The Association of Learning Health System Practicing Hospitals and other Health Information Interested Hospitals with Patient-Generated Health Data Uptake.

Patient generated health data (PGHD) has been described as a necessary addition to provider-generated information for improving care processes in US hospitals. This study evaluated the distribution of Health Information Interested (HII) US hospitals that are more likely to capture or use PGHD. The literature suggests that HII hospitals are more likely to capture and use PGHD. Cross-sectional analysis of the 2018 American Hospital Association's (AHA) health-IT-supplement and other supporting datasets showed that HII hospitals collectively and majority of HII hospital subcategories evaluated were associated with increased PGHD capture and use. The full Learning Health System (LHS) hospital subcategory had the highest association and hospitals in the meaningful use stage three compliant (MU3) and PCORI funded subcategory also had higher rates of PGHD capture or use when in combination with LHS hospitals. Hence, being LHS appears to be the strongest practice and policy lever to increase PGHD capture and use.

The Evolution and Typology of Learning Health System Hospitals and other Health Information Interested Hospitals in the US.

This study identifies the type, distribution, and interactions of US hospitals that identify as electronic-data-driven, patient-centric, and learning-focused. Such facilities, termed Health Information Interested (HII) hospitals in this study, meet the defining criteria for one or more of the following designations: learning health systems (LHS), Health Information Technology for Economic and Clinical Health (HITECH) meaningful use stage three compliant (MU3), Patient-Centered Outcomes Research Institute (PCORI) funded, or medical home/safety net (MH/SN) hospital. The American Hospital Association (AHA) IT supplemental survey and other supporting data spanning 2013 to 2018 were used to identify HII hospitals. HII hospitals increased from 19.9 percent to 62.4 percent of AHA reporting hospitals from 2013 to 2018. HII subcategories in 2018 such as the full LHS (37.2 percent) and MU3 (46.9 percent) were dominant, with 33.2 percent having both designations. This indicates increased interest in patient-centric, learning-focused care using electronic health data. This information can enable health information management (HIM) professionals to be aware of programs or approaches that can facilitate learning-focused, patient-centric care using electronic health data within health systems.

Oregon's Medicaid Reform And Transition To Global Budgets Were Associated With Reductions In Expenditures.

In 2012 Oregon initiated an ambitious delivery system reform, moving the majority of its Medicaid enrollees into sixteen coordinated care organizations, a type of Medicaid accountable care organization. Using claims data, we assessed measures of access, appropriateness of care, utilization, and expenditures for five service areas (evaluation and management, imaging, procedures, tests, and inpatient facility care), comparing Oregon to the neighboring state of Washington. Overall, the transformation into coordinated care organizations was associated with a 7 percent relative reduction in expenditures across the sum of these services, attributable primarily to reductions in inpatient utilization. The change to coordinated care organizations also demonstrated reductions in avoidable emergency department visits and improvements in some measures of appropriateness of care, but also exhibited reductions in primary care visits, a potential area of concern. Oregon's coordinated care organizations could provide lessons for controlling health care spending for other state Medicaid programs.

Start-Up and Ongoing Practice Expenses of Behavioral Health and Primary Care Integration Interventions in the Advancing Care Together (ACT) Program.

PURPOSE: Provide credible estimates of the start-up and ongoing effort and incremental practice expenses for the Advancing Care Together (ACT) behavioral health and primary care integration interventions. METHODS: Expenditure data were collected from 10 practice intervention sites using an instrument with a standardized general format that could accommodate the unique elements of each intervention. RESULTS: Average start-up effort expenses were $44,076 and monthly ongoing effort expenses per patient were $40.39. Incremental expenses averaged $20,788 for start-up and $4.58 per patient for monthly ongoing activities. Variations in expenditures across practices reflect the differences in intervention specifics and organizational settings. Differences in effort to incremental expenditures reflect the extensive use of existing resources in implementing the interventions. CONCLUSIONS: ACT program incremental expenses suggest that widespread adoption would likely have a relatively modest effect on overall health systems expenditures. Practice effort expenses are not trivial and may pose barriers to adoption. Payers and purchasers interested in attaining widespread adoption of integrated care must consider external support to practices that accounts for both incremental and effort expense levels. Existing knowledge transfer mechanisms should be employed to minimize developmental start-up expenses and payment reform focused toward value-based, Triple Aim-oriented reimbursement and purchasing mechanisms are likely needed.

Impact of comprehensive insurance parity on follow-up care after psychiatric inpatient treatment in Oregon.

OBJECTIVE: This study assessed the impact of Oregon's 2007 parity law, which required behavioral health insurance parity, on rates of follow-up care provided within 30 days of psychiatric inpatient care. METHODS: Data sources were claims (2005-2008) for 737 individuals with inpatient stays for a mental disorder who were continuously enrolled in insurance plans affected by the parity law (intervention group) or in commercial, self-insured plans that were not affected by the law (control group). A difference-in-difference analysis was used to compare rates of follow-up care before and after the parity law between discharges of individuals in the intervention group and the control group and between discharges of individuals in the intervention group who had or had not met preparity quantitative coverage limits during a coverage year. Estimates of the marginal effects of the parity law were adjusted for gender, discharge diagnosis, relationship to policy holder, and calendar quarter of discharge. RESULTS: The study included 353 discharges in the intervention group and 535 discharges in the control group. After the parity law, follow-up rates increased by 11% (p=.042) overall and by 20% for discharges of individuals who had met coverage limits (p=.028). CONCLUSIONS: The Oregon parity law was associated with a large increase in the rate of follow-up care, predominantly for discharges of individuals who had met preparity quantitative coverage limits. Given similarities between the law and the 2008 Mental Health Parity and Addiction Equity Act, the results may portend a national effect of more comprehensive parity laws.

The individual and program impacts of eliminating Medicaid dental benefits in the Oregon Health Plan.

OBJECTIVES: We determined how elimination of dental benefits among adult Medicaid beneficiaries in Oregon affected their access to dental care, Medicaid expenditures, and use of medical settings for dental services. METHODS: We used a natural experimental design using Medicaid claims data (n = 22 833) before and after Medicaid dental benefits were eliminated in Oregon in 2003 and survey data for continuously enrolled Oregon Health Plan enrollees (n = 718) covering 3 years after benefit cuts. RESULTS: Claims analysis showed that, compared with enrollees who retained dental benefits, those who lost benefits had large increases in dental-related emergency department use (101.7%; P < .001) and expenditures (98.8%; P < .001) and in all ambulatory medical care use (77.0%; P < .01) and expenditures (114.5%; P < .01). Survey results indicated that enrollees who lost dental benefits had nearly 3 times the odds (odds ratio = 2.863; P = .001) of unmet dental need, and only one third the odds (odds ratio = 0.340; P = .001) of getting annual dental checkups relative to those retaining benefits. CONCLUSIONS: Combined evidence from both analyses suggested that the elimination of dental benefits resulted in significant unmet dental health care needs, which led to increased use of medical settings for dental problems.

Capitation of public mental health services in Colorado: a five-year follow-up of system-level effects.

OBJECTIVE: Capitated Medicaid mental health programs have reduced costs over the short term by lowering the utilization of high-cost inpatient services. This study examined the five-year effects of capitated financing in community mental health centers (CMHCs) by comparing not-for-profit with for-profit programs. METHODS: Data were from the Medicaid billing system in Colorado for the precapitation year (1994) and a shadow billing system for the postcapitation years (1995-1999). In a panel design, a random-effect approach estimated the impact of two financing systems on service utilization and cost while adjusting for all the covariates. RESULTS: Consistent with predictions, in both the for-profit and the not-for-profit CMHCs, relative to the precapitation year, there were significant reductions in each postcapitation year in high-cost treatments (inpatient treatment) for all but one comparison (not-for-profit CMHCs in 1999). Also consistent with predictions, the for-profit programs realized significant reductions in cost per user for both outpatient services and total services. In the not-for-profit programs, there were no significant changes in cost per user for total services; a significant reduction in cost per user for outpatient services was found only in the first two years, 1995 and 1996). CONCLUSIONS: The evidence suggests that different strategies were used by the not-for-profit and for-profit programs to control expenditures and utilization and that the for-profit programs were more successful in reducing cost per user.

Limited English proficient Asian Americans: Threshold language policy and access to mental health treatment.

The importance of providing timely, effective mental health services is increasingly recognized worldwide, and language barriers are a formidable obstacle to achieving this objective. Threshold language policy is one response implemented by California and other states within the U.S., in accordance with Title VI of the Civil Rights Act of 1964, which prohibits discrimination on the basis of race, color, and national origin in programs receiving federal funding. This policy mandates language assistance services for Medicaid enrollees whose primary language is other than English once their population size reaches a designated level. Medicaid is the federal-state-funded health insurance program for specific classifications of low-income Americans. This study evaluated the impact of threshold language policy on Vietnamese, Cantonese, Hmong, and Cambodian limited English proficiency persons' use of public mental health services in California. Using random-effects regression on 247 observations, we regressed aggregate Vietnamese, Cantonese, Hmong, and Cambodian Medicaid mental health service penetration rates on an indicator of the threshold language policy's implementation, while controlling for a linear time trend and the effects of non-threshold language assistance programming. Immediately after implementation, threshold language policy requirements were associated with a penetration rate increase among this population. The penetration rate increase became greater after accounting for the impact of concurrent language assistance. However, this increase diminished over time. The findings indicate that, at least in the short run, language assistance measures requiring reasonable accommodations once populations of LEP persons reach a specified size have detectable effects on their mental health service use. These requirements increase the number of mental health consumers, but appear to provide declining benefit over time. California's threshold language policy provides one example of how public or national health systems worldwide may attempt to address the issue of equity of mental health service access for burgeoning immigrant/migrant populations with language assistance needs.

Benefit policy and disenrollment of adult Medicaid beneficiaries from the Oregon health plan.

Oregon's Medicaid program experienced a dramatic decrease in its non-categorically eligible adult members after implementing a new benefit policy in February 2003 for these beneficiaries. The policy included four main elements: premium increases for some enrollees; a more stringent premium payment policy; elimination of some benefits, including mental health and substance abuse treatment; and, the imposition of co-payments. The study compared monthly disenrollment rates eight months before and after the policy change. The new premium payment policy was found to be the main driver of disenrollment, followed by benefit elimination. Premium increases and co-payments had limited impact. Disenrollment was particularly high among vulnerable beneficiary groups, including people with no reported income, those previously obtaining premium waivers, methadone users, and other enrollees with substance abuse conditions. Better understanding of the relationship between benefit design and retention in public health insurance programs could help avoid the unintended policy effects experienced in Oregon.

Effect of eliminating behavioral health benefits for selected medicaid enrollees.

OBJECTIVE: To determine the extent to which the elimination of behavioral health benefits for selected beneficiaries of Oregon's Medicaid program affected general medical expenditures among enrollees using outpatient mental health and substance abuse treatment services. DATA SOURCE/STUDY SETTING: Twelve months of claims before and 12 months following a 2003 policy change, which included the elimination of the behavioral health benefit for selected Oregon Medicaid enrollees. STUDY DESIGN: We use a difference-in-differences approach to estimate the change in general medical expenditures following the 2003 policy change. We compare two methodological approaches: regression with propensity score weighting; and one-to-one covariate matching. PRINCIPAL FINDINGS: Enrollees who had accessed the substance abuse treatment benefit demonstrated substantial and statistically significant increases in expenditures. Individuals who accessed the outpatient mental health benefit demonstrated a decrease or no change in expenditures, depending on model specification. CONCLUSIONS: Elimination of the substance abuse benefit led to increased medical expenditures, although this offset was still smaller than the total cost of the benefit. In contrast, individuals who accessed the outpatient mental health benefit did not exhibit a similar increase, although these individuals did not include a portion of the Medicaid population with severe mental illnesses.

How effective are copayments in reducing expenditures for low-income adult Medicaid beneficiaries? Experience from the Oregon health plan.

OBJECTIVES: To determine the impact of introducing copayments on medical care use and expenditures for low-income, adult Medicaid beneficiaries. DATA SOURCES/STUDY SETTING: The Oregon Health Plan (OHP) implemented copayments and other benefit changes for some adult beneficiaries in February 2003. STUDY DESIGN: Copayment effects were measured as the "difference-in-difference" in average monthly service use and expenditures among cohorts of OHP Standard (intervention) and Plus (comparison) beneficiaries. DATA COLLECTION/EXTRACTION METHODS: There were 10,176 OHP Standard and 10,319 Plus propensity score-matched subjects enrolled during November 2001-October 2002 and May 2003-April 2004 that were selected and assigned to 59 primary care-based service areas with aggregate outcomes calculated in six month intervals yielding 472 observations. RESULTS: Total expenditures per person remained unchanged (+2.2 percent, p=.47) despite reductions in use (-2.7 percent, p<.001). Use and expenditures per person decreased for pharmacy (-2.2 percent, p<.001; -10.5 percent, p<.001) but increased for inpatient (+27.3 percent, p<.001; +20.1 percent, p=.03) and hospital outpatient services (+13.5 percent, p<.001; +19.7 percent, p<.001). Ambulatory professional (-7.7 percent, p<.001) and emergency department (-7.9 percent, p=.03) use decreased, yet expenditures remained unchanged (-1.5 percent, p=.75; -2.0 percent, p=.68, respectively) as expenditures per service user rose (+6.6 percent, p=.13; +7.9 percent, p=.03, respectively). CONCLUSIONS: In the Oregon Medicaid program applying copayments shifted treatment patterns but did not provide expected savings. Policy makers should use caution in applying copayments to low-income Medicaid beneficiaries.

Assessment, authorization and access to medicaid managed mental health care.

Examined were effects on access of managed care assessment and authorization processes in California's 57 county mental health plans. Primary data on managed care implementation were collected from surveys of county plan administrators; secondary data were from Medicaid claims and enrollment files. Using multivariate fixed effects regression, we found that following implementation of managed care, greater access occurred in county plans where assessments and treatment were performed by the same clinician, and where service authorizations were made more rapidly. Lower access occurred in county plans where treating clinicians authorized services themselves. Results confirm the significant effects of managed care processes on outcomes and highlight the importance of system capacity.

Capitation and racial and ethnic differences in use and cost of public mental health services.

This study investigated racial and ethnic differences in the probability of mental health service use and costs of treatment before and after the implementation of capitated financing. Models were created to test effects on utilization and costs of African American, Latinos, and white mental health consumers. As service use and costs declined under capitation, Latino, and white levels of use and cost tended to converge. African American utilization patterns in the capitated areas tended to parallel their white counterparts. Differential rejection by, or exclusion of, African American and Latino consumers did not appear to occur in response to capitation.

Social networks and their relationship to mental health service use and expenditures among Medicaid beneficiaries.

OBJECTIVE: This study examined the relationship between social networks and mental health services utilization and expenditures. METHODS: A sample of 522 Medicaid mental health consumers was randomly selected from the administrative records of Colorado's Department of Health Care Policy and Financing. The administrative records contain information on utilization of services and expenditures of Medicaid beneficiaries within Colorado's Mental Health Services. In addition to the administrative records, social network and psychosocial data were gathered through longitudinal survey interviews. The interviews were conducted at six-month intervals between 1994 and 1997. Measures used in the regression analysis included demographic characteristics, clinical diagnoses, the social network index, expenditures, and utilization variables. RESULTS: The social network index was positively associated with utilization of and expenditures for inpatient services in local hospitals but negatively associated with expenditures for inpatient services in state hospitals or outpatient services. Relationships with family were negatively related to expenditures for outpatient services. Relationships with friends were positively associated with utilization of and expenditures for psychiatric inpatient services in local hospitals. CONCLUSIONS: Consumers who had higher social network index scores utilized more inpatient psychiatric services in local hospitals and had higher expenditures than those who had lower scores. Consumers who had higher social network index scores also had lower expenditures for inpatient services in state hospitals and outpatient services than those who have lower scores. Findings suggest that social network is associated with mental health utilization and expenditures in various ways, associations that need to be researched further.

Effects on outpatient and emergency mental health care of strict Medicaid early periodic screening, diagnosis, and treatment enforcement.

We investigated enforcement of mental health benefits provided by California Medicaid's Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program. Enforcement, compelled by a consumer-driven lawsuit, resulted in an almost 4-fold funding increase over a 5-year period. We evaluated the impact of enforcement on outpatient treatment intensity (number of visits per child) and rates of emergency care treatment. Using fixed-effects regression, we examined the number of outpatient mental health visits per client and the percentage of all clients using crisis care across 53 autonomous California county mental health plans over 32 three-month periods (quarters; emergency crisis care rates) and 36 quarters (out-patient mental health visits). Enforcement of EPSDT benefits in accordance with federal law produced favorable changes in patterns of mental health service use, consistent with policy aims.

Medication treatment patterns for adults with schizophrenia in Medicaid managed care in Colorado.

OBJECTIVE: This study investigated the impact of Colorado's Medicaid mental health managed care program on patterns of antipsychotic medication treatment among persons with a diagnosis of schizophrenia. These patterns were compared with patterns of psychosocial treatment and a measure of symptom change. METHODS: Changes in study measures over time in two areas of the state where the policy intervention was implemented were compared with changes in measures in areas where it was not implemented. The study sample consisted of 235 consumers. Measures of antipsychotic medication treatment included any use in a given period, months in which a prescription was filled, and use of second-generation antipsychotics. Psychosocial treatment was measured by any use and expenditures per user. The schizophrenia subscale of the Brief Psychiatric Rating Scale was used to measure consumer outcomes. RESULTS: Probabilities of antipsychotic use in the managed care areas were stable or increased compared with the other areas. The average number of months with filled prescriptions was unchanged. Consumers served under managed care were less likely to use psychosocial treatment, and additional decreases in treatment costs were noted in one area. Difference scores for the schizophrenia subscale showed no change or positive effects for the managed care areas. CONCLUSIONS: Within the Colorado managed care program, antipsychotic medication therapy was not impaired, despite significant decreases in the continuity or intensity of psychosocial treatment, and no reduction in symptom levels was noted. Mental health managed care does not inherently impair medication therapy. Patterns of medication use appeared to be better indicators of program success than psychosocial treatment patterns and were more consistent with outcomes.