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1.
JAMA ; 328(11): 1085-1099, 2022 09 20.
Artigo em Inglês | MEDLINE | ID: mdl-36125468

RESUMO

Importance: Medicaid is the largest health insurance program by enrollment in the US and has an important role in financing care for eligible low-income adults, children, pregnant persons, older adults, people with disabilities, and people from racial and ethnic minority groups. Medicaid has evolved with policy reform and expansion under the Affordable Care Act and is at a crossroads in balancing its role in addressing health disparities and health inequities against fiscal and political pressures to limit spending. Objective: To describe Medicaid eligibility, enrollment, and spending and to examine areas of Medicaid policy, including managed care, payment, and delivery system reforms; Medicaid expansion; racial and ethnic health disparities; and the potential to achieve health equity. Evidence Review: Analyses of publicly available data reported from 2010 to 2022 on Medicaid enrollment and program expenditures were performed to describe the structure and financing of Medicaid and characteristics of Medicaid enrollees. A search of PubMed for peer-reviewed literature and online reports from nonprofit and government organizations was conducted between August 1, 2021, and February 1, 2022, to review evidence on Medicaid managed care, delivery system reforms, expansion, and health disparities. Peer-reviewed articles and reports published between January 2003 and February 2022 were included. Findings: Medicaid covered approximately 80.6 million people (mean per month) in 2022 (24.2% of the US population) and accounted for an estimated $671.2 billion in health spending in 2020, representing 16.3% of US health spending. Medicaid accounted for an estimated 27.2% of total state spending and 7.6% of total federal expenditures in 2021. States enrolled 69.5% of Medicaid beneficiaries in managed care plans in 2019 and adopted 139 delivery system reforms from 2003 to 2019. The 38 states (and Washington, DC) that expanded Medicaid under the Affordable Care Act experienced gains in coverage, increased federal revenues, and improvements in health care access and some health outcomes. Approximately 56.4% of Medicaid beneficiaries were from racial and ethnic minority groups in 2019, and disparities in access, quality, and outcomes are common among these groups within Medicaid. Expanding Medicaid, addressing disparities within Medicaid, and having an explicit focus on equity in managed care and delivery system reforms may represent opportunities for Medicaid to advance health equity. Conclusions and Relevance: Medicaid insures a substantial portion of the US population, accounts for a significant amount of total health spending and state expenditures, and has evolved with delivery system reforms, increased managed care enrollment, and state expansions. Additional Medicaid policy reforms are needed to reduce health disparities by race and ethnicity and to help achieve equity in access, quality, and outcomes.


Assuntos
Reforma dos Serviços de Saúde , Equidade em Saúde , Medicaid , Idoso , Criança , Etnicidade , Feminino , Reforma dos Serviços de Saúde/economia , Equidade em Saúde/normas , Humanos , Cobertura do Seguro/economia , Medicaid/economia , Medicaid/organização & administração , Medicaid/normas , Grupos Minoritários/estatística & dados numéricos , Patient Protection and Affordable Care Act/economia , Gravidez , Estados Unidos/epidemiologia
2.
JAMA ; 328(1): 27-37, 2022 07 05.
Artigo em Inglês | MEDLINE | ID: mdl-35788794

RESUMO

Importance: Improving birth outcomes for low-income mothers is a public health priority. Intensive nurse home visiting has been proposed as an intervention to improve these outcomes. Objective: To determine the effect of an intensive nurse home visiting program on a composite outcome of preterm birth, low birth weight, small for gestational age, or perinatal mortality. Design, Setting, and Participants: This was a randomized clinical trial that included 5670 Medicaid-eligible, nulliparous pregnant individuals at less than 28 weeks' gestation, enrolled between April 1, 2016, and March 17, 2020, with follow-up through February 2021. Interventions: Participants were randomized 2:1 to Nurse Family Partnership program (n = 3806) or control (n = 1864). The program is an established model of nurse home visiting; regular visits begin prenatally and continue through 2 postnatal years. Nurses provide education, assessments, and goal-setting related to prenatal health, child health and development, and maternal life course. The control group received usual care services and a list of community resources. Neither staff nor participants were blinded to intervention group. Main Outcomes and Measures: There were 3 primary outcomes. This article reports on a composite of adverse birth outcomes: preterm birth, low birth weight, small for gestational age, or perinatal mortality based on vital records, Medicaid claims, and hospital discharge records through February 2021. The other primary outcomes of interbirth intervals of less than 21 months and major injury or concern for abuse or neglect in the child's first 24 months have not yet completed measurement. There were 54 secondary outcomes; those related to maternal and newborn health that have completed measurement included all elements of the composite plus birth weight, gestational length, large for gestational age, extremely preterm, very low birth weight, overnight neonatal intensive care unit admission, severe maternal morbidity, and cesarean delivery. Results: Among 5670 participants enrolled, 4966 (3319 intervention; 1647 control) were analyzed for the primary maternal and neonatal health outcome (median age, 21 years [1.2% non-Hispanic Asian, Indigenous, or Native Hawaiian and Pacific Islander; 5.7% Hispanic; 55.2% non-Hispanic Black; 34.8% non-Hispanic White; and 3.0% more than 1 race reported [non-Hispanic]). The incidence of the composite adverse birth outcome was 26.9% in the intervention group and 26.1% in the control group (adjusted between-group difference, 0.5% [95% CI, -2.1% to 3.1%]). Outcomes for the intervention group were not significantly better for any of the maternal and newborn health primary or secondary outcomes in the overall sample or in either of the prespecified subgroups. Conclusions and Relevance: In this South Carolina-based trial of Medicaid-eligible pregnant individuals, assignment to participate in an intensive nurse home visiting program did not significantly reduce the incidence of a composite of adverse birth outcomes. Evaluation of the overall effectiveness of this program is incomplete, pending assessment of early childhood and birth spacing outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT03360539.


Assuntos
Enfermagem Domiciliar , Visita Domiciliar , Complicações na Gravidez , Criança , Pré-Escolar , Feminino , Enfermagem Domiciliar/economia , Enfermagem Domiciliar/estatística & dados numéricos , Visita Domiciliar/economia , Visita Domiciliar/estatística & dados numéricos , Humanos , Recém-Nascido de Baixo Peso , Recém-Nascido , Medicaid/economia , Medicaid/estatística & dados numéricos , Mortalidade Perinatal , Pobreza/economia , Pobreza/estatística & dados numéricos , Gravidez , Complicações na Gravidez/economia , Complicações na Gravidez/epidemiologia , Complicações na Gravidez/enfermagem , Complicações na Gravidez/prevenção & controle , Resultado da Gravidez/epidemiologia , Nascimento Prematuro/epidemiologia , Nascimento Prematuro/prevenção & controle , South Carolina/epidemiologia , Estados Unidos/epidemiologia , Adulto Jovem
5.
J Health Care Poor Underserved ; 33(2): 1036-1053, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35574892

RESUMO

OBJECTIVE: Examine the association between gaps in Medicaid coverage and negative health events (NHEs) for people with epilepsy (PWE). METHODS: Using five years of Medicaid claims for PWE, we identified gaps in Medicaid coverage. We used logistic regression to evaluate the association between a gap in coverage and being in the top quartile of NHEs and factors associated with having a gap. These models adjusted for: demographics, residence, medication adherence, disease severity, and comorbidities. RESULTS: Of 186,616 PWE, 21.7% had a gap in coverage. The odds of being in the top quartile of NHEs per year were 66% higher among those with a gap (OR: 1.66; 95% CI: 1.61, 1.70). Being female, younger, and having psychiatric comorbidities increased the odds of having a gap. CONCLUSIONS: Gaps in Medicaid coverage are associated with being a high utilizer during covered periods. Specific groups could be targeted with interventions to reduce churning.


Assuntos
Epilepsia/complicações , Cobertura do Seguro , Medicaid , Transtornos Mentais/complicações , Fatores Etários , Comorbidade , Epilepsia/epidemiologia , Epilepsia/terapia , Feminino , Humanos , Cobertura do Seguro/economia , Modelos Logísticos , Masculino , Medicaid/economia , Adesão à Medicação , Fatores Sexuais , Estados Unidos/epidemiologia
9.
PLoS One ; 17(3): e0264940, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35271632

RESUMO

BACKGROUND: The significant adverse social and economic impact of the COVID-19 pandemic has cast broader light on the importance of addressing social determinants of health (SDOH). Medicaid Managed Care Organizations (MMCOs) have increasingly taken on a leadership role in integrating medical and social services for Medicaid members. However, the experiences of MMCOs in addressing member social needs during the pandemic has not yet been examined. AIM: The purpose of this study was to describe MMCOs' experiences with addressing the social needs of Medicaid members during the COVID-19 pandemic. METHODS: The study was a qualitative study using data from 28 semi-structured interviews with representatives from 14 MMCOs, including state-specific markets of eight national and regional managed care organizations. Data were analyzed using thematic analysis. RESULTS: Four themes emerged: the impact of the pandemic, SDOH response efforts, an expanding definition of SDOH, and managed care beyond COVID-19. Specifically, participants discussed the impact of the pandemic on enrollees, communities, and healthcare delivery, and detailed their evolving efforts to address member nonmedical needs during the pandemic. They reported an increased demand for social services coupled with a significant retraction of community social service resources. To address these emerging social service gaps, participants described mounting a prompt and adaptable response that was facilitated by strong existing relationships with community partners. CONCLUSION: Among MMCOs, the COVID-19 pandemic has emphasized the importance of addressing member social needs, and the need for broader consideration of what constitutes SDOH from a healthcare delivery standpoint.


Assuntos
COVID-19/psicologia , Medicaid/tendências , Determinantes Sociais da Saúde/tendências , Atenção à Saúde , Humanos , Programas de Assistência Gerenciada/estatística & dados numéricos , Programas de Assistência Gerenciada/tendências , Medicaid/economia , Medicaid/estatística & dados numéricos , Pandemias , Pesquisa Qualitativa , SARS-CoV-2/patogenicidade , Comportamento Social , Determinantes Sociais da Saúde/estatística & dados numéricos , Serviço Social , Participação dos Interessados , Inquéritos e Questionários , Estados Unidos
11.
J Trauma Acute Care Surg ; 92(2): e25-e27, 2022 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-35081099

RESUMO

ABSTRACT: In recent years, calls to address gun violence through public health approaches have increased. However, securing funding for health-based community violence intervention models has remained a challenge. New actions suggest that this may be shifting. Upon taking office, the Biden administration announced a series of funding opportunities for these programs, which ranged from competitive grant programs to a proposed 8-year, $5 billion plan. Less publicized, but just as important, is the administration's announcement that Medicaid can be used to reimburse this work, specifically noting the eligibility of hospital-based violence intervention and prevention programs. For these programs, this creates a predictable and reliable funding source that has not existed to date. This integration of violence prevention programming in the traditional health care and financing systems represents a critical inflection point in the United States' shifting response to community violence. However, the decision to use this optional benefit lies with each state. States should strongly consider harnessing Medicaid as a wise investment to address the United States' gun violence epidemic. LEVEL OF EVIDENCE: Economic and value-based evaluation, level IV.


Assuntos
Financiamento Governamental , Violência com Arma de Fogo/prevenção & controle , Medicaid/economia , Humanos , Política , Governo Estadual , Estados Unidos
12.
JAMA Netw Open ; 5(1): e2140371, 2022 01 04.
Artigo em Inglês | MEDLINE | ID: mdl-35029667

RESUMO

Importance: Increasing prices of antidiabetic medications in the US have raised substantial concerns about the effects of drug affordability on diabetes care. There has been little rigorous evidence comparing the experiences of patients with diabetes across different types of insurance coverage. Objective: To compare the utilization patterns and costs of prescription drugs to treat diabetes among low-income adults with Medicaid vs those with Marketplace insurance in Colorado during 2014 and 2015. Design, Setting, and Participants: This cross-sectional study included diabetic patients enrolled in Colorado Medicaid and Marketplace plans who were aged 19 to 64 years and had incomes between 75% and 200% of the federal poverty level during 2014 and 2015. Data analysis was conducted from September 2020 to April 2021. Exposures: Health insurance through Colorado Medicaid or Colorado's state-based Marketplace. Main Outcomes and Measures: Primary outcomes were drug utilization (prescription drug fills) and drug costs (total costs and out-of-pocket costs). The secondary outcome was months with an active prescription for noninsulin antidiabetic medications. An all payer claims database was combined with income data, and linear models were used to adjust for clinical and demographic confounders. Results: Of 22 788 diabetic patients included in the study, 20 245 were enrolled in Medicaid and 2543 in a Marketplace plan. Marketplace-eligible individuals were older (mean [SD] age, 52.12 [10.60] vs 47.70 [11.33] years), and Medicaid-eligible individuals were more likely to be female (12 429 [61.4%] vs 1413 [55.6%]). Medicaid-eligible patients were significantly more likely than Marketplace-eligible patients to fill prescriptions for dipeptidyl peptidase 4 inhibitors (adjusted difference, -3.7%; 95% CI, -5.3 to -2.1; P < .001) and sulfonylureas (adjusted difference, -6.6%; 95% CI, -8.9 to -4.3; P < .001). Overall rates of insulin use were similar in the 2 groups (adjusted difference, -2.3%; -5.1 to 0.5; P = .11). Out-of-pocket costs for noninsulin medications were 84.4% to 95.2% lower and total costs were 9.4% to 54.2% lower in Medicaid than in Marketplace plans. Out-of-pocket costs for insulin were 76.7% to 94.7% lower in Medicaid than in Marketplace plans, whereas differences in total insulin costs were mixed. The percentage of months of apparent active medication coverage was similar between the 2 groups for 4 of 5 drug classes examined, with Marketplace-eligible patients having a greater percentage of months than Medicaid-eligible patients for sulfonylureas (adjusted difference, 5.3%; 95% CI, 0.3%-10.4%; P = .04). Conclusions and Relevance: In this cross-sectional study, drug utilization across multiple drug classes was higher and drug costs were significantly lower for adults with diabetes enrolled in Medicaid than for those with subsidized Marketplace plans. Patients with Marketplace coverage had a similar percentage of months with an active prescription as patients with Medicaid coverage.


Assuntos
Diabetes Mellitus Tipo 2 , Hipoglicemiantes , Cobertura do Seguro/economia , Medicaid/economia , Adulto , Colorado , Estudos Transversais , Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/economia , Diabetes Mellitus Tipo 2/epidemiologia , Custos de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Hipoglicemiantes/economia , Hipoglicemiantes/uso terapêutico , Masculino , Pessoa de Meia-Idade , Pobreza , Honorários por Prescrição de Medicamentos/estatística & dados numéricos , Estados Unidos , Adulto Jovem
13.
J Gen Intern Med ; 37(12): 3070-3079, 2022 09.
Artigo em Inglês | MEDLINE | ID: mdl-35048298

RESUMO

BACKGROUND: Inpatients with psychiatric diagnoses often require higher levels of care in skilled nursing facilities (SNFs) and are more likely to be covered by Medicaid, which reimburses SNFs at significantly lower rates than Medicare and commercial payors. OBJECTIVE: To characterize factors affecting length of stay in inpatients discharged to SNFs. DESIGN: A retrospective cross-sectional study design using 2016-2018 data from National Inpatient Sample. PARTICIPANTS: Inpatients aged ≥ 40 who were discharged to SNFs. EXPOSURES: Primary discharge diagnosis (medical, psychiatric, or substance use) and primary payor. MAIN OUTCOMES AND MEASURES: Length of stay, categorized non-exclusively as >3 days, >7 days, or > 14 days. RESULTS: Among 9,821,155 inpatient discharges to SNFs between 2016 and 2018, 95.7% had medical primary discharge diagnoses, 3.3% psychiatric diagnoses, and 1.0% substance use diagnoses; Medicare was the most common primary payor (83.3%), followed by private insurance (7.9%), Medicaid (6.6%), and others (2.2%). Median length of stay for all patients was 5.0 days (interquartile range [IQR], 3.0-8.0), 5.0 (IQR, 3.0-8.0) for those with medical diagnoses, 8.0 (IQR, 4.0-15.0) for psychiatric diagnoses, and 5.0 (IQR, 3.0-8.0) for substance use diagnoses. After multivariable adjustment, compared to patients with medical diagnoses, patients with psychiatric diagnoses were more likely to have hospital stays > 3, > 7, and > 14 days, respectively (p < 0.001). Compared to Medicare patients, Medicaid patients were more likely to have hospital stays > 3, > 7, and > 14 days, respectively (p < 0.001). Compared to patients with medical diagnoses, those with psychiatric diagnoses were also more likely to have lengths of stay 1 times, 1.5 times, and 2 times greater than the national geometric mean length of stay for that diagnosis-related group (p < 0.001). CONCLUSIONS: Patients discharged to SNFs after inpatient hospitalization for psychiatric diagnoses and with Medicaid coverage were more likely to have longer lengths of stay than patients with medical diagnoses and those with Medicare coverage, respectively.


Assuntos
Tempo de Internação/economia , Transtornos Mentais/terapia , Alta do Paciente , Instituições de Cuidados Especializados de Enfermagem , Adulto , Idoso , Estudos Transversais , Humanos , Pacientes Internados , Medicaid/economia , Medicare/economia , Transtornos Mentais/economia , Transtornos Mentais/enfermagem , Pessoa de Meia-Idade , Estudos Retrospectivos , Instituições de Cuidados Especializados de Enfermagem/economia , Estados Unidos
14.
J Autism Dev Disord ; 52(4): 1587-1597, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33966133

RESUMO

Using the 2008-2013 Medicaid Analytic eXtract files, this retrospective cohort study was to evaluate the effect of Medicaid home and community-based services (HCBS) waiver programs on emergency department (ED) utilizations among youth with autism spectrum disorder (ASD). Our study showed that the annual ED utilization rates were 13.5% and 18.8% for individuals on autism specific and intellectual and developmental disabilities (IDD) waivers respectively, vs. 28.5% for those without a waiver. Multivariable logistic regression showed that, compared to no waiver, autism specific waivers (adjusted odds ratio: 0.62; 95% Confidence Interval: [0.58-0.66]) and IDD waivers (0.65; [0.64-0.66]) were strongly associated with reduced ED. These findings suggest that HCBS waivers are effective in reducing the incidence of ED visits among youth with ASD.


Assuntos
Transtorno do Espectro Autista , Serviço Hospitalar de Emergência , Medicaid , Adolescente , Transtorno do Espectro Autista/economia , Transtorno do Espectro Autista/epidemiologia , Transtorno do Espectro Autista/terapia , Serviços de Saúde Comunitária/economia , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Serviços de Assistência Domiciliar/economia , Humanos , Deficiência Intelectual/economia , Deficiência Intelectual/epidemiologia , Deficiência Intelectual/terapia , Medicaid/economia , Medicaid/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos/epidemiologia
15.
Health Serv Res ; 57(1): 66-71, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34318499

RESUMO

OBJECTIVE: To examine long-run growth in the ambulatory surgery center (ASC) industry and potential factors influencing its trajectory. DATA SOURCES: National data for all Medicare-certified ASCs (1990-2015) and outpatient discharge records from the state of Florida in 2007. STUDY DESIGN: We documented the number of ASCs in the United States over time and decomposed the trend into underlying ASC market entry and exit behavior. We then examined the plausibility of 2008 Medicare payment reforms to influence the trend changes. DATA EXTRACTION METHODS: Data on ASC openings and closures are obtained from the Centers for Medicare and Medicaid Services Provider of Service files. Secondary data on ASC volume in Florida are obtained from the Florida Agency for Health Care Administration. PRINCIPAL FINDINGS: The number of ASCs in the United States grew 5%-10% annually between 1990 and 2007 but by 1% or less beginning in 2008. This change coincided with substantive reductions in Medicare payments for key ASC services. The annual number of new ASCs was as much as 50% lower following the payment change. CONCLUSIONS: ASCs are an important competitor for outpatient services, but growth has slowed dramatically. Sharp changes in new ASC entry align with less generous Medicare fees.


Assuntos
Instituições de Assistência Ambulatorial/economia , Procedimentos Cirúrgicos Ambulatórios/economia , Centers for Medicare and Medicaid Services, U.S./economia , Medicare/economia , Humanos , Medicaid/economia , Estados Unidos
16.
Surgery ; 171(1): 132-139, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34489109

RESUMO

BACKGROUND: Disparities exist in access to high-volume surgeons, who have better outcomes after thyroidectomy. The association of the Affordable Care Act's Medicaid expansion with access to high-volume thyroid cancer surgery centers remains unclear. METHODS: The National Cancer Database was queried for all adult thyroid cancer patients diagnosed from 2010 to 2016. Hospital quartiles (Q1-4) defined by operative volume were generated. Clinicodemographics and adjusted odds ratios for treatment per quartile were analyzed by insurance status. An adjusted difference-in-differences analysis examined the association between implementation of the Affordable Care Act and changes in payer mix by hospital quartile. RESULTS: In total, 241,448 patients were included. Medicaid patients were most commonly treated at Q3-Q4 hospitals (Q3 odds ratios 1.05, P = .020, Q4 1.11, P < .001), whereas uninsured patients were most often treated at Q2-Q4 hospitals (Q2 odds ratios 2.82, Q3 2.34, Q4 2.07, P < .001). After expansion, Medicaid patients had lower odds of surgery at Q3-Q4 compared with Q1 hospitals (odds ratios Q3 0.82, P < .001 Q4 0.85, P = .002) in expansion states, but higher odds of treatment at Q3-Q4 hospitals in nonexpansion states (odds ratios Q3 2.23, Q4 1.86, P < .001). Affordable Care Act implementation was associated with increased proportions of Medicaid patients within each quartile in expansion compared with nonexpansion states (Q1 adjusted difference-in-differences 5.36%, Q2 5.29%, Q3 3.68%, Q4 3.26%, P < .001), and a decrease in uninsured patients treated at Q4 hospitals (adjusted difference-in-differences -1.06%, P = .001). CONCLUSIONS: Medicaid expansion was associated with an increased proportion of Medicaid patients undergoing thyroidectomy for thyroid cancer in all quartiles, with increased Medicaid access to high-volume centers in expansion compared with nonexpansion states.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia/estatística & dados numéricos , Adulto , Idoso , Feminino , Acesso aos Serviços de Saúde/economia , Disparidades em Assistência à Saúde/economia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Masculino , Medicaid/economia , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/economia , Sistema de Registros/estatística & dados numéricos , Neoplasias da Glândula Tireoide/economia , Tireoidectomia/economia , Estados Unidos
17.
Surgery ; 171(1): 140-146, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34600741

RESUMO

BACKGROUND: We aimed to characterize the association between differentiated thyroid cancer (DTC) patient insurance status and appropriateness of therapy (AOT) regarding extent of thyroidectomy and radioactive iodine (RAI) treatment. METHODS: The National Cancer Database was queried for DTC patients diagnosed between 2010 and 2016. Adjusted odds ratios (AOR) for AOT, as defined by the American Thyroid Association guidelines, and hazard ratios (HR) for overall survival (OS) were calculated. A difference-in-differences (DD) analysis examined the association of Medicaid expansion with outcomes for low-income patients aged <65. RESULTS: A total of 224,500 patients were included. Medicaid and uninsured patients were at increased risk of undergoing inappropriate therapy, including inappropriate lobectomy (Medicaid 1.36, 95% confidence interval [CI]: 1.21-1.54; uninsured 1.30, 95% CI: 1.05-1.60), and under-treatment with RAI (Medicaid 1.20, 95% CI: 1.14-1.26; uninsured 1.44, 95% CI: 1.33-1.55). Inappropriate lobectomy (HR 2.0, 95% CI: 1.7-2.3, P < .001) and under-treatment with RAI (HR 2.3, 95% CI: 2.2-2.5, P < .001) were independently associated with decreased survival, while appropriate surgical resection (HR 0.3, 95% CI: 0.3-0.3, P < .001) was associated with improved odds of survival; the model controlled for all relevant clinico-pathologic variables. No difference in AOT was observed in Medicaid expansion versus non-expansion states with respect to surgery or adjuvant RAI therapy. CONCLUSION: Medicaid and uninsured patients are at significantly increased odds of receiving inappropriate treatment for DTC; both groups are at a survival disadvantage compared with Medicare and those privately insured.


Assuntos
Cobertura do Seguro/estatística & dados numéricos , Radioisótopos do Iodo/administração & dosagem , Neoplasias da Glândula Tireoide/terapia , Tireoidectomia/estatística & dados numéricos , Adulto , Idoso , Feminino , Humanos , Cobertura do Seguro/economia , Masculino , Medicaid/economia , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Medicare/economia , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Radioterapia Adjuvante/economia , Radioterapia Adjuvante/estatística & dados numéricos , Neoplasias da Glândula Tireoide/economia , Neoplasias da Glândula Tireoide/mortalidade , Tireoidectomia/economia , Estados Unidos/epidemiologia
18.
J Trauma Acute Care Surg ; 92(3): 567-573, 2022 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-34610619

RESUMO

BACKGROUND: Intentional injury (both self-harm and interpersonal) is a major cause of morbidity and mortality, yet there are little data on the per-person cost of caring for these patients. Extant data focus on hospital charges related to the initial admission but does not include actual dollars spent or follow-up outpatient care. The Affordable Care Act has made Medicaid the primary payor of intentional injury care (39%) in the United States and the ideal source of cost data for these patients. We sought to determine the total and per-person long-term cost (initial event and following 24 months) of intentional injury among Maryland Medicaid recipients. METHODS: Retrospective cohort study of Maryland Medicaid claims was performed. Recipients who submitted claims after receiving an intentional injury, as defined by the International Classification of Diseases, Tenth Revision, between October 2015 and October 2017, were included in this study. Subjects were followed for 24 months (last participant enrolled October 2017 and followed to October 2019). Our primary outcome was the dollars paid by Medicaid. We examined subgroups of patients who harmed themselves and those who received repeated intentional injury. RESULTS: Maryland Medicaid paid $11,757,083 for the care of 12,172 recipients of intentional injuries between 2015 and 2019. The per-person, 2-year health care cost of an intentional injury was a median of $183 (SD, $5,284). These costs were highly skewed: min, $2.56; Q1 = 117.60, median, $182.80; Q3 = $480.82; and max, $332,394.20. The top 5% (≥95% percentile) required $3,000 (SD, $6,973) during the initial event and $8,403 (SD, $22,024) per served month thereafter, or 55% of the overall costs in this study. CONCLUSION: The long-term, per-person cost of intentional injury can be high. Private insurers were not included and may experience different costs in other states. LEVEL OF EVIDENCE: Economic and Value Based Evaluations; level III.


Assuntos
Medicaid/economia , Comportamento Autodestrutivo/economia , Comportamento Autodestrutivo/terapia , Violência , Ferimentos e Lesões/economia , Ferimentos e Lesões/terapia , Feminino , Humanos , Masculino , Maryland/epidemiologia , Patient Protection and Affordable Care Act , Estudos Retrospectivos , Comportamento Autodestrutivo/epidemiologia , Estados Unidos/epidemiologia , Ferimentos e Lesões/epidemiologia
19.
Health Serv Res ; 57(1): 15-26, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34517427

RESUMO

OBJECTIVE: To estimate the impact of the $600 per week Federal Pandemic Unemployment Compensation (FPUC) payments on health care services spending during the Covid pandemic and to investigate if this impact varied by state Medicaid expansion status. DATA SOURCES: This study leverages novel, publicly available data from Opportunity Insights capturing consumer credit and debit card spending on health care services for January 18-August 15, 2020 as well as information on unemployment insurance claims, Covid cases, and state policy changes. STUDY DESIGN: Using triple-differences estimation, we leverage two sources of variation-within-state change in the unemployment insurance claims rate and the introduction of FPUC payments-to estimate the moderating effect of FPUC on health care spending losses as unemployment rises. Results are stratified by state Medicaid expansion status. EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: For each percentage point increase in the unemployment insurance claims rate, health care spending declined by 1.0% (<0.05) in Medicaid expansion states and by 2.0% (<0.01) in nonexpansion states. However, FPUC partially mitigated this association, boosting spending by 0.8% (<0.001) and 1.3% (<0.05) in Medicaid expansion and nonexpansion states, respectively, for every percentage point increase in the unemployment insurance claims rate. CONCLUSIONS: We find that FPUC bolstered health care spending during the Covid pandemic, but that both the negative consequences of unemployment and moderating effects of federal income supports were greatest in states that did not adopt Medicaid expansion. These results indicate that emergency federal spending helped to sustain health care spending during a period of rising unemployment. Yet, the effectiveness of this program also suggests possible unmet demand for health care services, particularly in states that did not adopt Medicaid expansion.


Assuntos
COVID-19/economia , Gastos em Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde/economia , Medicaid/economia , Desemprego/estatística & dados numéricos , COVID-19/epidemiologia , Humanos , Patient Protection and Affordable Care Act , Estados Unidos
20.
J Gerontol B Psychol Sci Soc Sci ; 77(1): 191-200, 2022 01 12.
Artigo em Inglês | MEDLINE | ID: mdl-33631012

RESUMO

OBJECTIVES: The Balancing Incentive Program (BIP) was an optional program for states within the Patient Protection and Affordable Care Act to promote Medicaid-funded home and community-based services (HCBS) for older adults and persons with disabilities. Twenty-one states opted to participate in BIP, including several states steadfastly opposed to the health insurance provisions of the Affordable Care Act. This study focused on identifying what factors were associated with states' participation in this program. METHODS: Event history analysis was used to model state adoption of BIP from 2011 to 2014. A range of potential factors was considered representing states' economic, political, and programmatic conditions. RESULTS: The results indicate that states with a higher percentage of Democrats in the state legislature, fewer state employees per capita, and more nursing facility beds were more likely to adopt BIP. In addition, states with fewer home health agencies per capita, that devoted smaller proportions of Medicaid long-term care spending to HCBS, and that had more Money Follows the Person transitions were also more likely to pursue BIP. DISCUSSION: The findings highlight the role of partisanship, administrative capacity, and program history in state BIP adoption decisions. The inclusion of BIP in the Affordable Care Act may have deterred some states from participating in the program due to partisan opposition to the legislation. To encourage the adoption of optional HCBS programs, federal policymakers should consider the role of financial incentives, especially for states with limited bureaucratic capacity and that have made less progress rebalancing Medicaid long-term services and supports.


Assuntos
Serviços de Saúde Comunitária , Pessoas com Deficiência , Programas Governamentais , Serviços de Assistência Domiciliar , Medicaid , Casas de Saúde , Patient Protection and Affordable Care Act , Política , Governo Estadual , Serviços de Saúde Comunitária/economia , Serviços de Saúde Comunitária/legislação & jurisprudência , Pessoas com Deficiência/legislação & jurisprudência , Programas Governamentais/economia , Programas Governamentais/legislação & jurisprudência , Serviços de Assistência Domiciliar/economia , Serviços de Assistência Domiciliar/legislação & jurisprudência , Humanos , Assistência de Longa Duração/economia , Assistência de Longa Duração/legislação & jurisprudência , Medicaid/economia , Medicaid/legislação & jurisprudência , Casas de Saúde/economia , Casas de Saúde/legislação & jurisprudência , Patient Protection and Affordable Care Act/economia , Patient Protection and Affordable Care Act/legislação & jurisprudência , Estados Unidos
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