Políticas Públicas de Saúde para o Enfrentamento do Câncer no Brasil: Análise dos Planos Estaduais de Atenção Oncológica / Public Health Policies to Combat Cancer in Brazil: Analysis of State Cancer Care Plans / Políticas de Salud Pública para Combatir el Cáncer en Brasil: Análisis de los Planes Estatales de Atención al Câncer

Introdução: O crescente número de mortalidade por neoplasias tem apontado para a necessidade de adoção de medidas sustentáveis e regionalmente situadas para prevenção e controle do câncer. Ao longo dos mais de 30 anos de existência do Sistema Único de Saúde (SUS), as políticas de Atenção Oncológica evoluíram de um modelo fragmentado rumo à noção de integralidade da assistência e qualificação da rede de atenção à pessoa com câncer. Objetivo: Analisar os Planos Estaduais de Atenção Oncológica dos Estados brasileiros, conforme previsto pelas Portarias n.º 874 de 2013 e n.º 1.399 de 2019, e descrever os dados de assistência e indicadores de saúde relacionados aos Estados que contemplam o planejamento da referida assistência. Método: Estudo de caráter misto com abordagem qualitativa baseada em revisão documental dos Planos Estaduais de Atenção Oncológica, e abordagem quantitativa realizada a partir de um estudo descritivo dos dados epidemiológicos relacionados ao câncer no Brasil. Resultados: Apenas 63% dos Estados brasileiros (n = 17) têm operacionalizado Planos Estaduais de Atenção Oncológica; destes, a maioria possui Planos em desacordo com a Portaria n.º 874.

The growing number of deaths by neoplasms has indicated the necessity to adopt sustainable, regionally-based measures to prevent and control cancer. Along more than 30 years of existence of the National Health System (SUS), cancer care policies have evolved from a fragmented model towards a concept of integrality and qualification of the cancer care network. Objective: Review brazilians State Oncology Care Plans according to Ordinance 874 of 2013 and Ordinance 1,399 of 2019, and to describe care data and health indicators of the States that comply with these two Ordinances. Method: Qualitative document-review of the States' Cancer Care Plans and quantitative approach study describing cancer epidemiological data in Brazil. Results: Only 63% of Brazilian States (n = 17) have implemented oncology care plans and of these, most does not comply with Ordinance 874.

El creciente número de muertes por neoplasias ha señalado la necesidad de adoptar medidas sostenibles y de base regional para prevenir y controlar el cáncer. A lo largo de los más de 30 años de existencia del Sistema Único de Salud (SUS), las políticas de atención oncológica evolucionaron de un modelo fragmentado hacia la noción de atención integral y cualificación de la red de atención a las personas con cáncer. Objetivo: Analizar los Planes Estaduales de Atención Oncológica de los Estados brasileños, previstos en la Ordenanza n.º 874 de 2013 y en la Ordenanza n.º 1.399 de 2019, y describir los datos asistenciales e indicadores de salud relacionados con los Estados que contemplan la planificación de esta atención. Método: Estudio de método mixto, con un enfoque cualitativo basado en una revisión documental de los Planes Estatales de Atención Oncológica y un enfoque cuantitativo basado en un estudio descriptivo de los datos epidemiológicos relacionados con el cáncer en Brasil. Resultados: Sólo el 63% de los Estados brasileños (n = 17) tienen Planes Estaduales de Atención Oncológica operacionalizados y, de ellos, la mayoría tiene Planes que no están alineados con la Ordenanza 874.

Differential Impact of a Plan-Led Standardized Complex Care Management Intervention on Subgroups of High-Cost High-Need Medicaid Patients.

Interventions to better coordinate care for high-need high-cost (HNHC) Medicaid patients frequently fail to demonstrate changes in hospitalizations or emergency department (ED) use. Many of these interventions are modeled after practice-level complex care management (CCM) programs. The authors hypothesized that a national CCM program may be effective for some subgroups of HNHC patients, and the overall null effect may obfuscate subgroup-level impact. They used a previously published typology defining 6 subgroups of high-cost Medicaid patients and evaluated program impact by subgroup. The analysis used an individual-level interrupted time series with a comparison group. Intervention subjects were high-cost adult Medicaid patients who enrolled in 1 of 2 national CCM programs implemented by UnitedHealthcare (UHC) (n = 39,687). The comparators were patients who met CCM program criteria but were ineligible due to current enrollment in another UHC/Optum led program (N = 26,359). The intervention was a CCM program developed by UHC/Optum to provide "whole person care" delivering standardized interventions to address medical, behavioral, and social needs for HNHC Medicaid patients, and the outcome was probability of hospitalization or ED use in a given month, estimated at 12 months postenrollment. A reduction in risk of ED utilization for 4 of 6 subgroups was found. A reduction in risk of hospitalization for 1 of 6 subgroups was also found. The authors conclude that standardized health plan led CCM programs demonstrate effectiveness for certain subgroups of HNHC patients in Medicaid. This effectiveness is principally in reducing ED risk and may extend to the risk of hospitalization for a small number of patients.

State-Level Variation in Supplemental Maternity Kick Payments in Medicaid Managed Care.

This cross-sectional study assesses the prevalence and magnitude of state-level delivery event­triggered kick payments to Medicaid managed care plans and their association with delivery costs.

How Does Medicaid Managed Care Address the Needs of Beneficiaries with Opioid Use Disorders? A Deep Dive into Contract Design.

Many people who experience opioid use disorder rely on Medicaid. The high penetration of managed care systems into Medicaid raises the importance of understanding states' expectations regarding coverage, access to care, and health system performance and effectively elevates agreements between states and plans into blueprints for coverage and care. Federal law broadly regulates these structured agreements while leaving a high degree of discretion to states and plans. In this study, researchers reviewed the provisions of 15 state Medicaid managed care contract related to substance use disorder (SUD) treatment to identify whether certain elements of SUD treatment were a stated expectation and the extent to which the details of those expectations varied across states in ways that ultimately could affect evaluation of performance and health outcomes. We found that while all states include SUD treatment as a stated contract expectation, discussions around coverage of specific services and nationally recognized guidelines varied. These variations reflect key state choices regarding how much deference to afford their plans in coverage design and plan administration and reveal important differences in purchasing expectations that could carry implications for efforts to examine similarities and differences in access, quality, and health outcomes within managed care across the states.

The Need for Transparency in Medicaid Managed Care: Section 1115 Waiver Requirements as a Blueprint.

Medicaid plays a significant role in the health care space, providing insurance coverage to nearly one quarter of the U.S. population. In recent years, managed care organizations have taken on an increasingly prominent role in the Medicaid space, and in many instances have become the sole insurance option for Medicaid recipients. The scale and method of implementation for managed care programs has varied widely from state to state. This Note discusses the many methods by which a state can enact managed care within its Medicaid program, and summarizes the challenges with assessing the success of such programs. It proposes a uniform approach to managed care reporting requirements designed to increase transparency and accountability across state lines, and in turn ensure quality care for Medicaid managed care beneficiaries.

Gestão em foco / Management in focus

Este e-book tem como objetivo trazer um compêndio de relatos de experiência relacionados à gestão de saúde do Estado de Goiás. Cada capítulo traz a descrição dos projetos desenvolvidos no âmbito da Secretaria de Estado da Saúde de Goiás, que são vinculados aos objetivos estratégicos do órgão. Estes projetos têm como objetivo fortalecer as ações estratégicas para otimizar o planejamento do Sistema Único de Saúde

This e-book aims to bring a compendium of experience reports related to health management in the State of Goiás. Each chapter brings a description of the projects developed within the scope of the State Department of Health of Goiás, which are linked to the strategic objectives of the agency. These projects aim to strengthen strategic actions to optimize the planning of the Unified Health System

Concordance of Disclosed Hospital Prices With Total Reimbursements for Hospital-Based Care Among Commercially Insured Patients in the US.

Importance: To improve health care price transparency and promote cost-conscious selection of health care organizations and practitioners, the Centers for Medicare & Medicaid Services (CMS) required that hospitals share payer-specific negotiated prices for selected shoppable health services by January 2021. While this regulation improves price transparency, it is unclear whether disclosed prices reflect total costs of care, since many hospital-based services are delivered and billed separately by independent practitioners or other health care entities. Objective: To assess the extent to which prices disclosed under the new hospital price transparency regulation are correlated with total costs of care among commercially insured individuals. Design, Setting, and Participants: This cross-sectional study used a large database of commercial claims from 2018 to analyze encounters at US hospitals for shoppable health care services for which price disclosure is required by CMS. Data were analyzed from November 2020 to February 2021. Exposures: Whether the service was billed by the hospital or another entity. Main Outcomes and Measures: Outcomes of interest were the percentage of encounters with at least 1 service billed by an entity other than the hospital providing care, number of billing entities, amounts billed by nonhospital entities, and the correlation between hospital and nonhospital reimbursements. Results: The study analyzed 4 545 809 encounters for shoppable care. Independent health care entities were involved in 7.6% (95% CI, 6.7% to 8.4%) to 42.4% (95% CI, 39.1% to 45.6%) of evaluation and management encounters, 15.9% (95% CI, 15.8% to 16%) to 22.2% (95% CI, 22% to 22.4%) of laboratory and pathology services, 64.9% (95% CI, 64.2% to 65.7%) to 87.2% (95% CI, 87.1% to 87.3%) of radiology services, and more than 80% of most medicine and surgery services. The median (IQR) reimbursement of independent practitioners ranged from $61 ($52-$102) to $412 ($331-$466) for evaluation and management, $5 ($4-$6) to $7 ($4-$12) for laboratory and pathology, $26 ($20-$32) to $210 ($170-$268) for radiology, and $47 ($21-$103) to $9545 ($7750-$18 277) for medicine and surgery. The reimbursement for services billed by the hospital was not strongly correlated with the reimbursement of independent clinicians, ranging from r = -0.11 (95% CI, -0.69 to 0.56) to r = 0.53 (95% CI, 0.13 to 0.78). Conclusions and Relevance: This cross-sectional study found that independent practitioners were frequently involved in the delivery of shoppable hospital-based care, and their reimbursement may have represented a substantial portion of total costs of care. These findings suggest that disclosed hospital reimbursement was usually not correlated with total cost of care, limiting the potential benefits of the hospital price transparency rule for improving consumer decision-making.

Severity of Inpatient Hospitalizations Among Undocumented Immigrants and Medi-Cal Patients in a Los Angeles, California, Hospital: 2019.

Objectives. To compare the severity of inpatient hospitalizations between undocumented immigrants and Medi-Cal patients in a large safety-net hospital in Los Angeles, California. Methods. We conducted a retrospective analysis of all 2019 inpatient stays at a Los Angeles hospital (n = 22 480), including patients of all races/ethnicities. We examined 3 measures by using insurance status to approximate immigration status: illness severity, length of hospital stay, and repeat hospitalizations. We calculated group differences between undocumented and Medi-Cal patients by using inverse probability weighted regression adjustment separately for patients aged 18 to 64 years and those aged 65 years and older. Results. Younger undocumented patients had less severe illness and shorter lengths of stay than their Medi-Cal counterparts. Older undocumented immigrants also had less severe illness, but had similar lengths of stay and were more likely to have repeated hospitalizations. Conclusions. While existing work suggests that undocumented immigrants could have more severe health care needs on account of their poorer access to medical care, we did not see clear health disadvantages among hospitalized undocumented immigrants, especially younger patients. There were fewer differences between undocumented and Medi-Cal patients who were older. (Am J Public Health. 2021;111(11):2019-2026. https://doi.org/10.2105/AJPH.2021.306485).

State-Level Sexism and Women's Health Care Access in the United States: Differences by Race/Ethnicity, 2014-2019.

Objectives. To quantify racial/ethnic differences in the relationship between state-level sexism and barriers to health care access among non-Hispanic White, non-Hispanic Black, and Hispanic women in the United States. Methods. We merged a multidimensional state-level sexism index compiled from administrative data with the national Consumer Survey of Health Care Access (2014-2019; n = 10 898) to test associations between exposure to state-level sexism and barriers to access, availability, and affordability of health care. Results. Greater exposure to state-level sexism was associated with more barriers to health care access among non-Hispanic Black and Hispanic women, but not non-Hispanic White women. Affordability barriers (cost of medical bills, health insurance, prescriptions, and tests) appeared to drive these associations. More frequent need for care exacerbated the relationship between state-level sexism and barriers to care for Hispanic women. Conclusions. The relationship between state-level sexism and women's barriers to health care access differs by race/ethnicity and frequency of needing care. Public Health Implications. State-level policies may be used strategically to promote health care equity at the intersection of gender and race/ethnicity. (Am J Public Health. 2021;111(10):1796-1805. https://doi.org/10.2105/AJPH.2021.306455).

Unmet financial burden of infertility care and the impact of state insurance mandates in the United States: analysis from a popular crowdfunding platform.

OBJECTIVE: To examine infertility-related fund-raising campaigns on a popular crowdfunding website and to compare campaign characteristics across states with and without legislative mandates for insurance coverage for infertility-related care. DESIGN: Retrospective cohort study. SETTING: Online crowdfunding platform (GoFundMe) between 2010 and 2020. PATIENT(S): GoFundMe campaigns in the United States containing the keywords "fertility" and "infertility." INTERVENTION(S): State insurance mandates for infertility treatment coverage. MAIN OUTCOME MEASURE(S): Primary outcomes included fund-raising goals, funds raised, campaign location, and campaigns per capita. RESULT(S): Of the 3,332 infertility-related campaigns analyzed, a total goal of $52.6 million was requested, with $22.5 million (42.8%) successfully raised. The average goal was $18,639 (standard deviation [SD] $32,904), and the average amount raised was $6,759 (SD $14,270). States with insurance mandates for infertility coverage had fewer crowdfunding campaigns per capita (0.75 vs. 1.15 campaigns per 100,000 population than states without insurance mandates. CONCLUSION(S): We found a large number of campaigns requesting financial assistance for costs associated with infertility care, indicating a substantial unmet financial burden. States with insurance mandates had fewer campaigns per capita, suggesting that mandates are effective in mitigating this financial burden. These data can inform future health policy legislation on the state and federal levels to assist with the financial burden of infertility.

A Comprehensive Review of State Vision Screening Mandates for Schoolchildren in the United States.

SIGNIFICANCE: Methods and frequency of vision screenings for school-aged children vary widely by state, and there has been no recent comparative analysis of state requirements. This analysis underscores the need for developing evidence-based criteria for vision screening in school-aged children across the United States. PURPOSE: The purpose of this study was to conduct an updated comprehensive analysis of vision screening requirements for school-aged children in the United States. METHODS: State laws pertaining to school-aged vision screening were obtained for each state. Additional information was obtained from each state's Department of Health and Education, through their websites or departmental representatives. A descriptive analysis was performed for states with data available. RESULTS: Forty-one states require vision screening for school-aged children to be conducted directly in schools or in the community. Screening is more commonly required in elementary school (n = 41) than in middle (n = 30) or high school (n = 19). Distance acuity is the most commonly required test (n = 41), followed by color vision (n = 11) and near vision (n = 10). Six states require a vision screening annually or every 2 years. CONCLUSIONS: Although most states require vision screening for some school-aged children, there is marked variation in screening methods and criteria, where the screening occurs, and grade levels that are screened. This lack of standardization and wide variation in state regulations point to a need for the development of evidence-based criteria for vision screening programs for school-aged children.

Short-Range Forecasting of COVID-19 During Early Onset at County, Health District, and State Geographic Levels Using Seven Methods: Comparative Forecasting Study.

BACKGROUND: Forecasting methods rely on trends and averages of prior observations to forecast COVID-19 case counts. COVID-19 forecasts have received much media attention, and numerous platforms have been created to inform the public. However, forecasting effectiveness varies by geographic scope and is affected by changing assumptions in behaviors and preventative measures in response to the pandemic. Due to time requirements for developing a COVID-19 vaccine, evidence is needed to inform short-term forecasting method selection at county, health district, and state levels. OBJECTIVE: COVID-19 forecasts keep the public informed and contribute to public policy. As such, proper understanding of forecasting purposes and outcomes is needed to advance knowledge of health statistics for policy makers and the public. Using publicly available real-time data provided online, we aimed to evaluate the performance of seven forecasting methods utilized to forecast cumulative COVID-19 case counts. Forecasts were evaluated based on how well they forecast 1, 3, and 7 days forward when utilizing 1-, 3-, 7-, or all prior-day cumulative case counts during early virus onset. This study provides an objective evaluation of the forecasting methods to identify forecasting model assumptions that contribute to lower error in forecasting COVID-19 cumulative case growth. This information benefits professionals, decision makers, and the public relying on the data provided by short-term case count estimates at varied geographic levels. METHODS: We created 1-, 3-, and 7-day forecasts at the county, health district, and state levels using (1) a naïve approach, (2) Holt-Winters (HW) exponential smoothing, (3) a growth rate approach, (4) a moving average (MA) approach, (5) an autoregressive (AR) approach, (6) an autoregressive moving average (ARMA) approach, and (7) an autoregressive integrated moving average (ARIMA) approach. Forecasts relied on Virginia's 3464 historical county-level cumulative case counts from March 7 to April 22, 2020, as reported by The New York Times. Statistically significant results were identified using 95% CIs of median absolute error (MdAE) and median absolute percentage error (MdAPE) metrics of the resulting 216,698 forecasts. RESULTS: The next-day MA forecast with 3-day look-back length obtained the lowest MdAE (median 0.67, 95% CI 0.49-0.84, P<.001) and statistically significantly differed from 39 out of 59 alternatives (66%) to 53 out of 59 alternatives (90%) at each geographic level at a significance level of .01. For short-range forecasting, methods assuming stationary means of prior days' counts outperformed methods with assumptions of weak stationarity or nonstationarity means. MdAPE results revealed statistically significant differences across geographic levels. CONCLUSIONS: For short-range COVID-19 cumulative case count forecasting at the county, health district, and state levels during early onset, the following were found: (1) the MA method was effective for forecasting 1-, 3-, and 7-day cumulative case counts; (2) exponential growth was not the best representation of case growth during early virus onset when the public was aware of the virus; and (3) geographic resolution was a factor in the selection of forecasting methods.

Home- and Community-Based Provider Preparation for Pennsylvania's Managed Long-term Services and Supports.

As Pennsylvania implements its managed long-term services and supports program, we explore how home- and community-based providers are preparing for and perceiving the transition through an online survey. We summarize responses and conduct chi-square analysis to measure differences between select provider groups. Despite high levels of uncertainty about program impact, over 84% of respondents plan to participate. We found that providers in the first implementation phase had more strategic and operational discussions with MCOs than the other two phases (p < .03). As program rollout continues, we anticipate changes in MCO-provider conversation frequency and topics based upon implementation zone.

Plano estadual de manejo de óbitos para enfrentamento da Covid-19: a experiência da Bahia / State Darth management plan for combating Covid-19: the Bahia experience / Plan estadual de manejo de muertes para enfrentar el Covid-19: la experiencia de Bahia

Os desafios impostos pela pandemia da Covid-19, relacionados a uma alta de letalidade e mortalidade pelo vírus SARS-CoV-2, alertou os gestores sobre a possibilidade de colapso da rede de serviços de manejo de óbitos no estado da Bahia. Este trabalho tem como objetivo descrever a experiência da equipe da vigilância em saúde da Bahia na formulação do Plano de Manejo do Óbito, direcionado a orientar as gestões estadual e municipais e serviços de saúde, públicos e privados, para a implementação de ações adequadas e oportunas frente à ocorrência de óbitos durante a pandemia. Para tanto, utilizou-se de revisão de literatura (em bases de dados internacionais), análise documental, questionários aplicados à gestão municipal e escuta de gestores e trabalhadores de serviços de saúde e afins por meio de webreuniões. O processo de formulação do plano partiu da classificação adotada pela Secretaria de Vigilância em Saúde do Ministério da Saúde para definir as fases da pandemia e estabelecer as ações e responsabilidades compartilhadas pelos entes federados. O documento foi aprovado pela Comissão Intergestores Bipartite (CIB) e publicado no site da Secretaria de Saúde do Estado da Bahia (Sesab), com vistas a atender os 417 municípios que compõem o território estadual.

The challenges imposed by the Covid-19 pandemic related to increased lethality and mortality from the SARS-CoV-2 virus alerted managers to the possibility of the collapse of the death management service network in the state of Bahia. Our study aims at describing the experience of the health surveillance team in Bahia in the formulation of the Death Management Plan, aimed at guiding state and municipal management, public and private health services for the implementation of appropriate and timely actions in the face of the occurrence deaths during the pandemic. For such purpose, we used literature review (in international databases), document analysis, questionnaires applied to municipal management and listening to managers and health service workers via web meetings. The process of formulating the Plan started from the classification adopted by the Health Surveillance Department of the Ministry of Health to define the phases of the pandemic and to establish the actions and responsibilities shared by the federated entities. The document was approved by the Bipartite Intergovernmental Commission (CIB) and published on the website of the Department of Health of the State of Bahia (Sesab), to serve the 417 municipalities that make up the state territory.

Los desafíos planteados por la pandemia del covid-19 relacionados con un aumento de la letalidad y mortalidad por el virus SARS-CoV-2 alertaron a los gerentes sobre la posibilidad del colapso de la red de servicios de gestión de muertes en el estado de Bahía. Este trabajo tiene como objetivo describir la experiencia del equipo de vigilancia en salud en Bahía en la formulación del Plan de Manejo de Muertes, destinado a orientar la gestión estadual y municipal, y los servicios de salud públicos y privados para la implementación de acciones adecuadas y oportunas ante las muertes ocurridas durante la pandemia. Para ello, se utilizaron revisión de la literatura (en bases de datos internacionales), análisis de documentos, cuestionarios aplicados a la gestión municipal y escucha a gerentes y trabajadores de servicios de salud y afines por medio de reuniones en línea. El proceso de formulación del Plan partió de la clasificación adoptada por la Secretaría de Vigilancia en Salud del Ministerio de Salud para definir las fases de la pandemia y establecer las acciones y responsabilidades compartidas por las entidades federativas. El documento fue aprobado por la Comisión Intergubernamental Bipartita (CIB) y publicado en el sitio web de la Secretaría de Salud del Estado de Bahía (Sesab), con el objetivo de atender a los 417 municipios que integran el territorio estadual.

Evaluating inpatient adverse outcomes under California's Delivery System Reform Incentive Payment Program.

OBJECTIVE: The California Delivery System Reform Incentive Payment Program (DSRIP) provided incentive payments to Designated Public Hospitals (DPHs) to improve quality of care. We assessed the program's impact on reductions in sepsis mortality, central line-associated bloodstream infections (CLABSIs), venous thromboembolisms (VTEs), and hospital-acquired pressure ulcers (HAPUs). DATA SOURCES: We used 2009-2014 discharge data from California hospitals. STUDY DESIGN: We used a pre-post study design with a comparison group. We constructed propensity scores and used them to assign inverse probability weights according to their similarity to DPH discharges. Interaction term coefficients of time trends and treatment group provided significance testing. DATA EXTRACTION: We used Patient Safety Indicators for CLABSI, HAPU, and VTE, and constructed a sepsis mortality measure. PRINCIPAL FINDINGS: Discharges from DPHs and non-DPHs both saw decreases in the four outcomes over the DSRIP period (2010-2014). The difference-in-difference estimator (DD) for sepsis was only significant during two time periods, comparing 2010 with 2012 (DD: -2.90 percent, 95% CI: -5.08, -0.72 percent) and 2010 with 2014 (DD: -5.74, 95% CI: -8.76 percent, -2.72 percent); the DD estimator was not significant comparing 2010 with 2012 (DD: -1.30, 95% CI: -3.18 percent, 0.58 percent) or comparing 2010 with 2013 (DD: -3.05 percent, 95% CI: -6.50 percent, 0.40 percent). For CLABSI, we did not find any meaningful differences between DPHs and non-DPHs across the four time periods. For HAPU and VTE, the only significant DD estimator compared 2014 with 2010. CONCLUSIONS: We did not find that DPHs participating in DSRIP outperformed non-DPHs during the DSRIP program. Our results were robust to multiple sensitivity analyses. Given multiple concurrent inpatient safety initiatives, it was challenging to assign improvements over time periods to DSRIP.

Quality Management Strategies in Medicaid Managed Care: Perspectives From Medicaid, Plans, and Providers.

Medicaid managed care allows Medicaid beneficiaries to receive services through contractual relationships between managed care organizations and state Medicaid offices. Medicaid offices monitor quality of care, and many states encourage or require plans to adopt quality management practices. This research examines quality management in Medicaid managed care from the perspectives of Medicaid officials, managed care plan representatives, and providers through 25 qualitative interviews in one Northeastern state. Plan representatives described quality management efforts as robust and discussed strategies targeting providers and beneficiaries. Medicaid officials indicated motivations for plans to be responsible for quality management. Providers were unaware of plan efforts or reported them to be counterproductive since performance data were thought to be inaccurate or limited, and modest incentive programs presented excessive administrative burden. Providers' general skepticism about managed care plans' quality improvement efforts may hinder their effectiveness, cause frustration, and lead to administrative burden that may harm care quality.

Engaging Consumers in Medicaid Program Design: Strategies from the States.

Policy Points As Medicaid programs grow in scale and complexity, greater consumer input may guide successful program design, but little is known about the extent to which state agencies are engaging consumers in the design and implementation of programs and policies. Through 50 semistructured interviews with Medicaid leaders in 14 states, we found significant variation in consumer engagement approaches, with many common facilitators, including leadership commitment, flexible strategies for recruiting and supporting consumer participation, and robust community partnerships. We provide early evidence on how state Medicaid agencies are integrating consumers' experiences and perspectives into their program design and governance. CONTEXT: Consumer engagement early in the process of health care policymaking may improve the effectiveness of program planning and implementation, promote patient-centric care, enhance beneficiary protections, and offer opportunities to improve service delivery. As Medicaid programs grow in scale and complexity, greater consumer input may guide successful program design, but little is known about the extent to which state agencies are currently engaging consumers in the design and implementation of programs and policies, and how this is being done. METHODS: We conducted semistructured interviews with 50 Medicaid program leaders across 14 states, employing a stratified purposive sampling method to select state Medicaid programs based on US census region, rurality, Medicaid enrollment size, total population, ACA expansion status, and Medicaid managed care penetration. Interview data were audio-recorded, professionally transcribed, and underwent iterative coding with content and thematic analyses. FINDINGS: First, we found variation in consumer engagement approaches, ranging from limited and largely symbolic interactions to longer-term deliberative bodies, with some states tailoring their federally mandated standing committees to engage consumers. Second, most states were motivated by pragmatic considerations, such as identifying and overcoming implementation challenges for agency programs. Third, states reported several common facilitators of successful consumer engagement efforts, including leadership commitment, flexible strategies for recruiting and supporting consumers' participation, and robust community partnerships. All states faced barriers to authentic and sustained engagement. CONCLUSIONS: Sharing best practices across states could help strengthen programs' engagement efforts, identify opportunities for program improvement reflecting community needs, and increase participation among a population that has traditionally lacked a political voice.