The Effects of Medicaid Eligibility on Mental Health Services and Out‐of‐Pocket Spending for Mental Health Services

Objective

Millions of low‐income Americans will gain health insurance through Medicaid under the Affordable Care Act. This study assesses the impact of previous Medicaid expansions on mental health services utilization and out‐of‐pocket spending.

Data Sources

Secondary data from the 1998–2011 Medical Expenditure Panel Survey Household Component merged with National Health Interview Survey and state Medicaid eligibility rules data.

Study Design

Instrumental variables regression models were used to estimate the impact of expanded Medicaid eligibility on health insurance coverage, mental health services utilization, and out‐of‐pocket spending for mental health services.

Data Extraction Methods

Person‐year files were constructed including adults ages 21–64 under 300 percent of the Federal Poverty Level.

Principal Findings

Medicaid expansions significantly increased health insurance coverage and reduced out‐of‐pocket spending on mental health services for low‐income adults. Effects of expanded Medicaid eligibility on out‐of‐pocket spending were strongest for adults with psychological distress. Expanding Medicaid eligibility did not significantly increase the use of mental health services.

Conclusions

Previous Medicaid eligibility expansions did not substantially increase mental health service utilization, but they did reduce out‐of‐pocket mental health care spending.     

Evaluating inpatient adverse outcomes under California's Delivery System Reform Incentive Payment Program

ObjectiveThe California Delivery System Reform Incentive Payment Program (DSRIP) provided incentive payments to Designated Public Hospitals (DPHs) to improve quality of care. We assessed the program''s impact on reductions in sepsis mortality, central line–associated bloodstream infections (CLABSIs), venous thromboembolisms (VTEs), and hospital‐acquired pressure ulcers (HAPUs).Data SourcesWe used 2009‐2014 discharge data from California hospitals.Study DesignWe used a pre‐post study design with a comparison group. We constructed propensity scores and used them to assign inverse probability weights according to their similarity to DPH discharges. Interaction term coefficients of time trends and treatment group provided significance testing.Data ExtractionWe used Patient Safety Indicators for CLABSI, HAPU, and VTE, and constructed a sepsis mortality measure.Principal FindingsDischarges from DPHs and non‐DPHs both saw decreases in the four outcomes over the DSRIP period (2010‐2014). The difference‐in‐difference estimator (DD) for sepsis was only significant during two time periods, comparing 2010 with 2012 (DD: −2.90 percent, 95% CI: −5.08, −0.72 percent) and 2010 with 2014 (DD: −5.74, 95% CI: −8.76 percent, −2.72 percent); the DD estimator was not significant comparing 2010 with 2012 (DD: −1.30, 95% CI: −3.18 percent, 0.58 percent) or comparing 2010 with 2013 (DD: −3.05 percent, 95% CI: −6.50 percent, 0.40 percent). For CLABSI, we did not find any meaningful differences between DPHs and non‐DPHs across the four time periods. For HAPU and VTE, the only significant DD estimator compared 2014 with 2010.ConclusionsWe did not find that DPHs participating in DSRIP outperformed non‐DPHs during the DSRIP program. Our results were robust to multiple sensitivity analyses. Given multiple concurrent inpatient safety initiatives, it was challenging to assign improvements over time periods to DSRIP.     

Population‐level changes in outcomes and Medicare cost following the introduction of new cancer therapies

ObjectiveTo examine the population‐level impacts of the introduction of novel cancer therapies with high cost in the United States, using immunotherapies in advanced nonsmall cell lung cancer (NSCLC) as an example.Data SourcesSurveillance, Epidemiology, and End Results data in 2012‐2015 linked to Medicare fee‐for‐service claims until 2016.Study DesignWe examined population‐level trends in treatment patterns, survival, and Medicare spending in patients diagnosed with advanced NSCLC, the leading cause of cancer death in the United States, between 2012 and 2015. We estimated the percentage of patients who received any antineoplastic therapy within two years of diagnosis, including novel immunotherapies. We compared the trends in overall survival and mean two‐year Medicare spending per each patient before and after the introduction of immunotherapies in 2015.Data Collection/Extraction MethodsNot Applicable.Principal FindingsThe percentage of patients treated with any antineoplastic therapy remained the same at 46.7% in 2012 and 2015, whereas the use of immunotherapies increased from 0% to 15.2%. The two‐year survival rate and median survival increased by 3.3 percentage points (95% CI: 2.0, 4.5) and 0.4 months (CI: 0.0, 0.9), respectively, during the same period. The mean two‐year total Medicare spending and outpatient spending per patient increased by $5735 (CI: 3479, 8040) and $7661 (CI: 5902, 9311), respectively, which were largely attributable to the increases in immunotherapy spending by $5806 (CI: 5165, 6459).ConclusionsThe introduction of lung cancer immunotherapies was accompanied by improvements in survival and increases in spending between 2012 and 2015 in the Medicare population. As novel immunotherapies and other target therapies continue to change the clinical management of various cancers, further efforts are needed to ensure their effective and efficient use, and to understand their population‐level impacts in the United States.     

Medicare fee reductions and the overuse of intensity‐modulated radiotherapy

ObjectiveTo estimate the impact of a large Medicare fee reduction for intensity‐modulated radiation therapy (IMRT) on its use in prostate and breast cancer patients.Data Sources/Study SettingSEER‐Medicare.Study DesignWe compared trends in the use of IMRT between patients treated in practices directly affected by fee reductions (for prostate cancer, men treated in urology practices that own IMRT equipment; for breast cancer, women treated in freestanding radiotherapy clinics) and patients treated in other types of practices.Data Collection/Extraction MethodsWe identified breast and prostate cancer patients receiving IMRT using outpatient and physician office claims. We classified urology practices based on whether they billed for IMRT and radiotherapy clinics based on whether they were reimbursed under the Physician Fee Schedule.Principal FindingsBetween 2006 and 2015 the payment for IMRT delivered in freestanding clinics and physician offices declined by $367 (−54.7%). However, the use of IMRT increased in physician practices subject to payment cuts, both in absolute terms and relative to use in practices unaffected by the payment cut. Use of IMRT in prostate cancer patients treated at urology practices that own IMRT equipment increased by 9.1 (95% CI: 2.0‐16.2) percentage points between 2005 and 2016 relative to use in patients treated at other urology practices. Use of IMRT in breast cancer patients treated at freestanding radiotherapy centers increased by 7.5 (95% CI: −5.1 to 20.1) percentage points relative to use in patients treated at hospital‐based centers.ConclusionsA steep decline in IMRT fees did not decrease IMRT use over the period from 2006 to 2015, though use has declined since 2010.     

Effects of cost sharing on long-term care service utilization among home-dwelling older adults in Japan

ObjectivesThis study aimed to examine the effect of increased cost sharing on long-term care (LTC) service utilization among home-dwelling older adults, using nationwide long-term care insurance (LTCI) claims data in Japan.MethodsIn August 2015, the coinsurance rate for Japanese LTCI increased from 10% to 20% for higher-income beneficiaries. We analyzed 27,911,076 person-month observations between April 2015 and July 2016 from 1,983,163 home-dwelling older adults (aged ≥ 65 years). We employed a difference-in-differences approach to estimate the effect of the increased coinsurance rate on overall LTC service utilization and for each of the four main service subcategories. The control group comprised those whose coinsurance rates remained at 10%.ResultsThe treatment group, whose coinsurance rate increased, accounted for 9.6% of all participants. The raised coinsurance rate caused statistically significant reductions of 0.46% (95% confidence interval [CI]: 0.36%, 0.56%) and $25.7 (95% CI: $23.7, $27.8) in the percentage of utilization of LTC services and total monthly LTC expenditures per person, respectively. Service utilization decreased in each of the four service subcategories.ConclusionsThe increased coinsurance rate resulted in statistically significant but small reductions in LTC service utilization overall and in each service type among higher-income home-dwelling beneficiaries. Requiring more cost sharing from higher-income individuals may alleviate the fiscal burden on LTC systems without serious reductions in service utilization.     

Comparative effectiveness of external vs blended facilitation on collaborative care model implementation in slow-implementer community practices

ObjectiveTo evaluate the comparative effectiveness of external facilitation (EF) vs external + internal facilitation (EF/IF), on uptake of a collaborative chronic care model (CCM) in community practices that were slower to implement under low‐level implementation support.Study SettingPrimary data were collected from 43 community practices in Michigan and Colorado at baseline and for 12 months following randomization.Study DesignSites that failed to meet a pre‐established implementation benchmark after six months of low‐level implementation support were randomized to add either EF or EF/IF support for up to 12 months. Key outcomes were change in number of patients receiving the CCM and number of patients receiving a clinically significant dose of the CCM. Moderators’ analyses further examined whether comparative effectiveness was dependent on prerandomization adoption, number of providers trained or practice size. Facilitation log data were used for exploratory follow‐up analyses.Data CollectionSites reported monthly on number of patients that had received the CCM. Facilitation logs were completed by study EF and site IFs and shared with the study team.Principal FindingsN = 21 sites were randomized to EF and 22 to EF/IF. Overall, EF/IF practices saw more uptake than EF sites after 12 months (Δ_EF/IF‐EF = 4.4 patients, 95% CI = 1.87‐6.87). Moderators'' analyses, however, revealed that it was only sites with no prerandomization uptake of the CCM (nonadopter sites) that saw significantly more benefit from EF/IF (Δ_EF/IF‐EF = 9.2 patients, 95% CI: 5.72, 12.63). For sites with prerandomization uptake (adopter sites), EF/IF offered no additional benefit (Δ_EF/IF‐EF = −0.9; 95% CI: −4.40, 2.60). Number of providers trained and practice size were not significant moderators.ConclusionsAlthough stepping up to the more intensive EF/IF did outperform EF overall, its benefit was limited to sites that failed to deliver any CCM under the low‐level strategy. Once one or more providers were delivering the CCM, additional on‐site personnel did not appear to add value to the implementation effort.     

Work-related respiratory symptoms and lung function among solderers in the electronics industry: a meta-analysis

Objective

Research on the respiratory effect of exposure to solder fumes in electronics workers has been conducted since the 1970s, but has yielded inconsistent results. The aim of this meta-analysis was to clarify the potential association.

Methods

Effect sizes with corresponding 95% confidence intervals (CIs) for odds of respiratory symptoms related to soldering and spirometric parameters of solderers were extracted from seven studies and pooled to generate summary estimates and standardized mean differences in lung function measures between exposed persons and controls.

Results

Soldering was positively associated with wheeze after controlling for smoking (meta-odds ratio: 2.60, 95% CI: 1.46, 4.63) and with statistically significant reductions in forced expiratory volume in 1 s (FEV1) (−0.88%, 95% CI: −1.51, −0.26), forced vital capacity (FVC) (−0.64%, 95% CI: −1.18, −0.10), and FEV1/FVC (−0.35%, 95% CI: −0.65, −0.05). However, lung function parameters of solderers were within normal ranges [pooled mean FEV1: 97.85 (as percent of predicted), 95% CI: 94.70, 100.95, pooled mean FVC: 94.92 (as percent of predicted), 95% CI: 81.21, 108.64, and pooled mean FEV1/FVC: 86.5 (as percent), 95% CI: 78.01, 94.98].

Conclusions

Soldering may be a risk factor for wheeze, but may not be associated with a clinically significant impairment of lung function among electronics workers.     

Awareness of diagnosis,treatment and risk of late effects in Chinese survivors of childhood cancer in Hong Kong

BackgroundFor survivors of childhood cancer, awareness of personal health risks is a critical component of long‐term health management.ObjectiveTo evaluate the awareness of the diagnosis, treatment and risk of late effects among survivors of childhood cancer in Hong Kong.MethodsBetween June 2019 and March 2020, this cross‐sectional study recruited 155 adult survivors (mean age = 26.9, standard deviation [SD] = 6.4 years) and 45 parents of paediatric survivors (mean age = 11.1, SD = 3.6 years) from a long‐term follow‐up clinic. At >10 years post‐treatment (mean = 13.4, SD = 7.6 years), they completed a structured questionnaire to report their cancer‐specific knowledge. Multiple linear regression analysis was conducted to identify clinical, socioeconomic and behavioural factors associated with poor awareness.ResultsThe majority of participants accurately recalled their diagnoses (73.5%) and major treatment modalities (chemotherapy 92.4%, radiation 82.9% and surgery 88.2%). However, less than half (45%) of the participants recognized more than 25% of the total late effects for which they were at risk. The highest levels of awareness were reported for endocrine problems (49%), neurocognitive impairment (44%) and secondary cancers (43%), and the lowest for peripheral neuropathy (21%) and vision problems (23%). Compared with survivors of haematological malignancies, those of central nervous system (CNS) tumours (standardized estimate [B] = −9.33, 95% confidence interval [95% CI]: −13.41 to −5.26) and non‐CNS solid tumours (B = −8.47, 95% CI: −12.39 to −4.94) had less knowledge about their diagnosis. Retaining medical records (P < .0001) and better medical information‐seeking habits (P = .048) were associated with better awareness.ConclusionsSurvivors of childhood cancer in Hong Kong have deficient awareness of their personal health risks. They may benefit from the provision of a survivorship care plan and personalized education regarding treatment‐related late effects.Patient ContributionPatients contributed in designing the study tools. Results were presented at a non‐governmental organization.     

A controlled trial of dissemination and implementation of a cardiovascular risk reduction strategy in small primary care practices

ObjectiveTo assess the effect of dissemination and implementation of an intervention consisting of practice facilitation and a risk‐stratified, population management dashboard on cardiovascular risk reduction for patients at high risk in small, primary care practices.Study SettingA total of 219 small primary care practices (≤10 clinicians per site) across North Carolina with primary data collection from electronic health records (EHRs) from the fourth quarter of 2015 through the second quarter of 2018.Study DesignWe performed a stepped‐wedge, stratified, cluster randomized trial of a one‐year intervention consisting of practice facilitation utilizing quality improvement techniques coupled with a cardiovascular dashboard that included lists of risk‐stratified adults, aged 40‐79 years and their unmet treatment opportunities. The primary outcome was change in 10‐Year ASCVD Risk score among all patients with a baseline score ≥10 percent from baseline to 3 months postintervention.Data Collection/ Extraction MethodsData extracts were securely transferred from practices on a nightly basis from their EHR to the research team registry.Principle FindingsASCVD risk scores were assessed on 437 556 patients and 146 826 had a calculated 10‐year risk ≥10 percent. The mean baseline risk was 23.4 percent (SD ± 12.6 percent). Postintervention, the absolute risk reduction was 6.3 percent (95% CI 6.3, 6.4). Models considering calendar time and stepped‐wedge controls revealed most of the improvement (4.0 of 6.3 percent) was attributable to the intervention and not secular trends. In multivariate analysis, male gender, age >65 years, low‐income (<$40 000), and Black race (P < .001 for all variables) were each associated with greater risk reductions.ConclusionA risk‐stratified, population management dashboard combined with practice facilitation led to substantial reductions of 10‐year ASCVD risk for patients at high risk. Similar approaches could lead to effective dissemination and implementation of other new evidence, especially in rural and other under‐resourced practices.Registration: ClinicalTrials.Gov 15‐0479.     

Costs of using evidence-based implementation strategies for behavioral health integration in a large primary care system

ObjectiveTo describe the cost of using evidence‐based implementation strategies for sustained behavioral health integration (BHI) involving population‐based screening, assessment, and identification at 25 primary care sites of Kaiser Permanente Washington (2015‐2018).Data Sources/Study SettingProject records, surveys, Bureau of Labor Statistics compensation data.Study DesignLabor and nonlabor costs incurred by three implementation strategies: practice coaching, electronic health records clinical decision support, and performance feedback.Data Collection/Extraction MethodsPersonnel time spent on these strategies was estimated for five broad roles: (a) project leaders and administrative support, (b) practice coaches, (c) clinical decision support programmers, (d) performance metric programmers, and (e) primary care local implementation team members.Principal FindingImplementation involved 286 persons, 18 131 person‐hours, costing $1 587 139 or $5 per primary care visit with screening or $38 per primary care visit identifying depression, suicidal thoughts and/or alcohol or substance use disorders, in a single year. The majority of person‐hours was devoted to project leadership (35%) and practice coaches (34%), and 36% of costs were for the first three sites.ConclusionsWhen spread across patients screened in a single year, BHI implementation costs were well within the range for commonly used diagnostic assessments in primary care (eg, laboratory tests). This suggests that implementation costs alone should not be a substantial barrier to population‐based BHI.     

Did Medicaid slow declines in access to health care during the great recession?

ObjectiveWe examine whether broadened access to Medicaid helped insulate households from declines in health coverage and health care access linked to the 2007‐2009 Great Recession.Data Source2004‐2010 Behavioral Risk Factor Surveillance System (BRFSS).Study DesignFlexible difference‐in‐difference regressions were used to compare the impact of county‐level unemployment on health care access in states with generous Medicaid eligibility guidelines versus states with restrictive guidelines.Data Collection/Extraction MethodsNonelderly adults (aged 19‐64) in the BRFSS were linked to county unemployment rates from the Bureau of Labor Statistics’ Local Area Unemployment Statistics Program. We created a Medicaid generosity index by simulating the share of a nationally representative sample of adults that would be eligible for Medicaid under each state''s 2007 Medicaid guidelines using data from the 2007 Current Population Survey''s Annual Social and Economic Supplement.Principal FindingsA percentage point (PPT) increase in the county unemployment rate was associated with a 1.3 PPT (95% CI: 0.9‐1.6, P < .01) increase in the likelihood of being uninsured and a 0.86 PPT (95% CI: 0.6‐1.1, P < .01) increase in unmet medical needs due to cost in states with restrictive Medicaid eligibility guidelines. Conversely, a one PPT increase in unemployment was associated with only a 0.64 PPT (P < .01) increase in uninsurance among states with the most generous eligibility guidelines. Among states in the fourth quartile of generosity (ie, most generous), rises in county‐level unemployment were associated with a 0.68 PPT (P < .10) increase in unmet medical needs due to cost—a 21% smaller decrease relative to states with the most restrictive Medicaid eligibility guidelines.ConclusionsIncreased access to Medicaid during the Great Recession mitigated the effects of increased unemployment on the rate of unmet medical need, particularly for adults with limited income.     

Educational Inequalities in Hospital Use Among Older Adults in England, 2004-2015

Policy Points

• US policymakers considering proposals to expand public health care (such as “Medicare for all”) as a means of reducing inequalities in health care access and use could learn from the experiences of nations where well‐funded universal health care systems are already in place.
• In England, which has a publicly funded universal health care system, the use of core inpatient services by adults 65 years and older is equal across groups defined by education level, after controlling for health status. However, variation among these groups in the use of outpatient and emergency department care developed between 2010 and 2015, a period of relative financial austerity.
• Based on England''s experience, introducing universal health care in the United States seems likely to reduce, but not entirely eliminate, inequalities in health care use across different population groups.

ContextExpanding access to health care is once again high on the US political agenda, as is concern about those who are being “left behind.” But is universal health care that is largely free at the point of use sufficient to eliminate inequalities in health care use? To explore this question, we studied variation in the use of hospital care among education‐level‐defined groups of older adults in England, before and after controlling for differences in health status. In England, the National Health Service (NHS) provides health care free to all, but the growth rate for NHS funding has slowed markedly since 2010 during a widespread austerity program, potentially increasing inequalities in access and use.MethodsNovel linkage of data from six waves (2004‐2015) of the English Longitudinal Study of Ageing (ELSA) with participants’ hospital records (Hospital Episode Statistics [HES]) produced longitudinal data for 7,713 older adults (65 years and older) and 25,864 observations. We divided the sample into three groups by education level: low (no formal qualifications), mid (completed compulsory education), and high (at least some higher education). Four outcomes were examined: annual outpatient appointments, elective inpatient admissions, emergency inpatient admissions, and emergency department (ED) visits. We estimated regressions for the periods 2004‐2005 to 2008‐2009 and 2010‐2011 to 2014‐2015 to examine whether potential education‐related inequalities in hospital use increased after the growth rate for NHS funding slowed in 2010.FindingsFor the study period, our sample of ELSA respondents in the low‐education group made 2.44 annual outpatient visits. In comparison, after controlling for health status, we found that participants in the high‐education group made an additional 0.29 outpatient visits annually (95% confidence interval [CI], 0.11‐0.47). Additional outpatient health care use in the high‐education group was driven by follow‐up and routine appointments. This inequality widened after 2010. Between 2010 and 2015, individuals in the high‐education group made 0.48 (95% CI, 0.21‐0.74) more annual outpatient visits than those in the low‐education (16.9% [7.5% to 26.2%] of annual average 2.82 visits). In contrast, after 2010, the high‐education group made 0.04 (95% CI, −0.075 to 0.001) fewer annual ED visits than the low‐education group, which had a mean of 0.30 annual ED visits. No significant differences by education level were found for elective or emergency inpatient admissions in either period.ConclusionsAfter controlling for demographics and health status, there was no evidence of inequality in elective and emergency inpatient admissions among the education groups in our sample. However, a period of financial budget tightening for the NHS after 2010 was associated with the emergence of education gradients in other forms of hospital care, with respondents in the high‐education group using more outpatient care and less ED care than peers in the low‐education group. These estimates point to rising inequalities in the use of hospital care that, if not reversed, could exacerbate existing health inequalities in England. Although the US and UK settings differ in many ways, our results also suggest that a universal health care system would likely reduce inequality in US health care use.     

Impact of the 1115 behavioral health Medicaid waiver on adult Medicaid beneficiaries in New York State

ObjectiveTo evaluate the impact of the Health and Recovery Plan (HARP), a capitated special needs Medicaid managed care product that fully integrates physical and behavioral health delivery systems in New York State.Data Sources2013‐2019 claims and encounters data on continuously enrolled individuals from the New York State Medicaid data system.Study DesignWe used a difference‐in‐difference approach with inverse probability of exposure weights to compare service use outcomes in individuals enrolled in the HARP versus HARP eligible comparison group in two regions, New York City (NYC) pre‐ (2013‐2015) versus post‐ (2016‐2018) intervention periods, and rest of the state (ROS) pre‐ (2014‐2016) versus post‐ (2017‐2019) intervention periods.Data Collection/Extraction MethodsNot applicable.Principal FindingsHARPs were associated with a relative decrease in all‐cause (RR = 0.78, 95% CI 0.68‐0.90), behavioral health‐related (RR = 0.76, 95% CI 0.60‐0.96), and nonbehavioral‐related (RR = 0.87, 95% CI 0.78‐0.97) stays in the NYC region. In the ROS region, HARPs were associated with a relative decrease in all‐cause (RR = 0.87, 95% CI 0.80‐0.94) and behavioral health‐related (RR = 0.80, 95% CI 0.70‐0.91) stays. Regarding outpatient visits, the HARPs benefit package were associated with a relative increase in behavioral health (RR = 1.21, 95% CI 1.13‐1.28) and nonbehavioral health (RR = 1.08, 95% CI 1.01‐1.15) clinic visits in the NYC region. In the ROS region, the HARPs were associated with relative increases in behavioral health (RR = 1.47, 95% CI 1.32‐1.64) and nonbehavioral health (RR = 1.17, 95% CI 1.11‐1.25) clinic visits.ConclusionsCompared to patients with similar clinical needs, HARPs were associated with a relative increase in services used and led to a better engagement in the HARPs group regardless of the overall decline in services used pre‐ to postperiod.     

Derivation and validation of a novel comorbidity‐based delirium risk index to predict postoperative delirium using national administrative healthcare database

ObjectiveTo derive and validate a comorbidity‐based delirium risk index (DRI) to predict postoperative delirium.Data Source/Study SettingData of 506 438 hip fracture repair surgeries from 2006 to 2016 were collected to derive DRI and perform internal validation from the Premier Healthcare Database, which provided billing information on 20‐25 percent of hospitalizations in the USA. Additionally, data of 1 130 569 knee arthroplasty surgeries were retrieved for external validation.Study DesignThirty‐six commonly seen comorbidities were evaluated by logistic regression with the outcome of postoperative delirium. The hip fracture repair surgery cohort was separated into a training dataset (60 percent) and an internal validation (40 percent) dataset. The least absolute shrinkage and selection operator (LASSO) procedure was applied for variable selection, and weights were assigned to selected comorbidities to quantify corresponding risks. The newly developed DRI was then compared to the Charlson‐Deyo Index for goodness‐of‐fit and predictive ability, using the Akaike information criterion (AIC), Bayesian information criterion (BIC), area under the ROC curve (AUC) for goodness‐of‐fit, and odds ratios for predictive performance. Additional internal validation was performed by splitting the data by four regions and in 4 randomly selected hospitals. External validation was conducted in patients with knee arthroplasty surgeries.Data CollectionHip fracture repair surgeries, knee arthroplasty surgeries, and comorbidities were identified by using ICD‐9 codes. Postoperative delirium was defined by using ICD‐9 codes and analyzing billing information for antipsychotics (specifically haloperidol, olanzapine, and quetiapine) typically recommended to treat delirium.Principal FindingsThe derived DRI includes 14 comorbidities and assigns comorbidities weights ranging from 1 to 6. The DRI outperformed the Charlson‐Deyo Comorbidity Index with better goodness‐of‐fit and predictive performance.ConclusionsDelirium risk index is a valid comorbidity index for covariate adjustment and risk prediction in the context of postoperative delirium. Future work is needed to test its performance in different patient populations and varying definitions of delirium.     

The implementation cost of a safety‐net hospital program addressing social needs in Atlanta

ObjectiveTo describe the cost of integrating social needs activities into a health care program that works toward health equity by addressing socioeconomic barriers.Data Sources/Study SettingCosts for a heart failure health care program based in a safety‐net hospital were reported by program staff for the program year May 2018–April 2019. Additional data sources included hospital records, invoices, and staff survey.Study DesignWe conducted a retrospective, cross‐sectional, case study of a program that includes health education, outpatient care, financial counseling and free medication; transportation and home services for those most in need; and connections to other social services. Program costs were summarized overall and for mutually exclusive categories: health care program (fixed and variable) and social needs activities.Data CollectionProgram cost data were collected using a activity‐based, micro‐costing approach. In addition, we conducted a survey that was completed by key staff to understand time allocation.Principal FindingsProgram costs were approximately $1.33 million, and the annual per patient cost was $1455. Thirty percent of the program costs was for social needs activities: 18% for 30‐day supply of medications and addressing socioeconomic barriers to medication adherence, 18% for mobile health services (outpatient home visits), 53% for navigating services through a financial counselor and community health worker, and 12% for transportation to visits and addressing transportation barriers. Most of the program costs were for personnel: 92% of the health care program fixed, 95% of the health care program variable, and 78% of social needs activities.DiscussionHistorically, social and health care services are funded by different systems and have not been integrated. We estimate the cost of implementing social needs activities into a health care program. This work can inform implementation for hospitals attempting to address social determinants of health and social needs in their patient population.     

Effects of forced disruption in Medicaid managed care on children with asthma

ObjectiveTo evaluate the effect of a forced disruption to Medicaid managed care plans and provider networks on health utilization and outcomes for children with persistent asthma.Data SourcesMedicaid managed care administrative claims data from 2013 to 2016, obtained from a southeastern state.Study DesignA difference‐in‐difference analysis compared patients’ outpatient, inpatient, and emergency department (ED) utilization and receipt of recommended services before and after implementation of a statewide redistribution of patients among nine managed care plans.Data Collection/Extraction MethodsEnrollment data for children with asthma were linked to the administrative claims. Children were included if they had a diagnosis of persistent asthma in 2013 and if they were enrolled continuously throughout 2014‐2016.Principal FindingsAmong the 28 537 children with asthma, 26% were forced to switch their managed care plan after the redistribution. Of these, 67% also switched their primary care provider (PCP). Relative to those who remained in their plan, disruption was associated with an additional 2.1 percentage‐point decrease in the number of children who had an outpatient visit per quarter [95%CI −2.8, −1.3], from 71% to 66% (compared to plan stayers: 74% to 71%). Among children experiencing a change to their plan, there was overall a decrease in the proportion of children receiving an asthma‐specific visit per quarter, but there was less of a decrease in children that also changed their PCP [1.6 percentage points, 95%CI 0.7, 2.5], from 9.7% to 8.3% (compared to those who did not switch their PCP: 12% to 8.6%). Indicators of asthma care quality and emergent care utilization were not significantly different between the two periods.ConclusionsWhile there was a decrease in the number of outpatient visits associated with forced disruption of Medicaid managed care plans for children with persistent asthma, there were no consistent associations with worse asthma quality performance or higher emergent health care utilization.     

The one‐year impact of accountable care networks among Washington State employees

ObjectiveTo estimate the impact of a new, two‐sided risk model accountable care network (ACN) on Washington State employees and their families.Data Sources/Study SettingAdministrative data (January 2013‐December 2016) on Washington State employees.Study DesignWe compared monthly health care utilization, health care intensity as measured through proxy pricing, and annual HEDIS quality metrics between the five intervention counties to 13 comparison counties, analyzed separately by age categories (ages 0‐5, 6‐18, 19‐26, 18‐64).Data Collection/Extraction MethodsWe used difference‐in‐difference methods and generalized estimating equations to estimate the effects after 1 year of implementation for adults and children.Principal FindingsWe estimate a 1‐2 percentage point decrease in outpatient hospital visits due to the introduction of ACNs (adults: −1.8, P < .01; age 0‐5: −1.2, P = .07; age 6‐18: −1.2, P = .06; age 19‐26; −1.2, P < .01). We find changes in primary and specialty care office visits; the direction of impact varies by age. Dependents age 19‐26 were also responsive with inpatient admissions declines (−0.08 percentage points, P = .02). Despite changes in utilization, there was no evidence of changes in intensity of care and mixed results in the quality measures.ConclusionsWashington''s state employee ACN introduction changed health care utilization patterns in the first year but was not as successful in improving quality.     

Examining the bidirectional relationship between food insecurity and healthcare spending

ObjectiveTo improve food insecurity interventions, we sought to better understand the hypothesized bidirectional relationship between food insecurity and health care expenditures.Data SourceNationally representative sample of the civilian noninstitutionalized population of the United States (2016‐2017 Medical Expenditure Panel Survey [MEPS]).Study DesignIn a retrospective longitudinal cohort, we conducted two sets of analyses: (a) two‐part models to examine the association between food insecurity in 2016 and health care expenditures in 2017; and (b) logistic regression models to examine the association between health care expenditures in 2016 and food insecurity in 2017. We adjusted for demographic and socioeconomic variables as well as 2016 health care expenditures and food insecurity.Data CollectionHealth care expenditures, food insecurity, and medical condition data from 10 886 adults who were included in 2016‐2017 MEPS.Principal FindingsFood insecurity in 2016, compared with being food secure, was associated with both a higher odds of having any health care expenditures in 2017 (OR 1.29, 95% CI: 1.04 to 1.60) and greater total expenditures ($1738.88 greater, 95% CI: $354.10 to $3123.57), which represents approximately 25% greater expenditures. Greater 2016 health care expenditures were associated with slightly higher odds of being food insecure in 2017 (OR 1.007 per $1000 in expenditures, 95% CI: 1.002 to 1.012, P =0.01). Exploratory analyses suggested that poor health status may underlie the relationship between food insecurity and health care expenditures.ConclusionsA bidirectional relationship exists between food insecurity and health care expenditures, but the strength of either direction appears unequal. Higher health care expenditures are associated with a slightly greater risk of being food insecure (adjusted for baseline food insecurity status) but being food insecure is associated with substantially greater subsequent health care expenditures (adjusted for baseline health care expenditures). Interventions to address food insecurity and poor health may be helpful to break this cycle.     

Inequities in access to VA’S aid and attendance enhanced pension benefit to help Veterans pay for long‐term care

ObjectiveTo examine characteristics that are associated with receipt of Aid and Attendance (A&A), an enhanced pension benefit for Veterans who qualify on the basis of needing daily assistance, among Veterans who receive pensions.Data sourcesSecondary data analysis of 2016‐2017 national VA administrative data linked with Medicare claims.Study designObservational study examining sociodemographic, medical, and healthcare utilization characteristics associated with receipt of A&A among Veterans receiving pension.Principal findingsIn 2017, 9.7% of Veterans with pension newly received the A&A benefit. The probability of receiving A&A among black and Hispanic pensioners was 4.6 percentage points lower than for white pensioners (95%CI = −0.051, −0.042). Married Veterans receiving pension had a 4.4‐percentage point higher probability of receiving A&A (95%CI = 0.039, 0.048). Most indicators of need for assistance (eg, home health utilization, dementia, stroke) were associated with significantly higher probabilities of receiving A&A, with notable exceptions: pensioners with a diagnosis of Post‐Traumatic Stress Disorder (marginal effect = −0.029 95%CI = −0.037, −0.021) or enrolled in Medicaid (marginal effect = −0.053, 95%CI = −0.057, −0.050) had lower probabilities of receiving A&A. Unadjusted and adjusted rates of receiving A&A among Veterans receiving pension varied by VA medical center.ConclusionsThis study identified potential inequities in receipt of the A&A enhanced pension among a sample of Veterans receiving pension. Increased Veteran outreach, provider education, and VA office coordination can potentially reduce inequities in access to this benefit.