Identifying Paths Forward: Expanding Palliative Care to Low-Income Patients in California.

Multiple studies demonstrate most consumers do not know about palliative care. And, since January 2018, California's Medi-Cal Managed Care patients have been eligible for palliative care services under Senate Bill 1004 (SB 1004). Yet, the uptake of palliative care services was underwhelming. The purpose of this study was to explore patient-centered barriers to palliative care. We recruited 27 adult Medicaid managed care patients from community-based sites in Los Angeles and conducted semi-structured qualitative interviews. Each participant was asked questions to elicit their knowledge about, and perspectives on, palliative care as well as their preferred communication approaches for receiving a referral to palliative care. The interviews were audio-recorded and transcribed verbatim. We used a grounded theory approach to guide our analysis of primary themes. Our findings indicated that the barriers to palliative care referrals among this population included lack of knowledge about palliative care and available services; the reliance on, and trust in, primary care physicians for information; language and cultural barriers; housing instability; and patient believing they are neither old enough nor sick enough to need palliative care. These findings emphasize the critical role primary care physicians play in advocating for low-income patients and the necessity for culturally sensitive education about palliative care. Promoting knowledge and understanding of palliative care among both primary care physicians and consumers is critical to ensuring access to care.

Health Care Provider Barriers to Patient Referral to Palliative Care.

OBJECTIVE: The purpose of this study was to explore healthcare provider-perceived challenges to HBPC patient referral and elicited providers' feedback for overcoming these challenges. METHODS: We conducted a qualitative study using semi-structured interviews with 25 Medicaid managed care providers (primary care physicians, nurse practitioners, and care managers) working in the greater Los Angeles area. Our interview protocol elicited providers' knowledge and awareness of palliative care; perceived barriers to HBPC referral; and suggestions for overcoming these barriers. We analyzed verbatim transcripts using a grounded theory approach. RESULTS: Themes related to referral barriers included providers' lack of palliative care knowledge and clarity regarding referral processes, provider reluctance to refer to HBPC, and provider culture. Providers also identified patient-level barriers, including financial barriers, reluctance to have home visits, health literacy, cultural barriers, and challenges related to living situations. Themes related to methods for overcoming challenges included increased HBPC education and outreach to providers, specifically by HBPC agency staff. CONCLUSIONS: Findings from this study underscore the need for additional palliative care education for Medicaid healthcare providers. They point to the need for novel strategies and approaches to address the myriad barriers to patient identification and referral to HBPC.

Non-Infection-Related And Non-Visit-Based Antibiotic Prescribing Is Common Among Medicaid Patients.

Ambulatory antibiotic stewardship policies focus on prescribing decisions made when patients present to clinicians with possible infections. They do not capture antibiotics prescribed outside of clinician visits or without clear indications for use. Antibiotic prescribing for vulnerable patients in the US has not been comprehensively measured. We measured the frequency with which all filled antibiotic prescriptions were associated with infections and in-person visits for Medicaid patients in the period 2004-13. We found that among 298 million antibiotic fills (62 percent for children) for 53 million patients, 55 percent were for clinician visits with an infection-related diagnosis, 17 percent were for clinician visits without an infection-related diagnosis, and 28 percent were not associated with a visit. Non-visit-based antibiotic prescriptions were less common for children than for adults and more common in the West than in other US regions. Large fractions of antibiotic prescriptions are filled without evidence of infection-related diagnoses or accompanying clinician visits. Current ambulatory antibiotic stewardship policies miss about half of antibiotic prescribing.

A Medicaid Alternative Payment Model Program In Oregon Led To Reduced Volume Of Imaging Services.

The patient-centered medical home model aspires to fundamentally restructure care processes, but a volume-based payment system may hinder such transformations. In 2013 Oregon's Medicaid program changed its reimbursement of traditional primary care services for selected community health centers (CHCs) from a per visit to a per patient rate. Using Oregon claims data, we analyzed the price-weighted volume of care for five service areas: traditional primary care services, including imaging, tests, and procedures; other services provided by CHCs that were carved out from the payment reform; emergency department visits; inpatient services; and other services of non-CHC providers. We further subdivided traditional primary care services using Berenson-Eggers Type of Service categories of care. We compared participating and nonparticipating CHCs in Oregon before and after the payment model was implemented. The payment reform was associated with a 42.4 percent relative reduction in price-weighted traditional primary care services, driven fully by decreased use of imaging services. Other outcomes remained unaffected. Oregon's initiative could provide lessons for other states interested in using payment reform to advance the patient-centered medical home model for the Medicaid population.

The COVID-19 Shadow Pandemic: Meeting Social Needs For A City In Lockdown.

Addressing patients' social needs is key to helping them heal from coronavirus disease 2019 (COVID-19), preventing the spread of the virus, and reducing its disproportionate burden on low-income communities and communities of color. New York City Health + Hospitals is the city's single largest health care provider to Medicaid and uninsured patients. In response to the COVID-19 pandemic, NYC Health + Hospitals staff developed and executed a strategy to meet patients' intensified social needs during the COVID-19 pandemic. NYC Health + Hospitals identified food, housing, and income support as patients' most pressing needs and built programming to quickly connect patients to these resources. Although NYC Health + Hospitals was able to build on its existing foundation of strong social work support of patients, all health systems must prioritize the social needs of patients and their families to mitigate the damage of COVID-19. National and local leaders should accelerate change by developing robust policy approaches to redesign the social and economic system that reinforces structural inequity and exacerbates crises such as COVID-19.

Medicare's Care Management Codes Might Not Support Primary Care As Expected.

To enhance compensation for primary care activities that occur outside of face-to-face visits, the Centers for Medicare and Medicaid Services recently introduced new billing codes for transitional care management (TCM) and chronic care management (CCM) services. Overall, rates of adoption of these codes have been low. To understand the patterns of adoption, we compared characteristics of the practices that billed for these services to those of the practices that did not and determined the extent to which a practice other than the beneficiary's usual primary care practice billed for the services. Larger practices and those using other novel billing codes were more likely to adopt TCM or CCM. Over a fifth of all TCM claims and nearly a quarter of all CCM claims were billed by a practice that was not the beneficiary's assigned primary care practice. Our results raise concerns about whether these codes are supporting primary care as originally expected.

Risk Corridors, COVID-19, And The ACA.

The Supreme Court holds that the government owes insurers the full risk corridors payments due under the Affordable Care Act.

How Have ACA Insurance Expansions Affected Health Outcomes? Findings From The Literature.

A growing body of literature examining the effects of the Affordable Care Act (ACA) on nonelderly adults provides promising evidence of improvements in health outcomes through insurance expansions. Our review of forty-three studies that employed a quasi-experimental research design found encouraging evidence of improvements in health status, chronic disease, maternal and neonatal health, and mortality, with some findings corroborated by multiple studies. Some studies further suggested that the beneficial effects have grown over time and thus may continue to grow if the ACA insurance expansions remain in force. However, not all studies reported a significant positive relationship between ACA provisions that expanded insurance coverage and health status. We highlight the challenges facing researchers, including the importance of nonmedical factors in determining individual health and the use of outcome data predominantly drawn from self-reports. In closing, we identify opportunities to enhance researchers' understanding of the relationship between the ACA insurance expansions and health outcomes using new data sources, including electronic health records.

Evidence-Based Community Health Worker Program Addresses Unmet Social Needs And Generates Positive Return On Investment.

Interventions that address socioeconomic determinants of health are receiving considerable attention from policy makers and health care executives. The interest is fueled in part by expected returns on investment. However, many current estimates of returns on investment are likely overestimated, because they are based on pre-post study designs that are susceptible to regression to the mean. We present a return-on-investment analysis that is based on a randomized controlled trial of Individualized Management for Patient-Centered Targets (IMPaCT), a standardized community health worker intervention that addresses unmet social needs for disadvantaged people. We found that every dollar invested in the intervention would return $2.47 to an average Medicaid payer within the fiscal year.

The Impact Of Decision Aids On Adults Considering Hip Or Knee Surgery.

Trials of decision aids developed for use in shared decision making find that patients engaged in that process tend to choose more conservative treatment for preference-sensitive conditions. Shared decision making is a collaborative process in which clinicians and patients discuss trade-offs and benefits of specific treatment options in light of patients' values and preferences. Decision aids are paper, video, or web-based tools intended to help patients match personal preferences with available treatment options. We analyzed data for 2012-15 about patients within the ten High Value Healthcare Collaborative member systems who were exposed to condition-specific decision aids in the context of consultations for hip and knee osteoarthritis, with the intention that the aids be used to support shared decision making. Compared to matched patients not exposed to the decision aids, those exposed had two-and-a-half times the odds of undergoing hip replacement surgery and nearly twice the odds of undergoing knee replacement surgery within six months of the consultation. These findings suggest that health care systems adopting decision aids developed for use in shared decision making, and used in conjunction with hip and knee osteoarthritis consultations, should not expect reduced surgical utilization.

The Development Of Health And Housing Consortia In New York City.

Health and housing consortia in New York City offer a model for bridging the divide between the health care and housing sectors. While staff in these sectors often recognize the need to better integrate their services, there are few models for doing so. In this article we describe the formation of a health and housing consortium in the Bronx, New York City, as well as the successful replication of its model in Brooklyn. While each consortium has some features specific to its service area, the primary goal of both is the same: to provide a neutral space for health care and housing organizations to collaborate in what is otherwise often competitive and fragmented territory. In addition, the work of both consortia coalesces around training and resource development, cross-sector communication, and research and advocacy. We provide examples of the Bronx Consortium's activities in each of these core areas, highlight tangible results to date, and offer recommendations for people interested in undertaking similar efforts.

Integrating Health And Human Services In California's Whole Person Care Medicaid 1115 Waiver Demonstration.

Policy makers are increasingly investing in programs focused on identifying and addressing the nonmedical needs of high-utilizing Medicaid beneficiaries, yet little is known about these programs' implementation. This study provides an overview of early progress in and strategies used to implement California's Whole Person Care (WPC) Pilot Program, a $3 billion Medicaid Section 1115(a) waiver demonstration project focused on improving the integrated delivery of health, behavioral health, and social services for Medicaid beneficiaries who use acute and costly services in multiple service sectors. WPC pilots reported significant progress in developing partnerships, data-sharing infrastructure, and services needed to coordinate care for identified patient populations. We also identified major barriers to WPC implementation, such as difficulty identifying and engaging eligible beneficiaries and the lack of affordable housing. Our findings offer insights to leaders and policy makers interested in testing new approaches for improving the health and well-being of medically and socially complex patients.

Clinicians With High Socially At-Risk Caseloads Received Reduced Merit-Based Incentive Payment System Scores.

To understand how clinicians with high caseloads of socially at-risk patients fare under Medicare's new outpatient Merit-based Incentive Payment System (MIPS), we examined the first (2019) round of MIPS performance data for 510,020 clinicians. Compared with clinicians with the lowest socially at-risk caseloads, those with the highest had 13.4 points lower MIPS performance scores, were 99 percent more likely to receive a negative payment adjustment, and were 52 percent less likely to receive an exceptional performance bonus payment. The lower performance scores were partly explained by lower clinician reporting of and performance on technology-dependent measures, which may reflect a lack of practice-level technological capability. If the Complex Patient Bonus were in effect, the performance scores and likelihood of receiving an exceptional performance bonus (payment of clinicians with the highest socially at-risk caseloads) would have increased by 4.7 percent and 2.8 percent, respectively; however, the proportion receiving negative payment adjustments would have remained unchanged. The Complex Patient Bonus appears unlikely to mitigate the most regressive effects of MIPS.

Are Patients Electronically Accessing Their Medical Records? Evidence From National Hospital Data.

Substantial policy effort has been directed at improving patients' ability to access and use electronic health records. Using nationwide data from 2,410 hospitals for the period 2014-16, we examined associations between patient- and hospital-level characteristics and access to and use of electronic health record data among discharged patients. On average, hospitals gave 95 percent of discharged patients access to view, download, and transmit their information, but only about 10 percent of those with access used it-levels that were stagnant during the study period. Access rates were highest among system-member, teaching, and for-profit hospitals. In contrast, access rates were lower for hospitals in the highest quartile for disproportionate share hospital status and for hospitals located in counties with high proportions of residents who were dually eligible for Medicare and Medicaid; use rates were lower for hospitals in counties with a high proportion of residents who were dually eligible, lacked computer or internet access, or were Hispanic. Overall, our findings suggest that policy efforts have failed to engage a large proportion of patients in the electronic use of their data or to bridge the "digital divide" that accompanies health care disparities. Additional-possibly targeted-policy incentives, as well as higher thresholds for meeting the requirements of the Promoting Interoperability Program, merit policy makers' consideration.

Frequent Emergency Department Users: Focusing Solely On Medical Utilization Misses The Whole Person.

Frequent emergency department (ED) users often have complex behavioral health and social needs. However, policy makers often focus on this population's medical system use without examining its use of behavioral health and social services systems. To illuminate the wide-ranging needs of frequent ED users, we compared medical, mental health, substance use, and social services use among nonelderly nonfrequent, frequent, and superfrequent ED users in San Francisco County, California. We linked administrative data for fiscal years 2013-15 for beneficiaries of the county's Medicaid managed care plan to a county-level integrated data system. Compared to nonfrequent users, frequent users were disproportionately female, white or African American/black, and homeless. They had more comorbidities and annual outpatient mental health visits (11.93 versus 4.16), psychiatric admissions (0.73 versus 0.07), and sobering center visits (0.17 versus <0.01), as well as disproportionate use of housing and jail health services. Our findings point to the need for shared knowledge across domains, at the patient and population levels. Integrated data can serve as a systems improvement tool and help identify patients who might benefit from coordinated care management. To deliver whole-person care, policy makers should prioritize improvements in data sharing and the development of integrated medical, behavioral, and social care systems.

Assessment of Annual Diabetic Eye Examination Using Telemedicine Technology Among Underserved Patients in Primary Care Setting.

CONTEXT: Digital retinal imaging with the application of telemedicine technology shows promising results for screening of diabetic retinopathy in the primary care setting without requiring an ophthalmologist on site. AIMS: We assessed whether the establishment of telemedicine technology was an effective and efficient way to increase completion of annual eye examinations among underserved, low-income (Medicaid) diabetic patients. SETTINGS AND DESIGN: A cross-sectional study in a primary care setting. SUBJECTS AND METHODS: Health care claims data were collected before the establishment of telemedicine technology in 2010 and after its implementation in 2012 for Medicaid patients at East Baltimore Medical Center (EBMC), an urban health center that is part of Johns Hopkins Health System. STATISTICAL ANALYSIS USED: The primary outcome measure was the compliance rate of patients with diabetic eye examinations; calculated as the number of diabetic patients with a completed telemedicine eye examination, divided by the total number of diabetic patients. RESULTS: In 2010, EBMC treated 213 Medicaid diabetic patients and in 2012 treated 228 Medicaid patients. In 2010, 47.89% of patients completed their annual diabetic eye examination while in 2012 it was 78.07% (P < 0.001). After adjustment for age, gender, HgBA1C, disease severity, using resource utilization band score as a proxy, and medication possession ratio; telemedicine technology significantly increased the compliance (odds ratio: 4.98, P < 0.001). CONCLUSIONS: Adherence to annual eye examinations is low in the studied Medicaid diabetic population. Telemedicine technology in a primary care setting can increase compliance with annual eye examinations.

Comparing Emergency Department Use Among Medicaid and Commercial Patients Using All-Payer All-Claims Data.

The high rate of emergency department (ED) use by Medicaid patients is not fully understood. The objective of this paper is (1) to provide context for ED service use by comparing Medicaid and commercial patients' differences across ED and non-ED health service use, and (2) to assess the extent to which Medicaid-commercial differences in ED use can be explained by observable factors in administrative data. Statistical decomposition methods were applied to ED, mental health, and inpatient care using 2011-2013 Medicaid and commercial insurance claims from the Oregon All Payer All Claims database. Demographics, comorbidities, health services use, and neighborhood characteristics accounted for 44% of the Medicaid-commercial difference in ED use, compared to 83% for mental health care and 75% for inpatient care. This suggests that relative to mental health and inpatient care, a large portion of ED use cannot be explained by administrative data. Models that further accounted for patient access to different primary care physicians explained an additional 8% of the Medicaid-commercial difference in ED use, suggesting that the quality of primary care may influence ED use. The remaining unexplained difference suggests that appropriately reducing ED use remains a credible target for policy makers, although success may require knowledge about patients' perceptions and behaviors as well as social determinants of health.

A comparison of compliance in Medicaid versus non-Medicaid patients.

BACKGROUND: Medicaid patients have been associated with lack of compliance during their orthodontic treatment in comparison with the non-Medicaid patients. In this study, Medicaid and non-Medicaid orthodontic patients' compliance from a state university and private practice orthodontic clinic within close location were analyzed. METHODS: Charts of 30 Medicaid and 30 non-Medicaid orthodontic patients at each orthodontic clinic were reviewed. From each chart, mean percentage of failed and late appointments, number of broken appliances, number of comments on compliance with auxiliary wear and number of comments on oral hygiene maintenance were recorded. RESULTS: Statistically significant differences between Medicaid and non-Medicaid orthodontic patients were not found. CONCLUSIONS: The results of this study indicated that in general there are no differences between Medicaid and non-Medicaid orthodontic patients. PRACTICAL IMPLICATIONS: These results may alleviate the doubts of the dental practitioner in treating Medicaid patients.