The Affordable Care Act's “community first choice” option: Effect on long-term care expenditures

Objective

To empirically assess the effect of adopting Affordable Care Act's Community First Choice (CFC) option on overall state home and community-based services (HCBS) expenditures as well as distribution of HCBS expenditures across different HCBS mechanisms. We also explore the heterogeneous effect of CFC across adopting states.

Data Source

We used data from the Medicaid Long Term Services and Support (LTSS) expenditure reports prepared by Truven Analytics and Mathematica for the Centers for Medicare & Medicaid Services from 2008–2018 for all 48 states and the District of Columbia.

Study Design

An event-study difference-in-differences model was used to estimate the effect of CFC on HCBS expenditures using Medicaid LTSS expenditure reports from 2008–2018. We also employ the synthetic control method to unmask heterogeneity across CFC adopting states using data from 2008–2018.

Data Collection/Extraction Methods

Not applicable.

Principal Findings

Overall, CFC was not associated with a change in HCBS expenditures per capita or HCBS expenditures as a proportion of LTSS expenditures. However, there appears to be an increase in HCBS expenditures among states that were institutionally-oriented prior to CFC adoption. Additionally, CFC adoption was associated with an overall decrease in expenditures in alternative HCBS mechanisms (Personal Care Services State Plan Option and 1915(c) waivers), suggesting potential substitution across overlapping programs.

Conclusion

Results indicate heterogeneity across states adopting CFC. More institutionally-oriented states appear to use CFC to expand HCBS. In contrast, more HCBS-oriented states appear to employ CFC to strategically restructure their overall portfolio and processes.     

The role of payment and financing in achieving health equity

Objective

The aim was to identify healthcare payment and financing reforms to promote health equity and ways that the Agency for Healthcare Research and Quality (AHRQ) may promote those reforms.

Data Sources and Study Setting

AHRQ convened a payment and financing workgroup–the authors of this paper–as part of its Health Equity Summit held in July 2022. This workgroup drew from its collective experience with healthcare payment and financing reform, as well as feedback from participants in a session at the Health Equity Summit, to identify the evidence base and promising paths for reforms to promote health equity.

Study Design

The payment and financing workgroup developed an outline of reforms to promote health equity, presented the outline to participants in the payment and financing session of the July 2022 AHRQ Health Equity Summit, and integrated feedback from the participants.

Data Collection/Extraction Methods

This paper did not require novel data collection; the authors collected the data from the existing evidence base.

Principal Findings

The paper outlines root causes of health inequity and corresponding potential reforms in five domains: (1) the differential distribution of resources between healthcare providers serving different communities, (2) scarcity of financing for populations most in need, (3) lack of integration/accountability, (4) patient cost barriers to care, and (5) bias in provider behavior and diagnostic tools.

Conclusions

Additional research is necessary to determine whether the proposed reforms are effective in promoting health equity.     

上海市社区药学服务需求现状

背景 随着患者就诊下沉明显，联合家庭医生团队开展社区药学服务日益重要，但如何发挥家庭医生团队作用以满足患者社区药学服务需求仍有待进一步探索。 目的 了解上海市社区药学服务需求现状，为改进社区药学人员参与家庭医生团队开展服务的方式提供参考建议。 方法 于2020年9—12月，采用多阶段抽样法抽取349例老年慢性病患者和855例家庭医生团队主要成员〔全科医生（n=481）、护士（n=234）、公共卫生医生（n=140）〕进行问卷调查。针对老年慢性病患者的调查问卷主要内容包括基本情况、患病情况、用药情况、社区药学服务需求情况和社区药学服务利用情况。针对家庭医生团队成员的调查问卷主要内容包括基本情况、社区药学服务认知情况和社区药学服务需求情况。 结果 349例老年慢性病患者中，125例（35.8%）同时患有≥3种慢性病，305例（87.4%）每日需多次用药。用药管理类药学服务方面，"用药重整及随访"需求人数最多，为52例（14.9%），"用药随访"利用人数最多，为49例（14.0%）。用药教育类药学服务方面，"慢性病用药特殊性的普及教育"需求人数最多，为247例（70.8%），"宣传健康生活方式"利用人数最多，为33例（9.4%）。家庭医生团队成员中，全科医生、护士、公共卫生医生对药学服务的了解程度方面，分别有440例（91.5%）、202例（86.3%）、112例（80.0%）表示了解；对药师的信任程度方面，分别有302例（62.8%）、183例（78.2%）、103例（73.6%）表示非常信任；"协同医师做好药物使用遴选"服务项目的需求人数分别有359例（74.6%）、112例（47.9%）、81例（57.8%）；"指导护士使用与管理药品"服务项目的需求人数分别有190例（39.5%）、153例（65.4%）、57例（40.7%）。 结论 一方面患者实际迫切需要用药管理类药学服务，另一方面患者的用药教育类药学服务需求远未得到满足。鉴于社区药学人员队伍薄弱及家庭医生团队对社区药学服务认知局限的现状，社区药学人员应通过培训团队成员，提升团队的社区药学服务认知水平及服务能力，借助团队力量及成员特性，更广泛高效地开展社区药学服务。     

Involvement of Patients and Medical Professionals in the Assessment of Relative Effectiveness: A Need for Closer Cooperation

ObjectivesInvolvement of patients and medical professionals in assessment of relative effectiveness (relative effectiveness assessment) contributes to an efficient and effective health technology assessment (HTA) process and supports acceptance and implementation of the outcome. This study aimed to analyze stakeholder involvement in assessing relative effectiveness and how the parties involved value this collaboration.MethodsThis is a document analysis of all drug assessments completed in 2019 (20) by the public HTA agency of The Netherlands, enriched with semistructured interviews with employees of the HTA agency (18) and representatives of patient (5) and medical (11) associations involved in these assessments. Data were analyzed, coded, and categorized.ResultsIn almost half of the assessments, there was no coordination with the medical associations at the start of the relative effectiveness assessment and no patient associations involved in this phase. During the assessment procedure, patient and medical associations were always asked to comment on the draft report. Nevertheless, the strict 5-day deadline that the HTA agency uses as a response period often hampered a proper response and involvement. According to interviewees of the HTA agency, this leads to a great diversity in the substantive quality of their input. Patient and medical associations indicated that the HTA agency relies too much on “paper knowledge,” which leads to a (perceived) lack of alignment with clinical practice.ConclusionsThe limited involvement results in a lack of coordination and mutual trust. Optimizing involvement of patients and medical professionals in HTA practice requires effort from all parties involved. Procedural adjustments and better coordination, especially at the start of the assessment, would probably improve cooperation.     

Mobile daily diaries to characterize stressors and acute health symptoms in an environmental justice neighborhood

Low-income communities and communities of color face multiple, cumulative environmental and social burdens. Methods development in environmental justice research has largely focused on spatial and quantitative approaches. Less attention has been paid to developing methodologies that help collect information on everyday stressors and quality of life experiences for residents in overburdened communities. Mixed methods approaches can be one way to structure study designs that help consider how residents experience environmental and socioeconomic impacts in a localized community context. In neighborhoods burdened by cumulative stressors, traditional cross-sectional epidemiological research designs can also be challenging, as well as limited or narrow in their application. However, repeat sampling of measures within a vulnerable population can approach a quasi-experimental design and help consider variations within residents in a single neighborhood as well as better parse relationships between exposures and outcomes. Through a community-academic partnership with university partners, local community partners, and a local promotores de salud (community health workers) network, we pilot tested a novel mobile daily diary approach in both English and Spanish in an urban, predominantly immigrant community in South Los Angeles as a potential method to collect information on daily stress, environmental quality, and health status/symptoms. We collected resident responses via a once per day 7-day SMS/text messaging survey. We sought to gather granular data on daily resident experiences of air pollution and environmental hazards. Residents reported acute health symptoms and stressors, with repeat measures demonstrating how residents might rank, categorize, or cope with stressors. We find that residents in environmental justice communities record variation in their daily diary responses and document changes in environmental quality, stressors, and odors. Refining this type of method could enable a more rigorous examination of co-occurrences of environmental quality and acute health symptoms. This approach supports the inclusion of residents in the research process and helps more systematically integrate open-ended environmental health relevant data in environmental justice efforts. Used with measured data such as air monitoring or health measures, mixed methods generated data can help support efforts that aim to alleviate sources of daily stress, alongside efforts to reduce overall pollution burdens. Mobile daily diaries can be one way to capture variable responses to environmental quality, acute health symptoms, and stressors.     

Effects of the Cerebral Aneurysm Treatment Method on Coil Packing Density and Its Relationship with the Ostium Area

PurposeTo test the following hypotheses: (a) balloon or stent assistance increases coil packing density (CPD) in the endovascular treatment of intracranial aneurysms, and (b) CPD correlates to ostium area (OA) and aneurysm volume (AV).Materials and MethodsThis retrospective study included 60 aneurysms (54 ruptured and 6 unruptured) treated with simple coiling (SC) (n = 18), balloon-assisted coiling (BAC) (n = 7), or stent-assisted coiling (SAC) (n = 35) at the authors’ institution between August 2017 and December 2019. AV and OA measurements were obtained from 3-dimensional digital subtraction angiography images using commercial software. Coil sizes were retrieved from patient files, and coil volume (CV) measurements were obtained from https://www.angiocalc.com/. Analysis of covariance, multivariate covariance analysis, and Pearson correlation analyses were performed.ResultsThe median value for AV, CV, CPD, and OA was 63.4 mm³ (range, 5.5–1,771.4 mm³), 23.13 mm³ (range, 2.03–296.95 mm³), 33.29% (range, 13.41%–81.02%), and 10.7 mm² (range, 2.7–49.9 mm²), respectively. Multivariate analysis showed that the CPD values were not significantly different among the treatment groups, although OA significantly differed between the SC and SAC groups (P < .05). Pearson correlations showed that similar to AV, OA was negatively correlated with CPD (r = ?0.321, P < .05).ConclusionsThe CPD value in cerebral aneurysms treated with BAC or SAC did not differ from that in aneurysms treated with SC.