Making pay-for-performance work in Medicaid

Findings from a Medicaid pay-for-performance (P4P) demonstration suggest that "money talks" only sometimes, when supportive program elements give it voice. In this paper we examine five Medicaid-focused health plans that implemented new financial incentives for physicians to improve the timeliness of well-baby care. By contrasting the experiences of plans with better and worse outcome trends, we identify key program features--including strong communication with providers and placing enough dollars at stake to compensate providers for the effort required to obtain them--taking into account the starting point. The findings also highlight barriers to improvement that future Medicaid P4P efforts should consider.     

Declining child mortality and continuing racial disparities in the era of the Medicaid and SCHIP insurance coverage expansions

Objectives. We investigated trends in national childhood mortality, racial disparities in child mortality, and the effect of Medicaid and State Children''s Health Insurance Program (SCHIP) eligibility expansions on child mortality.Methods. We analyzed child mortality by state, race, and age using the National Center for Health Statistics’ multiple cause of death files over 20 years, from 1985 to 2004.Results. Child mortality continued to decline in the United States, but racial disparities in mortality remained. Declines in child mortality (ages 1–17 years) were substantial for both natural (disease-related) and external (injuries, homicide, and suicide) causes for children of all races/ethnicities, although Black–White mortality ratios remained unchanged during the study period. Expanded Medicaid and SCHIP eligibility was significantly related to the decline in external-cause mortality; the relationship between natural-cause mortality and Medicaid or SCHIP eligibility remains unclear. Eligibility expansions did not affect relative racial disparities in child mortality.Conclusions. Although the study provides some evidence that public insurance expansions reduce child mortality, future research is needed on the effect of new health insurance on child health and on factors causing relative racial disparities.Over the past century, there have been substantial declines in child mortality in the United States and in almost all countries around the world, declines that have been called “spectacular.”¹ Declines have been observed across many of the major causes of death for children, including infectious disease,² unintentional injuries,³ asthma,⁴ and childhood cancer.⁵Although child mortality has declined overall, pronounced health disparities continue to exist by race^6–9 and socioeconomic status.^10–12 These health disparities are greatest for certain diagnoses that are particularly sensitive to delays in medical care (and thus suggestive of poor access to health care), such as asthma and diabetes, as well as others that are consistent with social stress, such as intentional injuries.¹³ Health disparities begin early in life¹⁴ and persist throughout childhood. This trend remained substantially unchanged throughout the 20th century^15,16 despite efforts to improve access to health care for disadvantaged children.An important intervention that is expected to improve health access has been the expansions in public health insurance coverage for children through Medicaid and, later, the State Children''s Health Insurance Program (SCHIP). Beginning in 1984, there was a “decoupling” of Medicaid eligibility from welfare receipt for children and pregnant women, resulting in state options, and eventual mandates, to cover children in families with incomes below certain levels. Many states took up the options to expand eligibility during the mid and late 1980s. By 1990, all states were required to cover children younger than 6 years with family incomes below 133% of the federal poverty level, and children born after September 30, 1983, with family incomes below 100% of the federal proverty level. Coverage for this cohort, who were aged 7 years at the time of the mandates, and for any children born after them, was phased in so that by 2002, all children younger than 18 years with family incomes below 100% of the federal poverty level were covered by Medicaid if enrolled by their parents. The same time period overlaps with the period of rapid implementation of the new SCHIP program, enacted in 1997. Under this program, children from families with much higher income levels could be covered—in some states, when family incomes were up to 300% of the federal poverty level. The majority of states expanded coverage through SCHIP for children with family incomes up to 200% of the federal poverty level. More information on the SCHIP programs is available elsewhere.¹⁷Most research on the impact of those expansions of coverage has focused on improvements in access to care and use of services, which are widely documented, with much less focus on the impact of the expansions on child health.¹⁸ One study, which examined the impact of the early expansions (between 1984 and 1992), found a significant effect on child mortality rates.¹⁹We update and expand on that research by examining child mortality for a longer time period—from 1986 through 2003. We examined trends in child mortality during the period of the Medicaid and SCHIP expansions, the association of child mortality with those expansions, and the effect of the expansions on racial disparities in child mortality.     

The future of scientific conferences in the era of the COVID-19 pandemic: Critical analysis and future perspectives

The global spread of COVID-19 pandemic forced the scientific community to identify new ways of exchanging and transferring the scientific knowledge, also considering that the measures taken to combat the pandemic, such as travel restrictions, closed borders and gathering bans, led to cancellations of many conferences, meetings and workshops. The enhancement of the existing digital platforms and the development of new systems to share scientific knowledge has allowed the scientific community to “meet” again in new virtual environments (e.g., Zoom, Cisco WebEx, Live Stream, Demio, GoToWebinar Seminar, Google Hangouts, Skype, Microsoft Teams, etc.), providing an unprecedented opportunity to reform methods of organizing academic conferences in all disciplines.Starting from the review of the existing literature, this study aimed at investigating the impact of the spreading of virtual conferences on the field of research. The SWOT analysis was used to identify strengths and weaknesses of the scientific conferences organized in the new format, as well as opportunities and threats created by the socio-economic and political context in the era of the COVID-19 pandemic.     

Training welfare caseworkers in service excellence: increasing children's Medicaid coverage

Many low-income children who are eligible for public sector health insurance remain uninsured. There are many barriers to enrolling these children, but one key issue is parents' reluctance to use the services of the local enrollment agency, which is usually the welfare office. The Eastside Access Partnership, a community-academic coalition on the Eastside of Detroit, addressed the problem of uninsured-but-eligible children through a variety of interventions focused on (1) enhancing community members' understanding of the enrollment process and (2) reducing institutional barriers to enrollment. One of these interventions addressed the institutional barriers by developing a customer service excellence training program for welfare caseworkers. The training program curriculum, which was developed following the principles of community-based participatory research, included extensive input from community residents, welfare agency staff, and academic researchers. The training sessions received positive evaluations from participants and agency executives. A more thorough evaluation of the project is under way.     

Containing Medicaid costs in an era of growing physician supply.

In this analysis, Medicaid cost containment is viewed within the theoretical framework of a price discrimination model. The value of viewing supply decisions made by physicians in terms of the conventional economic laws of supply and demand is demonstrated. Physicians are seen to respond to prices in a predictable way. As private prices increase, physicians are less willing to participate in Medicaid. As Medicaid prices increase, physicians are more willing to participate. Effects of changes in the number of persons eligible for Medicaid and in the physician supply are also analyzed.     

Medicaid coverage of abortions in New York City: costs and benefits

New York was among the first states to provide Medicaid financing of abortions for needy women. This was begun in July 1970 when the liberalized state abortion law took effect. Each year since, nearly 40% of the New York City abortion patients have been funded by Medicaid. There is evidence that Medicaid funding of abortions for indigent women has had a favorable impact on improving the health and welfare of these women. There are attempts nationwide to cut off or restrict Medicaid financing for abortions. Results of a cutback on funding will be 1) many septic and incomplete illegal abortions, 2) an increase of 10,000-15,000 births in New York City, and 3) added costs to federal, state, and local relief funds for delivery services, foster care, welfare payments, and day care facilities for these added births. Additional costs to government health and welfare organizations in the first year would be from 7-10 times what Medicaid coverage of abortions would cost.     

Immunization coverage and Medicaid managed care in New Mexico: a multimethod assessment

BACKGROUND: We wanted to examine the association between Medicaid managed care (MMC) and changing immunization coverage in New Mexico, a predominantly rural, poor, and multiethnic state. METHODS: As part of a multimethod assessment of MMC, we studied trends in quantitative data from the National Immunization Survey (NIS) using temporal plots, Fisher's exact test, and the Cochran-Armitage trend test. To help explain changes in immunization rates in relation to MMC, we analyzed qualitative data gathered through ethnographic observations at safety net institutions: income support (welfare) offices, community health centers, hospital emergency departments, private physicians' offices, mental health institutions, managed care organizations, and agencies of state government. RESULTS: Immunization coverage decreased significantly after implementation of MMC, from 80% in 1996 to 73% in 2001 for the 4:3:1 vaccination series (Fisher's exact test, P = .031). New Mexico dropped in rank among states from 30th for this vaccination series in 1996 to 50th in 2001. A significant decreasing trend (Cochran-Armitage P = .025) in coverage occurred between 1996 and 2001. Findings from the ethnographic study revealed conditions that might have contributed to decreased immunization coverage: (1) reduced funding for immunizations at public health clinics, and difficulties in gaining access to MMC providers; (2) informal referrals from managed care organizations and contracting physicians to community health centers and state-run public health clinics; and (3) increased workloads and delays at community health centers, linked partly to these informal referrals for immunizations. CONCLUSIONS: Medicaid reform in New Mexico did not improve immunization coverage, which declined significantly to among the lowest in the nation. Reduced funding for public health clinics and informal referrals may have contributed to this decline. These observations show how unanticipated and adverse consequences can result from policy interventions in complex insurance systems.     

The commercial health insurance industry in an era of eroding employer coverage

This paper analyzes the commercial health insurance industry in an era of weakening employer commitment to providing coverage and strengthening interest by public programs to offer coverage through private plans. It documents the willingness of the industry to accept erosion of employment-based enrollment rather than to sacrifice earnings, the movement of Medicaid beneficiaries into managed care, and the distribution of market shares in the employment-based, Medicaid, and Medicare markets. The profitability of the commercial health insurance industry, exceptionally strong over the past five years, will henceforth be linked to the budgetary cycles and political fluctuations of state and federal governments.     

后疫情时代中俄疫情防控合作机制构想

新型冠状病毒肺炎（简称“新冠肺炎”）疫情发生以来,中俄两国政府强化责任担当,落实边境管控措施,两国的疫情防控取得了良好成果。在疫情防控工作转为常态化后,境外输入仍然是重要的影响因素,中俄疫情防控工作不容忽视。加强中俄疫情防控合作需要从机制建设入手,本文从构建疫情监测预警机制、医疗资源共享机制、卫生部门会晤会谈机制、疫情信息互通机制、联防联控联动机制、加强学术交流及人才培养机制等提出建议。     

Organizational collaborative capacity in fighting pandemic crises: a literature review from the public management perspective

Collaborative capacity serves for organizations as the capacity to collaborate with other network players. Organizational capacity matters as collaboration outcomes usually go beyond single-shot implementation efforts or a single-minded focus on either the vertical dimension of program or the horizontal component. This review article explores organizational collaborative capacities from the perspective of public management, in particular, network theory. By applying the 5 attributes of network theory-interdependence, membership, resources, information, and learning-to the explanation of collaborative capacity in fighting pandemic crises, I argue in some ways organizational collaborative capacity is very much like an organization in its own right. Studying collaborative capacity in the battle against pandemics facilitate our understanding of multisectoral collaboration in technical, political, and institutional dimensions, and greatly advances the richness of capacity vocabulary in pandemic response and preparedness.     

Balancing investments in federally qualified health centers and Medicaid for improved access and coverage in Pennsylvania

Two common health disparities in the US include a lack of access to care and a lack of insurance coverage. To help address these disparities, healthcare reform will provide $11B to expand Federally Qualified Health Centers (FQHCs) over the next 5 years. In 2014, Medicaid rules will be modified so that more people will become eligible. There are, however, important tradeoffs in the investment in these two programs. We find a balanced investment between FQHC expansion and relaxing Medicaid eligibility to improve both access (by increasing the number of FQHCs) and coverage (by FQHC and Medicaid expansion) for the state of Pennsylvania. The comparison is achieved by integrating multi-objective mathematical models with several public data sets that allow for specific estimations of healthcare need. Demand is estimated based on current access and coverage status in order to target groups to be considered preferentially. Results show that for Pennsylvania, FQHCs are more cost effective than Medicaid if we invest all of the resources in just one policy. However, we find a better investment point balancing those two policies. This point is approximately where the additional expenses incurred from relaxing Medicaid eligibility equals the investment in FQHC expansion.     

Expenditure effects of changes in Medicaid benefit coverage: an alcohol and substance abuse example.

An evaluation of the effect on total health care costs of a Medicaid demonstration project to provide coverage for alcoholism and substance abuse was conducted in Illinois in 1985. A pre/post-treatment analysis of expenditures for a subgroup of demonstration clients suggests that the addition of the alcohol and drug benefit did not result in higher total expenditures. [An important policy implication is that, when medical services substitute for one another, costs savings (increases) will not necessarily be realized when benefit packages are cut (expanded).]     

Let fever do its job: The meaning of fever in the pandemic era

Although fever is one of the main presenting symptoms of COVID-19 infection, little public attention has been given to fever as an evolved defense. Fever, the regulated increase in the body temperature, is part of the evolved systemic reaction to infection known as the acute phase response. The heat of fever augments the performance of immune cells, induces stress on pathogens and infected cells directly, and combines with other stressors to provide a nonspecific immune defense. Observational trials in humans suggest a survival benefit from fever, and randomized trials published before COVID-19 do not support fever reduction in patients with infection. Like public health measures that seem burdensome and excessive, fevers involve costly trade-offs but they can prevent infection from getting out of control. For infections with novel SARS-CoV-2, the precautionary principle applies: unless evidence suggests otherwise, we advise that fever should be allowed to run its course.Lay summary: For COVID-19, many public health organizations have advised treating fever with medicines such as acetaminophen or ibuprofen. Even though this is a common practice, lowering body temperature has not improved survival in laboratory animals or in patients with infections. Blocking fever can be harmful because fever, along with other sickness symptoms, evolved as a defense against infection. Fever works by causing more damage to pathogens and infected cells than it does to healthy cells in the body. During pandemic COVID-19, the benefits of allowing fever to occur probably outweigh its harms, for individuals and for the public at large.     

School immunization coverage in adolescents during the COVID-19 pandemic: A retrospective cohort study

IntroductionFew studies have assessed the impact of the coronavirus disease 2019 (COVID-19) pandemic on immunization coverage for adolescents, and little is known about how coverage has changed throughout the pandemic. We aimed to: (1) assess the change in coverage for school-based vaccines in Alberta, Canada resulting from the pandemic; (2) determine whether coverage differed by geographic health zone and school type; and (3) ascertain whether coverage has returned to pre-pandemic levels.MethodsUsing a retrospective cohort design, we used administrative health data to compare coverage for human papillomavirus (HPV) and meningococcal conjugate A, C, Y, W-135 (MenC-ACYW) vaccines between pre-pandemic (2017–2018 school year) and pandemic (2019–2020 and 2020–2021 school years) cohorts (N = 289,420). Coverage was also compared by health zone and authority type. The 2019–2020 cohort was followed over one year to assess catch-up.ResultsCompared to 2017–2018, immunization coverage for HPV was significantly lower in the 2019–2020 (absolute difference: 60.8%; 95% CI: 60.4–61.3%) and 2020–2021 cohorts (absolute difference: 59.9%; 95% CI: 59.4–60.3%). There was a smaller, significant decline in MenC-ACYW coverage comparing 2017–2018 to 2019–2020 (absolute difference: 6.1%; 95% CI: 5.6–6.5%) and 2020–2021 (absolute difference: 32.2%; 95% CI: 31.6–32.7%). Private schools had low coverage overall, while coverage fluctuated by zone. During follow-up of the 2019–2020 cohort, coverage for HPV and MenC-ACYW increased from 5.6% to 50.2%, and 80.7% to 83.0%, respectively.ConclusionThere was a substantial decrease in school-based immunization coverage during the COVID-19 pandemic, and coverage has not returned to pre-pandemic levels, suggesting further catch-up is needed.