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2.
MMWR Morb Mortal Wkly Rep ; 69(6): 155-160, 2020 Feb 14.
Artigo em Inglês | MEDLINE | ID: mdl-32053583

RESUMO

The prevalence of current cigarette smoking is approximately twice as high among adults enrolled in Medicaid (23.9%) as among privately insured adults (10.5%), placing Medicaid enrollees at increased risk for smoking-related disease and death (1). Medicaid spends approximately $39 billion annually on treating smoking-related diseases (2). Individual, group, and telephone counseling and seven Food and Drug Administration (FDA)-approved medications* are effective in helping tobacco users quit (3). Comprehensive, barrier-free, widely promoted coverage of these treatments increases use of cessation treatments and quit rates and is cost-effective (3). To monitor changes in state Medicaid cessation coverage for traditional Medicaid enrollees† over the past decade, the American Lung Association collected data on coverage of nine cessation treatments by state Medicaid programs during December 31, 2008-December 31, 2018: individual counseling, group counseling, and the seven FDA-approved cessation medications§; states that cover all nine of these treatments are considered to have comprehensive coverage. The American Lung Association also collected data on seven barriers to accessing covered treatments.¶ As of December 31, 2018, 15 states covered all nine cessation treatments for all enrollees, up from six states as of December 31, 2008. Of these 15 states, Kentucky and Missouri were the only ones to have removed all seven barriers to accessing these cessation treatments. State Medicaid programs that cover all evidence-based cessation treatments, remove barriers to accessing these treatments, and promote covered treatments to Medicaid enrollees and health care providers could reduce smoking, smoking-related disease, and smoking-attributable federal and state health care expenditures (3-7).


Assuntos
Acesso aos Serviços de Saúde , Cobertura do Seguro/estatística & dados numéricos , Medicaid/economia , Abandono do Uso de Tabaco , Adulto , Humanos , Fumar/epidemiologia , Prevenção do Hábito de Fumar , Estados Unidos/epidemiologia
3.
BMJ ; 368: m40, 2020 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-32024637

RESUMO

OBJECTIVE: To examine the association between expansion of the Medicaid program under the Affordable Care Act and changes in healthcare spending among low income adults during the first four years of the policy implementation (2014-17). DESIGN: Quasi-experimental difference-in-difference analysis to examine out-of-pocket spending and financial burden among low income adults after Medicaid expansions. SETTING: United States. PARTICIPANTS: A nationally representative sample of individuals aged 19-64 years, with family incomes below 138% of the federal poverty level, from the 2010-17 Medical Expenditure Panel Survey. MAIN OUTCOMES AND MEASURES: Four annual healthcare spending outcomes: out-of-pocket spending; premium contributions; out-of-pocket plus premium spending; and catastrophic financial burden (defined as out-of-pocket plus premium spending exceeding 40% of post-subsistence income). P values were adjusted for multiple comparisons. RESULTS: 37 819 adults were included in the study. Healthcare spending did not change in the first two years, but Medicaid expansions were associated with lower out-of-pocket spending (adjusted percentage change -28.0% (95% confidence interval -38.4% to -15.8%); adjusted absolute change -$122 (£93; €110); adjusted P<0.001), lower out-of-pocket plus premium spending (-29.0% (-40.5% to -15.3%); -$442; adjusted P<0.001), and lower probability of experiencing a catastrophic financial burden (adjusted percentage point change -4.7 (-7.9 to -1.4); adjusted P=0.01) in years three to four. No evidence was found to indicate that premium contributions changed after the Medicaid expansions. CONCLUSION: Medicaid expansions under the Affordable Care Act were associated with lower out-of-pocket spending and a lower likelihood of catastrophic financial burden for low income adults in the third and fourth years of the act's implementation. These findings suggest that the act has been successful nationally in improving financial risk protection against medical bills among low income adults.


Assuntos
Financiamento Pessoal/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Renda/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Medicaid/legislação & jurisprudência , Pobreza/economia , Pobreza/estatística & dados numéricos , Adulto , Efeitos Psicossociais da Doença , Feminino , Financiamento Pessoal/economia , Gastos em Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde/economia , Inquéritos Epidemiológicos , Humanos , Cobertura do Seguro/economia , Masculino , Medicaid/economia , Pessoa de Meia-Idade , Estados Unidos/epidemiologia
4.
Plast Reconstr Surg ; 145(2): 333-339, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31985616

RESUMO

BACKGROUND: Rates of autologous breast reconstruction are stagnant compared with prosthetic techniques. Insufficient physician payment for microsurgical autologous breast reconstruction is one possible explanation. The payment difference between governmental and commercial payers creates a natural experiment to evaluate its impact on method of reconstruction. This study assessed the influence of physician payment differences for microsurgical autologous breast reconstruction and implants by insurance type on the likelihood of undergoing microsurgical reconstruction. METHODS: The Massachusetts All-Payer Claims Database was queried for women undergoing immediate autologous or implant breast reconstruction from 2010 to 2014. Univariate analyses compared demographic and clinical characteristics between different reconstructive approaches. Logistic regression explored the relative impact of insurance type and physician payments on breast reconstruction modality. RESULTS: Of the women in this study, 82.7 percent had commercial and 17.3 percent had governmental insurance. Implants were performed in 80 percent of women, whereas 20 percent underwent microsurgical autologous reconstruction. Women with Medicaid versus commercial insurance were less likely to undergo microsurgical reconstruction (16.4 percent versus 20.3 percent; p = 0.063). Commercial insurance, older age, and obesity independently increased the odds of microsurgical reconstruction (p < 0.01). When comparing median physician payments, governmental payers reimbursed 78 percent and 63 percent less than commercial payers for microsurgical reconstruction ($1831 versus $8435) and implants ($1249 versus $3359, respectively). Stratified analysis demonstrated that as physician payment increased, the likelihood of undergoing microsurgical reconstruction increased, independent of insurance type (p < 0.001). CONCLUSIONS: Women with governmental insurance had lower odds of undergoing microsurgical autologous breast reconstruction compared with commercial payers. Regardless of payer, greater reimbursement for microsurgical reconstruction increased the likelihood of microsurgical reconstruction. Current microsurgical autologous breast reconstruction reimbursements may not be commensurate with physician effort when compared to prosthetic techniques. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.


Assuntos
Reembolso de Seguro de Saúde/economia , Mamoplastia/economia , Microcirurgia/economia , Adulto , Implante Mamário/economia , Implante Mamário/estatística & dados numéricos , Implantes de Mama/economia , Implantes de Mama/estatística & dados numéricos , Neoplasias da Mama/economia , Neoplasias da Mama/cirurgia , Feminino , Retalhos de Tecido Biológico/economia , Humanos , Mamoplastia/estatística & dados numéricos , Massachusetts , Mastectomia/economia , Mastectomia/métodos , Medicaid/economia , Medicaid/estatística & dados numéricos , Microcirurgia/estatística & dados numéricos , Microvasos , Pessoa de Meia-Idade , Reoperação/economia , Reoperação/estatística & dados numéricos , Transplante Autólogo/economia , Estados Unidos
5.
Arthritis Care Res (Hoboken) ; 72(2): 208-215, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31562794

RESUMO

OBJECTIVE: To examine the impact of the Affordable Care Act on preventable hospitalizations and associated charges for patients living with systemic lupus erythematosus, before and after Medicaid expansion. METHODS: A retrospective, quasi-experimental study, using an interrupted time series research design, was conducted to analyze data for 8 states from the Healthcare Cost and Utilization Project state inpatient databases. Lupus hospitalizations with a principal diagnosis of predetermined ambulatory-care sensitive (ACS) conditions were the unit of primary analysis. The primary outcome variable was access to care measured by preventable hospitalizations caused by an ACS condition. RESULTS: There were 204,150 lupus hospitalizations in the final analysis, with the majority (53.5%) of lupus hospitalizations in states that did not expand Medicaid. In unadjusted analysis, Medicaid expansion states had significantly lower odds of having preventable lupus hospitalizations (odds ratio [OR] 0.958); however, after adjusting for several covariates, Medicaid expansion states had increased odds of having preventable lupus hospitalizations (OR 1.302). Adjusted analysis showed that those individuals with increased age, public insurance (Medicare or Medicaid), no health insurance, rural residence, or low income had significantly higher odds of having a preventable lupus hospitalization. States that expanded Medicaid had $523 significantly more charges than states that did not expand Medicaid. Older age and rural residence were associated with significantly higher charges. CONCLUSION: Our findings suggest that while Medicaid expansion increased health insurance coverage, it did not address other issues related to access to care that could reduce the number of preventable hospitalizations.


Assuntos
Acesso aos Serviços de Saúde/tendências , Preços Hospitalares/tendências , Hospitalização/tendências , Lúpus Eritematoso Sistêmico/epidemiologia , Medicaid/tendências , Patient Protection and Affordable Care Act/tendências , Adulto , Feminino , Acesso aos Serviços de Saúde/economia , Hospitalização/economia , Humanos , Análise de Séries Temporais Interrompida/economia , Análise de Séries Temporais Interrompida/tendências , Lúpus Eritematoso Sistêmico/economia , Lúpus Eritematoso Sistêmico/terapia , Masculino , Medicaid/economia , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/economia , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
6.
Health Serv Res ; 54(6): 1203-1213, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31742687

RESUMO

OBJECTIVE: To evaluate the impact of TEAM UP-an initiative that fully integrates behavioral health services into pediatric primary care in three Boston-area Community Health Centers (CHCs)-on health care utilization and costs. DATA SOURCES: 2014-2017 claims data on continuously enrolled children from a Massachusetts Medicaid managed care plan. STUDY DESIGN: We used a difference-in-difference approach with inverse probability of treatment weights to compare outcomes in children receiving primary care at TEAM UP CHCs versus comparison site CHCs, in the pre (2014-2016q2)- versus post (2016q3-2017)-intervention periods. Utilization outcomes included emergency department visits, inpatient admissions, primary care visits, and outpatient/professional visits (all cause and those with mental health (MH) diagnoses). Cost outcomes included total cost of care (inpatient, outpatient, professional, pharmacy). We further assessed differential effects by baseline MH diagnosis. PRINCIPAL FINDINGS: After 1.5 years, TEAM UP was associated with a relative increase in the rate of primary care visits (IRR = 1.15, 95% CI 1.04-1.27, or 115 additional visits/1000 patients/quarter), driven by children with a MH diagnosis at baseline. There was no significant change in avoidable health care utilization or cost. CONCLUSIONS: Expanding the TEAM UP behavioral health integration model to other sites has the potential to improve primary care engagement in low-income children with MH needs.


Assuntos
Prestação Integrada de Cuidados de Saúde/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitais Pediátricos/economia , Medicaid/economia , Medicaid/estatística & dados numéricos , Serviços de Saúde Mental/economia , Atenção Primária à Saúde/economia , Adolescente , Boston , Criança , Pré-Escolar , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Feminino , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Estudos Longitudinais , Masculino , Serviços de Saúde Mental/estatística & dados numéricos , Pobreza/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
7.
Spine (Phila Pa 1976) ; 44(22): 1585-1590, 2019 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-31568265

RESUMO

STUDY DESIGN: Health Services Research. OBJECTIVE: The purpose of this study is to determine the variability of Medicaid (MCD) reimbursement for patients who require spine procedures, and to assess how this compares to regional Medicare (MCR) reimbursement as a marker of access to spine surgery. SUMMARY OF BACKGROUND DATA: The current health care environment includes two major forms of government reimbursement: MCD and MCR, which are regulated and funded by the state and federal government, respectively. METHODS: MCD reimbursement rates from each state were obtained for eight spine procedures, utilizing online web searches: anterior cervical decompression and fusion, posterior cervical decompression and fusion, posterior lumbar decompression, single-level posterior lumbar fusion, posterior fusion for deformity (less than six levels; six to 12 levels; 13+ levels), and lumbar microdiscectomy. Discrepancy in reimbursement for these procedures on a state-to-state basis, as well as overall differences in MCD versus MCR reimbursement, was determined. Procedures were examined to identify whether certain surgical interventions have greater discrepancy in reimbursement. RESULTS: The average MCD reimbursement was 78.4% of that for MCR. However, there was significant variation between states (38.8%-140% of MCR for the combined eight procedures). On average, New York, New Jersey, Florida, and Rhode Island provided MCD reimbursements <50% of MCR reimbursements in the region. In total, 20 and 42 states provided <75% and 100% of MCR reimbursements, respectively. Based upon relative reimbursement, MCD appears to value microdiscectomy (84.1% of MCR; P = 0.10) over other elective spine procedures. Microdiscectomy also had the most interstate variation in MCD reimbursement: 39.0% to 207.0% of MCR. CONCLUSION: Large disparities were found between MCR and MCD when comparing identical procedures. Further research is necessary to fully understand the effect of these significant differences. However, it is likely that these discrepancies lead to suboptimal access to necessary spine care. LEVEL OF EVIDENCE: 4.


Assuntos
Descompressão Cirúrgica , Reembolso de Seguro de Saúde , Medicaid , Procedimentos Ortopédicos , Coluna Vertebral/cirurgia , Descompressão Cirúrgica/economia , Descompressão Cirúrgica/estatística & dados numéricos , Humanos , Reembolso de Seguro de Saúde/economia , Reembolso de Seguro de Saúde/estatística & dados numéricos , Medicaid/economia , Medicaid/estatística & dados numéricos , Procedimentos Ortopédicos/economia , Estados Unidos
8.
BMC Health Serv Res ; 19(1): 703, 2019 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-31619229

RESUMO

BACKGROUND: In the United States, there is well-documented regional variation in prescription drug spending. However, the specific role of physician adoption of brand name drugs on the variation in patient-level prescription drug spending is still being investigated across a multitude of drug classes. Our study aims to add to the literature by determining the association between physician adoption of a first-in-class anti-diabetic (AD) drug, sitagliptin, and AD drug spending in the Medicare and Medicaid populations in Pennsylvania. METHODS: We obtained physician-level data from QuintilesIMS Xponent™ database for Pennsylvania and constructed county-level measures of time to adoption and share of physicians adopting sitagliptin in its first year post-introduction. We additionally measured total AD drug spending for all Medicare fee-for-service and Part D enrollees (N = 125,264) and all Medicaid (N = 50,836) enrollees with type II diabetes in Pennsylvania for 2011. Finite mixture model regression, adjusting for patient socio-demographic/clinical characteristics, was used to examine the association between physician adoption of sitagliptin and AD drug spending. RESULTS: Physician adoption of sitagliptin varied from 44 to 99% across the state's 67 counties. Average per capita AD spending was $1340 (SD $1764) in Medicare and $1291 (SD $1881) in Medicaid. A 10% increase in the share of physicians adopting sitagliptin in a county was associated with a 3.5% (95% CI: 2.0-4.9) and 5.3% (95% CI: 0.3-10.3) increase in drug spending for the Medicare and Medicaid populations, respectively. CONCLUSIONS: In a medication market with many choices, county-level adoption of sitagliptin was positively associated with AD spending in Medicare and Medicaid, two programs with different approaches to formulary management.


Assuntos
Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipoglicemiantes/economia , Medicaid/economia , Medicare/economia , Padrões de Prática Médica/economia , Fosfato de Sitagliptina/economia , Administração Oral , Idoso , Diabetes Mellitus Tipo 2/economia , Planos de Pagamento por Serviço Prestado , Feminino , Gastos em Saúde/estatística & dados numéricos , Humanos , Hipoglicemiantes/administração & dosagem , Masculino , Pessoa de Meia-Idade , Pennsylvania , Fosfato de Sitagliptina/administração & dosagem , Estados Unidos
11.
N C Med J ; 80(5): 292-295, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31471512

RESUMO

The success of Medicaid transformation in North Carolina depends on participating health plans' ability to bring about better value to deliver on the Triple Aim of health care. Blue Cross and Blue Shield of North Carolina, working in collaboration with Amerigroup Partnership Plan, LLC, is making value-based care a cornerstone of its approach to serving the state's Medicaid population.


Assuntos
Medicaid/economia , Medicaid/organização & administração , Planos de Seguro Blue Cross Blue Shield , Redução de Custos , Humanos , North Carolina , Estados Unidos
12.
N C Med J ; 80(5): 312-316, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31471518

RESUMO

North Carolina's move to Medicaid managed care is part of the larger move to value-based care nationally. Keys to value-based care guide how practices and health systems can navigate the new payment model. The experience of North Carolina's Area Health Education Centers with primary care practices that work on value-based care can serve as an important case study.


Assuntos
Programas de Assistência Gerenciada/organização & administração , Medicaid/organização & administração , Logro , Humanos , Programas de Assistência Gerenciada/economia , Medicaid/economia , North Carolina , Atenção Primária à Saúde/economia , Avaliação de Programas e Projetos de Saúde , Estados Unidos
13.
Surgery ; 166(5): 793-799, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31405578

RESUMO

BACKGROUND: Studies using national data sets have suggested that insurance type drives a disparity in the care of emergency surgery patients. Large databases lack the granularity that smaller, single-institution series may provide. The goal of this study is to identify factors that may account for differences in care between Medicaid and non-Medicaid enrollees with appendicitis in central Massachusetts. METHODS: All adult patients with acute appendicitis in an academic medical center between 2010 and 2018 were included. Sociodemographic and clinical characteristics were compared according to Medicaid enrollment status. Analyses were performed to assess differences in the frequency of operative treatment, time to surgery, length of stay, and rates of readmission. RESULTS: The sample included 1,257 patients, 10.7% of whom (n = 135) were enrolled in Medicaid. The proportions of patients presenting with perforated appendicitis (28.9% vs 31.2%, P = .857) and undergoing laparoscopic appendectomy (96.3% vs 90.7%, P = .081) were similar between the 2 groups, as were length of stay (20 hours 30 minutes versus 22 hours 38 minutes, P = .109) and readmission rates (17.8% vs 14.5%, P = .683). Medicaid enrollees did experience somewhat greater time to surgery (6 hours 47 minutes versus 4 hours 49 minutes, P < .001). CONCLUSION: Despite anticipated differences in population, the treatment of appendicitis was similar between Medicaid and non-Medicaid enrollees. Medicaid enrollees experienced greater time to surgery; however, further studies are needed to explain this disparity in care.


Assuntos
Apendicectomia/estatística & dados numéricos , Apendicite/cirurgia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Laparoscopia/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Adulto , Apendicectomia/economia , Apendicite/economia , Feminino , Disparidades em Assistência à Saúde/economia , Humanos , Laparoscopia/economia , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Massachusetts , Medicaid/economia , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Socioeconômicos , Tempo para o Tratamento , Estados Unidos , Adulto Jovem
14.
Matern Child Health J ; 23(12): 1595-1603, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31363887

RESUMO

OBJECTIVES: Provision of long-acting reversible contraception (LARC) after delivery and prior to discharge is safe and advantageous, yet few Texas hospitals offer this service. Our study describes experiences of Texas hospitals that implemented immediate postpartum LARC (IPLARC) programs, in order to inform the development of other IPLARC programs and guide future research on system-level barriers to broader adoption. METHODS: Eight Texas hospitals that had implemented an IPLARC program were identified, and six agreed to participate in the study. Interviews with 19 key hospital staff covered (1) factors that led the development of an IPLARC program; (2) billing, pharmacy, and administrative operations related to implementation; (3) patient demand and readiness; (4) the consent process; (5) staff training; and (6) hospital plans for monitoring and evaluation of IPLARC services. RESULTS: Most hospitals in this study primarily served Medicaid and un- or under-insured populations. Participants from all six hospitals perceived high levels of patient demand for IPLARC and provider interest in providing this service. The major challenges were related to financing IPLARC programs. Participants from half of the hospitals reported that leadership had concerns about financial viability of providing IPLARC. The hospitals with the longest-running IPLARC programs were safety net hospitals with family planning training programs. CONCLUSIONS FOR PRACTICE: We found that hospitals with IPLARC programs all had strong support from both providers and hospital leadership and had funding sources to offset costs that were not reimbursed. Strategies to reduce the financial risks related to IPLARC provision could provide the impetus for new programs to launch and support their sustainability.


Assuntos
Anticoncepção/economia , Benefícios do Seguro/legislação & jurisprudência , Contracepção Reversível de Longo Prazo/estatística & dados numéricos , Medicaid/legislação & jurisprudência , Demandas Administrativas em Assistência à Saúde , Anticoncepção/métodos , Serviços de Planejamento Familiar , Feminino , Gastos em Saúde , Hospitais , Humanos , Benefícios do Seguro/economia , Medicaid/economia , Período Pós-Parto , Gravidez , Avaliação de Programas e Projetos de Saúde , Mecanismo de Reembolso , Texas , Estados Unidos
15.
Surgery ; 166(5): 820-828, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31402131

RESUMO

BACKGROUND: Obesity disproportionately affects vulnerable populations. Bariatric surgery is an effective long-term treatment for obesity-related complications; however, bariatric surgical rates are lower among racial minorities and low-income and publicly insured patients. The Affordable Care Act's Medicaid expansion improved access to health insurance, but its impact on bariatric surgical disparities has not been evaluated. We sought to determine the impact of the Affordable Care Act's Medicaid expansion on disparate utilization rates of bariatric surgery. METHODS: A total of 47,974 nonelderly adult bariatric surgical patients (ages 18-64 years) were identified in 2 Medicaid-expansion states (Kentucky and Maryland) versus 2 nonexpansion control states (Florida and North Carolina) between 2012 and 2015 using the Healthcare Cost and Utilization Project's State Inpatient Database. Poisson interrupted time series were conducted to determine the adjusted incidence rates of bariatric surgery by insurance (Medicaid/uninsured versus privately insured), income (high income versus low income), and race (African American versus white). The difference in the counts of bariatric surgery were then calculated to measure the gap in bariatric surgery rates. RESULTS: The adjusted incidence rate of bariatric surgery among Medicaid or uninsured and low-income patients increased by 15.8% and 5.1% per quarter, respectively, after the Affordable Care Act in expansion states (P < .001). No marginal change was seen in privately insured and high-income patients in expansion states. The adjusted incidence rates increased among African American and white patients, but these rates did not change significantly before and after the Affordable Care Act in expansion states. CONCLUSION: The gap in bariatric surgery rates by insurance and income was reduced after the Affordable Care Act's Medicaid expansion, but racial disparities persisted. Future research should track these trends and identify factors to reduce racial disparity in bariatric surgery.


Assuntos
Cirurgia Bariátrica/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Obesidade Mórbida/cirurgia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act/legislação & jurisprudência , Populações Vulneráveis/estatística & dados numéricos , Adolescente , Adulto , Afro-Americanos/estatística & dados numéricos , Cirurgia Bariátrica/economia , Cirurgia Bariátrica/legislação & jurisprudência , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Humanos , Masculino , Medicaid/economia , Medicaid/legislação & jurisprudência , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Grupos Minoritários/estatística & dados numéricos , Obesidade Mórbida/economia , Patient Protection and Affordable Care Act/economia , Patient Protection and Affordable Care Act/estatística & dados numéricos , Estudos Retrospectivos , Fatores Socioeconômicos , Estados Unidos , Adulto Jovem
16.
J Bone Joint Surg Am ; 101(16): 1451-1459, 2019 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-31436652

RESUMO

BACKGROUND: There is variability in access to and utilization of orthopaedic care, particularly for those with Medicaid insurance. One potential contributor is perceived unwillingness of surgeons and hospitals to accept underinsured patients. We used administrative data to examine the payer mix for select inpatient orthopaedic surgical procedures at all hospitals within a single region, hypothesizing that the delivery of orthopaedic surgery to Medicaid beneficiaries varies highly at the hospital level. METHODS: Using administrative data, we analyzed inpatient hospitalizations for elective cases (total knee or hip arthroplasty; spinal decompression or fusion) and trauma cases (hip hemiarthroplasty; femoral or tibial and fibular fracture repair) among 22 hospitals in a single region from 2011 to 2016 for patients who were 18 to 64 years of age. The primary outcome was the percentage of each hospital's caseload with Medicaid listed as the primary payer. The secondary outcome measured each hospital's Medicaid percentage against the percentage of Medicaid-insured individuals within 10 miles of the hospital (Medicaid share ratio), using a ratio of 1 as a benchmark. To quantify variation, we calculated a weighted coefficient of variation of the Medicaid share ratio for all cases combined, elective cases only, and trauma cases only. RESULTS: For all cases (n = 19,204), the mean percentage of Medicaid-funded surgical procedures was 7.6% (range, 0.2% to 57.3%). The mean Medicaid share ratio was 1.0 (range, 0.05 to 4.20). Across 22 hospitals, the weighted coefficient of variation for Medicaid share was 69, indicating very high variation. For elective cases alone, the mean percentage of Medicaid-funded surgical procedures was 5.5% (range, 0.2% to 64.6%). The mean Medicaid share ratio was 0.71 (range, 0.05 to 4.73), and the weighted coefficient of variation was 93. For trauma cases alone, Medicaid-funded surgical procedures were 14.7% (range, 0.0% to 35.7%). The mean Medicaid share ratio was 2.0 (range, 0 to 3.93), and the weighted coefficient of variation was 34. CONCLUSIONS: Delivery of care was highly variable when benchmarking against the insurance composition of each hospital's surrounding community. Although generalizability to other regions is limited, our findings support previously asserted notions that delivery of orthopaedic care may differ on the basis of socioeconomic markers (such as insurance status). If not addressed, these inequities may exacerbate existing racially and socioeconomically based disparities in care.


Assuntos
Assistência à Saúde/economia , Acesso aos Serviços de Saúde/economia , Disparidades em Assistência à Saúde/economia , Medicaid/economia , Procedimentos Ortopédicos/economia , Adolescente , Adulto , Fatores Etários , Estudos de Coortes , Bases de Dados Factuais , Feminino , Humanos , Pacientes Internados/estatística & dados numéricos , Cobertura do Seguro/economia , Masculino , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , Procedimentos Ortopédicos/métodos , Estudos Retrospectivos , Medição de Risco , Estados Unidos , Adulto Jovem
17.
Tex Med ; 115(8): 23, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31369139

RESUMO

Medicine didn't get everything it needed from lawmakers for Medicaid, including TMA's biggest and boldest ask of the 2019 session. Still, progress TMA achieved on managed care reform and other facets of Medicaid will advance physicians' efforts to care for the most vulnerable Texans.


Assuntos
Reforma dos Serviços de Saúde , Programas de Assistência Gerenciada , Medicaid/organização & administração , Humanos , Medicaid/economia , Planos Governamentais de Saúde , Texas , Estados Unidos
19.
J Manag Care Spec Pharm ; 25(9): 973-983, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31313621

RESUMO

BACKGROUND: The treatment of postsurgical pain with prescription opioids has been associated with persistent opioid use and increased health care utilization and costs. OBJECTIVE: To compare the health care burden between opioid-naive adult patients who were prescribed opioids after a major surgery and opioidnaive adult patients who were not prescribed opioids. METHODS: Administrative claims data from the IBM Watson Health MarketScan Research Databases for 2010-2016 were used. Opioid-naive adult patients who underwent major inpatient or outpatient surgery and who had at least 1 year of continuous enrollment before and after the index surgery date were eligible for inclusion. Cohorts were defined based on an opioid pharmacy claim between 7 days before index surgery and 1 year after index surgery (opioid use during surgery and inpatient use were not available). To ensure an opioid-naive population, patients with opioid claims between 365 and 8 days before surgery were excluded. Acute medical outcomes, opioid utilization, health care utilization, and costs were measured during the post-index period (index surgery hospitalization and day of index outpatient surgery not included). Predicted costs were estimated from multivariable log-linked gamma-generalized linear models. RESULTS: The final sample consisted of 1,174,905 opioid-naive patients with an inpatient surgery (73% commercial, 20% Medicare, 7% Medicaid) and 2,930,216 opioid-naive patients with an outpatient surgery (74% commercial, 23% Medicare, and 3% Medicaid). Opioid use after discharge was common among all 3 payer types but was less common among Medicare patients (63% inpatient/43% outpatient) than patients with commercial (80% inpatient/75% outpatient) or Medicaid insurance (86% inpatient/81% outpatient). Across all 3 payers, opioid users were younger, were more likely to be female, and had a higher preoperative comorbidity burden than nonopioid users. In unadjusted analyses, opioid users tended to have more hospitalizations, emergency department visits, and pharmacy claims. Adjusted predicted 1-year post-period total health care costs were significantly higher (P< 0.001) for opioid users than nonopioid users for commercial insurance (inpatient: $22,209 vs. $14,439; outpatient: $13,897 vs. $8,825), Medicare (inpatient: $31,721 vs. $26,761; outpatient: $24,529 vs. $15,225), and Medicaid (inpatient: $13,512 vs. $9,204; outpatient: $11,975 vs. $8,212). CONCLUSIONS: Filling an outpatient opioid prescription (vs. no opioid prescription) in the 1 year after inpatient or outpatient surgery was associated with increased health care utilization and costs across all payers. DISCLOSURES: Funding for this study was provided by Heron Therapeutics, which participated in analysis and interpretation of data, drafting, reviewing, and approving the publication. All authors contributed to the development of the publication and maintained control over the final content. Brummett is a paid consultant for Heron Therapeutics and Recro Pharma and reports receipt of research funding from MDHHS (Sub K Michigan Open), NIDA (Centralized Pain Opioid Non-Responsiveness R01 DA038261-05), NIH0DHHS-US-16 PAF 07628 (R01 NR017096-05), NIH-DHHS (P50 AR070600-05 CORT), NIH-DHHS-US (K23 DA038718-04), NIH-DHHS-US-16-PAF06270 (R01 HD088712-05), NIH-DHHS-US-17-PAF02680 (R01 DA042859-05), and UM Michigan Genomics Initiative and holding a patent for peripheral perineural dexmedetomidine. Oderda is a paid consultant for Heron Therapeutics. Pawasauskas is a paid consultant to Heron Therapeutics and Mallinckrodt Pharmaceuticals. England and Evans-Shields are employees of Heron Therapeutics. Kong, Lew, Zimmerman, and Henriques are employees of IBM Watson Health, which was compensated by Heron Therapeutics for conducting this research. Portions of this work were presented as a poster at the AMCP Managed Care and Specialty Pharmacy Annual Meeting 2019; March 25-28, 2019; San Diego, CA.


Assuntos
Analgésicos Opioides/economia , Analgésicos Opioides/uso terapêutico , Assistência à Saúde/economia , Pacientes Ambulatoriais/educação , Adulto , Idoso , Procedimentos Cirúrgicos Ambulatórios/economia , Analgésicos Opioides/efeitos adversos , Comorbidade , Efeitos Psicossociais da Doença , Feminino , Custos de Cuidados de Saúde , Humanos , Pacientes Internados , Masculino , Programas de Assistência Gerenciada/economia , Medicaid/economia , Medicare/economia , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/economia , Transtornos Relacionados ao Uso de Opioides/etiologia , Dor/tratamento farmacológico , Dor/economia , Aceitação pelo Paciente de Cuidados de Saúde , Estudos Retrospectivos , Estados Unidos
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