Utilization and Adherence in Medical Homes: An Assessment of Rural-Urban Differences for People With Severe Mental Illness.

BACKGROUND: The complex nature of managing care for people with severe mental illness (SMI), including major depression, bipolar disorder, and schizophrenia, is a challenge for primary care practices, especially in rural areas. The team-based emphasis of medical homes may act as an important facilitator to help reduce observed rural-urban differences in care. OBJECTIVE: The objective of this study was to examine whether enrollment in medical homes improved care in rural versus urban settings for people with SMI. RESEARCH DESIGN: Secondary data analysis of North Carolina Medicaid claims from 2004-2007, using propensity score weights and generalized estimating equations to assess differences between urban, nonmetropolitan urban and rural areas. SUBJECTS: Medicaid-enrolled adults with diagnoses of major depressive disorder, bipolar disorder or schizophrenia. Medicare/Medicaid dual eligibles were excluded. MEASURES: We examined utilization measures of primary care use, specialty mental health use, inpatient hospitalizations, and emergency department use and medication adherence. RESULTS: Rural medical home enrollees generally had higher primary care use and medication adherence than rural nonmedical home enrollees. Rural medical home enrollees had fewer primary care visits than urban medical home enrollees, but both groups were similar on the other outcome measures. These findings varied somewhat by SMI diagnosis. CONCLUSIONS: Findings indicate that enrollment in medical homes among rural Medicaid beneficiaries holds the promise of reducing rural-urban differences in care. Both urban and rural medical homes may benefit from targeted resources to help close the remaining gaps and to improve the success of the medical home model in addressing the health care needs of people with SMI.

Implementing a Prison Medicaid Enrollment Program for Inmates with a Community Inpatient Hospitalization.

In 2011, North Carolina (NC) created a program to facilitate Medicaid enrollment for state prisoners experiencing community inpatient hospitalization during their incarceration. The program, which has been described as a model for prison systems nationwide, has saved the NC prison system approximately $10 million annually in hospitalization costs and has potential to increase prisoners' access to Medicaid benefits as they return to their communities. This study aims to describe the history of NC's Prison-Based Medicaid Enrollment Assistance Program (PBMEAP), its structure and processes, and program personnel's perspectives on the challenges and facilitators of program implementation. We conducted semi-structured interviews and a focus group with PBMEAP personnel including two administrative leaders, two "Medicaid Facilitators," and ten social workers. Seven major findings emerged: 1) state legislation was required to bring the program into existence; 2) the legislation was prompted by projected cost savings; 3) program development required close collaboration between the prison system and state Medicaid office; 4) technology and data sharing played key roles in identifying inmates who previously qualified for Medicaid and would likely qualify if hospitalized; 5) a small number of new staff were sufficient to make the program scalable; 6) inmates generally cooperated in filling out Medicaid applications, and their cooperation was encouraged when social workers explained possible benefits of receiving Medicaid after release; and 7) the most prominent program challenges centered around interaction with county Departments of Social Services, which were responsible for processing applications. Our findings could be instructive to both Medicaid non-expansion and expansion states that have either implemented similar programs or are considering implementing prison Medicaid enrollment programs in the future.

Medicaid Enrollment among Prison Inmates in a Non-expansion State: Exploring Predisposing, Enabling, and Need Factors Related to Enrollment Pre-incarceration and Post-Release.

Prison inmates suffer from a heavy burden of physical and mental health problems and have considerable need for healthcare and coverage after prison release. The Affordable Care Act may have increased Medicaid access for some of those who need coverage in Medicaid expansion states, but inmates in non-expansion states still have high need for Medicaid coverage and face unique barriers to enrollment. We sought to explore barriers and facilitators to Medicaid enrollment among prison inmates in a non-expansion state. We conducted qualitative interviews with 20 recently hospitalized male prison inmates who had been approached by a prison social worker due to probable Medicaid eligibility, as determined by the inmates' financial status, health, and past Medicaid enrollment. Interviews were transcribed verbatim and analyzed using a codebook with both thematic and interpretive codes. Coded interview text was then analyzed to identify predisposing, enabling, and need factors related to participants' Medicaid enrollment prior to prison and intentions to enroll after release. Study participants' median age, years incarcerated at the time of the interview, and projected remaining sentence length were 50, 4, and 2 years, respectively. Participants were categorized into three sub-groups based on their self-reported experience with Medicaid: (1) those who never applied for Medicaid before prison (n = 6); (2) those who unsuccessfully attempted to enroll in Medicaid before prison (n = 3); and (3) those who enrolled in Medicaid before prison (n = 11). The six participants who had never applied to Medicaid before their incarceration did not hold strong attitudes about Medicaid and mostly had little need for Medicaid due to being generally healthy or having coverage available from other sources such as the Veteran's Administration. However, one inmate who had never applied for Medicaid struggled considerably to access mental healthcare due to lapses in employer-based health coverage and attributed his incarceration to this unmet need for treatment. Three inmates with high medical need had their Medicaid applications rejected at least once pre-incarceration, resulting in periods without health coverage that led to worsening health and financial hardship for two of them. Eleven inmates with high medical need enrolled in Medicaid without difficulty prior to their incarceration, largely due to enabling factors in the form of assistance with the application by their local Department of Social Services or Social Security Administration, their mothers, medical providers, or prison personnel during a prior incarceration. Nearly all inmates acknowledged that they would need health coverage after release from prison, and more than half reported that they would need to enroll in Medicaid to gain healthcare coverage following their release. Although more population-based assessments are necessary, our findings suggest that greater assistance with Medicaid enrollment may be a key factor so that people in the criminal justice system who qualify for Medicaid-and other social safety net programs-may gain their rightful access to these benefits. Such access may benefit not only the individuals themselves but also the communities to which they return.

Gender norms and modern contraceptive use in urban Nigeria: a multilevel longitudinal study.

BACKGROUND: Evidence suggests that gender equality positively influences family planning. However, the evidence from urban Africa is sparse. This study aimed to examine the association between changes in gender norms and modern contraceptive use over time among women in urban Nigeria. METHODS: Data were collected in 2010/2011 from 16,118 women aged 15-49 living in six cities in Nigeria (Abuja, Benin, Ibadan, Ilorin, Kaduna, and Zaria) and again in 2014 from 10,672 of the same women (34% attrition rate). The analytical sample included 9933 women living in 480 neighborhoods. A four-category outcome variable measured their change in modern contraceptive use within the study period. The exposure variables measured the changes in the level of gender-equitable attitudes towards: a) wife beating; b) household decision-making; c) couples' family planning decisions; and d) family planning self-efficacy. Multilevel multinomial logistic regression models estimated the associations between the exposure variables at the individual and neighborhood levels and modern contraceptive use controlling for the women's age, education, marital status, religion, parity, household wealth, and city of residence. RESULTS: The proportion of women who reported current use of modern contraceptive methods increased from 21 to 32% during the four-year study period. At both surveys, 58% of the women did not report using modern contraceptives while 11% reported using modern contraceptives; 21% did not use in 2010/2011 but started using by 2014 while 10% used in 2010/2011 but discontinued use by 2014. A positive change in the gender-equitable attitudes towards household decision-making, couples' family planning decisions, and family planning self-efficacy at the individual and neighborhood levels were associated with increased relative probability of modern contraceptive use (adoption and continued use) and decreased relative probability of modern contraceptive discontinuation by 2014. No such associations were found between the individual and neighborhood attitudes towards wife beating and modern contraceptive use. Accounting for the individual and neighborhood gender-equitable attitudes and controlling for the women's demographic characteristics accounted for 55-61% of the variation between neighborhoods in the change in modern contraceptive use during the study period. CONCLUSION: Interventions that promote gender equality have the potential to increase modern contraceptive use in Nigerian cities.

Connecting Mentally Ill Detainees in Large Urban Jails with Community Care.

Large urban jails have become a collection point for many persons with severe mental illness. Connections between jail and community mental health services are needed to assure in-jail care and to promote successful community living following release. This paper addresses this issue for 2855 individuals with severe mental illness who received community mental health services prior to jail detention in King County (Seattle), Washington over a 5-year time period using a unique linked administrative data source. Logistic regression was used to determine the probability that a detainee with severe mental illness received mental health services while in jail as a function of demographic and clinical characteristics. Overall, 70 % of persons with severe mental illness did receive in-jail mental health treatment. Small, but statistically significant sex and race differences were observed in who received treatment in the jail psychiatric unit or from the jail infirmary. Findings confirm the jail's central role in mental health treatment and emphasize the need for greater information sharing and collaboration with community mental health agencies to minimize jail use and to facilitate successful community reentry for detainees with severe mental illness.

Do medical homes increase medication adherence for persons with multiple chronic conditions?

BACKGROUND: Medications are an integral component of management for many chronic conditions, and suboptimal adherence limits medication effectiveness among persons with multiple chronic conditions (MCC). Medical homes may provide a mechanism for increasing adherence among persons with MCC, thereby enhancing management of chronic conditions. OBJECTIVE: To examine the association between medical home enrollment and adherence to newly initiated medications among Medicaid enrollees with MCC. RESEARCH DESIGN: Retrospective cohort study comparing Community Care of North Carolina medical home enrollees to nonenrollees using merged North Carolina Medicaid claims data (fiscal years 2008-2010). SUBJECTS: Among North Carolina Medicaid-enrolled adults with MCC, we created separate longitudinal cohorts of new users of antidepressants (N=9303), antihypertensive agents (N=12,595), oral diabetic agents (N=6409), and statins (N=9263). MEASURES: Outcomes were the proportion of days covered (PDC) on treatment medication each month for 12 months and a dichotomous measure of adherence (PDC>0.80). Our primary analysis utilized person-level fixed effects models. Sensitivity analyses included propensity score and person-level random-effect models. RESULTS: Compared with nonenrollees, medical home enrollees exhibited higher PDC by 4.7, 6.0, 4.8, and 5.1 percentage points for depression, hypertension, diabetes, and hyperlipidemia, respectively (P's<0.001). The dichotomous adherence measure showed similar increases, with absolute differences of 4.1, 4.5, 3.5, and 4.6 percentage points, respectively (P's<0.001). CONCLUSIONS: Among Medicaid enrollees with MCC, adherence to new medications is greater for those enrolled in medical homes.

Effects of maternity care coordination on pregnancy outcomes: propensity-weighted analyses.

Care coordination services that link pregnant women to health-promoting resources, avoid duplication of effort, and improve communication between families and providers have been endorsed as a strategy for reducing disparities in adverse pregnancy outcomes, however empirical evidence regarding the effects of these services is contradictory and incomplete. This study investigates the effects of maternity care coordination (MCC) on pregnancy outcomes in North Carolina. Birth certificate and Medicaid claims data were analyzed for 7,124 women delivering live infants in North Carolina from October 2008 through September 2010, of whom 2,255 received MCC services. Propensity-weighted analyses were conducted to reduce the influence of selection bias in evaluating program participation. Sensitivity analyses compared these results to conventional ordinary least squares analyses. The unadjusted preterm birth rate was lower among women who received MCC services (7.0 % compared to 8.3 % among controls). Propensity-weighted analyses demonstrated that women receiving services had a 1.8 % point reduction in preterm birth risk; p < 0.05). MCC services were also associated with lower pregnancy weight gain (p = 0.10). No effects of MCC were seen for birthweight. These findings suggest that coordination of care in pregnancy can significantly reduce the risk of preterm delivery among Medicaid-enrolled women. Further research evaluating specific components of care coordination services and their effects on preterm birth risk among racial/ethnic and geographic subgroups of Medicaid enrolled mothers could inform efforts to reduce disparities in pregnancy outcome.

Heterogeneity in the quality of care for patients with multiple chronic conditions by psychiatric comorbidity.

BACKGROUND: Little is known about the quality of care received by Medicaid enrollees with multiple chronic conditions (MCCs) and whether quality is different for those with mental illness. OBJECTIVES: To examine cancer screening and single-disease quality of care measures in a Medicaid population with MCC and to compare quality measures among persons with MCC with varying medical comorbidities with and without depression or schizophrenia. RESEARCH DESIGN: Secondary data analysis using a unique data source combining Medicaid claims with other administrative datasets from North Carolina's mental health system. SUBJECTS: Medicaid-enrolled adults aged 18 and older with ≥2 of 8 chronic conditions (asthma, chronic obstructive pulmonary disease, diabetes, hypertension, hyperlipidemia, seizure disorder, depression, or schizophrenia). Medicare/Medicaid dual enrollees were excluded due to incomplete data on their medical care utilization. MEASURES: We examined a number of quality measures, including cancer screening, disease-specific metrics, such as receipt of hemoglobin A1C tests for persons with diabetes, and receipt of psychosocial therapies for persons with depression or schizophrenia, and medication adherence. RESULTS: Quality of care metrics was generally lower among those with depression or schizophrenia, and often higher among those with increasing levels of medical comorbidities. A number of exceptions to these trends were noted. CONCLUSIONS: Cancer screening and single-disease quality measures may provide a benchmark for overall quality of care for persons with MCC; these measures were generally lower among persons with MCC and mental illness. Further research on quality measures that better reflect the complex care received by persons with MCC is essential.

Use of medical homes by patients with comorbid physical and severe mental illness.

BACKGROUND: Patients with comorbid severe mental illness (SMI) may use primary care medical homes differently than other patients with multiple chronic conditions (MCC). OBJECTIVE: To compare medical home use among patients with comorbid SMI to use among those with only chronic physical comorbidities. RESEARCH DESIGN: We examined data on children and adults with MCC for fiscal years 2008-2010, using generalized estimating equations to assess associations between SMI (major depressive disorder or psychosis) and medical home use. SUBJECTS: Medicaid and medical home enrolled children (age, 6-17 y) and adults (age, 18-64 y) in North Carolina with ≥2 of the following chronic health conditions: major depressive disorder, psychosis, hypertension, diabetes, hyperlipidemia, seizure disorder, asthma, and chronic obstructive pulmonary disease. MEASURES: We examined annual medical home participation (≥1 visit to the medical home) among enrollees and utilization (number of medical home visits) among participants. RESULTS: Compared with patients without depression or psychosis, children and adults with psychosis had lower rates of medical home participation (-12.2 and -8.2 percentage points, respectively, P<0.01) and lower utilization (-0.92 and -1.02 visits, respectively, P<0.01). Children with depression had lower participation than children without depression or psychosis (-5.0 percentage points, P<0.05). Participation and utilization among adults with depression was comparable with use among adults without depression or psychosis (P>0.05). CONCLUSIONS: Overall, medical home use was relatively high for Medicaid enrollees with MCC, though it was somewhat lower among those with SMI. Targeted strategies may be required to increase medical home participation and utilization among SMI patients.

Is medical home enrollment associated with receipt of guideline-concordant follow-up care among low-income breast cancer survivors?

BACKGROUND: Community Care of North Carolina (CCNC) initiated an innovative medical home program in the 1990 s to improve primary care in Medicaid-insured populations. CCNC has been successful in improving asthma, diabetes, and cardiovascular outcomes but has not been evaluated in the context of cancer care. We explored whether CCNC enrollment was associated with guideline-concordant follow-up care among breast cancer survivors. METHODS: Using state cancer registry records matched to Medicaid claims, we identified women 18 to 64 years old who were diagnosed with stage 0, I, II, or unstaged breast cancer from 2003 to 2007 and tracked their monthly CCNC enrollment. Using published American Society for Clinical Oncology guidelines to define our outcomes, we employed multivariate logistic regressions to examine, as a function of CCNC enrollment, receipt of mammogram and at least 2 physical examinations/history-taking visits within observational windows consistent with the guidelines. RESULTS: Of the 840 women, approximately half were enrolled into the CCNC for some time during the study period. Between 40% and 85% received follow-up mammogram in accordance with guidelines, with significant variation by CCNC status, and 95% of women received at least 2 physical examinations/history-taking visits. In multivariate models, increasing months of CCNC enrollment was significantly positively associated with receipt of follow-up mammogram but not with physical examinations/history-taking visits. CONCLUSIONS: Results suggest that CCNC enrollment is associated with guideline-concordant follow-up care for Medicaid-insured survivors. Given the growing population of cancer survivors and increased emphasis on primary care medical homes, future studies should explore what factors are associated with medical home participation and whether similar findings are observed with extended follow-up.

The impact of changes in psychiatric bed supply on jail use by persons with severe mental illness.

BACKGROUND: There is an on-going concern that reductions in psychiatric inpatient bed capacity beyond a critical threshold will further exacerbate the incarceration of persons with mental illness. However, research to date to assess the proposed relationship between inpatient bed capacity and jail use has been limited in several ways. In addition, mechanisms through which changes in psychiatric bed capacity may affect jail use by persons with mental illness remain unexamined empirically. AIMS OF THE STUDY: The aim of this study is to test whether changes in inpatient psychiatric resources, measured by per-capita psychiatric beds, inversely affect the likelihood of jail use by persons with severe mental illness. We also examine mechanisms that link psychiatric bed supply and jail detention. METHODS: We analyze unique individual-level panel data on 41,236 adults in King County, Washington who were users of jails, the public mental health system, or the Medicaid program from 1993 to 1998. Using administrative records, we identify persons ever diagnosed with severe mental illness during the study period. Our analyses build upon a system of simultaneous equations that captures mechanisms from changes in psychiatric bed supply to jail detention. We estimate a reduced-form model and calculate the total effect of a shift in psychiatric bed supply on the likelihood of jail use by persons with severe mental illness. We also estimate a semi-reduced-form equation to examine whether changes in mental health and substance use mediate the relationship between bed supply and jail detention. We estimate linear probability models with person-level fixed effects to control for individual heterogeneity. Standard errors are adjusted for intra-cluster correlations. When an equation includes an endogenous variable, we calculate generalized method of moments estimators with instrumental variables. RESULTS: A decrease in the supply of psychiatric hospital beds is significantly associated with a greater probability of jail detention for minor charges among persons diagnosed with severe mental illness. Substance use appears to mediate this relationship. DISCUSSION: A reduction of inpatient psychiatric beds, ceteris paribus, is associated with an increase in jail detention among persons with severe mental illness via substance use problems. Further research should examine whether the magnitude of this relationship is greater for persons who have severe mental illness but are unable to obtain necessary treatment. IMPLICATIONS FOR HEALTH POLICIES: This study further confirms an identified relationship between the supply of inpatient psychiatric beds, substance use and jail detention among persons with severe mental illness. These important relationships should be incorporated in the policy planning process, especially at the time of psychiatric inpatient bed reductions.

Does managed care affect the diffusion of psychotropic medications?

Newer technologies to treat many mental illnesses have shown substantial heterogeneity in diffusion rates across states. In this paper, I investigate whether variation in the level of managed care penetration is associated with changes in state-level diffusion of three newer classes of psychotropic medications in fee-for-service Medicaid programs from 1991 to 2005. Three different types of managed care programs are examined: capitated managed care, any type of managed care and behavioral health carve-outs. A fourth-order polynomial fixed effect regression model is used to model the diffusion path of newer antidepressant and antipsychotic medications controlling for time-varying state characteristics. Substantial differences are found in the diffusion paths by the degree of managed care use in each state Medicaid program. The largest effect is seen through spillover effects of capitated managed care programs; states with greater capitated managed care have greater initial shares of newer psychotropic medications. The influence of carve-outs and of all types of managed care combined on the diffusion path was modest.

Differential service utilization associated with trauma-informed integrated treatment for women with co-occurring disorders.

Women with co-occurring mental health and substance use disorders and trauma histories vary greatly in symptom severity and use of support services. This study estimated differential effects of an integrated treatment intervention (IT) across sub-groups of women in this population on services utilization outcomes. Data from a national study were used to cluster participants by symptoms and service utilization, and then estimate the effect of IT versus usual care on 12-month service utilization for each sub-group. The intervention effect varied significantly across groups, in particular indicating relative increases in residential treatment utilization associated with IT among women with predominating trauma and substance abuse symptoms. Understanding how IT influences service utilization for different groups of women in this population with complex needs is an important step toward achieving an optimal balance between need for treatment and service utilization, which can ultimately improve outcomes and conserve resources.

Service Utilization Patterns as Predictors of Response to Trauma-Informed Integrated Treatment for Women With Co-occurring Disorders.

OBJECTIVE: The current study examined whether clinical responses to an integrated treatment intervention among women with co-occurring disorders and histories of abuse varied according to their service use patterns at baseline. METHODS: Data were from a national, multi-site, integrated treatment intervention study in 1998-2003. Analyses included 999 study participants assigned to the integrated treatment group and who were symptomatic at baseline. Participants' baseline service use activity was characterized according to five distinct baseline service use clusters. Logistic regression models estimated study participants' odds of good clinical responses to integrated treatment at 12 months across the five service clusters. RESULTS: Participants with high levels of psychotropic medication and medical care use at baseline had significantly lower odds than low-intensity service users of having a good response to integrated treatment at 12 months on mental health, alcohol addiction, and posttraumatic stress measures. A majority of women in this group had serious medical illness or disability and were more likely than their counterparts with other service use patterns to have used homeless or domestic violence shelters. CONCLUSIONS: Women who used high levels of medication and medical services appear to have faced especially difficult barriers in responding well to integrated treatment. Careful assessments of their mental health, trauma, and medical treatment needs may be required as part of integrated treatment in an effort to improve their response to integrated treatment, clinical outcomes and well-being. This information can also be used to target integrated treatment to women who are likely to respond positively and achieve meaningful improvements in their functioning.

Mercury in South Carolina fishes, USA.

The South Carolina Department of Health and Environmental Control has collected, processed, and analyzed fish tissue total mercury (Hg) since 1976. For this study, skin-on-filet data from 1993 to 2007 were examined to determine biotic, spatial and temporal trends in tissue Hg levels for SC fishes. Because of the relatively high number of tissue Hg values below the analytical detection limits interval censored regression and censored least absolute deviations were used to construct several models to characterize trends. Large pelagic, piscivorous fish species, such as bowfin (Amia calva Linnaeus 1766), had higher levels of tissue Hg than smaller omnivorous species. Estuarine species had relatively low levels of tissue Hg compared to freshwater species, while two large open ocean species, king mackerel (Scomberomorus cavalla Cuvier 1829) and swordfish (Xiphias gladius Linnaeus 1758), had higher tissue Hg readings. For a given fish species, length was an important predictor of tissue Hg with larger individuals having higher levels than smaller individuals. The USEPA Level III ecoregion and water body type from where the fishes were collected were important in predicting the levels of tissue Hg. The Middle Atlantic Coastal Plain ecoregion had fishes with the highest levels of tissue Hg, while the Piedmont and Southern Coastal Plain ecoregions had the lowest. For a given ecoregion, large reservoirs and regulated rivers had fish with lower levels of tissue Hg than unregulated rivers. For reservoirs, the size of the impoundment was a significant predictor of tissue mercury with small reservoirs having higher levels of tissue mercury than large reservoirs. Landuse and water chemistry accounted for differences seen in fish of various ecoregions and waterbody types. Sampling locations associated with a high percentage of wetland area had fish with high levels of tissue Hg. Correlation analysis showed a strong positive relationship between tissue Hg levels and water column iron, total organic carbon, ammonia, and total kjedahl nitrogen, and a negative relationship with alkalinity, dissolved oxygen and pH. Results from principle component analysis revealed patterns between waterbody type and water chemistry variables that suggests hydrologic modification can have profound effects on the levels of fish tissue Hg in riverine systems. From 1993 to 2007, fish tissue Hg levels have trended lower. A spike in tissue Hg levels was observed in 2003-2005. The drying and rewetting of the landscape after the 2002 drought is hypothesized to have caused an increase in the methylation efficiencies of the system.

Antidepressant and antipsychotic use and adherence among Medicaid youths: differences by race.

The purpose of our study is to use Medicaid data to examine the relationship between race and (a) whether youth with schizophrenia or depression diagnoses receive anti-psychotic and antidepressant prescriptions and (b) adherence to anti-psychotics and antidepressants. The analysis is based on claims files from January 1, 2000 through June 30, 2001. To assess adherence, we used the Proportion of Days Covered (PDC) measure. Multivariable logistic regression was used to analyze the data. Black children with schizophrenia were significantly less likely to be adherent to anti-psychotics during a quarter than White children. White children with depression were significantly more likely to receive an antidepressant prescription and they were significantly more adherent during a quarter than Black children. Providers should make sure to investigate both youth and caregiver concerns, fears, and barriers to using these medications and work with the families to develop strategies to improve medication use among youth.

The effect of Medicaid expansion on use of opioid agonist treatment and the role of provider capacity constraints.

OBJECTIVE: To determine the effect of Medicaid expansion on the use of opioid agonist treatment for opioid use disorder (OUD) and to examine heterogeneous effects by provider supply and Medicaid acceptance rates. DATA SOURCES: Yearly state-level data on methadone dispensed from opioid treatment programs (OTPs), buprenorphine dispensed from OTPs and pharmacies, number of OTPs and buprenorphine-waivered providers, and percent of OTPs and physicians accepting Medicaid. STUDY DESIGN: This study used difference-in-differences models to examine the effect of Medicaid expansion on the amount of methadone and buprenorphine dispensed in states between 2006 and 2017. Interaction terms were used to estimate heterogeneous effects. Sensitivity analyses included testing the association of outcomes with Medicaid enrollment and state insurance rates. PRINCIPAL FINDINGS: The estimated effects of Medicaid expansion on buprenorphine and methadone dispensed were positive but imprecise, meaning we could not rule out negative or null effects of expansion. The estimated associations between state insurance rates and dispensed methadone and buprenorphine were centered near zero, suggesting that improvements in health coverage may not have increased OUD treatment use. The effect of Medicaid expansion was larger in the states with the most waivered providers compared to states with the fewest waivered providers. In the states with the most waivered providers, the average estimated effect of expansion on buprenorphine dispensed was 12 kg/y, enough to treat about 7500 individuals. We did not find evidence that the effect of expansion was consistently modified by OTP concentration, OTP Medicaid acceptance, or physician Medicaid acceptance. CONCLUSIONS: Gains in health coverage may not be sufficient to increase OUD treatment, even in the context of high treatment need. Provider capacity likely limited Medicaid expansion's effect on buprenorphine dispensed. Policies to increase buprenorphine providers, such as ending the waiver requirement, may be needed to ensure coverage gains translate to treatment access.

Enhancing the medical homes model for children with asthma.

BACKGROUND: Medical Home is an evolving concept of patient-centered care yet little information is available on its effect on health care expenditures for children. OBJECTIVES: To quantify differences in patterns of care and costs to the North Carolina (NC) Medicaid program for children with asthma across 3 programs: fee-for-service (FFS), primary care case management (PCCM), and Medical Homes. RESEARCH DESIGN: NC Medicaid claims from 1998-2001 for children with asthma were used to examine monthly expenditures and patterns of health care use, including emergency department and hospital use. Children in the FFS program served as controls for trends in asthma care over the study period. Tests examined the potential for selection by program and fixed-effect 2-part model regressions were used to control for differences in program enrollees. SUBJECTS: Children under age 21 with asthma. MEASURES: Monthly Medicaid expenditures and measures of health service use. RESULTS: We found considerable evidence of quality improvement in patterns of care for children enrolled in both the PCCM and Medical Homes models in NC. After controlling for selection into these programs, use of maintenance as well as rescue medications increased, use of services increased, and emergency department and hospital use went down. Total spending (asthma and nonasthma related) on children in the Medical Homes program was $148 greater than spending for FFS children (95% bootstrapped confidence interval: $140-$158) per child per month and no difference in spending between Medical Homes and PCCM was detected. CONCLUSIONS: Our results indicate that enhancement of PCCM programs is one way for Medicaid programs to improve care, but may require substantial investments by states.

Contrasting measures of adherence with simple drug use, medication switching, and therapeutic duplication.

BACKGROUND: Multiple measures of adherence have been reported in the research literature and it is difficult to determine which is best, as each is nuanced. Occurrences of medication switching and polypharmacy or therapeutic duplication can substantially complicate adherence calculations when adherence to a therapeutic class is sought. OBJECTIVE: To contrast the Proportion of Days Covered (PDC) adherence metric with 2 variants of the Medication Possession Ratio (MPR, truncated MPR). METHODS: This study was a retrospective analysis of the North Carolina Medicaid administrative claims data from July 1999 to June 2000. Data for patients with schizophrenia (ICD-9-CM code 295.xx) who were not part of a health maintenance organization, not hospitalized, and not pregnant, taking at least one antipsychotic, were aggregated for each person into person-quarters. The numerator for PDC was defined as the number of days one or more antipsychotics was available and the MPR numerator was defined as the total days' supply of antipsychotics; both were divided by the total days in each person-quarter. Adherence rates were estimated for subjects who used only one antipsychotic, switched medications, or had therapeutic duplication in the quarter. RESULTS: The final sample consisted of 25,200 person-quarters from 7069 individuals. For person-quarters with single antipsychotic use, adherence to antipsychotics as a class was: PDC 0.607, truncated MPR 0.640, and MPR 0.695 (p < 0.001). For person-quarters with switching, the average MPR was 0.690, truncated MPR was 0.624, and PDC was 0.562 (p < 0.001). In the presence of therapeutic duplication, the PDC was 0.669, truncated MPR was 0.774, and MPR was 1.238 (p < 0.001). CONCLUSIONS: The PDC provides a more conservative estimate of adherence than the MPR across all types of users; however, the differences between the 2 methods are more substantial for persons switching therapy and prescribed therapeutic duplication, where MPR may overstate true adherence. The PDC should be considered when a measure of adherence to a class of medications is sought, particularly in clinical situations in which multiple medications within a class are often used concurrently.

Patient-centered medical homes and preventive service use.

OBJECTIVES: Despite data suggesting that patient-centered medical homes (PCMHs) improve preventive service use, limited nationally representative evidence exists. This study compared preventive service use between patients with and without a usual source of care (USC) and, of the patients with a USC, between those in practices with and without PCMH status. STUDY DESIGN: This study used a cross-sectional study design. METHODS: We constructed general and disease-specific preventive service indicators using the 2015 Medical Expenditure Panel Survey. Preventive service rates were compared between patients reporting a USC versus no USC and between patients whose USC practices were PCMH certified versus not PCMH certified. Unadjusted outcomes were tested using χ2 tests. Multivariable logistic regression was used to test differences between groups, controlling for predisposing, enabling, and need variables. RESULTS: Using multivariable logistic regression, respondents with a USC reported higher rates of screening for breast cancer (odds ratio [OR], 2.40; 95% CI, 1.81-3.17) and cervical cancer (OR, 1.99; 95% CI, 1.61-2.47) than respondents with no USC. Diabetes respondents with a USC had higher odds of an annual eye exam (OR, 2.05; 95% CI, 1.26-3.33) than respondents with no USC. Diabetes respondents with a USC that was PCMH certified reported higher rates of annual foot screenings (OR, 2.01; 95% CI, 1.31-3.08) and lower rates of annual cholesterol screenings (OR, 0.30; 95% CI, 0.11-0.83) than those with a USC that was not PCMH certified. CONCLUSIONS: Having a USC was associated with higher rates of several preventive screening measures. However, there were fewer significant preventive screening relationships by PCMH status among individuals with a USC. Our results suggest that improving access to a USC may be as important as the application of PCMH principles to a USC practice.