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2.
PLoS One ; 15(7): e0235262, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32716927

RESUMO

OBJECTIVE: Public insurance (Medicaid) covered 42% of all U.S. births in 2018. This paper describes and analyzes the self-reported experiences of women with Medicaid versus commercial insurance relating to autonomy, control and respectful treatment in maternity care. METHODS: The sampling frame for the Listening to Mothers in California survey was drawn from 2016 California birth certificate files. The 30-minute survey had a 55% response rate. A secondary multivariable analysis of results from the survey included 2,318 women with commercial private insurance (1,087) or public (Medi-Cal) (1,231) coverage. Results were weighted and were representative of all births in 2016 in California. The multivariable analysis of variables related to maternal agency included engagement in decision making regarding interventions such as vaginal birth after cesarean and episiotomy, feeling pressured to have interventions and sense of fair treatment. We examined their relationship to insurance status adjusted for maternal age, race/ethnicity, education, nativity and attitude toward birth as well as type of prenatal provider, type of birth attendant and pregnancy complications. RESULTS: Women with Medi-Cal had a demographic profile distinct from those with commercial insurance. In multivariable analysis, women with Medi-Cal reported less control over their maternity care experience than women with commercial insurance, including less choice of prenatal provider (AOR 1.61 95%C.I. 1.20, 2.17), or a vaginal birth after cesarean (AOR 2.93 95%C.I. 1.49, 5.73). Mothers on Medi-Cal were also less likely to be consulted before experiencing an episiotomy (AOR 0.30 95%C.I. 0.09, 0.94). They were more likely to report feeling pressure to have a primary cesarean (AOR 2.54 95%C.I. 1.55, 4.16) and less likely to be encouraged by staff to make their own decisions (AOR 0.63 95%C.I. 0.47, 0.85). CONCLUSIONS: Childbearing women with public insurance in California clearly and consistently reported less opportunity to choose their care than women with private insurance. These inequities are a call to action for increased accountability and quality improvement relating to care of the many childbearing women with Medicaid coverage.


Assuntos
Disparidades em Assistência à Saúde/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Serviços de Saúde Materna/estatística & dados numéricos , Relações Profissional-Paciente , Respeito , Adulto , California , Feminino , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/economia , Humanos , Cobertura do Seguro/economia , Idade Materna , Serviços de Saúde Materna/economia , Medicaid/economia , Medicaid/estatística & dados numéricos , Gravidez , Autorrelato/estatística & dados numéricos , Fatores Socioeconômicos , Estados Unidos , Adulto Jovem
3.
Am J Public Health ; 110(S2): S222-S224, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32663091

RESUMO

In response to the growing regional (and national) focus on health and housing intersections, two public housing authorities (PHAs) in Washington-the King County Housing Authority and the Seattle Housing Authority-joined with Public Health-Seattle & King County to form the Housing and Health (H&H) partnership in 2016. H&H linked Medicaid health claims with PHA administrative data to create a sustainable public-facing dashboard that informs health and housing stakeholders such as an Accountable Community of Health (a governing body that oversees local Medicaid transformation projects), managed care organizations, and PHAs, allowing insights into the low-income communities they serve.


Assuntos
Medicaid/estatística & dados numéricos , Administração em Saúde Pública , Habitação Popular/organização & administração , Habitação Popular/estatística & dados numéricos , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pobreza , Saúde Pública , Estados Unidos , Washington
4.
J Ment Health Policy Econ ; 23(2): 61-75, 2020 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-32621726

RESUMO

BACKGROUND: Boarding of patients in hospital emergency departments (EDs) occurs routinely across the U.S. ED patients with behavioral health conditions are more likely to be boarded than other patients. However, the existing literature on ED boarding of psychiatric patients remains largely descriptive and has not empirically related mental health system capacity to psychiatric boarding. Nor does it show how the mental health system could better address the needs of populations at the highest risk of ED boarding. AIMS OF THE STUDY: We examined extent and determinants of "boarding" of patients with severe mental illness (SMI) in hospital emergency departments (ED) and tested whether greater mental health system capacity may mitigate the degree of ED boarding. METHODS: We linked Oregon's ED Information Exchange, hospital discharge, and Medicaid data to analyze encounters in Oregon hospital EDs from October 2014 through September 2015 by 7,103 persons aged 15 to 64 with SMI (N = 34,207). We additionally utilized Medicaid claims for years 2010-2015 to identify Medicaid beneficiaries with SMI. Boarding was defined as an ED stay over six hours. We estimated a recursive simultaneous-equation model to test the pathway that mental health system capacity affects ED boarding via psychiatric visits. RESULTS: Psychiatric visits were more likely to be boarded than non-psychiatric visits (30.2% vs. 7.4%). Severe psychiatric visits were 1.4 times more likely to be boarded than non-severe psychiatric visits. Thirty-four percent of psychiatric visits by children were boarded compared to 29.6% for adults. Statistical analysis found that psychiatric visit, substance abuse, younger age, black race and urban residence corresponded with an elevated risk of boarding. Discharge destinations such as psychiatric facility and acute care hospitals also corresponded with a higher probability of ED boarding. Greater supply of mental health resources in a county, both inpatient and intensive community-based, corresponded with a reduced risk of ED boarding via fewer psychiatric ED visits. DISCUSSION: Psychiatric visit, severity of psychiatric diagnosis, substance abuse, and discharge destinations are among important predictors of psychiatric ED boarding by persons with SMI. A greater capacity of inpatient and intensive community mental health systems may lead to a reduction in psychiatric ED visits by persons with SMI and thereby decrease the extent of psychiatric ED boarding. IMPLICATIONS FOR HEALTH POLICIES: Continued investment in mental health system resources may reduce psychiatric ED visits and mitigate the psychiatric ED boarding problem.


Assuntos
Ocupação de Leitos/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Pacientes Internados/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Transtornos Mentais/terapia , Adolescente , Adulto , Humanos , Transtornos Mentais/psicologia , Pessoa de Meia-Idade , Oregon , Admissão do Paciente/estatística & dados numéricos , Qualidade da Assistência à Saúde , Transtornos Relacionados ao Uso de Substâncias/complicações , Estados Unidos , Adulto Jovem
5.
Med Care ; 58(8): 727-733, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32692139

RESUMO

BACKGROUND: Hospital Presumptive Eligibility (HPE) is a national policy stemming from the Affordable Care Act that allows qualified hospitals, working with state officials, to enroll eligible patients for temporary Medicaid coverage. Although all states are required to operate an HPE program, hospital participation is elective and variable. It is unclear which hospitals choose to participate in HPE and how participation affects hospital utilization and revenue. OBJECTIVE: We examined hospital factors associated with HPE participation in the state of California and assessed pre and post changes in hospital revenue and utilization for HPE and non-HPE hospitals. RESEARCH DESIGN: We performed a logistic regression to identify hospital attributes associated with HPE participation. We then used a difference in differences methodology with a hospital fixed effect to test whether HPE enrollment was associated with changes in annual revenues by payer source, uncompensated care costs, outpatient visits, and/or discharges. RESULTS: Three quarters (76%) of qualified hospitals elected to participate in HPE by the end of 2018. Hospitals with 100 or more beds had over 10 times greater odds of participating in HPE compared with smaller hospitals. Hospitals that did not provide outpatient care were significantly less likely to participate. Among hospitals included in trend analyses, enrollment in HPE was associated with increased annual net patient Medicaid revenue and decreased uncompensated care charges. We predicted that HPE enrollment was associated with an average of 9.7% (95% confidence interval: 3.4%-16.4%) increase in annual net patient Medicaid revenue. As of 2018, ∼33,000 adults and children were enrolled in California's HPE program per month. CONCLUSION: Hospital enrollment in the HPE program shifted costs from uncompensated care to Medicaid.


Assuntos
Medicina Hospitalar/economia , Medicaid/economia , Patient Protection and Affordable Care Act/estatística & dados numéricos , California , Definição da Elegibilidade/métodos , Definição da Elegibilidade/estatística & dados numéricos , Humanos , Medicaid/estatística & dados numéricos , Estados Unidos
6.
Med Care ; 58(8): 749-755, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32692142

RESUMO

BACKGROUND: Low-income adults in the United States have historically had poor access to dental services largely due to limited dental coverage. OBJECTIVE: We examined the effects of recent Medicaid income-eligibility expansions under the Affordable Care Act on dental visits separately for preventive care and treatments. RESEARCH DESIGN: We used restricted data from the 2011 to 2016 Medical Expenditure Panel Survey with state geocodes. The main analytical sample included nearly 21,000 individuals who were newly eligible for Medicaid. We employed a quasi-experimental difference-in-differences design to identify the impact of the state Medicaid expansions effective in 2014 on dental services use by the level of state Medicaid dental benefit for the newly eligible. RESULTS: Expanding Medicaid in 2014 with extensive or limited dental coverage increased preventive dental visits and use of major dental treatments by over 5 percentage-points in 2014 and 2015. The increase in preventive visits continued in 2016 in expanding states with extensive coverage, while increase in major dental treatments continued in 2016 in expanding states with limited coverage. There is some but less consistent evidence of an increase in dental treatment with emergency-only coverage. CONCLUSIONS: Medicaid expansions with dental coverage beyond emergency-only services have increased access of the newly eligible low-income adults to dental treatments and preventive services, with extensive coverage showing continuing increase in preventive services use 3 years after the expansion. With limited coverage, there is some evidence of individuals needing to stretch treatments over a longer period. Providing comprehensive dental coverage can address unmet dental needs and improve oral health among low-income adults.


Assuntos
Assistência Odontológica/economia , Medicaid/tendências , Patient Protection and Affordable Care Act/tendências , Adulto , Assistência Odontológica/métodos , Assistência Odontológica/estatística & dados numéricos , Feminino , Acesso aos Serviços de Saúde/normas , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Cobertura do Seguro/estatística & dados numéricos , Masculino , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/estatística & dados numéricos , Inquéritos e Questionários , Estados Unidos
7.
Am J Public Health ; 110(8): 1208-1210, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32552024

RESUMO

Objectives. To identify risk factors for Medicaid disenrollment after the implementation of Arkansas's work requirements.Methods. Using a 2018 telephone survey of 1208 low-income adults aged 30 to 49 years in Arkansas (expansion state with work requirements implemented in June 2018), Kentucky (expansion state with proposed work requirements blocked by courts), Louisiana (expansion state without work requirements), and Texas (nonexpansion state), we assessed Medicaid disenrollment rates among the age group targeted by Arkansas's policy.Results. The Medicaid disenrollment rate was highest in Texas (12.8%), followed by Arkansas (10.5%), Kentucky (5.8%), and Louisiana (2.8%). Over half of those who disenrolled in Texas and Arkansas became uninsured, compared with less than a quarter in Kentucky and Louisiana. In multivariate models, Arkansas had significantly higher disenrollment compared with the 3 comparison states; men and non-Hispanic Whites experienced higher disenrollment than women and racial minorities. In Arkansas, having a chronic condition was associated with higher disenrollment.Conclusions. As states debate work requirements and Medicaid reforms, our findings provide insights for policymakers about which populations may be most vulnerable to losing Medicaid coverage.


Assuntos
Emprego , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Adulto , Feminino , Humanos , Masculino , Pessoas sem Cobertura de Seguro de Saúde/etnologia , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/legislação & jurisprudência , Políticas , Pobreza/estatística & dados numéricos , Fatores Sexuais , Inquéritos e Questionários , Estados Unidos
8.
Am J Public Health ; 110(8): 1205-1207, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32552026

RESUMO

Objectives. To study the impact on mortality in Hawaii from the revoked state Medicaid program coverage in March 2015 for most Compact of Free Association (COFA) migrants who were nonblind, nondisabled, and nonpregnant.Methods. We computed quarterly crude mortality rates for COFA migrants, Whites, and Japanese Americans from March 2012 to November 2018. We employed a difference-in-difference research design to estimate the impact of the Medicaid expiration on log mortality rates.Results. We saw larger increases in COFA migrant mortality rates than White mortality rates after March 2015. By 2018, the increase was 43% larger for COFA migrants (P = .003). Mortality trends over this period were similar for Whites and Japanese Americans, who were not affected by the policy.Conclusions. Mortality rates of COFA migrants increased after Medicaid benefits expired despite the availability of state-funded premium coverage for private insurance and significant outreach efforts to reduce the impact of this coverage change.


Assuntos
Cobertura do Seguro , Seguro Saúde , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Mortalidade , Migrantes/estatística & dados numéricos , Adulto , Americanos Asiáticos/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Hawaii , Acesso aos Serviços de Saúde , Humanos , Pessoas sem Cobertura de Seguro de Saúde/etnologia , Pessoa de Meia-Idade , Mortalidade/etnologia , Mortalidade/tendências , Estados Unidos
9.
Womens Health Issues ; 30(4): 248-259, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32505430

RESUMO

BACKGROUND: The United States has a relatively high preterm birth rate compared with other developed nations. Before the enactment of the Affordable Care Act in 2010, many women at risk of a preterm birth were not able to access affordable health insurance or a wide array of preventive and maternity care services needed before, during, and after pregnancy. The various health insurance market reforms and coverage expansions contained in the Affordable Care Act sought in part to address these problems. This analysis aims to describe changes in the patterns of payer mix of preterm births in the context of a post-Affordable Care Act insurance market, explore possible factors for the observed changes, and discuss some of the implications for the Medicaid program. METHODS: We applied a repeated cross-sectional study design to explore payment mix patterns of all births and preterm births between 2011 and 2016, using publicly available National Vital Statistics Birth Data. We included an equal number of years with payment source available in the dataset before and after January 1, 2014, when the coverage expansions became effective. RESULTS: We found a small relative change in payment mix during the study period. Private health insurance (PHI) paid for a higher percentage of all births and this rate increased steadily between 2011 and 2016. Preterm births paid by PHI increased by 1.4 percentage points between 2011 and 2016 and self-pay/uninsured preterm births decreased by 0.3 percentage points over the same time period. Medicaid had the highest, and a relatively stable, preterm birth coverage percentage (48.9% in 2011, 49.2% in 2014, and 48.9% in 2016). Medicaid was also more likely to pay for preterm births than PHI, but this likelihood decreased by more than one-half after 2014 (8.2% in 2013 vs. 3.8% in 2014). CONCLUSIONS: After the 2010 reforms, Medicaid remained a constant source of coverage for the most vulnerable women in society when faced with the high cost of a preterm birth. Nationwide, of the 64 million women ages 15 to 44, 4% gained PHI (directly purchased or employer sponsored) and another 4% Medicaid, with a concomitant 8% decrease in uninsured women of reproductive age between 2013 and 2017. More research is needed to conclude with certainty that the reforms worked as intended, but the important role of Medicaid as a financial safety net is undeniable.


Assuntos
Cobertura do Seguro/economia , Seguro Saúde/economia , Serviços de Saúde Materna/organização & administração , Medicaid/estatística & dados numéricos , Patient Protection and Affordable Care Act , Nascimento Prematuro/economia , Adolescente , Adulto , Custos e Análise de Custo , Estudos Transversais , Feminino , Humanos , Recém-Nascido , Cobertura do Seguro/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde , Parto , Gravidez , Nascimento Prematuro/epidemiologia , Estados Unidos , Adulto Jovem
10.
Am J Perinatol ; 37(10): 1005-1014, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32516816

RESUMO

OBJECTIVE: This study aimed to (1) determine to what degree prenatal care was able to be transitioned to telehealth at prenatal practices associated with two affiliated hospitals in New York City during the novel coronavirus disease 2019 (COVID-19) pandemic and (2) describe providers' experience with this transition. STUDY DESIGN: Trends in whether prenatal care visits were conducted in-person or via telehealth were analyzed by week for a 5-week period from March 9 to April 12 at Columbia University Irving Medical Center (CUIMC)-affiliated prenatal practices in New York City during the COVID-19 pandemic. Visits were analyzed for maternal-fetal medicine (MFM) and general obstetrical faculty practices, as well as a clinic system serving patients with public insurance. The proportion of visits that were telehealth was analyzed by visit type by week. A survey and semistructured interviews of providers were conducted evaluating resources and obstacles in the uptake of telehealth. RESULTS: During the study period, there were 4,248 visits, of which approximately one-third were performed by telehealth (n = 1,352, 31.8%). By the fifth week, 56.1% of generalist visits, 61.5% of MFM visits, and 41.5% of clinic visits were performed via telehealth. A total of 36 providers completed the survey and 11 were interviewed. Accessing technology and performing visits, documentation, and follow-up using the telehealth electronic medical record were all viewed favorably by providers. In transitioning to telehealth, operational challenges were more significant for health clinics than for MFM and generalist faculty practices with patients receiving public insurance experiencing greater difficulties and barriers to care. Additional resources on the patient and operational level were required to optimize attendance at in-person and video visits for clinic patients. CONCLUSION: Telehealth was rapidly implemented in the setting of the COVID-19 pandemic and was viewed favorably by providers. Limited barriers to care were observed for practices serving patients with commercial insurance. However, to optimize access for patients with Medicaid, additional patient-level and operational supports were required. KEY POINTS: · Telehealth uptake differed based on insurance.. · Medicaid patients may require increased assistance for telehealth.. · Quick adoption of telehealth is feasible..


Assuntos
Infecções por Coronavirus/prevenção & controle , Pessoal de Saúde/organização & administração , Pandemias/estatística & dados numéricos , Segurança do Paciente/estatística & dados numéricos , Pneumonia Viral/prevenção & controle , Cuidado Pré-Natal/métodos , Telemedicina/estatística & dados numéricos , Centros Médicos Acadêmicos , Adulto , Atitude do Pessoal de Saúde , Infecções por Coronavirus/epidemiologia , Estudos de Avaliação como Assunto , Feminino , Idade Gestacional , Humanos , Controle de Infecções/métodos , Medicaid/estatística & dados numéricos , Cidade de Nova Iorque , Pandemias/prevenção & controle , Pneumonia Viral/epidemiologia , Gravidez , Pesquisa Qualitativa , Telemedicina/tendências , Cuidado Transicional/organização & administração , Estados Unidos
11.
Natl Vital Stat Rep ; 69(3): 1-11, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32510315

RESUMO

Objectives-This report presents data on recent trends for three sexually transmitted infections (STIs)-chlamydia, gonorrhea, and syphilis-reported among women giving birth in the United States from 2016 through 2018, and rates by selected characteristics for 2018. Methods-Data are from birth certificates and are based on 100% of births registered in the United States for 2016, 2017, and 2018. Birth certificate data on infections during pregnancy are recommended to be collected from the mother's medical records (1). Mothers are to be reported as having an infection if there is a confirmed diagnosis or documented treatment for the infection in their medical record (2). Results-Among women giving birth in 2018, the overall rates of chlamydia, gonorrhea, and syphilis were 1,843.9, 310.2, and 116.7 per 100,000 births, respectively. The rates for these STIs increased 2% (chlamydia), 16% (gonorrhea), and 34% (syphilis) from 2016 through 2018. In 2018, rates of chlamydia and gonorrhea decreased with advancing maternal age, whereas those for syphilis decreased with maternal age through 30-34 years and then increased for women aged 35 and over. In 2018, rates of all three STIs were highest for non-Hispanic black women, women who smoked during pregnancy, women who received late or no prenatal care, and women for whom Medicaid was the principal source of payment for the delivery. Among women aged 25 and over, rates of each of the STIs decreased with increasing maternal education.


Assuntos
Complicações Infecciosas na Gravidez/epidemiologia , Doenças Sexualmente Transmissíveis/epidemiologia , Adulto , Declaração de Nascimento , Infecções por Chlamydia/epidemiologia , Infecções por Chlamydia/etnologia , Grupos de Populações Continentais/estatística & dados numéricos , Parto Obstétrico/economia , Escolaridade , Feminino , Gonorreia/epidemiologia , Gonorreia/etnologia , Humanos , Idade Materna , Medicaid/estatística & dados numéricos , Gravidez , Complicações Infecciosas na Gravidez/etnologia , Cuidado Pré-Natal/estatística & dados numéricos , Doenças Sexualmente Transmissíveis/etnologia , Fumar/epidemiologia , Fumar/etnologia , Sífilis/epidemiologia , Sífilis/etnologia , Estados Unidos/epidemiologia , Adulto Jovem
12.
Med Care ; 58(6): 497-503, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32412941

RESUMO

BACKGROUND: Rates of low birthweight and prematurity vary 2-fold across states in the United States, with increased rates among states with higher concentrations of racial minorities. Medicaid expansion may serve as a mechanism to reduce geographic variation within states that expanded, by improving health and access to care for vulnerable populations. OBJECTIVE: The objective of this study was to identify the association of Medicaid expansion with changes in county-level geographic variation in rates of low birthweight and preterm births, overall and stratified by race/ethnicity. RESEARCH DESIGN: We compared changes in the coefficient of variation and the ratio of the 80th-to-20th percentiles using bootstrap samples (n=1000) of counties drawn separately for all births and for white, black, and Hispanic births, separately. MEASURES: County-level rates of low birthweight and preterm birth. RESULTS: Before Medicaid expansion, counties in expansion states were concentrated among quintiles with lower rates of adverse birth outcomes and counties in nonexpansion states were concentrated among quintiles with higher rates. In expansion states, county-level variation, measured by the coefficient of variation, declined for both outcomes among all racial/ethnic categories. In nonexpansion states, geographic variation reduced for both outcomes among Hispanic births and for low birthweight among white births, but increased for both outcomes among black births. CONCLUSIONS: The decrease in county-level variation in adverse birth outcomes among expansion states suggests improved equity in these states. Further reduction in geographic variation will depend largely on policies or interventions that reduce racial disparities in states that did and did not expand Medicaid.


Assuntos
Grupos de Populações Continentais/estatística & dados numéricos , Recém-Nascido de Baixo Peso , Medicaid/estatística & dados numéricos , Patient Protection and Affordable Care Act/legislação & jurisprudência , Nascimento Prematuro/etnologia , Afro-Americanos/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Inquéritos Epidemiológicos , Hispano-Americanos/estatística & dados numéricos , Humanos , Recém-Nascido , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Análise Espacial , Estados Unidos/epidemiologia
13.
Med Care ; 58 Suppl 6 Suppl 1: S14-S21, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32412949

RESUMO

BACKGROUND: Medical, behavioral, and social determinants of health are each associated with high levels of emergency department (ED) visits and hospitalizations. OBJECTIVE: The objective of this study was to evaluate a care coordination program designed to provide combined "whole-person care," integrating medical, behavioral, and social support for high-cost, high-need Medicaid beneficiaries by targeting access barriers and social determinants. RESEARCH DESIGN: Individual-level interrupted time series with a comparator group, using person-month as the unit of analysis. SUBJECTS: A total of 42,214 UnitedHealthcare Medicaid beneficiaries (194,834 person-months) age 21 years or above with diabetes, with Temporary Assistance to Needy Families, Medicaid expansion, Supplemental Security Income without Medicare, or dual Medicaid/Medicare. MEASURES: Our outcome measures were any hospitalizations and any ED visits in a given month. Covariates of interest included an indicator for intervention versus comparator group and indicator and spline variables measuring changes in an outcome's time trend after program enrollment. RESULTS: Overall, 6 of the 8 examined comparisons were not statistically significant. Among Supplemental Security Income beneficiaries, we observed a larger projected decrease in ED visit risk among the intervention sample versus the comparator sample at 12 months postenrollment (difference-in-difference: -6.6%; 95% confidence interval: -11.2%, -2.1%). Among expansion beneficiaries, we observed a greater decrease in hospitalization risk among the intervention sample versus the comparator sample at 12 months postenrollment (difference-in-difference: -5.8%; 95% confidence interval: -11.4%, -0.2%). CONCLUSION: A care coordination program designed to reduce utilization among high-cost, high-need Medicaid beneficiaries was associated with fewer ED visits and hospitalizations for patients with diabetes in selected Medicaid programs but not others.


Assuntos
Diabetes Mellitus/economia , Medicaid/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adulto , Idoso , Diabetes Mellitus/terapia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Medicaid/economia , Medicaid/organização & administração , Pessoa de Meia-Idade , Estados Unidos , Adulto Jovem
14.
Med Care ; 58 Suppl 6 Suppl 1: S40-S45, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32412952

RESUMO

BACKGROUND/OBJECTIVES: Medicaid beneficiaries with diabetes have complex care needs. The Accountable Care Communities (ACC) Program is a practice-level intervention implemented by UnitedHealthcare to improve care for Medicaid beneficiaries. We examined changes in costs and utilization for Medicaid beneficiaries with diabetes assigned to ACC versus usual care practices. RESEARCH DESIGN: Interrupted time series with concurrent control group analysis, at the person-month level. The ACC was implemented in 14 states, and we selected comparison non-ACC practices from those states to control for state-level variation in Medicaid program. We adjusted the models for age, sex, race/ethnicity, comorbidities, seasonality, and state-by-year fixed effects. We examined the difference between ACC and non-ACC practices in changes in the time trends of expenditures and hospital and emergency room utilization, for the 4 largest categories of Medicaid eligibility [Temporary Assistance to Needy Families, Supplemental Security Income (without Medicare), Expansion, Dual-Eligible]. SUBJECTS/MEASURES: Eligibility and claims data from Medicaid adults with diabetes from 14 states between 2010 and 2016, before and after ACC implementation. RESULTS: Analyses included 1,200,460 person-months from 66,450 Medicaid patients with diabetes. ACC implementation was not associated with significant changes in outcome time trends, relative to comparators, for all Medicaid categories. CONCLUSIONS: Medicaid patients assigned to ACC practices had no changes in cost or utilization over 3 years of follow-up, compared with patients assigned to non-ACC practices. The ACC program may not reduce costs or utilization for Medicaid patients with diabetes.


Assuntos
Organizações de Assistência Responsáveis/estatística & dados numéricos , Diabetes Mellitus/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Organizações de Assistência Responsáveis/economia , Adulto , Idoso , Diabetes Mellitus/terapia , Feminino , Humanos , Masculino , Medicaid/economia , Pessoa de Meia-Idade , Estados Unidos , Adulto Jovem
15.
Med Care ; 58 Suppl 6 Suppl 1: S46-S52, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32412953

RESUMO

BACKGROUND: Electronic health records (EHRs) provide rich data on many domains not routinely available in other data, as such, they are a promising source to study changes in health outcomes using longitudinal study designs (eg, cohort studies, natural experiments, etc.). Yet, patient attrition rates in these data are unknown. OBJECTIVE: The objective of this study was to estimate overall and among adults with diabetes or hypertension: (1) patient attrition over a 3-year period at community health centers; and (2) the likelihood that patients with Medicaid permanently switched their source of primary care. RESEARCH DESIGN: A retrospective cohort study of 2012-2017 data from the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) Clinical Data Research Network of community health centers were used to assess EHR data attrition. Oregon Medicaid enrollment and claims data were used to estimate the likelihood of changing the source of primary care. SUBJECTS: A total of 827,657 patients aged 19-64 with ≥1 ambulatory visit from 76 community health center systems across 20 states. In all, 232,891 Oregon Medicaid enrollees (aged 19-64) with a gap of ≥6 months following a claim for a visit billed to a primary care source. MEASURES: Percentage of patients not returning within 3 years of their qualifying visit (attrition). The probability that a patient with Medicaid permanently changed their primary care source. RESULTS: Attrition over the 3 years averaged 33.5%; attrition rates were lower (<25%) among patients with diabetes and/or hypertension. Among Medicaid enrollees, the percentage of provider change after a 6-month gap between visits was 12% for community health center patients compared with 39% for single-provider practice patients. Over 3 years, the likelihood of a patient changing to a new provider increased with length of time since their last visit but remained lowest among community health center patients. CONCLUSION: This study demonstrates the use of the EHR dataset is a reliable source of data to support longitudinal studies while highlighting variability in attrition by primary care source and chronic conditions.


Assuntos
Registros Eletrônicos de Saúde/estatística & dados numéricos , Estudos Longitudinais , Pacientes Desistentes do Tratamento/estatística & dados numéricos , Adulto , Diabetes Mellitus/epidemiologia , Diabetes Mellitus/terapia , Feminino , Humanos , Hipertensão/epidemiologia , Hipertensão/terapia , Masculino , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , Atenção Primária à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
16.
PLoS Med ; 17(5): e1003119, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32421717

RESUMO

BACKGROUND: Criminal justice involvement is common among pregnant women with opioid use disorder (OUD). Medications for OUD improve pregnancy-related outcomes, but trends in treatment data among justice-involved pregnant women are limited. We sought to examine trends in medications for OUD among pregnant women referred to treatment by criminal justice agencies and other sources before and after the Affordable Care Act's Medicaid expansion. METHODS AND FINDINGS: We conducted a serial, cross-sectional analysis using 1992-2017 data from pregnant women admitted to treatment facilities for OUD using a national survey of substance use treatment facilities in the United States (N = 131,838). We used multiple logistic regression and difference-in-differences methods to assess trends in medications for OUD by referral source. Women in the sample were predominantly aged 18-29 (63.3%), white non-Hispanic, high school graduates, and not employed. Over the study period, 26.3% (95% CI 25.7-27.0) of pregnant women referred by criminal justice agencies received medications for OUD, which was significantly less than those with individual referrals (adjusted rate ratio [ARR] 0.45, 95% CI 0.43-0.46; P < 0.001) or those referred from other sources (ARR 0.51, 95% CI 0.50-0.53; P < 0.001). Among pregnant women referred by criminal justice agencies, receipt of medications for OUD increased significantly more in states that expanded Medicaid (n = 32) compared with nonexpansion states (n = 18) (adjusted difference-in-differences: 12.0 percentage points, 95% CI 1.0-23.0; P = 0.03). Limitations of this study include encounters that are at treatment centers only and that do not encompass buprenorphine prescribed in ambulatory care settings, prisons, or jails. CONCLUSIONS: Pregnant women with OUD referred by criminal justice agencies received evidence-based treatment at lower rates than women referred through other sources. Improving access to medications for OUD for pregnant women referred by criminal justice agencies could provide public health benefits to mothers, infants, and communities. Medicaid expansion is a potential mechanism for expanding access to evidence-based treatment for pregnant women in the US.


Assuntos
Medicina Baseada em Evidências/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/terapia , Adulto , Feminino , Hispano-Americanos , Humanos , Patient Protection and Affordable Care Act , Gravidez , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
17.
J Surg Res ; 252: 183-191, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32278973

RESUMO

BACKGROUND: Timing of surgical treatment of facial fractures may vary with the patient age, injury type, and presence of polytrauma. Previous studies using national data sets have suggested that trauma patients with government insurance experience fewer operations, longer length of hospital stay (LOS), and worse outcomes compared with privately insured patients. The objective of this study is to compare treatment of facial fractures in patients with and without Medicaid insurance (excluding Medicare). METHODS: All adults with mandibular, orbital, and midface fractures at a Level 1 Trauma Center between 2009 and 2018 were included. Statistical analyses were performed to assess the differences in the frequency of surgery, time to surgery (TTS), LOS, and mortality based on insurance type. RESULTS: The sample included 1541 patients with facial fractures (mandible, midface, orbital), of whom 78.8% were male, and 13.1% (208) were enrolled in Medicaid. Mechanism of injury was predominantly assault for Medicaid enrollees and falls or motor vehicle accidents for non-Medicaid enrollees (P < 0.001). Patients with mandible and midface fractures underwent similar rates of surgical repair. Medicaid enrollees with orbital fractures underwent less frequent surgery for facial fractures (24.8% versus 34.7%, P = 0.0443) and had higher rates of alcohol and drug intoxication compared with non-Medicaid enrollees (42.8% versus 31.6%, P = 0.008). TTS, LOS, and mortality were similar in both groups with facial fractures. CONCLUSIONS: Overall, the treatment of facial fractures was similar regardless of the insurance type, but Medicaid enrollees with orbital fractures experienced less frequent surgery for facial fractures. Further studies are needed to identify specific socioeconomic and geographic factors contributing to these disparities in care.


Assuntos
Fixação de Fratura/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Fraturas Orbitárias/cirurgia , Centros de Traumatologia/estatística & dados numéricos , Adulto , Intoxicação Alcoólica/epidemiologia , Comorbidade , Feminino , Fixação de Fratura/economia , Mortalidade Hospitalar , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Fraturas Orbitárias/economia , Fraturas Orbitárias/mortalidade , Estudos Retrospectivos , Tempo para o Tratamento/economia , Tempo para o Tratamento/estatística & dados numéricos , Centros de Traumatologia/economia , Estados Unidos
18.
Matern Child Health J ; 24(9): 1138-1150, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32335806

RESUMO

OBJECTIVE: To compare patterns of routine postpartum health care utilization for women in Wisconsin with continuous Medicaid eligibility versus pregnancy-only Medicaid METHODS: This analysis used Medicaid records and linked infant birth certificates for Medicaid paid births in Wisconsin during 2011-2015 (n = 105,718). We determined if women had continuous or pregnancy-only eligibility from the Medicaid eligibility file. We used a standard list of billing codes to identify if women received routine postpartum care. We examined maternal characteristics and receipt of postpartum care overall and by Medicaid eligibility category. Finally, we used a binomial model to calculate the relationship between Medicaid eligibility category and receipt of postpartum care, adjusted for maternal characteristics. RESULTS: Women with continuous Medicaid had profiles more consistent with low postpartum visit attendance rates (e.g., younger, more likely to use tobacco) than women with pregnancy-only Medicaid. However, after adjusting for maternal characteristics, women with continuous Medicaid eligibility had a postpartum visit rate that was 6 percentage points higher than the rate for women with pregnancy-only Medicaid (RD: 6.27, 95% CI 5.72, 6.82). CONCLUSIONS FOR PRACTICE: Women with pregnancy-only Medicaid were less likely to have received routine postpartum care than women with continuous Medicaid. Medicaid coverage beyond the current guaranteed 60 days postpartum could help provide more women access to postpartum care.


Assuntos
Definição da Elegibilidade , Revisão da Utilização de Seguros/estatística & dados numéricos , Cobertura do Seguro , Medicaid/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Cuidado Pós-Natal/economia , Adulto , Declaração de Nascimento , Feminino , Acesso aos Serviços de Saúde , Humanos , Medicaid/economia , Gravidez , Estados Unidos , Wisconsin
19.
Womens Health Issues ; 30(4): 240-247, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32253056

RESUMO

OBJECTIVE: To compare the outcomes and cost effectiveness of two alternate policy strategies for prenatal care among low-income, immigrant women: coverage for delivery only (the federal standard) and prenatal care with delivery coverage (state option under the Children's Health Insurance Program). METHODS: A decision-analytic model was developed to determine the cost effectiveness of two alternate policies for pregnancy coverage. All states currently provide coverage for delivery, and 19 states also provide coverage for prenatal care. An estimated 84,000 unauthorized immigrant women have pregnancies where no prenatal care is covered. Our outcomes were costs, quality-adjusted life-years, and cases of cerebral palsy and infant death before age 1. Model inputs were obtained from a database of Oregon Medicaid claims and the literature. Univariate and bivariate sensitivity analyses, as well as a Monte Carlo simulation, were performed. RESULTS: Extending prenatal coverage is a cost-effective strategy. Providing prenatal care for the 84,000 women annually who are currently uninsured could prevent 117 infant deaths and 34 cases of cerebral palsy. Prenatal care coverage costs $380 more per woman than covering the delivery only. For every 865 additional women receiving prenatal care, one infant death would be averted, at an average cost of $328,700. Cost-effectiveness acceptability curve analyses suggest a 99% probability that providing prenatal care is more cost effective at a willingness-to-pay threshold of $100,000 per quality-adjusted life-year. CONCLUSIONS: Extending prenatal care to low-income, immigrant women, regardless of citizenship status, is a cost-effective strategy.


Assuntos
Emigrantes e Imigrantes/estatística & dados numéricos , Cobertura do Seguro/economia , Seguro Saúde/economia , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pobreza , Cuidado Pré-Natal/economia , Criança , Análise Custo-Benefício , Feminino , Humanos , Lactente , Mortalidade Infantil , Cobertura do Seguro/estatística & dados numéricos , Oregon , Gravidez , Cuidado Pré-Natal/métodos , Anos de Vida Ajustados por Qualidade de Vida , Estados Unidos
20.
PLoS One ; 15(4): e0231417, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32271845

RESUMO

OBJECTIVE: Evaluate how the use of a Section 1115 waiver in Arkansas was associated with health insurance coverage compared to Medicaid expansion states that did not use a waiver. METHODS: Difference in difference analysis was conducted of 1,320,790 adults aged 19-64 with family incomes at or below 138% of the federal poverty level from the 2010-2017 American Community Survey. Arkansas was compared to states that expanded without a waiver in calendar year 2014. States that expanded Medicaid with an approved Section 1115 waiver during the study period or expanded without a waiver after 2014 or did not expand Medicaid were excluded from the analysis. The outcome measures were no health insurance coverage, Medicaid coverage, employer sponsored private insurance, and non-group direct purchase private insurance. RESULTS: Arkansas's use of a waiver to expand Medicaid was associated with a lower uninsured rate (-3.7%, p< 0.001), a higher Medicaid coverage rate (2.0%, p< 0.001), and a higher non-group, direct purchase private insurance coverage rate (2.9%, p< 0.001) compared to states that expanded Medicaid in 2014 without a waiver. CONCLUSION: Compared to states that implemented traditional Medicaid expansion, we found that Arkansas's waiver was associated with increases in health insurance coverage rates.


Assuntos
Cobertura do Seguro/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Adulto , Arkansas , Feminino , Humanos , Seguro Saúde/estatística & dados numéricos , Masculino , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act , Pobreza , Estados Unidos , Adulto Jovem
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