Primary Care Access to New Patient Appointments for California Medicaid Enrollees: A Simulated Patient Study.

PURPOSE: We undertook a study to evaluate variation in the availability of primary care new patient appointments for Medi-Cal (California Medicaid) enrollees in Northern California, and its relationship to emergency department (ED) use after Medicaid expansion. METHODS: We placed simulated calls by purported Medi-Cal enrollees to 581 primary care clinicians (PCCs) listed as accepting new patients in online directories of Medi-Cal managed care plans. Data from the California Health Interview Survey, Medi-Cal enrollment reports, and California hospital discharge records were used in analyses. We developed multilevel, mixed-effect models to evaluate variation in appointment access. Multiple linear regression was used to examine the relationship between primary care access and ED use by county. RESULTS: Availability of PCC new patient appointments to Medi-Cal enrollees lacking a PCC varied significantly across counties in the multilevel model, ranging from 77 enrollees (95% CI, 70-81) to 472 enrollees (95% CI, 378-628) per each available new patient appointment. Just 19% of PCCs had available appointments within the state-mandated 10 business days. Clinicians at Federally Qualified Health Centers had higher availability of new patient appointments (rate ratio = 1.56; 95% CI, 1.24-1.97). Counties with poorer PCC access had higher ED use by Medi-Cal enrollees. CONCLUSIONS: In contrast to findings from other states, access to primary care in Northern California was limited for new patient Medi-Cal enrollees and varied across counties, despite standard statewide reimbursement rates. Counties with more limited access to primary care new patient appointments had higher ED use by Medi-Cal enrollees.

Radiation-Induced Breast Cancer Incidence and Mortality From Digital Mammography Screening: A Modeling Study.

BACKGROUND: Estimates of risk for radiation-induced breast cancer from mammography screening have not considered variation in dose exposure or diagnostic work-up after abnormal screening results. OBJECTIVE: To estimate distributions of radiation-induced breast cancer incidence and mortality from digital mammography screening while considering exposure from screening and diagnostic mammography and dose variation among women. DESIGN: 2 simulation-modeling approaches. SETTING: U.S. population. PATIENTS: Women aged 40 to 74 years. INTERVENTION: Annual or biennial digital mammography screening from age 40, 45, or 50 years until age 74 years. MEASUREMENTS: Lifetime breast cancer deaths averted (benefits) and radiation-induced breast cancer incidence and mortality (harms) per 100,000 women screened. RESULTS: Annual screening of 100,000 women aged 40 to 74 years was projected to induce 125 breast cancer cases (95% CI, 88 to 178) leading to 16 deaths (CI, 11 to 23), relative to 968 breast cancer deaths averted by early detection from screening. Women exposed at the 95th percentile were projected to develop 246 cases of radiation-induced breast cancer leading to 32 deaths per 100,000 women. Women with large breasts requiring extra views for complete examination (8% of population) were projected to have greater radiation-induced breast cancer risk (266 cancer cases and 35 deaths per 100,000 women) than other women (113 cancer cases and 15 deaths per 100,000 women). Biennial screening starting at age 50 years reduced risk for radiation-induced cancer 5-fold. LIMITATION: Life-years lost from radiation-induced breast cancer could not be estimated. CONCLUSION: Radiation-induced breast cancer incidence and mortality from digital mammography screening are affected by dose variability from screening, resultant diagnostic work-up, initiation age, and screening frequency. Women with large breasts may have a greater risk for radiation-induced breast cancer. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality, U.S. Preventive Services Task Force, National Cancer Institute.

Program-specific cost-effectiveness analysis: breast cancer screening policies for a safety-net program.

BACKGROUND: Every Woman Counts (EWC), a California breast cancer screening program, faced challenging budget cutbacks and policy choices. METHODS: A microsimulation model evaluated costs, outcomes, and cost-effectiveness of EWC program mammography policy options on coverage for digital mammography (which has a higher cost than film mammography but recent legislation allowed reimbursement at the lower film rate); screening eligibility age; and screening frequency. Model inputs were based on analyses of program claims data linked to California Cancer Registry data, Surveillance, Epidemiology, and End Results data, and the Medi-Cal literature. Outcomes included number of procedures, cancers, cancer deaths, costs, and incremental cost per life-year. RESULTS: Projected model outcomes matched program data closely. With restrictions on the number of clients screened, strategies starting screening at age 40 years were dominated (not cost-effective). This finding was highly robust in sensitivity analyses. Compared with no screening, biennial film mammography for women aged 50 to 64 years was projected to reduce 15-year breast cancer mortality by nearly 7.8% at $18,999 per additional life-year, annual film mammography was $106,428 per additional life-year, and digital mammography $180,333 per additional life-year. This more effective, more expensive strategy was projected to reduce breast cancer mortality by 8.6%. Under equal mammography reimbursement, biennial digital mammography beginning at age 50 years was projected to decrease 15-year breast cancer mortality by 8.6% at an incremental cost per additional life-year of $17,050. CONCLUSIONS: For the EWC program, biennial screening mammography starting at age 50 years was the most cost-effective strategy. The impact of digital mammography on life expectancy was small. Program-specific cost-effectiveness analysis can be completed in a policy-relevant time frame to assist policymakers faced with difficult program choices.

Public Deliberation as a Novel Method for an Exception From Informed Consent Community Consultation.

OBJECTIVES: Community consultation is required for clinical trials considering federal exception from informed consent (EFIC) procedures. Questions remain about the value of the community consult process and whether it adds intended protections to study subjects. Public deliberation methods that provide baseline participant education and elicit values and opinions about consent options is a novel approach for community consultation. This study evaluated the use of structured public deliberation methods to assess a community's values and opinions about informed consent procedures for a pediatric trauma trial. METHODS: This was a mixed-methods descriptive study of public deliberation sessions assessing participants' opinions about informed consent procedures for a pediatric trauma randomized controlled trial (RCT). Participants from communities with high rates of pediatric trauma were recruited via community-based organizations and social media. Deliberation focused on three consent options for a proposed RCT: 1) enrollment using EFIC procedures with no attempt to obtain informed consent, 2) enrollment using EFIC procedures after attempting to reach a parent, or 3) enrollment only with informed consent. Participant demographic data and their opinions about the proposed study and deliberative session were also collected. RESULTS: There were 102 participants across eight sessions (range of nine to 15/session, mean of 13). Most participants were female (n = 78, 76%) and a plurality were black (n = 48, 47%). The majority of participants preferred enrollment using EFIC procedures only after an attempt was made to reach a parent and informed consent was not possible (n = 56, 55%), followed by enrollment using EFIC procedures with no attempt to obtain informed consent (n = 32, 32%), and enrollment only with written informed consent (n = 13, 13%). One participant declined all options. Eighty-four participants (82%) agreed or strongly agreed that the RCT was important to do, and 79 participants (77%) said that the sessions provided enough information to make an informed decision about the proposed RCT. CONCLUSIONS: Structured public deliberation is an effective approach when consulting communities for trials considering EFIC procedures. Future studies are needed to evaluate whether public deliberation methods provide participants with enhanced understanding of clinical trials compared to other community consultation methods.

Health Benefits Mandates and Their Potential Impacts on Racial/Ethnic Group Disparities in Insurance Markets.

Addressing racial/ethnic group disparities in health insurance benefits through legislative mandates requires attention to the different proportions of racial/ethnic groups among insurance markets. This necessary baseline data, however, has proven difficult to measure. We applied racial/ethnic data from the 2009 California Health Interview Survey to the 2012 California Health Benefits Review Program Cost and Coverage Model to determine the racial/ethnic composition of ten health insurance market segments. We found disproportional representation of racial/ethnic groups by segment, thus affecting the health insurance impacts of benefit mandates. California's Medicaid program is disproportionately Latino (60 % in Medi-Cal, compared to 39 % for the entire population), and the individual insurance market is disproportionately non-Latino white. Gender differences also exist. Mandates could unintentionally increase insurance coverage racial/ethnic disparities. Policymakers should consider the distribution of existing racial/ethnic disparities as criteria for legislative action on benefit mandates across health insurance markets.

Defining risk of prescription opioid overdose: pharmacy shopping and overlapping prescriptions among long-term opioid users in medicaid.

UNLABELLED: Use of multiple pharmacies concurrently (pharmacy shopping) and overlapping prescriptions may be indicators of potential misuse or abuse of prescription opioid medications. To evaluate strategies for identifying patients at high risk, we first compared different definitions of pharmacy shopping and then added the indicator of overlapping opioid prescriptions. We identified a cohort of 90,010 Medicaid enrollees who used ≥ 3 opioid prescriptions for ≥ 90 days during 2008 to 2010 from a multistate Medicaid claims database. We compared the diagnostic odds ratios for opioid overdose events of 9 pharmacy shopping definitions. Within a 90-day interval, a threshold of 4 pharmacies had the highest diagnostic odds ratio and was used to define pharmacy shopping. The overdose rate was higher in the subgroup with overlapping prescriptions (18.5 per 1,000 person-years [PYs]) than in the subgroup with pharmacy shopping as the sole indicator (10.7 per 1,000 PYs). Among the subgroup with both conditions, the overdose rate was 26.3 per 1,000 PYs, compared with 4.3 per 1,000 PYs for those with neither condition. Overlapping opioid prescriptions and pharmacy shopping measures had adjusted hazard ratios of 3.0 and 1.8, respectively, for opioid overdose. Using these measures will improve accurate identification of patients at highest risk of opioid overdose, the first step in implementing targeted prevention policies. PERSPECTIVE: Long-term prescription opioid use may lead to adverse events, including overdose. Both pharmacy shopping and overlapping opioid prescriptions are associated with adverse outcomes. This study demonstrates that using both indicators will better identify those at high risk of overdose.

State policies and language access in California's HMOs: public reporting and regulation of HMOs' language services.

OBJECTIVE: Describe the status of language access services for California's limited English proficient (LEP) health maintenance organization (HMO) members within the context of voluntary public reporting and anticipated state regulation. STUDY DESIGN: Descriptive analysis of longitudinal data provided by health plans. METHODS: Retrospective, descriptive analysis of responses to voluntary annual/biennial surveys of commercial, Medicare, Medicaid, and Healthy Families HMOs, 2003-2008. RESULTS: From 2003 to 2008, during California's public reporting of HMO language services, the percentage of HMOs providing in-person interpretation free of charge to consumers increased to over 80% across all product lines. By 2008, the percentage of commercial HMO plans matching new LEP members to providers by language increased to 70%, while 79% provided telephone interpretation services in at least seven languages. CONCLUSIONS: Increasingly HMOs provide language access services for LEP Californians, perhaps resulting from public reporting and anticipated state regulation, although similar trends in other states cannot be ruled out.