The effect of Medicaid expansion on use of opioid agonist treatment and the role of provider capacity constraints.

OBJECTIVE: To determine the effect of Medicaid expansion on the use of opioid agonist treatment for opioid use disorder (OUD) and to examine heterogeneous effects by provider supply and Medicaid acceptance rates. DATA SOURCES: Yearly state-level data on methadone dispensed from opioid treatment programs (OTPs), buprenorphine dispensed from OTPs and pharmacies, number of OTPs and buprenorphine-waivered providers, and percent of OTPs and physicians accepting Medicaid. STUDY DESIGN: This study used difference-in-differences models to examine the effect of Medicaid expansion on the amount of methadone and buprenorphine dispensed in states between 2006 and 2017. Interaction terms were used to estimate heterogeneous effects. Sensitivity analyses included testing the association of outcomes with Medicaid enrollment and state insurance rates. PRINCIPAL FINDINGS: The estimated effects of Medicaid expansion on buprenorphine and methadone dispensed were positive but imprecise, meaning we could not rule out negative or null effects of expansion. The estimated associations between state insurance rates and dispensed methadone and buprenorphine were centered near zero, suggesting that improvements in health coverage may not have increased OUD treatment use. The effect of Medicaid expansion was larger in the states with the most waivered providers compared to states with the fewest waivered providers. In the states with the most waivered providers, the average estimated effect of expansion on buprenorphine dispensed was 12 kg/y, enough to treat about 7500 individuals. We did not find evidence that the effect of expansion was consistently modified by OTP concentration, OTP Medicaid acceptance, or physician Medicaid acceptance. CONCLUSIONS: Gains in health coverage may not be sufficient to increase OUD treatment, even in the context of high treatment need. Provider capacity likely limited Medicaid expansion's effect on buprenorphine dispensed. Policies to increase buprenorphine providers, such as ending the waiver requirement, may be needed to ensure coverage gains translate to treatment access.

Patient-centered medical homes and preventive service use.

OBJECTIVES: Despite data suggesting that patient-centered medical homes (PCMHs) improve preventive service use, limited nationally representative evidence exists. This study compared preventive service use between patients with and without a usual source of care (USC) and, of the patients with a USC, between those in practices with and without PCMH status. STUDY DESIGN: This study used a cross-sectional study design. METHODS: We constructed general and disease-specific preventive service indicators using the 2015 Medical Expenditure Panel Survey. Preventive service rates were compared between patients reporting a USC versus no USC and between patients whose USC practices were PCMH certified versus not PCMH certified. Unadjusted outcomes were tested using χ2 tests. Multivariable logistic regression was used to test differences between groups, controlling for predisposing, enabling, and need variables. RESULTS: Using multivariable logistic regression, respondents with a USC reported higher rates of screening for breast cancer (odds ratio [OR], 2.40; 95% CI, 1.81-3.17) and cervical cancer (OR, 1.99; 95% CI, 1.61-2.47) than respondents with no USC. Diabetes respondents with a USC had higher odds of an annual eye exam (OR, 2.05; 95% CI, 1.26-3.33) than respondents with no USC. Diabetes respondents with a USC that was PCMH certified reported higher rates of annual foot screenings (OR, 2.01; 95% CI, 1.31-3.08) and lower rates of annual cholesterol screenings (OR, 0.30; 95% CI, 0.11-0.83) than those with a USC that was not PCMH certified. CONCLUSIONS: Having a USC was associated with higher rates of several preventive screening measures. However, there were fewer significant preventive screening relationships by PCMH status among individuals with a USC. Our results suggest that improving access to a USC may be as important as the application of PCMH principles to a USC practice.

Implications of eligibility category churn for pediatric payment in Medicaid.

OBJECTIVES: To describe the extent and implications of "churn" between different Medicaid eligibility classifications in a pediatric population: (1) aged, blind, and disabled (ABD) Medicaid eligibility, determined by disability status and family income; and (2) Healthy Start Medicaid eligibility, determined by family income alone. STUDY DESIGN: As a result of a 2013 policy change, children with ABD eligibility transitioned from fee-for-service to capitated care. We used Ohio Medicaid claims data from July 2013 through June 2015 to explore the relationships among instability in eligibility category, demographics, and utilization. METHODS: To examine the potential financial effect of categorical churn, an effective capitation rate was created to capture the proportion of the maximum potential capitation rate that was realized. RESULTS: More than 20% of children exited ABD-based eligibility at least once. Switching was associated with younger age and rural residence and was not associated with healthcare use. CONCLUSIONS: Switching between eligibility categories is common and affects average capitation but not health service use.

Gender norms and modern contraceptive use in urban Nigeria: a multilevel longitudinal study.

BACKGROUND: Evidence suggests that gender equality positively influences family planning. However, the evidence from urban Africa is sparse. This study aimed to examine the association between changes in gender norms and modern contraceptive use over time among women in urban Nigeria. METHODS: Data were collected in 2010/2011 from 16,118 women aged 15-49 living in six cities in Nigeria (Abuja, Benin, Ibadan, Ilorin, Kaduna, and Zaria) and again in 2014 from 10,672 of the same women (34% attrition rate). The analytical sample included 9933 women living in 480 neighborhoods. A four-category outcome variable measured their change in modern contraceptive use within the study period. The exposure variables measured the changes in the level of gender-equitable attitudes towards: a) wife beating; b) household decision-making; c) couples' family planning decisions; and d) family planning self-efficacy. Multilevel multinomial logistic regression models estimated the associations between the exposure variables at the individual and neighborhood levels and modern contraceptive use controlling for the women's age, education, marital status, religion, parity, household wealth, and city of residence. RESULTS: The proportion of women who reported current use of modern contraceptive methods increased from 21 to 32% during the four-year study period. At both surveys, 58% of the women did not report using modern contraceptives while 11% reported using modern contraceptives; 21% did not use in 2010/2011 but started using by 2014 while 10% used in 2010/2011 but discontinued use by 2014. A positive change in the gender-equitable attitudes towards household decision-making, couples' family planning decisions, and family planning self-efficacy at the individual and neighborhood levels were associated with increased relative probability of modern contraceptive use (adoption and continued use) and decreased relative probability of modern contraceptive discontinuation by 2014. No such associations were found between the individual and neighborhood attitudes towards wife beating and modern contraceptive use. Accounting for the individual and neighborhood gender-equitable attitudes and controlling for the women's demographic characteristics accounted for 55-61% of the variation between neighborhoods in the change in modern contraceptive use during the study period. CONCLUSION: Interventions that promote gender equality have the potential to increase modern contraceptive use in Nigerian cities.

Utilization and Adherence in Medical Homes: An Assessment of Rural-Urban Differences for People With Severe Mental Illness.

BACKGROUND: The complex nature of managing care for people with severe mental illness (SMI), including major depression, bipolar disorder, and schizophrenia, is a challenge for primary care practices, especially in rural areas. The team-based emphasis of medical homes may act as an important facilitator to help reduce observed rural-urban differences in care. OBJECTIVE: The objective of this study was to examine whether enrollment in medical homes improved care in rural versus urban settings for people with SMI. RESEARCH DESIGN: Secondary data analysis of North Carolina Medicaid claims from 2004-2007, using propensity score weights and generalized estimating equations to assess differences between urban, nonmetropolitan urban and rural areas. SUBJECTS: Medicaid-enrolled adults with diagnoses of major depressive disorder, bipolar disorder or schizophrenia. Medicare/Medicaid dual eligibles were excluded. MEASURES: We examined utilization measures of primary care use, specialty mental health use, inpatient hospitalizations, and emergency department use and medication adherence. RESULTS: Rural medical home enrollees generally had higher primary care use and medication adherence than rural nonmedical home enrollees. Rural medical home enrollees had fewer primary care visits than urban medical home enrollees, but both groups were similar on the other outcome measures. These findings varied somewhat by SMI diagnosis. CONCLUSIONS: Findings indicate that enrollment in medical homes among rural Medicaid beneficiaries holds the promise of reducing rural-urban differences in care. Both urban and rural medical homes may benefit from targeted resources to help close the remaining gaps and to improve the success of the medical home model in addressing the health care needs of people with SMI.

Medicaid Enrollment among Prison Inmates in a Non-expansion State: Exploring Predisposing, Enabling, and Need Factors Related to Enrollment Pre-incarceration and Post-Release.

Prison inmates suffer from a heavy burden of physical and mental health problems and have considerable need for healthcare and coverage after prison release. The Affordable Care Act may have increased Medicaid access for some of those who need coverage in Medicaid expansion states, but inmates in non-expansion states still have high need for Medicaid coverage and face unique barriers to enrollment. We sought to explore barriers and facilitators to Medicaid enrollment among prison inmates in a non-expansion state. We conducted qualitative interviews with 20 recently hospitalized male prison inmates who had been approached by a prison social worker due to probable Medicaid eligibility, as determined by the inmates' financial status, health, and past Medicaid enrollment. Interviews were transcribed verbatim and analyzed using a codebook with both thematic and interpretive codes. Coded interview text was then analyzed to identify predisposing, enabling, and need factors related to participants' Medicaid enrollment prior to prison and intentions to enroll after release. Study participants' median age, years incarcerated at the time of the interview, and projected remaining sentence length were 50, 4, and 2 years, respectively. Participants were categorized into three sub-groups based on their self-reported experience with Medicaid: (1) those who never applied for Medicaid before prison (n = 6); (2) those who unsuccessfully attempted to enroll in Medicaid before prison (n = 3); and (3) those who enrolled in Medicaid before prison (n = 11). The six participants who had never applied to Medicaid before their incarceration did not hold strong attitudes about Medicaid and mostly had little need for Medicaid due to being generally healthy or having coverage available from other sources such as the Veteran's Administration. However, one inmate who had never applied for Medicaid struggled considerably to access mental healthcare due to lapses in employer-based health coverage and attributed his incarceration to this unmet need for treatment. Three inmates with high medical need had their Medicaid applications rejected at least once pre-incarceration, resulting in periods without health coverage that led to worsening health and financial hardship for two of them. Eleven inmates with high medical need enrolled in Medicaid without difficulty prior to their incarceration, largely due to enabling factors in the form of assistance with the application by their local Department of Social Services or Social Security Administration, their mothers, medical providers, or prison personnel during a prior incarceration. Nearly all inmates acknowledged that they would need health coverage after release from prison, and more than half reported that they would need to enroll in Medicaid to gain healthcare coverage following their release. Although more population-based assessments are necessary, our findings suggest that greater assistance with Medicaid enrollment may be a key factor so that people in the criminal justice system who qualify for Medicaid-and other social safety net programs-may gain their rightful access to these benefits. Such access may benefit not only the individuals themselves but also the communities to which they return.

Continuity of Medication Management among Adults with Schizophrenia and Comorbid Cardiometabolic Conditions.

OBJECTIVES: Adults with schizophrenia and cardiometabolic conditions may be good candidates for co-management by primary care prescribers and specialists. Associated risks for discontinuity in medication management have not been well-studied. This study examines whether medication adherence, inpatient admissions, and emergency department (ED) visits vary by the number and types of prescribers seen by adults with schizophrenia and cardiometabolic conditions. METHODS: This study used a retrospective cohort of 4,223 adult Medicaid enrollees with schizophrenia and hypertension, hyperlipidemia, and/or diabetes from three states in 2009-2010. Logistic regression models were run on outcome variables reflecting medication adherence, ED utilization, and inpatient admissions as a function of the number and types of prescribers. KEY FINDINGS: Increases in number of psychiatric specialists were associated with better antipsychotic adherence, but decreasing statin adherence. Increases in number of psychiatric specialists were also associated with a higher probability of inpatient admission and ED visits, while increases in number of primary care prescribers were associated with increases in the probability of ED visits. CONCLUSION: Greater antipsychotic adherence for adults receiving prescriptions from multiple psychiatric specialists was counteracted by lower statin adherence and greater risk of ED and inpatient utilization. This may help inform optimal care models for these complex individuals.

Implementing a Prison Medicaid Enrollment Program for Inmates with a Community Inpatient Hospitalization.

In 2011, North Carolina (NC) created a program to facilitate Medicaid enrollment for state prisoners experiencing community inpatient hospitalization during their incarceration. The program, which has been described as a model for prison systems nationwide, has saved the NC prison system approximately $10 million annually in hospitalization costs and has potential to increase prisoners' access to Medicaid benefits as they return to their communities. This study aims to describe the history of NC's Prison-Based Medicaid Enrollment Assistance Program (PBMEAP), its structure and processes, and program personnel's perspectives on the challenges and facilitators of program implementation. We conducted semi-structured interviews and a focus group with PBMEAP personnel including two administrative leaders, two "Medicaid Facilitators," and ten social workers. Seven major findings emerged: 1) state legislation was required to bring the program into existence; 2) the legislation was prompted by projected cost savings; 3) program development required close collaboration between the prison system and state Medicaid office; 4) technology and data sharing played key roles in identifying inmates who previously qualified for Medicaid and would likely qualify if hospitalized; 5) a small number of new staff were sufficient to make the program scalable; 6) inmates generally cooperated in filling out Medicaid applications, and their cooperation was encouraged when social workers explained possible benefits of receiving Medicaid after release; and 7) the most prominent program challenges centered around interaction with county Departments of Social Services, which were responsible for processing applications. Our findings could be instructive to both Medicaid non-expansion and expansion states that have either implemented similar programs or are considering implementing prison Medicaid enrollment programs in the future.

Does Maternity Care Coordination Influence Perinatal Health Care Utilization? Evidence from North Carolina.

OBJECTIVE: To examine effects of maternity care coordination (MCC) on perinatal health care utilization among low-income women. DATA SOURCES: North Carolina Center for Health Statistics Baby Love files that include birth certificates, maternity care coordination records, WIC records, and Medicaid claims. STUDY DESIGN: Causal effects of MCC participation on health care outcomes were estimated in a sample of 7,124 singleton Medicaid-covered births using multiple linear regressions with inverse probability of treatment weighting (IPTW). PRINCIPAL FINDINGS: Maternity care coordination recipients were more likely to receive first-trimester prenatal care (p < .01) and averaged three more prenatal visits and two additional primary care visits during pregnancy; they were also more likely to participate in WIC and to receive postpartum family planning services (p < .01). Medicaid expenditures were greater among mothers receiving MCC. CONCLUSIONS: Maternity care coordination facilitates access to health care and supportive services among Medicaid-covered women. Increased maternal service utilization may increase expenditures in the short run; however, improved newborn health may reduce the need for costly neonatal care, and by implication the need for early intervention and other supports for at-risk children.

Do Maternity Care Coordination Services Encourage Use of Behavioral Health Treatment among Pregnant Women on Medicaid?

OBJECTIVE: Maternity care coordination (MCC) may provide an opportunity to enhance access to behavioral health treatment services. However, this relationship has not been examined extensively in the empirical literature. This study examines the effect of MCC on use of behavioral health services among perinatal women. METHODS: Medicaid claims data from October 2008 to September 2010 were analyzed using linear fixed effects models to investigate the effects of receipt of MCC services on mental health and substance use-related service use among Medicaid-eligible pregnant and postpartum women in North Carolina (n = 7,406). RESULTS: Receipt of MCC is associated with a 20% relative increase in the contemporaneous use of any mental health treatment (within-person change in probability of any mental health visit 0.5% [95% CI, 0.1%-1.0%], or an increase from 8.3% to 8.8%); MCC in the prior month is associated with a 34% relative increase in the number of mental health visits among women who receive MCC (within-person change in the number of visits received 1.7% [95 CI, 0.2%-3.3%], or from 0.44 to 0.46 mental health visits). No relationship was observed between MCC and Medicaid-funded substance use-related treatment services. CONCLUSIONS: MCC may be an effective way to quickly address perinatal mental health needs and engage low-income women in mental health care. However, currently there may be a lost opportunity within MCC to increase access to substance use-related treatment. Future studies should examine how MCC improves access to mental health care such that the program's ability can be strengthened to identify women with substance use-related disorders and transition them into available care.

Continuity of medication management in Medicaid patients with chronic comorbid conditions: An examination by mental health status.

OBJECTIVE: Patients with serious mental illness (SMI) often have comorbid cardiometabolic conditions (CMCs) that may increase the number of prescribers involved in treatment. This study examined whether patients with SMI (depression and schizophrenia) and comorbid CMCs experience greater discontinuity of prescribing than patients with CMCs alone. METHODS: 2009 Medicaid data were used to compare number and types of prescribers (primary care, cardiometabolic, psychiatric, other) in individuals with 1-3 CMCs (diabetes, hypertension, dyslipidemia) alone (n=76.451); with CMC and schizophrenia (n=6507); and with CMC and depression (n=23.510) and the degree of prescribing within a provider's area of specialty. RESULTS: 44%, 61%, and 71% of individuals with CMCs only, with CMCs and schizophrenia, and with CMCs and depression had medications from these classes prescribed by 5 or more providers respectively. >35% of patients with CMCs alone or CMCs and schizophrenia had prescriptions provided by 3 or more PCP providers, which increased to 49.1% for patients with CMCs and depression. In the schizophrenia cohort, 29% of antipsychotics were PCP-prescribed while psychiatrists prescribed 10%, 9%, and 9% of antihypertensive, antihyperlipidemic, and antidiabetic medications respectively. CONCLUSIONS: The presence of SMI increases the number of prescribers treating individuals with CMCs. The impact of this fragmentation in medication management on health outcomes is unknown.

Effect of Medicaid Policy Changes on Medication Adherence: Differences by Baseline Adherence.

BACKGROUND: In 2001, the North Carolina (NC) Medicaid program reduced the number of days prescription supply that enrollees could fill from 100 days to 34 days and increased copayments for brand-name medications. Previous work has shown that a change in these policies led to a decrease in medication adherence from 2.9 to 8.0 percentage points in specific populations with chronic conditions. Studies have also shown that days supply limits and copayment increases have heterogeneous effects based on enrollees' baseline characteristics, including baseline adherence. However, this phenomenon has not been studied in the Medicaid population. We undertook this study to assess the heterogeneous effect of the NC Medicaid policy changes in groups with varying levels of baseline adherence. OBJECTIVE: To examine whether restrictions on days supply had heterogeneous effects in subgroups defined by medication adherence before the policy changes. METHODS: A partial difference-in-difference-in-differences model with fixed effects was used to compare medication adherence before and after the NC Medicaid policy changes among Medicaid enrollees subject to the policy changes because of their use of long prescriptions (> 40 days) as compared with (a) NC Medicaid enrollees using short prescriptions (< 40 days) before policy adoption, as well as (b) Medicaid enrollees in Georgia restricted to a 31 days supply through the study period. Medicaid enrollees were included if they filled a prescription for 1 of the following medication classes: antihypertensives, lipid-lowering drugs, or antipsychotics. The effect of the policy changes on medication adherence, calculated using the proportion of days covered (PDC) each quarter by baseline adherence level and clinical condition group, was studied. Average adherence levels over the 18-month prechange period were used to stratify individuals into 3 baseline adherence groups: fully adherent (PDC ≥ 80%), partially adherent (50%-79%), and nonadherent (PDC ≤ 50%). RESULTS: Enrollees fully adherent at baseline observed a 2.0 (P = 0.001) and 1.2 (P < 0.001) percentage-point decline in adherence for the lipid-lowering drug and antihypertensive cohorts, respectively, in the period after the policy changes. The nonadherent and partially adherent cohorts in the statin group observed an increase in adherence by 1.7-2.6 (P < 0.05) percentage points in the post-index period. CONCLUSIONS: Adherence changes after cost containment policies have a heterogeneous effect on individuals with varying baseline adherence in the Medicaid population. Individuals fully adherent at baseline decreased adherence following policy changes, while individuals partially adherent and nonadherent at baseline either had no change or showed increases in adherence, possibly because of increased contact with pharmacists and clinicians required by shorter prescription lengths. Managed care strategies to control costs should take into consideration the heterogeneity of responses by the enrollees to these policies. Furthermore, policies that consider baseline characteristics of enrollees may be more effective in improving adherence. DISCLOSURES: This study was partly funded by a grant from the Robert Wood Johnson Foundation for use in data creation. Maciejewski was supported by a Research Career Scientist Award from the Department of Veterans Affairs (RCS 10-391) and owns stock in Amgen. Farley reports consultancy fees from Daiichi Sankyo outside of the conduct of this study. The other authors report no financial or other conflicts of interest related to the subject of this article. The views expressed in this article are those of the authors and do not reflect the position or policy of the Centers for Medicare & Medicaid Services, University of North Carolina at Chapel Hill, Department of Veteran Affairs, or Duke University. Study design and concept were contributed by Amin and Domino, along with Farley and Maciejewski. Domino collected the data, and data interpretation was performed primarily by Amin, along with Domino, with assistance from Farley and Maciejewski. The manuscript was primarily written by Amin, along with Domino, and revised by all the authors.

Connecting Mentally Ill Detainees in Large Urban Jails with Community Care.

Large urban jails have become a collection point for many persons with severe mental illness. Connections between jail and community mental health services are needed to assure in-jail care and to promote successful community living following release. This paper addresses this issue for 2855 individuals with severe mental illness who received community mental health services prior to jail detention in King County (Seattle), Washington over a 5-year time period using a unique linked administrative data source. Logistic regression was used to determine the probability that a detainee with severe mental illness received mental health services while in jail as a function of demographic and clinical characteristics. Overall, 70 % of persons with severe mental illness did receive in-jail mental health treatment. Small, but statistically significant sex and race differences were observed in who received treatment in the jail psychiatric unit or from the jail infirmary. Findings confirm the jail's central role in mental health treatment and emphasize the need for greater information sharing and collaboration with community mental health agencies to minimize jail use and to facilitate successful community reentry for detainees with severe mental illness.

Expedited Medicaid Enrollment, Mental Health Service Use, and Criminal Recidivism Among Released Prisoners With Severe Mental Illness.

OBJECTIVE: This study investigated whether Washington State's 2006 policy of expediting Medicaid enrollment for offenders with severe mental illness released from state prisons increased Medicaid access and use of community mental health services while decreasing criminal recidivism. METHODS: A quasi-experimental design with linked administrative data was used to select all prisoners with a severe mental illness (schizophrenia or bipolar disorder) released during the policy's first two years (January 1, 2006, through December 31, 2007), and those referred for expedited Medicaid (N=895) were separated from a propensity-weighted control group of those not referred (N=2,191). Measures included binary indicators of Medicaid enrollment, other public insurance enrollment, postrelease use of inpatient and outpatient health services, and any postrelease criminal justice contacts. All data were collapsed to person-level observations during the 12 months after the index release, and outcomes were estimated via propensity-weighted logit models. RESULTS: Referral for expedited Medicaid on release from prison greatly increased Medicaid enrollment (p<.01) and use of community mental health and general medical services (p<.01) for persons with severe mental illness. No evidence was found that expediting Medicaid reduced criminal recidivism. CONCLUSIONS: Expediting Medicaid was associated with increased Medicaid enrollment and both mental health and general medical service use, but study findings strongly suggest that rather than relying on indirect spillover effects from Medicaid to reduce criminal recidivism, advocates and policy makers would better address the needs of offenders with severe mental illness through direct interventions targeted at underlying causes of recidivism.

Enrollment and Service Use Patterns Among Persons With Severe Mental Illness Receiving Expedited Medicaid on Release From State Prisons, County Jails, and Psychiatric Hospitals.

OBJECTIVE: This study examined postrelease patterns of Medicaid coverage and use of services among persons with severe mental illness who were referred for expedited Medicaid enrollment before their release from state prisons, county jails, and psychiatric hospitals in Washington State during 2006, the first year of a new policy authorizing this practice. METHODS: A retrospective cohort design was used with linked administrative data to identify persons with severe mental illness (schizophrenia, bipolar disorder, or major depression) who were referred for expedited Medicaid enrollment from state prisons (N=252), county jails (N=489), and psychiatric hospitals (N=507). For each cohort, logistic regression was used to compare those who were approved for expedited Medicaid with those who were not approved; for the 30-, 60-, and 90-day periods after release, Medicaid enrollment status and use of outpatient mental health services were also compared. RESULTS: Approval rates were higher for persons released from psychiatric hospitals (91%) and state prisons (83%) than for those released from jails (66%) (p<.001). Across settings, approval was more likely for those with a diagnosis of schizophrenia and for women (p<.001), as well as for whites and older offenders (p<.01). At the 90-day follow-up, those who were approved were more likely than those who were denied to be enrolled in Medicaid (p<.001) and to have used outpatient mental health services (p<.001). CONCLUSIONS: Expediting Medicaid benefits for persons with severe mental illness was associated with increased enrollment and outpatient mental health service use in the 90 days after release from state prisons, county jails, and psychiatric hospitals in Washington State.

Do primary care medical homes facilitate care transitions after psychiatric discharge for patients with multiple chronic conditions?

OBJECTIVE: Primary-care-based medical homes may facilitate care transitions for persons with multiple chronic conditions (MCC) including serious mental illness. The purpose of this manuscript is to assess outpatient follow-up rates with primary care and mental health providers following psychiatric discharge by medical home enrollment and medical complexity. METHODS: Using a quasi-experimental design, we examined data from North Carolina Medicaid-enrolled adults with MCC hospitalized with an inpatient diagnosis of depression or schizophrenia during 2008-2010. We used inverse-probability-of-treatment weighting and assessed associations between medical home enrollment and outpatient follow-up within 7 and 30 days postdischarge. RESULTS: Medical home enrollees (n=16,137) were substantially more likely than controls (n= 11,304) to receive follow-up care with any provider 30 days post discharge. Increasing patient complexity was associated with a greater probability of primary care follow-up. Medical complexity and medical home enrollment were not associated with follow-up with a mental health provider. CONCLUSIONS: Hospitalized persons with MCC including serious mental illness enrolled in a medical home were more likely to receive timely outpatient follow-up with a primary care provider but not with a mental health specialist. These findings suggest that the medical home model may be more adept at linking patients to providers in primary care rather than to specialty mental health providers.

Serving persons with severe mental illness in primary care-based medical homes.

OBJECTIVE: Primary care-based medical homes are rapidly disseminating through populations with chronic illnesses. Little is known about how these models affect the patterns of care for persons with severe mental illness who typically receive much of their care from mental health specialists. This study examined whether enrollment in a primary care medical home alters the patterns of care for Medicaid enrollees with severe mental illness. METHODS: The authors conducted a retrospective secondary data analysis of medication adherence, outpatient and emergency department visits, and screening services used by adult Medicaid enrollees with diagnoses of schizophrenia (N=7,228), bipolar disorder (N=13,406), or major depression (N=45,000) as recorded in North Carolina Medicaid claims from 2004-2007. Participants not enrolled in a medical home (control group) were matched by propensity score to medical home participants on the basis of demographic characteristics and comorbidities. Those dually enrolled in Medicare were excluded. RESULTS: Results indicate that medical home enrollees had greater use of both primary and specialty mental health care, better medication adherence, and reduced use of the emergency department. Better rates of preventive lipid and cancer screening were found only for persons with major depression. CONCLUSIONS: Enrollment in a medical home was associated with substantial changes in patterns of care among persons with severe mental illness. These changes were associated with only a modest set of incentives, suggesting that medical homes can have large multiplier effects in primary care of persons with severe mental illness.

Do medical homes increase medication adherence for persons with multiple chronic conditions?

BACKGROUND: Medications are an integral component of management for many chronic conditions, and suboptimal adherence limits medication effectiveness among persons with multiple chronic conditions (MCC). Medical homes may provide a mechanism for increasing adherence among persons with MCC, thereby enhancing management of chronic conditions. OBJECTIVE: To examine the association between medical home enrollment and adherence to newly initiated medications among Medicaid enrollees with MCC. RESEARCH DESIGN: Retrospective cohort study comparing Community Care of North Carolina medical home enrollees to nonenrollees using merged North Carolina Medicaid claims data (fiscal years 2008-2010). SUBJECTS: Among North Carolina Medicaid-enrolled adults with MCC, we created separate longitudinal cohorts of new users of antidepressants (N=9303), antihypertensive agents (N=12,595), oral diabetic agents (N=6409), and statins (N=9263). MEASURES: Outcomes were the proportion of days covered (PDC) on treatment medication each month for 12 months and a dichotomous measure of adherence (PDC>0.80). Our primary analysis utilized person-level fixed effects models. Sensitivity analyses included propensity score and person-level random-effect models. RESULTS: Compared with nonenrollees, medical home enrollees exhibited higher PDC by 4.7, 6.0, 4.8, and 5.1 percentage points for depression, hypertension, diabetes, and hyperlipidemia, respectively (P's<0.001). The dichotomous adherence measure showed similar increases, with absolute differences of 4.1, 4.5, 3.5, and 4.6 percentage points, respectively (P's<0.001). CONCLUSIONS: Among Medicaid enrollees with MCC, adherence to new medications is greater for those enrolled in medical homes.

Effects of maternity care coordination on pregnancy outcomes: propensity-weighted analyses.

Care coordination services that link pregnant women to health-promoting resources, avoid duplication of effort, and improve communication between families and providers have been endorsed as a strategy for reducing disparities in adverse pregnancy outcomes, however empirical evidence regarding the effects of these services is contradictory and incomplete. This study investigates the effects of maternity care coordination (MCC) on pregnancy outcomes in North Carolina. Birth certificate and Medicaid claims data were analyzed for 7,124 women delivering live infants in North Carolina from October 2008 through September 2010, of whom 2,255 received MCC services. Propensity-weighted analyses were conducted to reduce the influence of selection bias in evaluating program participation. Sensitivity analyses compared these results to conventional ordinary least squares analyses. The unadjusted preterm birth rate was lower among women who received MCC services (7.0 % compared to 8.3 % among controls). Propensity-weighted analyses demonstrated that women receiving services had a 1.8 % point reduction in preterm birth risk; p < 0.05). MCC services were also associated with lower pregnancy weight gain (p = 0.10). No effects of MCC were seen for birthweight. These findings suggest that coordination of care in pregnancy can significantly reduce the risk of preterm delivery among Medicaid-enrolled women. Further research evaluating specific components of care coordination services and their effects on preterm birth risk among racial/ethnic and geographic subgroups of Medicaid enrolled mothers could inform efforts to reduce disparities in pregnancy outcome.