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1.
J Manag Care Spec Pharm ; 27(10): 1489-1493, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34595946

RESUMO

SUMMARY The 1-month drug-dispensing limit is a common drug utilization tool used by state Medicaid agencies to control spending. Since the beginning of the COVID-19 pandemic, many states relaxed the 1-month dispensing limit restriction in order to align with social distancing recommendations. Yet, some states have not relaxed this limit and have differed substantially regarding the policies that have been implemented. Among states that relaxed the 1-month supply limit, determining which chronic disease drugs qualified for this extension can be challenging for patients and clinicians. As more commercial and Medicare insurance beneficiaries are offered 90-day drug supplies, the 30-day drug supply limit with Medicaid has become a health equity issue, since many individuals insured by Medicaid have already experienced a disproportionate impact from and remain at high risk for severe COVID-19 disease. Thus, we propose policy solutions to ensure that Medicaid beneficiaries have safe and uninterrupted access to chronic disease medications during and beyond the COVID-19 pandemic. DISCLOSURES: No funding was received for this work. Alpern has received funding from Arnold Ventures for research related to the use and spending of off-patent drugs, unrelated to this work, and is a member of the Pharmacy and Therapeutics Committee at Regions Hospital, St. Paul, MN. DeSilva has received CDC support for work on Vaccine Safety Datalink, VISION network, and Center of Excellence for Newcomer Health, unrelated to this work. Chomilo is Medicaid Medical Director for the State of Minnesota's Department of Human Services.


Assuntos
COVID-19/epidemiologia , Medicaid/normas , Distanciamento Físico , Doença Crônica , Humanos , Reembolso de Seguro de Saúde/economia , Reembolso de Seguro de Saúde/normas , Medicaid/economia , Pandemias , Políticas , SARS-CoV-2 , Estados Unidos/epidemiologia
2.
J Manag Care Spec Pharm ; 27(10): 1426-1437, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34595954

RESUMO

BACKGROUND: Duchenne muscular dystrophy (DMD) is a severe X-linked progressive neurodegenerative disease characterized by loss of ambulation, cardiomyopathy, respiratory insufficiency, and early mortality. Few data are available that describe the direct medical costs among patients with DMD in the United States. OBJECTIVE: To characterize the demographics, comorbidity burden, and direct monthly costs of care among patients with DMD with Medicaid and with commercial insurance coverage. METHODS: IBM MarketScan Commercial and Multi-State Medicaid claims (2013-2018) were used to identify males aged 30 years or under with diagnostic codes for muscular dystrophy or DMD; additional exclusion criteria were applied to identify those with probable DMD. Baseline characteristics and comorbidities were tabulated. The frequency of health care resource use and median (interquartile range [IQR]) monthly costs (in 2018 USD) were estimated from those with at least 12 months of continuous follow-up. RESULTS: Median (IQR) baseline ages were similar between the Medicaid (14 [9-20] years; n = 2,007) and commercial (15 [9-21] years; n = 1,964) DMD cohorts. The frequency of comorbidities over the period was slightly higher with those on Medicaid. The median duration of follow-up was 3.1 years among members of the Medicaid DMD cohort and 1.7 years among the commercial DMD cohort. Median monthly resource use was generally higher among the Medicaid DMD cohort; nonetheless, median (IQR) monthly costs were similar at $1,735 ($367-$5,281) for the Medicaid DMD cohort vs $1,883 ($657-$6,796) for the commercial DMD cohort. CONCLUSIONS: The demographic characteristics and median direct medical costs were similar between patients with commercial vs Medicaid coverage, even though patients with Medicaid coverage had higher resource use. Despite challenges in definitively identifying DMD patients using claims data, these findings help characterize contemporary DMD populations in the United States and the related direct economic burden to the payer. DISCLOSURES: This study was funded by Sarepta Therapeutics, Inc. Klimchak and Gooch are employees of Sarepta Therapeutics Inc. Szabo, Qian, and Popoff are employees of Broadstreet HEOR, which received funds from Sarepta Therapeutics, Inc., for work on this study. Iannaccone has received research funding or consulting fees from Avexis, Biogen, Fibrogen, Mallinkrodt, Regeneron, Sarepta Therapeutics, Inc., Scholar Rock, PTC Therapeutics, Pfizer, MDA, CureSMA, NIH, Genentech-Roche, and BCBS. Publication of the study results was not contingent on the sponsor's approval or censorship of the manuscript. Information from this study was presented, in part, at the AMCP Virtual Annual Meeting, April 21-24, 2020.


Assuntos
Comorbidade , Custos de Cuidados de Saúde , Cobertura do Seguro/economia , Medicaid/economia , Distrofia Muscular de Duchenne/economia , Setor Privado , Adolescente , Adulto , Criança , Pré-Escolar , Bases de Dados Factuais , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
3.
PLoS One ; 16(10): e0257796, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34705847

RESUMO

Sickle cell disease is a progressively debilitating genetic condition that affects red blood cells and can result in a variety of serious medical complications, reduced life expectancy, and diminished quality of life. Medicaid nationwide covered 66 percent of sickle cell disease hospitalizations in 2004 and 58 percent of emergency department visits for the disease between 1999 and 2007. Using Medicaid data from four states with large populations that account for more than one-third of Medicaid program enrollment, we examined the characteristics of those with sickle cell disease. We found instances of mortality rates more than nine times the age-adjusted population average (in Texas, a mortality rate for Medicaid enrollees with SCD of 1.11 percent compared to 0.12 percent overall); rates of disability-related eligibility-which is associated with long-term Medicaid enrollment-of up to 69 percent; and half or more of affected enrollees having (all-cause) hospital stays, emergency department visits, and opioid prescription fills. With gene therapies on the horizon that will spur discussions of treatment coverage, costs, and outcomes for people with sickle cell disease, it is important for relevant stakeholders to understand the affected populations.


Assuntos
Analgésicos Opioides/uso terapêutico , Anemia Falciforme/epidemiologia , Serviço Hospitalar de Emergência/economia , Medicaid/economia , Adulto , Idoso , Analgésicos Opioides/economia , Anemia Falciforme/economia , Anemia Falciforme/terapia , Pessoas com Deficiência , Feminino , Hospitalização/economia , Humanos , Pacientes Internados , Masculino , Medicare/economia , Pessoa de Meia-Idade , Mortalidade , Pacientes Ambulatoriais , Prescrições/economia , Qualidade de Vida , Texas/epidemiologia , Estados Unidos/epidemiologia
5.
Am J Public Health ; 111(8): 1523-1529, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34213978

RESUMO

Objectives. To identify the association between Medicaid eligibility expansion and medical debt. Methods. We used difference-in-differences design to compare changes in medical debt for those gaining coverage through Louisiana's Medicaid expansion with those in nonexpansion states. We matched individuals gaining Medicaid coverage because of Louisiana's Medicaid expansion (n = 196 556) to credit report data on medical debt and compared them with randomly selected credit reports of those living in Southern nonexpansion state zip codes with high rates of uninsurance (n = 973 674). The study spanned July 2014 through July 2019. Results. One year after Louisiana Medicaid expansion, medical collections briefly rose before declining by 8.1 percentage points (95% confidence interval [CI] = -0.107, -0.055; P ≤ .001), or 13.5%, by the third postexpansion year. Balances also briefly rose before falling by 0.621 log points (95% CI = -0.817, -0.426; P ≤ .001), or 46.3%. Conclusions. Louisiana's Medicaid expansion was associated with a reduction in the medical debt load for those gaining coverage. These results suggest that future Medicaid eligibility expansions may be associated with similar improvements in the financial well-being of enrollees.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Medicaid , Adulto , Feminino , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Louisiana , Masculino , Medicaid/economia , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , Pobreza , Estados Unidos
6.
JAMA ; 326(3): 250-256, 2021 07 20.
Artigo em Inglês | MEDLINE | ID: mdl-34283184

RESUMO

Importance: Medical debt is an increasing concern in the US, yet there is limited understanding of the amount and distribution of medical debt, and its association with health care policies. Objective: To measure the amount of medical debt nationally and by geographic region and income group and its association with Medicaid expansion under the Affordable Care Act. Design, Setting, and Participants: Data on medical debt in collections were obtained from a nationally representative 10% panel of consumer credit reports between January 2009 and June 2020 (reflecting care provided prior to the COVID-19 pandemic). Income data were obtained from the 2014-2018 American Community Survey. The sample consisted of 4.1 billion person-month observations (nearly 40 million unique individuals). These data were used to estimate the amount of medical debt (nationally and by geographic region and zip code income decile) and to examine the association between Medicaid expansion and medical debt (overall and by income group). Exposures: Geographic region (US Census region), income group (zip code income decile), and state Medicaid expansion status. Main Outcomes and Measures: The stock (all unpaid debt listed on credit reports) and flow (new debt listed on credit reports during the preceding 12 months) of medical debt in collections that can be collected on by debt collectors. Results: In June 2020, an estimated 17.8% of individuals had medical debt (13.0% accrued debt during the prior year), and the mean amount was $429 ($311 accrued during the prior year). The mean stock of medical debt was highest in the South and lowest in the Northeast ($616 vs $167; difference, $448 [95% CI, $435-$462]) and higher in poor than in rich zip code income deciles ($677 vs $126; difference, $551 [95% CI, $520-$581]). Between 2013 and 2020, the states that expanded Medicaid in 2014 experienced a decline in the mean flow of medical debt that was 34.0 percentage points (95% CI, 18.5-49.4 percentage points) greater (from $330 to $175) than the states that did not expand Medicaid (from $613 to $550). In the expansion states, the gap in the mean flow of medical debt between the lowest and highest zip code income deciles decreased by $145 (95% CI, $95-$194) while the gap increased by $218 (95% CI, $163-$273) in the nonexpansion states. Conclusions and Relevance: This study provides an estimate of the amount of medical debt in collections in the US based on consumer credit reports from January 2009 to June 2020, reflecting care delivered prior to the COVID-19 pandemic, and suggests that the amount of medical debt was highest among individuals living in the South and in lower-income communities. However, further study is needed regarding debt related to COVID-19.


Assuntos
Financiamento Pessoal/economia , Gastos em Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/economia , Humanos , Renda , Seguro Saúde/economia , Medicaid/economia , Pessoas sem Cobertura de Seguro de Saúde , Determinantes Sociais da Saúde , Estados Unidos
7.
J Trauma Acute Care Surg ; 91(4): 728-735, 2021 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-34252061

RESUMO

BACKGROUND: Nearly 1-in-10 trauma patients in the United States are readmitted within 30 days of discharge, with a median hospital cost of more than $8,000 per readmission. There are national efforts to reduce readmissions in trauma care, but we do not yet understand which are potentially preventable. Our study aims to quantify the potentially preventable readmissions (PPRs) in trauma care to serve as the anchor point for ongoing efforts to curb hospital readmissions and ultimately, bring preventable readmissions to zero. METHODS: We identified inpatient hospitalizations after trauma and readmissions within 90 days in the 2017 National Readmissions Database (NRD). Potentially preventable readmissions were defined as the Agency for Healthcare Research and Quality-defined Ambulatory Care Sensitive Conditions, in addition to superficial surgical site infection, acute kidney injury/acute renal failure, and aspiration pneumonitis. Mean costs for these admissions were calculated using the NRD. A multivariable logistic regression model was used to characterize the relationship between patient characteristics and PPR. RESULTS: A total of 1,320,083 patients were admitted for trauma care in the 2017 NRD, and 137,854 (10.4%) were readmitted within 90 days of discharge. Of these readmissions, 22.7% were potentially preventable. The mean cost was $10,001/PPR, resulting in $313,802,278 in cost to the US health care system. Of readmitted trauma patients younger than 65 years, Medicaid or Medicare patients had 2.7-fold increased odds of PPRs compared with privately insured patients. Patients of any age with congestive heart failure had 2.9 times increased odds of PPR, those with chronic obstructive pulmonary disease or complicated diabetes mellitus had 1.8 times increased odds, and those with chronic kidney disease had 1.7 times increased odds. Furthermore, as the days from discharge increased, the proportion of readmissions due to PPRs increased. CONCLUSION: One-in-five trauma readmissions are potentially preventable, which account for more than $300 million annually in health care costs. Improved access to postdischarge ambulatory care may be key to minimizing PPRs, especially for those with certain comorbidities. LEVEL OF EVIDENCE: Economic and value-based evaluations, level II.


Assuntos
Assistência ao Convalescente/organização & administração , Assistência Ambulatorial/organização & administração , Custos Hospitalares/estatística & dados numéricos , Readmissão do Paciente/economia , Ferimentos e Lesões/terapia , Idoso , Comorbidade , Redução de Custos , Bases de Dados Factuais/estatística & dados numéricos , Humanos , Medicaid/economia , Medicaid/estatística & dados numéricos , Medicare/economia , Medicare/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Estados Unidos , Ferimentos e Lesões/economia , Ferimentos e Lesões/epidemiologia
8.
J Am Heart Assoc ; 10(15): e022040, 2021 08 03.
Artigo em Inglês | MEDLINE | ID: mdl-34323114

RESUMO

Maternal mortality has been increasing in the United States over the past 3 decades, while decreasing in all other high-income countries during the same period. Cardiovascular conditions account for over one fourth of maternal deaths, with two thirds of deaths occurring in the postpartum period. There are also significant healthcare disparities that have been identified in women experiencing maternal morbidity and mortality, with Black women at 3 to 4 times the risk of death as their White counterparts and women in rural areas at heightened risk for cardiovascular morbidity and maternal morbidity. However, many maternal deaths have been shown to be preventable, and improving access to care may be a key solution to addressing maternal cardiovascular mortality. Medicaid currently finances almost half of all births in the United States and is mandated to provide coverage for women with incomes up to 138% of the federal poverty level, for up to 60 days postpartum. In states that have not expanded coverage, new mothers become uninsured after 60 days. Medicaid expansion has been shown to reduce maternal mortality, particularly benefiting racial and ethnic minorities, likely through reduced insurance churn, improved postpartum access to care, and improved interpregnancy care. However, even among states with Medicaid expansion, significant care gaps exist. An additional proposed intervention to improve access to care in these high-risk populations is extension of Medicaid coverage for 1 year after delivery, which would provide the most benefit to women in Medicaid nonexpanded states, but also improve care to women in Medicaid expanded states.


Assuntos
Acesso aos Serviços de Saúde , Mortalidade Materna , Medicaid , Complicações Cardiovasculares na Gravidez , Adulto , Grupos Étnicos , Feminino , Política de Saúde/tendências , Acesso aos Serviços de Saúde/organização & administração , Acesso aos Serviços de Saúde/normas , Disparidades em Assistência à Saúde/etnologia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Mortalidade Materna/etnologia , Mortalidade Materna/tendências , Medicaid/economia , Medicaid/normas , Formulação de Políticas , Período Pós-Parto , Gravidez , Complicações Cardiovasculares na Gravidez/economia , Complicações Cardiovasculares na Gravidez/mortalidade , Estados Unidos/epidemiologia
9.
Med Care ; 59(9): 785-788, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-34081674

RESUMO

BACKGROUND: Six states expanding Medicaid under the Affordable Care Act have obtained waivers to incorporate cost-sharing. OBJECTIVE: We describe the magnitude and distribution of cost-sharing imposed by the Healthy Michigan Plan and enrollees' propensity to pay. RESEARCH DESIGN: Enrollees are followed for at least 18 months (6-mo baseline period for utilization and spending before receipt of first cost-sharing statement; ≥12 mo follow-up thereafter to ascertain obligations and payments). Analyses stratified by income, comparing enrollees with income less than Federal Poverty Level (FPL) who faced only utilization-based copayments and those greater than or equal to FPL who also faced premium contributions. SUBJECTS: A total of 158,322 enrollees aged 22-62 who initially enrolled during the first year of the program and remained continuously enrolled ≥18 months. RESULTS: Among those enrolled ≥18 months, 51.0% faced cost-sharing. Average quarterly invoices were $4.85 ($11.11 for those with positive invoices) for income less than FPL and $26.71 ($30.93 for those with positive invoices) for incomes greater than or equal to FPL. About half of enrollees with obligations made at least partial payments, with payments being more likely among those >100% FPL. Payment of the full obligation was highest in the initial 6 months. CONCLUSIONS: Many payment obligations go uncollected, suggesting that in a system without the threat of disenrollment, the impacts of cost-sharing may be muted. Similarly, the ability of cost-sharing to defray the program's budgetary impact may also be less than anticipated.


Assuntos
Custo Compartilhado de Seguro/economia , Gastos em Saúde/estatística & dados numéricos , Medicaid/economia , Adulto , Custo Compartilhado de Seguro/estatística & dados numéricos , Feminino , Humanos , Renda/estatística & dados numéricos , Masculino , Michigan , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/economia , Pobreza , Estados Unidos
10.
J Bone Joint Surg Am ; 103(16): 1521-1530, 2021 08 18.
Artigo em Inglês | MEDLINE | ID: mdl-34166267

RESUMO

BACKGROUND: Patient-reported outcome measures (PROMs) are frequently utilized to assess patient perceptions of health and function. Numerous factors influence self-reported physical and mental health outcome scores. The purpose of this study was to examine if an association exists between insurance payer type and baseline PROM scores in patients diagnosed with hip osteoarthritis. METHODS: We retrospectively reviewed the baseline PROM scores of 5,974 patients diagnosed with hip osteoarthritis according to the International Classification of Diseases, Tenth Revision (ICD-10) code within our institutional database from 2015 to 2020. We examined Hip disability and Osteoarthritis Outcome Score-Physical Function Short-form (HOOS-PS), Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Short Form 10a (PF10a), PROMIS Global-Mental, and PROMIS Global-Physical scores. Descriptive analyses, analysis of variance (ANOVA), analysis of covariance (ANCOVA), and post hoc analyses were utilized to assess variations in PROM scores across insurance type. RESULTS: The mean age (and standard deviation) of the study population was 63.5 ± 12.2 years, and 55.7% of patients were female. The Medicaid cohort had a comparatively higher percentage of Black, Hispanic, and non-English-speaking patients and a lower median household income. The Charlson Comorbidity Index was highest in the Medicare and Medicaid insurance cohorts. Patients utilizing commercial insurance consistently demonstrated the highest baseline PROMs, and patients utilizing Medicaid consistently demonstrated the lowest baseline PROMs. Subsequent analyses found significantly poorer mean scores for the Medicaid cohort for all 4 PROMs when compared with the commercial insurance and Medicare cohorts. These score differences exceeded the minimal clinically important differences (MCIDs). For the PROMIS Global-Mental subscore, a significantly lower mean score was observed for the Workers' Compensation and motor vehicle insurance cohort when compared with the commercial insurance and Medicare cohort. This difference also exceeded the MCID. CONCLUSIONS: PROM scores in patients with hip osteoarthritis varied among those with different insurance types. Variations in certain demographic and health indices are potential drivers of these observed baseline PROM differences. For patients with hip osteoarthritis, the use of PROMs for research, clinical, or quality-linked payment metrics should acknowledge baseline variation between patients with different insurance types. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Artroplastia de Quadril/estatística & dados numéricos , Seguradoras/estatística & dados numéricos , Osteoartrite do Quadril/cirurgia , Medidas de Resultados Relatados pelo Paciente , Idoso , Artroplastia de Quadril/economia , Feminino , Humanos , Seguradoras/economia , Masculino , Medicaid/economia , Medicaid/estatística & dados numéricos , Medicare/economia , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Osteoartrite do Quadril/diagnóstico , Osteoartrite do Quadril/economia , Estudos Retrospectivos , Autorrelato/estatística & dados numéricos , Estados Unidos
11.
Med Care ; 59(6): 487-494, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-33973937

RESUMO

BACKGROUND: Physicians often receive lower payments for dual-eligible Medicare-Medicaid beneficiaries versus nondual Medicare beneficiaries because of state reimbursement caps. The Affordable Care Act (ACA) primary care fee bump temporarily eliminated this differential in 2013-2014. OBJECTIVE: To examine how dual payment policy impacts primary care physicians' (PCP) acceptance of duals. RESEARCH DESIGN: We assessed differences in the likelihood that PCPs had dual caseloads of ≥10% or 20% in states with lower versus full dual reimbursement using linear probability models adjusted for physician and area-level traits. Using a triple-difference approach, we examined changes in dual caseloads for PCPs versus a control group of specialists in states with fee bumps versus no change during years postbump versus prebump. SUBJECTS: PCPs and specialists (cardiologists, orthopedic surgeons, general surgeons) that billed fee-for-service Medicare. MEASURES: State dual payment policies and physicians' dual caseloads as a percentage of their Medicare patients. RESULTS: In 2012, 81% of PCPs had dual caseloads of ≥10% and this was less likely among PCPs in states with lower versus full dual reimbursement (eg, difference=-4.52 percentage points; 95% confidence interval, -6.80 to -2.25). The proportion of PCPs with dual caseloads of ≥10% or 20% decreased significantly between 2012 and 2017 and the fee bump was not consistently associated with increases in dual caseloads. CONCLUSIONS: Pre-ACA, PCPs' participation in the dual program appeared to be lower in states with lower reimbursement for duals. Despite the ACA fee bump, dual caseloads declined over time, raising concerns of worsening access to care.


Assuntos
Acesso aos Serviços de Saúde/economia , Medicaid/economia , Medicare/economia , Patient Protection and Affordable Care Act , Médicos de Atenção Primária/economia , Planos de Pagamento por Serviço Prestado , Feminino , Humanos , Masculino , Médicos de Atenção Primária/estatística & dados numéricos , Estados Unidos
12.
PLoS One ; 16(5): e0251353, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34032811

RESUMO

BACKGROUND: Research on children and youth on the autism spectrum reveal racial and ethnic disparities in access to healthcare and utilization, but there is less research to understand how disparities persist as autistic adults age. We need to understand racial-ethnic inequities in obtaining eligibility for Medicare and/or Medicaid coverage, as well as inequities in spending for autistic enrollees under these public programs. METHODS: We conducted a cross-sectional cohort study of U.S. publicly-insured adults on the autism spectrum using 2012 Medicare-Medicaid Linked Enrollee Analytic Data Source (n = 172,071). We evaluated differences in race-ethnicity by eligibility (Medicare-only, Medicaid-only, Dual-Eligible) and spending. FINDINGS: The majority of white adults (49.87%) were full-dual eligible for both Medicare and Medicaid. In contrast, only 37.53% of Black, 34.65% Asian/Pacific Islander, and 35.94% of Hispanic beneficiaries were full-dual eligible for Medicare and Medicare, with most only eligible for state-funded Medicaid. Adjusted logistic models controlling for gender, intellectual disability status, costly chronic condition, rural status, county median income, and geographic region of residence revealed that Black beneficiaries were significantly less likely than white beneficiaries to be dual-eligible across all ages. Across these three beneficiary types, total spending exceeded $10 billion. Annual total expenditures median expenditures for full-dual and Medicaid-only eligible beneficiaries were higher among white beneficiaries as compared with Black beneficiaries. CONCLUSIONS: Public health insurance in the U.S. including Medicare and Medicaid aim to reduce inequities in access to healthcare that might exist due to disability, income, or old age. In contrast to these ideals, our study reveals that racial-ethnic minority autistic adults who were eligible for public insurance across all U.S. states in 2012 experience disparities in eligibility for specific programs and spending. We call for further evaluation of system supports that promote clear pathways to disability and public health insurance among those with lifelong developmental disabilities.


Assuntos
Transtorno Autístico/economia , Medicaid/economia , Medicaid/estatística & dados numéricos , Medicare/economia , Medicare/estatística & dados numéricos , Adolescente , Adulto , Idoso , Estudos de Coortes , Estudos Transversais , Definição da Elegibilidade/economia , Definição da Elegibilidade/estatística & dados numéricos , Grupos Étnicos/estatística & dados numéricos , Feminino , Gastos em Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Armazenamento e Recuperação da Informação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Grupos Minoritários/estatística & dados numéricos , Estados Unidos , Adulto Jovem
13.
Obstet Gynecol ; 137(6): e163-e168, 2021 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-33760779

RESUMO

ABSTRACT: Medicaid, the state-federal health insurance program for individuals with low incomes, serves as a safety net for women throughout the life span. Historically, expansions of Medicaid have been associated with improved access to health care, less delay in obtaining health care, better self-reported health, and reductions in mortality. Compared with nonexpansion states, states that have participated in the Affordable Care Act's Medicaid expansion have experienced improvements in maternal and infant mortality and decreases in uninsured rates and have decreased racial inequities for these measures. In addition to supporting policies that expand access to Medicaid, the American College of Obstetricians and Gynecologists strongly supports education for its members, other obstetrician-gynecologists, and other health care practitioners regarding the complex system for regulation of Medicaid and encourages advocacy for policies that increase access to care for all women. This Committee Opinion has been revised to emphasize the importance of Medicaid to improving women's health, the history and growth of Medicaid, including the ACA's Medicaid expansion, and the mechanisms by which changes to the Medicaid program can occur, and it includes relevant examples for each.


Assuntos
Acesso aos Serviços de Saúde , Medicaid/legislação & jurisprudência , Saúde da Mulher , Feminino , Política de Saúde , Acesso aos Serviços de Saúde/legislação & jurisprudência , Disparidades nos Níveis de Saúde , Humanos , Medicaid/economia , Medicaid/organização & administração , Patient Protection and Affordable Care Act , Estados Unidos
14.
J Ment Health Policy Econ ; 24(1): 3-11, 2021 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-33739932

RESUMO

BACKGROUND: SSRIs and SNRIs are antidepressants that have largely substituted old antidepressants like Monoamine Oxidase Inhibitors (MAOIs) and Tricyclic Antidepressants (TCAs). They have been widely used since 1987 when the FDA approved the first SSRI Fluoxetine and the first SNRI Venlafaxine in 1993. Since then, several new SSRIs and SNRIs have been approved and entered the market. Utilization, pricing, and spending trends of SSRIs and SNRIs have not been analyzed yet in Medicaid. AIM: To assess the trends of drug expenditure, utilization, and price of SSRI and SNRI antidepressants in the US Medicaid program, and to highlight the market share of SSRIs and SNRIs and the effect of generic drug entry on Medicaid drug expenditure. METHODS: A retrospective descriptive data analysis was conducted for this study. National pharmacy summary data for study brand and generic drugs were retrieved from the Medicaid State Outpatient Drug Utilization Data. These data were collected by the US Centers for Medicare and Medicaid Services (CMS). The study period was between 1991 and 2018. Study drugs include 12 different SSRI and SNRI brands and their generics available in the market, such as citalopram, escitalopram, paroxetine, fluoxetine, sertraline, venlafaxine, desvenlafaxine, duloxetine, and levomilnacipran. Data were analyzed annually and categorized by total prescriptions (utilization), total reimbursement (spending), and cost per prescription as the proxy of the price for each drug. RESULTS: From 1991 to 2018, total prescriptions of SSRI and SNRI drugs rose by 3001%. Total Medicaid spending on SSRIs and SNRIs increased from USD 64.5 million to USD 2 billion in 2004, then decreased steadily until it reached USD 755 million in 2018. The SSRIs average utilization market share was 87% compared to 13% of the SNRIs utilization market share. About 72% of total Medicaid spending on the two groups goes to SSRIs, while the remaining 28% goes to SNRIs. Brand SSRIs and SNRIs prices increased over time. On the contrary, generic drugs prices steadily decreased over time. DISCUSSION: An increase in utilization and spending for both SSRI and SNRI drugs was observed. After each generic drug entered the market, utilization shifted from the brand name to the respective generic due to their lower price. These generic substitutions demonstrate a meaningful cost-containment policy for Medicaid programs. IMPLICATIONS FOR HEALTH POLICIES: Our findings show the overall view of Medicaid expenditure on one of the most commonly prescribed drug classes in the US. They also provide an important insight toward the antidepressant market and the importance of monitoring different drugs and their alternatives.


Assuntos
Antidepressivos/economia , Antidepressivos/uso terapêutico , Custos de Medicamentos/tendências , Uso de Medicamentos/tendências , Medicaid/economia , Inibidores de Captação de Serotonina/economia , Inibidores de Captação de Serotonina/uso terapêutico , Inibidores da Recaptação de Serotonina e Norepinefrina/economia , Inibidores da Recaptação de Serotonina e Norepinefrina/uso terapêutico , Idoso , Gastos em Saúde , Humanos , Medicaid/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
15.
Value Health ; 24(3): 361-368, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33641770

RESUMO

OBJECTIVES: Promoting patient involvement in managing co-occurring physical and mental health conditions is increasingly recognized as critical to improving outcomes and controlling costs in this growing chronically ill population. The main objective of this study was to conduct an economic evaluation of the Wellness Incentives and Navigation (WIN) intervention as part of a longitudinal randomized pragmatic clinical trial for chronically ill Texas Medicaid enrollees with co-occurring physical and mental health conditions. METHODS: The WIN intervention used a personal navigator, motivational interviewing, and a flexible wellness expense account to increase patient activation, that is, the patient's knowledge, skills, and confidence in managing their self-care and co-occurring physical and mental health conditions. Regression models were fit to both participant-level quality-adjusted life years (QALYs) and total costs of care (including the intervention) controlling for demographics, health status, poverty, Medicaid managed care plan, intervention group, and baseline health utility and costs. Incremental costs and QALYs were calculated based on the difference in predicted costs and QALYs under intervention versus usual care and were used to calculate the incremental cost-effectiveness ratios (ICERs). Confidence intervals were calculated using Fieller's method, and sensitivity analyses were performed. RESULTS: The mean ICER for the intervention compared with usual care was $12 511 (95% CI $8971-$16 842), with a sizable majority of participants (70%) having ICERs below $40 000. The WIN intervention also produced higher QALY increases for participants who were sicker at baseline compared to those who were healthier at baseline. CONCLUSION: The WIN intervention shows considerable promise as a cost-effective intervention in this challenging chronically ill population.


Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Promoção da Saúde/organização & administração , Medicaid/estatística & dados numéricos , Múltiplas Afecções Crônicas/epidemiologia , Adulto , Análise Custo-Benefício , Feminino , Promoção da Saúde/economia , Nível de Saúde , Humanos , Estudos Longitudinais , Masculino , Medicaid/economia , Entrevista Motivacional/organização & administração , Navegação de Pacientes/organização & administração , Anos de Vida Ajustados por Qualidade de Vida , Autocuidado , Autoimagem , Fatores Socioeconômicos , Texas/epidemiologia , Estados Unidos , Adulto Jovem
16.
Public Health Rep ; 136(4): 441-450, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33673781

RESUMO

OBJECTIVE: Given the growth in national disability-associated health care expenditures (DAHE) and the changes in health insurance-specific DAHE distribution, updated estimates of state-level DAHE are needed. The objective of this study was to update state-level estimates of DAHE. METHODS: We combined data from the 2013-2015 Medical Expenditure Panel Survey, 2013-2015 Behavioral Risk Factor Surveillance System, and 2014 National Health Expenditure Accounts to calculate state-level DAHE for US adults in total, per adult, and per (adult) person with disability (PWD). We adjusted expenditures to 2017 prices and assessed changes in DAHE from 2003 to 2015. RESULTS: In 2015, DAHE were $868 billion nationally (range, $1.4 billion in Wyoming to $102.8 billion in California) accounting for 36% of total health care expenditures (range, 29%-41%). From 2003 to 2015, total DAHE increased by 65% (range, 35%-125%). In 2015, DAHE per PWD were highest in the District of Columbia ($27 839) and lowest in Alabama ($12 603). From 2003 to 2015, per-PWD DAHE increased by 13% (range, -20% to 61%) and per-capita DAHE increased by 28% (range, 7%-84%). In 2015, Medicare DAHE per PWD ranged from $10 067 in Alaska to $18 768 in New Jersey. Medicaid DAHE per PWD ranged from $9825 in Nevada to $43 365 in the District of Columbia. Nonpublic-health insurer per-PWD DAHE ranged from $7641 in Arkansas to $18 796 in Alaska. CONCLUSION: DAHE are substantial and vary by state. The public sector largely supports the health care costs of people with disabilities. State policy makers and other stakeholders can use these results to inform the development of public health programs that support and provide ongoing health care to people with disabilities.


Assuntos
Pessoas com Deficiência/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Governo Estadual , Humanos , Medicaid/economia , Medicare/economia , Estados Unidos
17.
J Trauma Acute Care Surg ; 91(1): 154-163, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-33755642

RESUMO

BACKGROUND: The need for extensive surgical debridement with necrotizing soft tissue infections (NSTIs) may put patients at high risk for unplanned readmission. However, there is a paucity of data on the burden of readmission in patients afflicted with NSTI. We hypothesized that unplanned readmission would significantly contribute to the burden of disease after discharge from initial hospitalization. METHODS: The Nationwide Readmission Database was used to identify adults undergoing debridement for NSTI hospitalizations from 2010 to 2017. Risk factors for 90-day readmission were assessed by Cox proportional hazards regression. RESULTS: There were a total of 82,738 NSTI admissions during the study period, of which 25,076 (30.3%) underwent 90-day readmissions. Median time to readmission was 25 days (interquartile range, 9-49 days). Fragmentation of care, longer length of index stay (>2 weeks), and Medicaid status were independent risk factors for readmission. Median cost of a readmission was US $10,543. Readmission added 174,640 hospital days to episodes of care over the study period, resulting in an estimated financial burden of US $1.4 billion. CONCLUSION: Unplanned readmission caused by NSTIs is common and costly. Interventions that target patients at risk for readmission may help decrease the burden of disease. LEVEL OF EVIDENCE: Economic/Epidemiological, level IV.


Assuntos
Readmissão do Paciente/economia , Infecções dos Tecidos Moles/terapia , Adolescente , Adulto , Idoso , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/economia , Modelos Logísticos , Masculino , Medicaid/economia , Pessoa de Meia-Idade , Alta do Paciente , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Infecções dos Tecidos Moles/economia , Infecções dos Tecidos Moles/mortalidade , Fatores de Tempo , Estados Unidos/epidemiologia , Adulto Jovem
18.
J Trauma Acute Care Surg ; 91(2): 249-259, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-33783416

RESUMO

INTRODUCTION: Uninsured trauma patients are at higher risk of mortality, limited access to postdischarge resources, and catastrophic health expenditure. Hospital Presumptive Eligibility (HPE), enacted with the 2014 Affordable Care Act, enables uninsured patients to be screened and acquired emergency Medicaid at the time of hospitalization. We sought to identify factors associated with successful acquisition of HPE insurance at the time of injury, hypothesizing that patients with higher Injury Severity Score (ISS) (ISS >15) would be more likely to be approved for HPE. METHODS: We identified Medicaid and uninsured patients aged 18 to 64 years with a primary trauma diagnosis (International Classification of Diseases, Tenth Revision) in a large level I trauma center between 2015 and 2019. We combined trauma registry data with review of electronic medical records, to determine our primary outcome, HPE acquisition. Descriptive and multivariate analyses were performed. RESULTS: Among 2,320 trauma patients, 1,374 (59%) were already enrolled in Medicaid at the time of hospitalization. Among those uninsured at arrival, 386 (40.8%) acquired HPE before discharge, and 560 (59.2%) remained uninsured. Hospital Presumptive Eligibility patients had higher ISS (ISS >15, 14.8% vs. 5.7%; p < 0.001), longer median length of stay (2 days [interquartile range, 0-5 days] vs. 0 [0-1] days, p < 0.001), were more frequently admitted as inpatients (64.5% vs. 33.6%, p < 0.001), and discharged to postacute services (11.9% vs. 0.9%, p < 0.001). Patient, hospital, and policy factors contributed to HPE nonapproval. In adjusted analyses, Hispanic ethnicity (vs. non-Hispanic Whites: aOR, 1.58; p = 0.02) and increasing ISS (p ≤ 0.001) were associated with increased likelihood of HPE approval. CONCLUSION: The time of hospitalization due to injury is an underused opportunity for intervention, whereby uninsured patients can acquire sustainable insurance coverage. Opportunities to increase HPE acquisition merit further study nationally across trauma centers. As administrative and trauma registries do not capture information to compare HPE and traditional Medicaid patients, prospective insurance data collection would help to identify targets for intervention. LEVEL OF EVIDENCE: Economic, level IV.


Assuntos
Serviço Hospitalar de Emergência/economia , Cobertura do Seguro/estatística & dados numéricos , Medicaid/legislação & jurisprudência , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act , Ferimentos e Lesões/terapia , Adolescente , Adulto , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Gastos em Saúde/legislação & jurisprudência , Gastos em Saúde/estatística & dados numéricos , Hospitalização/economia , Hospitalização/legislação & jurisprudência , Hospitalização/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Cobertura do Seguro/economia , Cobertura do Seguro/legislação & jurisprudência , Modelos Logísticos , Masculino , Medicaid/economia , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , Análise Multivariada , Centros de Traumatologia/economia , Estados Unidos , Ferimentos e Lesões/economia , Adulto Jovem
19.
Med Care ; 59(Suppl 2): S199-S205, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33710096

RESUMO

BACKGROUND: Permanent supportive housing (PSH) programs have the potential to improve health and reduce Medicaid expenditures for beneficiaries experiencing homelessness. However, most research on PSH has been limited to small samples of narrowly defined populations. OBJECTIVE: To evaluate the effects of PSH on Medicaid enrollees across New Jersey. RESEARCH DESIGN: Linked data from the Medicaid Management Information System and the Homeless Management Information System were used to compare PSH-placed Medicaid enrollees with a matched sample of other Medicaid enrollees experiencing homelessness. Comparisons of Medicaid-financed health care utilization and spending measures were made in a difference-in-differences framework 6 quarters before and after PSH placement. SUBJECTS: A total of 1442 Medicaid beneficiaries enrolled in PSH and 6064 Medicaid-enrolled homeless individuals not in PSH in 2013-2014. RESULTS: PSH placement is associated with a 14.3% reduction in emergency department visits (P<0.001) and a 25.2% reduction in associated spending (P<0.001). PSH also appears to reduce inpatient utilization and increase pharmacy spending with neutral effects on primary care visits and total costs of care (TCOC). CONCLUSIONS: Placement in PSH is associated with lower hospital utilization and spending. No relationship was found, however, between PSH placement and TCOC, likely due to increased pharmacy spending in the PSH group. Greater access to prescription drugs may have improved the health of PSH-placed individuals in a way that reduced hospital episodes with neutral effects on TCOC.


Assuntos
Pessoas em Situação de Rua , Aceitação pelo Paciente de Cuidados de Saúde , Habitação Popular , Bases de Dados Factuais , Feminino , Humanos , Masculino , Medicaid/economia , New Jersey , Estados Unidos
20.
MMWR Morb Mortal Wkly Rep ; 70(8): 269-272, 2021 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-33630818

RESUMO

Hepatitis A is a vaccine-preventable disease caused by the hepatitis A virus (HAV). Transmission of the virus most commonly occurs through the fecal-oral route after close contact with an infected person. Widespread outbreaks of hepatitis A among persons who use illicit drugs (injection and noninjection drugs) have increased in recent years (1). The Advisory Committee on Immunization Practices (ACIP) recommends routine hepatitis A vaccination for children and persons at increased risk for infection or severe disease, and, since 1996, has recommended hepatitis A vaccination for persons who use illicit drugs (2). Vaccinating persons who are at-risk for HAV infection is a mainstay of the public health response for stopping ongoing person-to-person transmission and preventing future outbreaks (1). In response to a large hepatitis A outbreak in West Virginia, an analysis was conducted to assess total hepatitis A-related medical costs during January 1, 2018-July 31, 2019, among West Virginia Medicaid beneficiaries with a confirmed diagnosis of HAV infection. Among the analysis population, direct clinical costs ranged from an estimated $1.4 million to $5.6 million. Direct clinical costs among a subset of the Medicaid population with a diagnosis of a comorbid substance use disorder ranged from an estimated $1.0 million to $4.4 million during the study period. In addition to insight on preventing illness, hospitalization, and death, the results from this study highlight the potential financial cost jurisdictions might incur when ACIP recommendations for hepatitis A vaccination, especially among persons who use illicit drugs, are not followed (2).


Assuntos
Custos e Análise de Custo/estatística & dados numéricos , Surtos de Doenças , Hepatite A/economia , Medicaid/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Hepatite A/epidemiologia , Hepatite A/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos , West Virginia/epidemiologia , Adulto Jovem
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