Inequities in Telehealth Use Associated with Payer Type During the COVID-19 Pandemic.

Introduction: The COVID-19 pandemic has prompted a shift in health care delivery and compelled a heavier reliance on telehealth. The objective of this study was to determine if differences in coverage policies by payer type resulted in differential telehealth use during the first 3 months of the COVID-19 pandemic. In this population-based cohort study of low-income Arkansans, Medicaid beneficiaries enrolled in the traditional Primary Care Case Management (PCCM) program were compared with Medicaid beneficiaries covered through premium assistance in private Qualified Health Plans (QHPs). Methods: A retrospective review was conducted of insurance claims records from June 1, 2019, to June 30, 2020, for synchronous telehealth and mobile health (m-health) visits, as well as other forms of telehealth. To establish the baseline equivalence of enrollees in the two groups, propensity score matching design was used on demographic and geographic characteristics, Charlson Comorbidity Index, broadband availability, and prior service utilization. Results: Compared with enrollees in the PCCM program, Medicaid expansion enrollees in QHPs had higher odds of having had at least one telehealth visit (adjusted odds ratio [aOR] = 1.35, 95% confidence interval [CI]: 1.29-1.42) during the early phase of the COVID-19 pandemic. Categorizing utilizations by domain, QHP enrollees were more likely to use synchronous telehealth (aOR = 1.31; 95% CI: 1.25-1.37) and m-health (aOR = 5.91; 95% CI: 4.25-8.21). A higher proportion of QHP enrollees also had at least one mental or behavioral health telehealth session (aOR = 1.13; 95% CI: 1.07-1.19). Conclusions: Our study demonstrated that within low-income populations, payer type was associated with inequitable access to telehealth during the early phase of the COVID-19 pandemic.

SARS-CoV-2 Incidence in K-12 School Districts with Mask-Required Versus Mask-Optional Policies - Arkansas, August-October 2021.

Masks are effective at limiting transmission of SARS-CoV-2, the virus that causes COVID-19 (1), but the impact of policies requiring masks in school settings has not been widely evaluated (2-4). During fall 2021, some school districts in Arkansas implemented policies requiring masks for students in kindergarten through grade 12 (K-12). To identify any association between mask policies and COVID-19 incidence, weekly school-associated COVID-19 incidence in school districts with full or partial mask requirements was compared with incidence in districts without mask requirements during August 23-October 16, 2021. Three analyses were performed: 1) incidence rate ratios (IRRs) were calculated comparing districts with full mask requirements (universal mask requirement for all students and staff members) or partial mask requirements (e.g., masks required in certain settings, among certain populations, or if specific criteria could not be met) with school districts with no mask requirement; 2) ratios of observed-to-expected numbers of cases, by district were calculated; and 3) incidence in districts that switched from no mask requirement to any mask requirement were compared before and after implementation of the mask policy. Mean weekly district-level attack rates were 92-359 per 100,000 persons in the community* and 137-745 per 100,000 among students and staff members; mean student and staff member vaccination coverage ranged from 13.5% to 18.6%. Multivariable adjusted IRRs, which included adjustment for vaccination coverage, indicated that districts with full mask requirements had 23% lower COVID-19 incidence among students and staff members compared with school districts with no mask requirements. Observed-to-expected ratios for full and partial mask policies were lower than ratios for districts with no mask policy but were slightly higher for districts with partial policies than for those with full mask policies. Among districts that switched from no mask requirement to any mask requirement (full or partial), incidence among students and staff members decreased by 479.7 per 100,000 (p<0.01) upon implementation of the mask policy. In areas with high COVID-19 community levels, masks are an important part of a multicomponent prevention strategy in K-12 settings (5).

Multicomponent Informed Consent with Marshallese Participants.

Pacific Islanders are the second fastest-growing population in the United States; however, Pacific Islanders, and Marshallese specifically, are underrepresented in health research. A community-based participatory research (CBPR) approach was used to engage Marshallese stakeholders and build an academic-community research collaborative to conduct health disparities research. Our CBPR partnership pilot tested a multicomponent consent process that provides participants the option to control the use of their data. Consent forms used concise plain language to describe study information, including participant requirements, risks, and personal health information protections, and were available in both English and Marshallese. This study demonstrates that when provided a multicomponent consent, the vast majority of consenting study participants (89.6%) agreed to all additional options, and only five (10.4%) provided consent for some but not all options. Our description of the development and implementation of a multicomponent consent using a CBPR approach adds a specific example of community engagement and may be informative for other indigenous populations.

Enrollee Experience with Providers in the Arkansas Medicaid Expansion Program.

BACKGROUND: Patient ratings of their healthcare experience as a quality measure have become critically important since the implementation of the Affordable Care Act (ACA). The ACA enabled states to expand Medicaid eligibility to reduce uninsurance nationally. Arkansas gained approval to use Medicaid funds to purchase a qualified health plan (QHP) through the ACA marketplace for newly eligible beneficiaries. OBJECTIVE: We compare patient-reported satisfaction between fee-for-service Medicaid and QHP participants. DESIGN: The Consumer Assessment of Healthcare Providers and Systems (CAHPS) was used to identify differences in Medicaid and QHP enrollee healthcare experiences. Data were analyzed using a regression discontinuity design. PARTICIPANTS: Newly eligible Medicaid expansion participants enrolled in Medicaid during 2013 completed the Consumer Assessment of Health Providers and Systems (CAHPS) survey in 2014. Survey data was analyzed for 3156 participants (n = 1759 QHP/1397 Medicaid). MEASURES: Measures included rating of personal and specialist provider, rating of all healthcare received, and whether the provider offered to communicate electronically. Demographic and clinical characteristics of the enrollees were controlled for in the analyses. METHODS: Regression-discontinuity analysis was used to evaluate differential program effects on positive ratings as measured by the CAHPS survey while controlling for demographic and health characteristics of participants. KEY RESULTS: Adjusted logistic regression models for overall healthcare (OR = 0.71, 95%CI = 0.56-0.90, p = 0.004) and personal doctor (OR = 0.68, 95%CI = 0.53-0.87, p = 0.002) predicted greater satisfaction among QHP versus Medicaid participants. Results were not significant for specialists or for use of electronic communication with provider. CONCLUSIONS: Using a quasi-experimental statistical approach, we were able to control for observed and unobserved heterogeneity showing that among participants with similar characteristics, including income, QHP participants rated their personal providers and healthcare higher than those enrolled in Medicaid. Access to care, utilization of care, and healthcare and health insurance literacy may be contributing factors to these results.

"It's been like a miracle": Low-income Arkansans and access to health care services following Medicaid reform.

This article reports qualitative results from a mixed-methods evaluation of the Arkansas Health Care Independence Program. Qualitative data was collected using telephone interviews with 24 low-income Arkansans newly enrolled in Medicaid or a Qualified Health Plan in 2014. We used methods developed for rapid qualitative assessment to explore a range of general barriers and facilitators to accessing health care services. Secondary analysis guided by the most significant change technique aided in the construction of case summaries that permitted insights into participants' experiences of managing their health over time. Barriers to accessing health care services included treatment costs, beliefs and values related to health, limited health literacy, poor quality health care, provider stigma, and difficulties that made travel challenging. For 1 participant who was no longer eligible for Medicaid or a QHP, lacking health care coverage was also problematic. Facilitators included having health care coverage, life experiences that re-enforced the value of prevention, health literacy, and enhanced health care services. Low-income Arkansans experiences accessing health care elucidate access as multi-dimensional, involving not only the availability of affordable services, but treatment effectiveness and patient experiences interacting with providers and clinic staff. We use these findings to formulate recommendations for programs and policies aimed at further increasing access to high-quality health care as a strategy for reducing health disparities.

Impact of an Episode-Based Payment Initiative by Commercial Payers in Arkansas on Procedure Volume: an Observational Study.

BACKGROUND: Episode-based payment (EBP) is gaining traction among payers as an alternative to fee-for-service reimbursement. However, there is concern that EBP could influence the number of episodes. OBJECTIVE: To examine how procedure volume changed after the introduction of EBP in 2013 and 2014 under the Arkansas Health Care Payment Improvement Initiative. DESIGN: Using 2011-2016 commercial claims data, we estimate a difference-in-differences model to assess the impact of EBP on the probability of a beneficiary having an episode for four procedures that were reimbursed under EBP in Arkansas: total joint replacement, cholecystectomy, colonoscopy, and tonsillectomy. PARTICIPANTS: Commercially insured beneficiaries in Arkansas serve as our treatment group, while commercially insured beneficiaries in neighboring states serve as our comparison group. INTERVENTIONS: Statewide implementation of EBP for various clinical conditions by two of Arkansas' largest commercial insurers. MAIN MEASURES: For a given procedure type, the primary outcomes are the annual rate of procedures (number of procedures per 1000 beneficiaries) and the probability of a beneficiary undergoing that procedure in a given quarter. KEY RESULTS: The relationship between EBP and procedure volume varies across procedures. After EBP was implemented, the probability of undergoing colonoscopy increased by 17.2% (point estimate, 2.63; 95% CI, 1.18 to 4.08; p < 0.001; Arkansas pre-period mean, 15.29). The probability of undergoing total joint replacement increased by 9.9% (point estimate, 0.091; 95% CI, - 0.011 to 0.19; p = 0.08; Arkansas pre-period mean, 0.91), though this effect is not significant. There is no discernable impact on cholecystectomy or tonsillectomy volume. CONCLUSIONS: We do not find clear evidence of deleterious volume expansion. However, because the impact of EBP on procedure volume may vary by procedure, payers planning to implement EBP models should be aware of this possibility.

Arkansas's novel approach to expanding health care coverage.

The state of Arkansas is implementing a novel approach to expanding health care coverage for individuals newly eligible for Medicaid under the Patient Protection and Affordable Care Act (ACA). Through a section 1115 demonstration waiver, the state will use federal funding via a premium assistance model to secure private health insurance offered through the newly formed health insurance marketplace to those individuals aged nineteen to sixty-four who have incomes at or below 138 percent of the federal poverty level. As of April 2014, the Health Care Independence Program (HCIP), as it is formally known, had over 155,000 individuals who had been determined eligible. The HCIP premium assistance approach is commonly referred to as the "private option" and was designed to achieve comparable access, network availability, quality of care, and opportunities for improved outcomes for HCIP enrollees (i.e., those who would be eligible for traditional, fee-for-service Medicaid through ACA expansion) when compared with their privately insured counterparts. This article provides the background, political discourse, policy development, evaluation strategy, and progress report for this innovative new program.

Statewide policies for safer teen driving: an evaluation of the impact of graduated driver licensing in Arkansas.

BACKGROUND: Graduated driver licensing (GDL) requirements aim to reduce the incidence of motor vehicle crashes and crash-related fatalities for novice drivers by limiting their exposure to the most risky driving situations. These programs vary across states in their scope, intensity, and impact. The purpose of this study was to evaluate the short-term impact of the 2009 Arkansas GDL on reducing teen crashes and fatal crashes. METHODS: Arkansas motor vehicle crash data for 2008 and 2010 were compared. Changes in rates per 10,000 licensed drivers were calculated by age, during the night restriction, and for drivers with passengers. χ2 analyses were used to test significant differences in rates between pre- and post-GDL years for each age group. RESULTS: Significant decreases in crash rates were found for each age group younger than 19 years, with the largest change evident for 16-year-olds (reduction of 22%). Similar decreases were not found for adults 19 years and older. Rates of fatal crashes for 14- to 18-year-olds were reduced 59%. Nighttime crashes and crashes in vehicles driven by teens with more than one unrelated passenger also demonstrated reductions. CONCLUSION: This study provides evidence of a short-term impact of GDL restrictions on reducing teen driver crashes and fatal crashes in Arkansas. Findings for teen drivers were significantly different from those of adult drivers during the same time frame, further strengthening the results as a function of GDL restrictions as compared with alternative explanations.

Arkansas' experience: statewide surveillance and parental information on the child obesity epidemic.

Parents, clinicians, public health officials, and policy makers need readily available information on the extent of the childhood obesity epidemic. As in any epidemic, the strategies and tools used to combat the imminent threat are frequently based on scientific rationale and experience but applied in areas in which we lack complete understanding. The urgent need for information requires execution of decisions that are not risk-free--such is the case of BMI screening obesity. Use of BMI percentiles to classify weight status among youth and quantify the epidemic can inform and engage parents and other key stakeholders. Arkansas has completed its sixth year of BMI screenings for public school students. Through a groundbreaking legislative mandate that requires BMI assessments in public schools, the state has achieved both enhanced awareness among parents and their children and increased engagement by school, clinical, public health, and community leaders in response to the epidemic. External evaluations conducted since institution of BMI assessments have revealed none of the initially feared negative consequences of BMI measurements such as teasing, use of diet pills, or excessive concerns about weight. In the face of this epidemic, the risks of using BMI assessments in clinical or school-based settings must be recognized but can be managed. Arkansas' Act 1220 and BMI-reporting efforts have not only afforded parents detailed information about their children's health but also provided longitudinal data needed to fully understand the scope of childhood and adolescent obesity in the state and to track progress made in combating this epidemic.

Poor performance of body mass index as a marker for hypercholesterolemia in children and adolescents.

OBJECTIVE: To evaluate the test performance of specific body mass index (BMI) percentile cutoffs for detecting children/adolescents with hypercholesterolemia. DESIGN: Cross-sectional analysis. SETTING: National Health and Nutrition Examination Survey 1999-2004. PARTICIPANTS: Population-based sample of children (aged 3-18 years) with nonfasting total cholesterol (TC) and high-density lipoprotein (HDL) cholesterol levels and adolescents (aged 12-18 years) with fasting low-density lipoprotein (LDL) cholesterol and triglyceride (TG) levels. MAIN OUTCOME MEASURES: Individuals were classified as having hypercholesterolemia if they had a TC level greater than 200 mg/dL, HDL cholesterol level less than 35 mg/dL, LDL cholesterol level greater than 130 mg/dL, or TG level greater than 150 mg/dL, and sensitivity, specificity, and likelihood ratios were calculated for specific BMI percentiles. Receiver operating characteristic curves were constructed and area under the curve (AUC) was calculated. RESULTS: Receiver operating characteristic curves using BMI percentiles to predict abnormal levels of TC and LDL cholesterol had AUC values (0.60 for TC level and 0.63 for LDL cholesterol level) that were less than the threshold of acceptable discrimination (between 0.7-0.8). Body mass index percentiles provided better discrimination for detecting children with abnormal HDL cholesterol and TG levels, with AUC values approaching levels of acceptable discrimination (0.69 and 0.72, respectively), although there are no specific guidelines regarding management of children with these abnormalities. CONCLUSIONS: According to the American Academy of Pediatrics guidelines, abnormal levels of LDL cholesterol are used to determine which children require nutritional and pharmacologic therapy. Because BMI percentiles did not adequately identify children and adolescents with abnormal TC and LDL cholesterol levels, the new recommendations for targeted screening of obese children and adolescents may require further consideration.

Self-reported health risks linked to health plan cost and age group.

BACKGROUND: Studies of private sector employee populations have shown an association between health-risk factors and healthcare costs. Few studies have been conducted on large, public sector employee populations. The objective of the current study was to quantify health plan costs associated with individual tobacco, obesity, and physical inactivity risks in Arkansas's state employee plan. METHODS: De-identified medical and pharmacy claim costs incurred October 1, 2004-February 28, 2006 were linked with results from self-reported health-risk assessments (HRA) completed August 1, 2006-October 31, 2006. High- and no-risk groups were defined on the basis of cigarette use, BMI, and days/week of moderate physical activity. Annualized costs were compared between groups and across ages. Data were analyzed in September 2007. RESULTS: Of the eligible adults (n=77,774), 56% (n=43,461) voluntarily accessed and completed an Internet-based HRA and had claims data-linked for analyses. Average annual costs across the eligible population totaled $3205. Respondents with high risks incurred greater annual costs ($4432) than those with no risks ($2382). Costs were greater among those with one or more risks, compared with no risks, and increased with age. The greatest average annual cost was for people aged 55-64 years in the high-risk group, who had a 2.2-fold higher cost than those aged 55-64 years in the no-risk group ($7233 versus $3266). CONCLUSIONS: Healthcare costs increased with age and were differentially higher for those who used tobacco, were obese, or were physically inactive. The financial viability of the healthcare system is at risk, particularly in plans with a high proportion of adults with health-risk factors.

Considerations for an obesity policy research agenda.

The rise in obesity levels in the U.S. in the past several decades has been dramatic, with serious implications for public health and the economy. Experiences in tobacco control and other public health initiatives have shown that public policy may be a powerful tool to effect structural change to alter population-level behavior. In 2007, the National Cancer Institute convened a meeting to discuss priorities for a research agenda to inform obesity policy. Issues considered were how to define obesity policy research, key challenges and key partners in formulating and implementing an obesity policy research agenda, criteria by which to set research priorities, and specific research needs and questions. Themes that emerged were: (1) the embryonic nature of obesity policy research, (2) the need to study "natural experiments" resulting from policy-based efforts to address the obesity epidemic, (3) the importance of research focused beyond individual-level behavior change, (4) the need for economic research across several relevant policy areas, and (5) the overall urgency of taking action in the policy arena. Moving forward, timely evaluation of natural experiments is of especially high priority. A variety of policies intended to promote healthy weight in children and adults are being implemented in communities and at the state and national levels. Although some of these policies are supported by the findings of intervention research, additional research is needed to evaluate the implementation and quantify the impact of new policies designed to address obesity.

Arkansas Act 1220 of 2003 to reduce childhood obesity: its implementation and impact on child and adolescent body mass index.

Arkansas was among the first states to pass comprehensive legislation to combat childhood obesity, with Arkansas Act 1220 of 2003. Two distinct but complementary evaluations of the process, impact, and outcomes of Act 1220 are being conducted: first, surveillance of the weight status of Arkansas children and adolescents, using the statewide data amassed from the required measurements of students' body mass indexes (BMIs); and second, an independent evaluation of the process, impact, and outcomes associated with Act 1220. Various stakeholder groups initially expressed concerns about the Act, specifically concerns related to negative social and emotional consequences for students and an excessive demand on health care. Evaluation data, however, suggest that few adverse effects have occurred either in these areas of concern or in other concerns which have emerged over time. Schools are changing environments and implementing policies and programs to promote healthy behaviors and BMI levels have not increased since the implementation of Act 1220 in 2004. The Arkansas experience to date may serve to inform the efforts of other states to adopt policies to address the epidemic of childhood obesity.

Safety restraint use linked to hospital use and charges in Arkansas.

Crash data from 2001-2005 was linked to hospital discharge data to determine the impact of safety restraint use on crashed-related hospital charges and use for 4013 hospitalizations. Safety restraint use, year of hospitalization and age group affected the hospital charges and length of stay after a crash. Mean hospital charges were 44% greater for unrestrained patients ($44,736 versus $30,990); mean length of stay was 23% longer for the unrestrained (9.2 days versus 7.5 days). Lack of safety restraint use was associated with greater use of hospital resources. Prevention efforts should focus on increasing compliance.

Impact of addition of philosophical exemptions on childhood immunization rates.

BACKGROUND: Although incidence of vaccine-preventable diseases has decreased, states' school immunization requirements are increasingly challenged. Subsequent to a federal court ruling affecting religious immunization exemptions to school requirements, new legislation made philosophical immunization exemptions available in Arkansas in 2003-2004. This retrospective study conducted in 2006 describes the impact of philosophical exemption legislation in Arkansas. METHODS: Arkansas Division of Health data on immunization exemptions granted were linked to Department of Education data for all school attendees (grades K through 12) during 2 school years before the legislation (2001-2002 and 2002-2003 [Years 1 and 2, respectively]) and 2 years after philosophical exemptions were available (2003-2004 and 2004-2005 [Years 3 and 4, respectively]). Changes in numbers, types, and geographic distribution of exemptions granted are described. RESULTS: The total number of exemptions granted increased by 23% (529 to 651) from Year 1 to 2; by 17% (total 764) from Year 2 to 3 after philosophical exemptions were allowed; and by another 50% from Year 3 to 4 (total 1145). Nonmedical exemptions accounted for 79% of exemptions granted in Years 1 and 2, 92% in Year 3, and 95% in Year 4. Importantly, nonmedical exemptions clustered geographically, suggesting concentrated risks for vaccine-preventable diseases in Arkansas communities. CONCLUSIONS: Legislation allowing philosophical exemptions from school immunization requirements was linked to increased numbers of parents claiming nonmedical exemptions, potentially causing an increase in risk for vaccine-preventable diseases. Continued education and dialogue are needed to explore the balance between individual rights and the public's health.

Arkansas fights fat: translating research into policy to combat childhood and adolescent obesity.

National recommendations to address the emerging obesity epidemic include increased awareness, individual interventions, and environmental changes. However, guidance for translating public health and clinical evidence into meaningful policies has been limited. Arkansas formulated and passed simple yet powerful legislation to combat childhood obesity through actions in public schools. Specific legislative requirements were straightforward. Importantly, the act included an independent mechanism to identify, examine, debate, and develop further action steps. Based on our experience, we present a framework for developing a cross-sector approach to translating science into policy and practice, and we offer this guide to other states facing similar health threats.