: Seven states that best represented the national population in terms of the proportion of those > or = 65 years of age and smoking rate. PARTICIPANTS: There were 7,354 seniors voluntarily enrolled in the Medicare Stop Smoking Program and they were followed-up for 12 months. INTERVENTION(S): (1) Usual Care, (2) reimbursement for Provider Counseling, (3) reimbursement for Provider Counseling with Pharmacotherapy, and (4) telephone counseling Quitline with nicotine patch. MAIN OUTCOME MEASURE: Seven-day self-reported cessation at 6- and 12-month follow-ups. PRINCIPAL FINDINGS: Unadjusted quit rates assuming missing data=smoking were 10.2 percent (9.0-11.5), 14.1 percent (11.7-16.5), 15.8 percent (14.4-17.2), and 19.3 percent (17.4-21.2) at 12 months for the Usual Care, Provider Counseling, Provider Counseling + Pharmacotherapy, and Quitline arms, respectively. Results were robust to sociodemographics, smoking history, motivation, health status, and survey nonresponse. The additional cost per quitter (relative to Usual Care) ranged from several hundred dollars to $6,450. CONCLUSIONS: A telephone Quitline in conjunction with low-cost Pharmacotherapy was the most effective means of reducing smoking in the elderly.

Can health promotion programs save Medicare money?

The impact of an aging population on escalating US healthcare costs is influenced largely by the prevalence of chronic disease in this population. Consequently, preventing or postponing disease onset among the elderly has become a crucial public health issue. Fortunately, much of the total burden of disease is attributable to conditions that are preventable. In this paper, we address whether well-designed health promotion programs can prevent illness, reduce disability, and improve the quality of life. Furthermore, we assess evidence that these programs have the potential to reduce healthcare utilization and related expenditures for the Medicare program. We hypothesize that seniors who reduce their modifiable health risks can forestall disability, reduce healthcare utilization, and save Medicare money. We end with a discussion of a new Senior Risk Reduction Demonstration, which will be initiated by the Centers for Medicare and Medicaid Services in 2007, to test whether risk reduction programs developed in the private sector can achieve health improvements among seniors and a positive return on investment for the Medicare program.

Use of Medicare summary notice inserts to generate interest in the Medicare stop smoking program.

PURPOSE: Evaluations of outreach strategies that effectively and efficiently reach the senior population often go unreported. The Medicare Stop Smoking Program (MSSP) was a seven-state demonstration project funded by the Centers for Medicare and Medicaid Services. The 1-year recruitment plan for MSSP included a multifaceted paid media campaign; however, enrollment was slower than anticipated. The purpose of this substudy was to test the effects of including envelope-sized advertisement inserts with Medicare Summary Notices (MSNs) as a supplemental recruitment strategy. METHODS: Information obtained from enrollees on where they had learned about the program as well as overall enrollment rates were analyzed and compared with the time periods during which the inserts were included in MSN mailings. RESULTS: Average call volume to the enrollment center increased by 65.7% in Alabama, the pilot state, and by more than 200% in the subsequent demonstration states. Despite the introduction of the MSN inserts late in the recruitment period, 32.2 % of the 7354 total enrollees stated that they learned about the project through the inserts. CONCLUSIONS: This recruitment method is highly recommended as a cost-effective way to reach the senior population.

Health promotion in later life: it's never too late.

The clinical and epidemiological rationale for the health improvement benefits of health promotion in the later years of life are provided in this article. The authors review the emerging scientific consensus concerning the utility of lifestyle interventions for health improvement in the context of a narrowed definition of health promotion. Governmental initiatives for testing health promotion among Medicare beneficiaries are also discussed. Major research findings are reviewed and implications for health promotion practioners are also provided.

Fall-risk evaluation and management: challenges in adopting geriatric care practices.

One third of older adults fall each year, placing them at risk for serious injury, functional decline, and health care utilization. Despite the availability of effective preventive approaches, policy and clinical efforts at preventing falls among older adults have been limited. In this article we present the burden of falls, review evidence concerning the effectiveness of fall-prevention services, describe barriers for clinicians and for payers in promoting these services, and suggest strategies to encourage greater use of these services. The challenges are substantial, but strategies for incremental change are available while more broad-based changes in health care financing and clinical practice evolve to better manage the multiple chronic health conditions, including falls, experienced by older Americans.

Predictors of preventive service use among Medicare beneficiaries.

Despite Medicare coverage, receipt of clinical preventive services is suboptimal. Using multivariate regression analyses and Medicare Current Beneficiary Survey (MCBS) data for 2001, we estimated the relationship between the number of preventive services received in the 12-month recall period and: socioeconomics, plan type, health status, health risks, and ability to address daily needs. Results are nationally representative for the study year. With the exception of blood pressure and cholesterol screening, approximately one- to two-thirds of Medicare beneficiaries did not receive recommended preventive services. Strategies should be developed to ensure appropriate use of preventive services over time.

Alcohol consumption in older adults and Medicare costs.

We determined the relationship of alcohol consumption and Medicare costs among 4,392 participants in the Cardiovascular Health Study (CHS), a longitudinal, population-based cohort study of adults age 65 or over in four U.S. communities. We assessed 5-year Parts A and B costs and self-reported intake of beer, wine, and liquor at baseline. Among both sexes, total costs were approximately $2,000 lower among consumers of > 1-6 drinks per week than abstainers. The lower costs associated with moderate drinking were most apparent among participants with cardiovascular disease (CVD) and for hospitalization costs for CVD among healthy participants. Former drinkers had the highest costs.

Smoking patterns among seniors and the medicare stop smoking program.

OBJECTIVES: To characterize smoking patterns in the older U.S. community-dwelling Medicare population at the national level and in states chosen to participate in the new Medicare Stop Smoking Program (MSSP) demonstration. To describe the MSSP. DESIGN: Data from the Behavioral Risk Factor Surveillance System (BRFSS) 1996 to 1999 were analyzed. SETTING: The BRFSS is a cross-sectional random-digit-dialed telephone survey conducted in all states plus the District of Columbia and Puerto Rico. PARTICIPANTS: BRFSS respondents aged 65 and older who self-identified as receiving Medicare benefits. MEASUREMENTS: Using BRFSS core questionnaire variables, recent trends in prevalence of current smoking and smoking cessation were estimated, as were prevalences by various demographic characteristics, for both the nation and the MSSP states as a group. RESULTS: As of 1999, an estimated 10.2% of this population were current smokers, with those aged 65 to 74 smoking at twice the rate (12.9%) of those aged 75 and older (6.1%) and blacks (14.7%) smoking more than whites (10.0%). Between 1996 and 1999, the prevalence of everyday smokers indicating they had attempted to quit for 1 day or longer in the past year rose from 37.1% to 42.2%. National patterns were mirrored in the states chosen to participate in the MSSP. CONCLUSIONS: Young-old Medicare recipients have a higher smoking prevalence, although interest in quitting appears to be rising. The chosen MSSP states appear to be a representative of national smoking patterns in the older Medicare population.