Opioid utilization after orthopaedic trauma hospitalization among Medicaid-insured adults.

Opioids are vital to pain management and sedation after trauma-related hospitalization. However, there are many confounding clinical, social, and environmental factors that exacerbate pain, post-injury care needs, and receipt of opioid prescriptions following orthopaedic trauma. This retrospective study sought to characterize differences in opioid prescribing and dosing in a national Medicaid eligible sample from 2010-2018. The study population included adults, discharged after orthopaedic trauma hospitalization, and receiving an opioid prescription within 30 days of discharge. Patients were identified using the International Classification of Diseases (ICD-9; ICD-10) codes for inpatient diagnosis and procedure. Filled opioid prescriptions were identified from National Drug Codes and converted to morphine milligram equivalents (MME). Opioid receipt and dosage (e.g., morphine milligram equivalents [MME]) were examined as the main outcomes using regressions and analyzed by year, sex, race/ethnicity, residence rurality-urbanicity, and geographic region. The study population consisted of 86,091 injured Medicaid-enrolled adults; 35.3% received an opioid prescription within 30 days of discharge. Male patients (OR = 1.12, 95% CI: 1.07-1.18) and those between 31-50 years of age (OR = 1.15, 95% CI: 1.08-1.22) were found to have increased odds ratio of receiving an opioid within 30 days of discharge, compared to female and younger patients, respectively. Patients with disabilities (OR = 0.75, 95% CI: 0.71-0.80), prolonged hospitalizations, and both Black (OR = 0.87, 95% CI: 0.83-0.92) and Hispanic patients (OR = 0.72, 95% CI: 0.66-0.77), relative to white patients, had lower odds ratio of receiving an opioid prescription following trauma. Additionally, Black and Hispanic patients received lower prescription doses compared to white patients. Individuals hospitalized in the Southeastern United States and those between the ages of 51-65 age group were found to be prescribed lower average daily MME. There were significant variations in opioid prescribing practices by race, sex, and region. National guidelines for use of opioids and other pain management interventions in adults after trauma hospitalization may help limit practice variation and reduce implicit bias and potential harms in outpatient opioid usage.

Consensus-based recommendations for diagnosis and surgical management of cranioplasty and post-traumatic hydrocephalus from a European panel.

Introduction: Planning cranioplasty (CPL) in patients with suspected or proven post-traumatic hydrocephalus (PTH) poses a significant management challenge due to a lack of clear guidance. Research question: This project aims to create a European document to improve adherence and adapt to local protocols based on available resources and national health systems. Methods: After a thorough non-systematic review, a steering committee (SC) formed a European expert panel (EP) for a two-round questionnaire using the Delphi method. The questionnaire employed a 9-point Likert scale to assess the appropriateness of statements inherent to two sections: "Diagnostic criteria for PTH" and "Surgical strategies for PTH and cranial reconstruction." Results: The panel reached a consensus on 29 statements. In the "Diagnostic criteria for PTH" section, five statements were deemed "appropriate" (consensus 74.2-90.3 %), two were labeled "inappropriate," and seven were marked as "uncertain."In the "Surgical strategies for PTH and cranial reconstruction" section, four statements were considered "appropriate" (consensus 74.2-90.4 %), six were "inappropriate," and five were "uncertain." Discussion and conclusion: Planning a cranioplasty alongside hydrocephalus remains a significant challenge in neurosurgery. Our consensus conference suggests that, in patients with cranial decompression and suspected hydrocephalus, the most suitable diagnostic approach involves a combination of evolving clinical conditions and neuroradiological imaging. The recommended management sequence prioritizes cranial reconstruction, with the option of a ventriculoperitoneal shunt when needed, preferably with a programmable valve. We strongly recommend to adopt local protocols based on expert consensus, such as this, to guide patient care.

Opioid Utilization after Cardiac Surgery in the Pediatric Medicaid-Insured Population.

OBJECTIVE: To determine the variation of outpatient opioid prescribing across the US in postoperative pediatric cardiac patients. STUDY DESIGN: Retrospective, cross-sectional study using a concatenated database of Medicaid claims between from 2016 through 2018 of children 0-17 years, discharged after cardiac surgery and receiving an opioid prescription within 30 days. Filled prescriptions were identified and converted to morphine milligram equivalents (MME). Use, duration, and dose were analyzed by sex, race, ethnicity, residence urbanicity, and region. RESULTS: Among 17 186 Medicaid-enrolled children after cardiac surgery, 2129 received opioids within 30 days of discharge. Females received lower doses than males (coefficient -0.17, P = .022). Hispanic individuals were less likely to receive opioids (coefficient 0.53, P < .05, 95% CI: 0.38-0.71) and for shorter periods (coefficient 0.83, P < .001). Midwest (MW) (OR 0.61, 95% P-values < 0.05, 95% CI: 0.46-0.80) and Northeast (NE) (OR 0.43, 95% P-values < 0.05, 95% CI: 0.30-0.61) regions were less likely to receive opioids but used higher doses compared with the Southeast (SE) (MW coefficient 0.41, Southwest (SW) coefficient 0.18, NE coefficient 0.32, West (W) coefficient 0.19, P < .05). CONCLUSIONS: There were significant variations in opioid prescribing after cardiac surgery by race, ethnicity, sex, and region. National guidelines for outpatient use of opioids in children after cardiac surgery may help limit practice variation and reduce potential harms in outpatient opioid usage.

The impact of dentists' availability in delivering dental care in Florida Elementary Schools.

OBJECTIVE: This study evaluates the dentists' availability to deliver preventive dental care to children in schools and the impact of school-based programs on access. METHODS: The study population included Florida elementary-school children, differentiated by dental insurance (Medicaid, CHIP, private, or none). We considered the implementation of school-based programs using optimization modeling to (re)allocate the dentists' caseload to schools to meet demand for preventive care under resource constraints. We considered multiple settings for school-based program implementation: (i) school prioritization; and (ii) dentists' participation in public insurance. Statistical inference was used to identify communities to improve access and reduce disparities. RESULTS: School-based programs reduced unmet demand (3%-12%), being more efficient if prioritizing schools in communities targeted to improve access. The access improvement varied by insurance status and geography. Uninsured urban children benefited most from school-based programs, with 15%-75% unmet need reduction. The percentage of urban communities targeted to improve access decreased by 12% against no-school program. Such percentage remained large for suburban (15%-100%) and rural (50%-100%) communities. Disparity in access for public-insured vs. private-insured children persisted under school-based programs (32%-84% identified communities). CONCLUSION: School-based programs improve dental care access; the improvement was however different by insurance status, with uninsured children benefiting the most. Accounting to the dentists' availability in prioritizing schools resulted in effective resource allocation to school-based programs. Access disparities between public and private-insured children did not improve; school-based programs shifted resources from public-insured to uninsured. School-based programs are effective in addressing access barriers to those children experiencing them most.

Assessment of Dentist Participation in Public Insurance Programs for Children in the US.

Importance: Evaluating the availability of dentists to provide dental care services to children is important for identifying interventions for improving access. Objective: To assess dental care availability for children in the US by public insurance participation, rural-urban setting, and dentist taxonomy (general, pediatric, or specialized). Design, Setting, and Participants: This cross-sectional study analyzed the availability of dentists from matching 3 data sets: the 2020 National Plan and Provider Enumeration System, the 2019-2020 State Board of Dentistry information acquired from each state, and the 2019 InsureKidsNow.org database. Data on active dentists in most states (including the District of Columbia [combined hereinafter with states] and excluding Hawaii and Washington) were included in the analysis. The study was conducted from January 2019 to March 2022. Main Outcomes and Measures: The number and percentage of dentists participating in public insurance programs (Medicaid and/or Children's Health Insurance Program [CHIP]) were aggregated at the dental office and stratified by the rurality of their practice and taxonomy. State-level comparisons were derived between this study and reports from the Health Policy Institute of the American Dental Association, along with maps and summary statistics disseminated through a data portal and state reports. Results: Among 204 279 active dentists, participation in public insurance varied widely across states, especially for the states that manage the Medicaid and CHIP programs separately. Participation rates in Medicaid and CHIP varied substantially from those of the Health Policy Institute of the American Dental Association. Participation in Medicaid and CHIP was lowest among urban dentists (Medicaid, 26%; CHIP, 29%) and highest among rural dentists (Medicaid, 39%; CHIP, 40%), while urban dentists accounted for most of the dentist population (urban, 84%; rural, 5%). Similarly, participation in Medicaid and CHIP was substantially lower among general dentists (Medicaid, 28%; CHIP, 29%) vs pediatric dentists (57% in both programs), while each state's dentist population consisted of notably more general (84%) than pediatric (3%) dentists. Nearly half of the states revealed wide variations in Medicaid and CHIP participation between counties, ranging from no participation (21 states) to full participation (22 states). Conclusions and Relevance: The findings of this study suggest that disparities in the availability of dentists for pediatric dental care are extensive, particularly for Medicaid- and CHIP-insured children, those living in rural communities, and those receiving specialized care. Lack of dentist availability for Medicaid- and CHIP-insured children appears to deter access to receiving dental care.

Association Between In-Home Treatment and Engagement in Psychosocial Services Among Medicaid-Enrolled Youth.

OBJECTIVE: Prior studies have identified low rates of engagement in mental health (MH) services in clinic settings among children enrolled in Medicaid. Yet, little is known about whether the delivery of in-home MH treatment (in which the clinician travels to the child's home) improves engagement for this population. This study examines the association between the delivery of in-home psychosocial treatment and engagement in services among Medicaid-enrolled youth. METHOD: We used 2010 to 2014 Georgia Medicaid claims data to identify 53,508 children and adolescents (aged 5-17 years) with a MH diagnosis that initiated new psychosocial treatment. We estimated regression models controlling for covariates to examine the relationship of the receipt of any in-home psychosocial treatment in the home setting with 3 outcome measures of engagement: receipt of at least 4 psychosocial visits during the first 12 weeks; total number of psychosocial visits during the first 12 weeks; and total duration of service use. RESULTS: Those who received any in-home psychosocial treatment (compared to those who did not) had 4.3 times the odds (odds ratio = 4.3, 95% CI = 4.0, 4.7) of receiving at least 4 visits during the first 12 weeks, had 4.5 (95% CI = 4.3, 4.7) more predicted visits during the first 12 weeks, and had a longer treatment episode duration (mean rate ratio = 1.54, 95% CI = 1.48,1.59). CONCLUSION: Although many Medicaid-enrolled youth do not receive a sufficient number of MH services to achieve positive outcomes, our findings suggest that providing in-home psychosocial treatment can improve service engagement and potentially help address this challenge.

Evaluating scenarios for school reopening under COVID19.

BACKGROUND: Thousands of school systems have struggled with the decisions about how to deliver education safely and effectively amid the COVID19 pandemic. This study evaluates the public health impact of various school reopening scenarios (when, and how to return to in-person instruction) on the spread of COVID19. METHODS: An agent-based simulation model was adapted and used to project the impact of various school reopening strategies on the number of infections, hospitalizations, and deaths in the state of Georgia during the study period, i.e., February 18th-November 24th, 2020. The tested strategies include (i) schools closed, i.e., all students receive online instruction, (ii) alternating school day, i.e., half of the students receive in-person instruction on Mondays and Wednesdays and the other half on Tuesdays and Thursdays, (iii) alternating school day for children, i.e., half of the children (ages 0-9) receive in-person instruction on Mondays and Wednesdays and the other half on Tuesdays and Thursdays, (iv) children only, i.e., only children receive in-person instruction, (v) regular, i.e., all students return to in-person instruction. We also tested the impact of universal masking in schools. RESULTS: Across all scenarios, the number of COVID19-related deaths ranged from approximately 8.8 to 9.9 thousand, the number of cumulative infections ranged from 1.76 to 1.96 million for adults and 625 to 771 thousand for children and youth, and the number of COVID19-related hospitalizations ranged from approximately 71 to 80 thousand during the study period. Compared to schools reopening August 10 with a regular reopening strategy, the percentage of the population infected reduced by 13%, 11%, 9%, and 6% in the schools closed, alternating school day for children, children only, and alternating school day reopening strategies, respectively. Universal masking in schools for all students further reduced outcome measures. CONCLUSIONS: Reopening schools following a regular reopening strategy would lead to higher deaths, hospitalizations, and infections. Hybrid in-person and online reopening strategies, especially if offered as an option to families and teachers who prefer to opt-in, provide a good balance in reducing the infection spread compared to the regular reopening strategy, while ensuring access to in-person education.

Evaluating access to pediatric oral health care in the southeastern states.

BACKGROUND: In this article, the authors addressed shortcomings in existing research on pediatric oral health care access using rigorous data and methods for identifying statistically significant disparities in oral health care access for children. METHODS: The study population included children, differentiated by insurance status (Medicaid, Children's Health Insurance Program, private, none). The authors measured provider-level supply as the number of oral health care visits, stratified by provider type and urbanicity-rurality. The authors defined demand as the number of dental visits for children and derived demand and supply mainly from 2019 and 2020 data. Using statistical modeling, the authors evaluated where disparities in travel distance across communities or by insurance status were statistically significant. RESULTS: Although Dental Health Professional Shortage Areas are primarily rural, this study found that the proportions of rural, suburban, and urban communities identified for access interventions ranged from 24% through 66% and from 8% through 86%, respectively. For some states (Florida, Louisiana, Texas), rural and suburban communities showed a need for interventions for all children, whereas in the remaining states, the lack of Medicaid and Children's Health Insurance Program access mainly contributed to these disparities. Variations in access disparities with respect to insurance status across states or by urbanicity-rurality were extensive, with the rate of communities identified for reducing disparities ranging from 1% through 100%. CONCLUSIONS: All states showed a need for access interventions and for reducing disparities due to geographic location or insurance status. The sources of disparities were different across states, suggesting need for different policies and interventions across the 10 states. PRACTICAL IMPLICATIONS: The study findings support the need for policies toward reducing disparities in oral health care access.

Parallel Subgradient Algorithm with Block Dual Decomposition for Large-scale Optimization.

This paper studies computational approaches for solving large-scale optimization problems using a Lagrangian dual reformulation, solved by parallel sub-gradient methods. Since there are many possible reformulations for a given problem, an important question is: Which reformulation leads to the fastest solution time? One approach is to detect a block diagonal structure in the constraint matrix, and reformulate the problem by dualizing the constraints outside of the blocks; the approach is defined herein as block dual decomposition. Main advantage of such a reformulation is that the Lagrangian relaxation has a block diagonal constraint matrix, thus decomposable into smaller sub-problems that can solved in parallel. We show that the block decomposition can critically affect convergence rate of the sub-gradient method. We propose various decomposition methods that use domain knowledge or apply algorithms using knowledge about the structure in the constraint matrix or the dependence in the decision variables, towards reducing the computational effort to solve large-scale optimization problems. In particular, we introduce a block decomposition approach that reduces the number of dualized constraints by utilizing a community detection algorithm. We present empirical experiments on an extensive set of problem instances including a real application. We illustrate that if the number of the dualized constraints in the decomposition increases, the computational effort within each iteration of the sub-gradient method decreases while the number of iterations required for convergence increases. The key message is that it is crucial to employ prior knowledge about the structure of the problem when solving large scale optimization problems using dual decomposition.

Global Sensitivity Analysis via a Statistical Tolerance Approach.

Sensitivity analysis and multiparametric programming in optimization modeling study variations of optimal value and solutions in the presence of uncertain input parameters. In this paper, we consider simultaneous variations in the inputs of the objective and constraint (jointly called the RIM parameters), where the uncertainty is represented as a multivariate probability distribution. We introduce a tolerance approach based on principal component analysis, which obtains a tolerance region that is suited to the given distribution and can be considered a confidence set for the random input parameters. Since a tolerance region may contain parameters with different optimal bases, we extend the tolerance approach to the case where multiple optimal bases cover the tolerance region, by studying theoretical properties of critical regions (defined as the set of input parameters having the same optimal basis). We also propose a computational algorithm to find critical regions covering a given tolerance region in the RIM parameter space. Our theoretical results on geometric properties of critical regions contribute to the existing theory of parametric programming with an emphasis on the case where RIM parameters vary jointly, and provide deeper geometric understanding of critical regions. We evaluate the proposed framework using a series of experiments for sensitivity analysis, for model predictive control of an inventory management problem, and for large optimization problem instances.

Homebound by COVID19: the benefits and consequences of non-pharmaceutical intervention strategies.

BACKGROUND: Recent research has been conducted by various countries and regions on the impact of non-pharmaceutical interventions (NPIs) on reducing the spread of COVID19. This study evaluates the tradeoffs between potential benefits (e.g., reduction in infection spread and deaths) of NPIs for COVID19 and being homebound (i.e., refraining from interactions outside of the household). METHODS: An agent-based simulation model, which captures the natural history of the disease at the individual level, and the infection spread via a contact network assuming heterogeneous population mixing in households, peer groups (workplaces, schools), and communities, is adapted to project the disease spread and estimate the number of homebound people and person-days under multiple scenarios, including combinations of shelter-in-place, voluntary quarantine, and school closure in Georgia from March 1 to September 1, 2020. RESULTS: Compared to no intervention, under voluntary quarantine, voluntary quarantine with school closure, and shelter-in-place with school closure scenarios 4.5, 23.1, and 200+ homebound adult-days were required to prevent one infection, with the maximum number of adults homebound on a given day in the range of 119 K-248 K, 465 K-499 K, 5388 K-5389 K, respectively. Compared to no intervention, school closure only reduced the percentage of the population infected by less than 16% while more than doubling the peak number of adults homebound. CONCLUSIONS: Voluntary quarantine combined with school closure significantly reduced the number of infections and deaths with a considerably smaller number of homebound person-days compared to shelter-in-place.

Accounting for uncertainty in policy decision making: Improving access to pediatric dental care.

OBJECTIVE: To introduce a statistical inference framework for policy decision making on access to pediatric dental care. DATA SOURCES: Secondary data were collected for the state of Colorado for year 2019. STUDY DESIGN: The access model was an optimization model, matching the demand (patients) and supply (providers) of dental care. Sampling distributions of model inputs were specified using hierarchical Bayesian models, with hyperparameters informed by prior information derived from multiple data sources. Simultaneous inference was applied to identify areas for access improvement. The model was applied to make inference on the pediatric dental care in Colorado, accounting for financial access, differentiated into public (Medicaid and CHIP), private (commercial and out-of-pocket), and without financial access. DATA COLLECTION/EXTRACTION METHODS: Multiple data sources informed the access measurement approach including: 2017 American Community Survey, 2019 Colorado Dental Board, and 2019 National Provider Plan and Enumeration System, 2019 InsureKidsNow.gov among others. PRINCIPAL FINDINGS: The median access measure (travel distance) was greater than the Colorado access standards in 16.9% and 65.1% of census tracts for children with private financial access and publicly insured, respectively. Accounting for uncertainty (confidence level 99%), these percentages decreased to 14.6% and 25.6%, respectively, with mostly suburban and rural tracts failing to meet the standards. The median disparity for Medicaid and CHIP versus private financial access was greater than 5 miles in 84.5% and 81.6% of census tracts, respectively. Accounting for uncertainty (confidence level 99%), these percentages declined to 19.5% and 10.5%, respectively, with significant disparities around the metropolitan areas. CONCLUSIONS: While many communities failed to meet access standards, when accounting for uncertainty, most urban ones did not fail. Disparities in spatial access between publicly and privately insured were most acute in urban communities. Medicaid insured experienced higher disparities than CHIP insured; those differences were not identified when not accounting for uncertainty.

Reflecting on prediction strategies for epidemics: Preparedness and public health response.

OBJECTIVE: To provide an overview of the literature on respiratory infectious disease epidemic prediction, preparedness, and response (including pharmaceutical and nonpharmaceutical interventions) and their impact on public health, with a focus on respiratory conditions such as asthma. DATA SOURCES: Published literature obtained through PubMed database searches. STUDY SELECTIONS: Studies relevant to infectious epidemics, asthma, modeling approaches, health care access, and data analytics related to intervention strategies. RESULTS: Prediction, prevention, and response strategies for infectious disease epidemics use extensive data sources and analytics, addressing many areas including testing and early diagnosis, identifying populations at risk of severe outcomes such as hospitalizations or deaths, monitoring and understanding transmission and spread patterns by age group, social interactions geographically and over time, evaluating the effectiveness of pharmaceutical and nonpharmaceutical interventions, and understanding prioritization of and access to treatment or preventive measures (eg, vaccination, masks), given limited resources and system constraints. CONCLUSION: Previous epidemics and pandemics have revealed the importance of effective preparedness and response. Further research and implementation need to be performed to emphasize timely and actionable strategies, including for populations with particular health conditions (eg, chronic respiratory diseases) at risk for severe outcomes.

Assessing Health and Wellness Outcomes of Medicaid-Enrolled Infants Born to Adolescent Mothers.

OBJECTIVE: To assess the effect of adolescent birth on the health and wellness of these infants within their first year of life. METHODS: Our study focused on 2011 Medicaid births nationwide. The study group (infants born to adolescents, aged 10 to 19 at time of birth) was matched with infants born to adults (aged 20 to 44 at time of birth), based on demographics. Statistical tests (proportion test and Poisson test) were used to compare the outcomes of these two groups to determine if differences were significant. RESULTS: The outcomes assessed were: low birth weight (LBW), substance exposure, foster care, health status, infant mortality, emergency department (ED) visits, and wellness visits. Of the 68,562 infant pairs included in the study, we found statistically significant higher rates of LBW (P ≤ 0·005), infant mortality (P = 0·05), and ED visits (P ≤ 0·005) for infants born to adolescents at the 95% confidence interval. The rate of wellness visits for all infants was well below the recommended amount. Additional differences were found at the race/ethnicity and urbanicity levels. CONCLUSION FOR PRACTICE: Infants born to adolescents had a higher rate of ED visits within the first year of life, however, the increased rates of LBW and mortality for the Medicaid population are not as significant as previous national studies suggest. Analysis of outcomes across stratification helped identify vulnerable populations (i.e. urban infants). Public health programs are urged to examine ED visits in infants born to adolescents among the Medicaid population. Improved health education or phone-based resources could help reduce unnecessary visits and reduce cost.

The impact of social distancing on COVID19 spread: State of Georgia case study.

As the spread of COVID19 in the US continues to grow, local and state officials face difficult decisions about when and how to transition to a "new normal." The goal of this study is to project the number of COVID19 infections and resulting severe outcomes, and the need for hospital capacity under social distancing, particularly, shelter-in-place and voluntary quarantine for the State of Georgia. We developed an agent-based simulation model to project the infection spread. The model utilizes COVID19-specific parameters and data from Georgia on population interactions and demographics. The simulation study covered a seven and a half-month period, testing different social distancing scenarios, including baselines (no-intervention or school closure only) and combinations of shelter-in-place and voluntary quarantine with different timelines and compliance levels. The following outcomes are compared at the state and community levels: the number and percentage of cumulative and daily new symptomatic and asymptomatic infections, hospitalizations, and deaths; COVID19-related demand for hospital beds, ICU beds, and ventilators. The results suggest that shelter-in-place followed by voluntary quarantine reduced peak infections from approximately 180K under no intervention and 113K under school closure, respectively, to below 53K, and delayed the peak from April to July or later. Increasing shelter-in-place duration from four to five weeks yielded 2-9% and 3-11% decrease in cumulative infection and deaths, respectively. Regardless of the shelter-in-place duration, increasing voluntary quarantine compliance decreased daily new infections from almost 53K to 25K, and decreased cumulative infections by about 50%. The cumulative number of deaths ranged from 6,660 to 19,430 under different scenarios. Peak infection date varied across scenarios and counties; on average, increasing shelter-in-place duration delayed the peak day by 6 days. Overall, shelter-in-place followed by voluntary quarantine substantially reduced COVID19 infections, healthcare resource needs, and severe outcomes.

Provider-Level Caseload of Psychosocial Services for Medicaid-Insured Children.

OBJECTIVE: We estimated the caseload of providers, practices, and clinics for psychosocial services (including psychotherapy) to Medicaid-insured children to improve the understanding of the current supply of such services and to inform opportunities to increase their accessibility. METHODS: We used 2012-2013 Medicaid claims data and data from the 2013 National Plan and Provider Enumeration System to identify and locate therapists, psychiatrists, and mental health centers along with primary, rehabilitative, and developmental care providers in the United States who provided psychosocial services to Medicaid-insured children. We estimated the per-provider, per-location, and state-level caseloads of providers offering these services to Medicaid-insured children in 34 states with sufficiently complete data to perform this analysis, by using the most recent year of Medicaid claims data available for each state. We measured caseload by calculating the number of psychosocial visits delivered by each provider in the selected year. We compared caseloads across states, urbanicity, provider specialty (eg, psychiatry, psychology, primary care), and practice setting (eg, mental health center, single practitioner). RESULTS: We identified 63 314 providers, practices, or centers in the Medicaid claims data that provided psychosocial services to Medicaid-insured children in either 2012 or 2013. The median provider-level per-year caseload was <25 children and <250 visits across all provider types. Providers with a mental health center-related taxonomy accounted for >40% of visits for >30% of patients. Fewer than 10% of providers and locations accounted for >50% of patients and visits. CONCLUSIONS: Psychosocial services are concentrated in a few locations, thereby reducing geographic accessibility of providers. Providers should be incentivized to offer care in more locations and to accept more Medicaid-insured patients.

An Economic Analysis of Intensive Multidisciplinary Interventions for Treating Medicaid-Insured Children with Pediatric Feeding Disorders.

Background. Intensive multidisciplinary intervention (IMI) represents a well-established treatment for pediatric feeding disorders (PFDs), but program availability represents an access care barrier. We develop an economic analysis of IMI for weaning from gastronomy tube (G-tube) treatment for children diagnosed with PFDs from the Medicaid programs' perspective, where Medicaid programs refer to both fee-for-service and managed care programs. Methods. The 2010-2012 Medicaid Analytic eXtract claims provided health care data for children aged 13 to 72 months. An IMI program provided data on average admission costs. We employed a finite-horizon Markov model to simulate PFD treatment progression assuming 2 treatment arms: G-tube only v. IMI targeting G-tube weaning. We compared the expenditure differential between the 2 arms under varying time horizons and treatment effectiveness. Results. Overall Medicaid expenditure per member per month was $6814, $2846, and $1550 for the study population of children with PFDs and G-tube treatment, the control population with PFDs without G-tube treatment, and the no-PFD control population, respectively. The PFD-diagnosed children with G-tube treatment only had the highest overall expenditures across all health care settings except psychological services. The expenditure at the end of the 8-year time horizon was $405,525 and $208,218 per child for the G-tube treatment only and IMI arms, respectively. Median Medicaid expenditure was between 1.7 and 2.2 times higher for the G-tube treatment arm than for the IMI treatment arm. Limitations. Data quality issues could cause overestimates or underestimates of Medicaid expenditure. Conclusions. This study demonstrated the economic benefits of IMI to treat complex PFDs from the perspective of Medicaid programs, indicating this model of care not only holds benefit in terms of improving overall quality of life but also brings significant expenditure savings in the short and long term.

Medicaid caseload for pediatric oral health care.

BACKGROUND: The authors' aims were to compare, according to strata, dentists' participation in Medicaid and Medicaid provider-level caseload measured as the number of patients or visits for preventive or restorative care for 2 comparison years. METHODS: The data sources were the 2012-2013 Medicaid Analytic eXtract claims and 2013 National Plan and Provider Enumeration System data sets. The authors measured Medicaid participation as the proportion of dentists participating in Medicaid among those in the National Plan and Provider Enumeration System. The authors measured provider-level caseload according to the number of patients or visits. The authors stratified oral health care providers according to state; whether practicing in rural, suburban, or urban communities; and provider type. RESULTS: The differences in participation rates for rural versus suburban and versus urban communities ranged from -4% through 27% and -6% through 37%, respectively. The 2012 state median number of patients per provider for preventive care ranged from 99 through 358. The provider-level caseload increased from rural to urban and from other provider to general dentist to pediatric dentist. The difference in caseload from 2012 to 2013 was not statistically significant except for the pediatric dentist type. CONCLUSIONS: This study's results suggest that the realized caseload for children enrolled in Medicaid varies according to provider type and urbanicity. The state median caseload for preventive care is lower than the 500:1 patient to provider ratio used as the minimum caseload in access estimates from other studies. PRACTICAL IMPLICATIONS: This study's results can assist states in gauging the level of oral health care provided to children insured by Medicaid compared with that in other states, with implications for the specification of oral health policies.

Projecting the economic impact of silver diamine fluoride on caries treatment expenditures and outcomes in young U.S. children.

OBJECTIVE: To quantify the economic impact of using silver diamine fluoride (SDF) to arrest the progression of dental caries in Medicaid-enrolled children (aged 1-5 years) relative to the standard restorative treatment from the Medicaid programs' perspective. METHODS: We used Monte Carlo simulation to estimate averted restorative visits and associated expenditures for varying SDF effectiveness and intervention penetration levels. We compared the current standard of care for treating caries to applying SDF. We estimated expenditures from the 2010-2012 Medicaid Analytic Extract files for seven US states and the incremental cost effectiveness ratio for SDF application on averted restorative visits. RESULTS: Across the seven states, averted restorative visits ranged from 2,049 (Vermont) to 60,542 (North Carolina), assuming an SDF penetration level of 50%. Averted per-restorative visit costs ranged from $100 to $350 per-visit. There were higher averted per-restorative visit costs in nonmetropolitan counties than metropolitan counties. CONCLUSIONS: Providing SDF as a caries management strategy can reduce Medicaid program dental care expenditures by averting expensive caries treatment options. It could also prevent stressful restorative procedures. State Medicaid programs should consider reimbursing for SDF to arrest the progression of dental caries in young children.

Medicaid Claims for Contraception Among Women With Medical Conditions After Release of the US Medical Eligibility Criteria for Contraceptive Use.

INTRODUCTION: The US Medical Eligibility Criteria for Contraceptive Use (MEC) identified 20 medical conditions that increase a woman's risk for adverse outcomes in pregnancy. MEC recommends that women with these conditions use long-acting, highly effective contraceptive methods. The objective of our study was to examine provision of contraception to women enrolled in Medicaid who had 1 or more of these 20 medical conditions METHODS: We used Medicaid Analytic Extract claims data to study Medicaid-enrolled women who were of reproductive age in the 2-year period before MEC's release (2008 and 2009) (N = 442,424) and the 2-year period after its release (2011 and 2012) (N = 533,619) for 14 states. We assessed 2 outcomes: provision of family planning management (FPM) and provision of highest efficacy methods (HEMs) for the entire study population and by health condition. The ratio of the after-MEC rate to the before-MEC rate was used to determine significance in MEC's uptake. RESULTS: Outcomes increased significantly from the before-MEC period to the after-MEC period for both FPM (1.06; lower bound confidence interval [CI], 1.05) and HEM (1.37; lower bound CI, 1.36) for a 1-sided hypothesis test. For the 19 of 20 conditions we were able to test for FPM, contraceptive use increased significantly for 12 conditions, with ratios ranging from 1.05 to 2.14. For the 16 of 20 conditions tested for HEM, contraception use increased significantly for all conditions, with ratios ranging from 1.19 to 2.80. CONCLUSION: Provision of both FPM and HEM increased significantly among women with high-risk health conditions from the before-MEC period (2008 and 2009) to the after-MEC period (2011 and 2012). Health policy makers and clinicians need to continue promotion of effective family planning management for women with high-risk conditions.