Alison Evans Cuellar

Proportion Of Physicians In Large Group Practices Continued To Grow In 2009–11

Payers and advocates for improved health care quality are raising expectations for greater care coordination and accountability for care delivery, and physician groups may be responding by becoming larger. We used Medicare claims from the period 2009-11, merged with information from the Medicare provider enrollment database, to measure whether physician group sizes have been increasing over time and in association with physician characteristics. All US physicians serving Medicare fee-for-service patients in any practice setting were included. The percentage of physicians in groups of more than fifty increased from 30.9 percent in 2009 to 35.6 percent in 2011. This shift occurred across all specialty categories, both sexes, and all age groups, although it was more prominent among physicians under age forty than those age sixty or older. The movement of physicians into groups is not a new phenomenon, but our data suggest that the groups are larger than surveys have previously indicated. Questions for future studies include whether there are significant cost savings or quality improvements associated with increased practice size.

Medicaid Enrollment and Mental Health Service Use Following Release of Jail Detainees With Severe Mental Illness

OBJECTIVE This study assessed the extent to which Medicaid enrollment increased access to and use of services by persons with severe mental illness after their release from jail. METHODS A prospective cohort design was used that linked administrative data from several agencies in two large urban areas: King County (Seattle) from 1996 to 1998 and Pinellas County (Clearwater and St. Petersburg), Florida, from 1998 to 2000. Access to and use of community mental health services within 90 days after release from jail was examined, depending on whether persons were enrolled in Medicaid at the time of their release. All analyses were based on detentions, rather than unique persons. The effects of Medicaid status (enrolled or not enrolled) on four dependent variables (probability of use, days to first service, number of services used, and rate of service use) were estimated separately for each county. RESULTS A total of 1,210 persons who had 2,878 detentions were identified in Pinellas County: 2,215 of these detentions represented persons with Medicaid and 663 represented those without Medicaid. For King County, the corresponding numbers were 1,816 persons and 4,482 detentions: 2,752 of these detentions represented persons with Medicaid and 1,730 represented those without Medicaid. In both counties, those who had Medicaid at the time of their release were more likely to use services (p < .001), accessed community services more quickly (p < .001), and received more days of services (p < .001) than those without Medicaid. CONCLUSIONS Medicaid enrollment enhanced receipt of community services after jail release in these two large urban counties. These are the best currently available data, and the data suggest that efforts to enroll persons with severe mental illness in Medicaid and ensure enrollment upon jail release will improve their access to and receipt of community-based services after release.

Minority youth in foster care: Managed care and access to mental health treatment

Background. Public sector mental health treatment has been transformed in recent years by the advent of managed care, but investigators of managed care policy have not yet focused on ethnic minority children, especially those involved with the child welfare system. Because of an overrepresentation of high-need minority children, foster care in particular is important to consider. Objectives. The present study examined children placed in foster care and documented differences between minority children and youth (black persons, Hispanic persons, and white persons) in use of mental health services. The primary concern of the study was to consider whether there were differences in access to services or service use among the groups in the transition to capitated managed care. Materials and methods. Medicaid claims and encounter data for two experimental managed care sites and one comparison fee-for-service site are used in a “difference-in-difference” analysis to estimate a changes in inpatient, outpatient, and residential treatment center (RTC) utilization, controlling for patient characteristics. Results. The study finds persistent declines in inpatient and outpatient use for all ethnic groups, persistent under-representation of Hispanic persons and black persons in treatment regardless of managed care, and greater use of RTCs by black persons and Hispanic persons that is attributable in part to managed care. Conclusions. Black and Hispanic children received more rather than less mental health care under capitated managed care. The significance of this shift, largely increased in use of RTCs, however, cannot be determined at present, as the effectiveness of treatment delivered in RTCs is not known.

Anti-inflammatory Medication Adherence, Healthcare Utilization and Expenditures Among Medicaid and Children's Health Insurance Program Enrollees with Asthma

AbstractBackground: Underuse of controller therapy among Medicaid-enrolled children is common and leads to more emergency department (ED) visits and hospitalizations. However, there is little evidence about the relationship between medication adherence, outcomes and costs once controller therapy is initiated. Objective: This study examined the relationship between adherence to two commonly prescribed anti-inflammatory medications, inhaled corticosteroids (ICS) and leukotriene inhibitors (LI), and healthcare utilization and expenditures among children enrolled in Medicaid and the Children’s Health Insurance Program in Florida and Texas in the US. Methods: The sample for this retrospective observational study consisted of 18456 children aged 2–18 years diagnosed with asthma, who had been continuously enrolled for 24 months during 2004–7 and were on monotherapy with ICS or LI. State administrative enrolment files were linked to medical claims data. Children were grouped into three adherence categories based on the percentage of days per year they had prescriptions filled (medication possession ratio). Bivariate and multivariable regression analyses that adjusted for the children’s demographic and health characteristics were used to examine the relationship between adherence and ED visits, hospitalizations, and expenditures. Results: Average adherence was 20% for ICS-treated children and 28% for LI-treated children. Children in the highest adherence category had lower odds of an ED visit than those in the lowest adherence category (p < 0.001). We did not detect a statistically significant relationship between adherence and hospitalizations; however, only 3.7% of children had an asthma-related hospitalization. Overall asthma care expenditures increased with greater medication adherence. Conclusions: Although greater adherence was associated with lower rates of ED visits, higher medication expenditures outweighed the savings. The overall low adherence rates suggest that quality improvement initiatives should continue to target adherence regardless of the class of medication used. However, low baseline hospitalization rates may leave little opportunity to significantly decrease costs through better disease management, without also decreasing medication costs.

Delinquent youth in corrections: Medicaid and reentry into the community.

In general, states and public agencies acting as custodians for youth in the corrections branch of the juvenile justice system are responsible for ensuring that such youth receive access to timely and appropriate physical and mental health care. However, to date, health care for youth in the juvenile justice system has generally been considered inadequate. Note that in this article “health care” refers to the treatment of both physical and mental health problems. The American Academy of Pediatrics and others have issued policy statements in the past 2 decades that stress the need for better health care for juvenile offenders in correctional facilities.1–4 In response, correctional facilities have put in place enhanced acute care services for children and adolescents in juvenile justice. Although such services are almost certainly needed, these efforts are likely to be deficient on at least 2 counts. First, many of these youth suffer not only from acute medical and psychiatric problems but also chronic ones including substance abuse and other psychiatric disorders. Second, with an estimated 88000 youth being released from juvenile commitment facilities each year,5 the need for ongoing medical treatment after parole and reentry into the community is high. However, care often stops when the juveniles leave the system, with little or no reintroduction to community services.6 Pediatricians and other primary care clinicians have a central role to play in establishing a medical home for these youth and expediting access to critical medical and behavioral services. This review will provide an overview of the juvenile justice system, present the extant literature on the chronic health problems found in incarcerated youth, and discuss how the absence of care after release from the juvenile justice system impacts public health and society. We argue that Medicaid financing could be used as an … Reprint requests to (K.K.) Office of Clinical Sciences, Columbus Children’s Research Institute, 700 Children’s Dr, Suite J1401, Columbus, OH 43205. E-mail: kellehek{at}pediatrics.ohio-state.edu

How Capitated Mental Health Care Affects Utilization by Youth in the Juvenile Justice and Child Welfare Systems

Examine the impact of Colorados Medicaid mental health carve-out program on children in child welfare and juvenile justice systems. Medicaid claims and encounter data for two experimental managed care sites and one comparison fee-for-service site are used to estimate a two-part model of inpatient, outpatient, and residential treatment center utilization, controlling for patient characteristics. The study finds that juvenile justice and child welfare populations were more strongly affected by managed care than the general youth population, regarding reduced utilization of inpatient and outpatient services. Increases in Residential Treatment Centers use were greater for juvenile justice than either the child welfare sample or the total sample. Youth in child welfare increase utilization of outpatient services. Most utilization effects are stronger for not-for-profit than for-profit managed care organizations. The experience of Colorado implies that a mental health carve-out affects patterns of care for youth and differentially so for youth in juvenile justice and child welfare systems. Controlling for population characteristics, the effects are stronger for not-for-profit than for-profit managed care organizations.

Medicaid Insurance Policy for Youths Involved in the Criminal Justice System

Juvenile justice and Medicaid agencies share an interest in serving delinquent youths, many of whom have a relatively poor health status. However, many state and local Medicaid policies result in these youths having no insurance coverage, making access to needed services difficult. A nationally representative survey of state and community juvenile justice and Medicaid agencies was conducted to assess Medicaid policies. Evidence from the survey suggests that in some areas delinquent youths are actively disenrolled from Medicaid benefits, and in others little effort is made to connect them to Medicaid coverage. Discrepancies between justice agency and Medicaid agency responses point to poor communication and coordination. Overall, the survey identified several opportunities for policy intervention to enhance access to services for justice-involved youths.

Increasing California children's Medicaid-financed mental health treatment by vigorously implementing Medicaid's Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program.

Background: Children living in poverty—especially children living in rural areas and in areas lacking a commitment to providing mental health care—have considerable unmet need for mental health treatment. Expansion of Medicaids Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program might help to address this problem. Objective: To evaluate whether a legally compelled expansion of mental health screening, treatment, and financing under EPSDT would translate into higher Medicaid penetration rates. Our particular focus was on changes in rural treatment systems and systems historically receiving low levels of state funding (ie, “underequity” counties). Methods: We used fixed-effects regression methods by observing 53 California county mental health plans over 36 quarters, yielding 1908 observations. Our models controlled for all static, county, and service system characteristics, and for ongoing linear trends in penetration rates. Results: After controlling for previous trends, mental health treatment access increased following EPSDT mental health program expansion. The increase was greatest in rural systems, and counties that previously received less state funding which showed the greatest penetration rate increases. Conclusions: EPSDT mental health expansion and increased funding increased Medicaid-financed mental health treatment. The expansion efforts had the greatest effects in rural and underequity counties that faced the greatest barriers to mental health service use.

Health Care Reform, Behavioral Health, and the Criminal Justice Population

The 2010 Patient Protection and Affordable Care Act (ACA) has a number of important features for individuals who are involved with the criminal justice system. Among the most important changes is the expansion of Medicaid to more adults. The current study estimates that 10% of the total Medicaid expansion could include individuals who have experienced recent incarceration. The ACA also emphasizes the importance of mental health and substance abuse benefits, potentially changing the landscape of behavioral health treatment providers willing to serve criminal justice populations. Finally, it seeks to promote coordinated care delivery. New care delivery and appropriate funding models are needed to address the behavioral health and other chronic conditions experienced by those in criminal justice and to coordinate care within the complex structure of the justice system itself.

Use of Hospitalists by Medicare Beneficiaries: A National Picture

OBJECTIVE To describe the characteristics of hospitalists serving Medicare beneficiaries. DATA SOURCES Medicare claims from 2009 and 2011 merged with the Provider Enrollment, Chain, and Ownership System file for physician characteristics. STUDY DESIGN Our construction of the Medicare Data on Physician Practice and Specialty (MD-PPAS) enabled identification of hospitalists based on the attending physician for Medicare admissions (medical and surgical) in 2009 and 2011. PRINCIPAL FINDINGS In 2011, hospitalists constituted 13.3% of physicians who designated their specialty as primary care and 4.4% of all physicians serving Medicare beneficiaries. Compared to other physicians, hospitalists were more likely to be female, under forty, and in large practices. More than a quarter of Medicare admissions had a hospitalist as the attending physician, though the rate was substantially higher for medical than surgical admissions (31.8% versus 11.3%). Between 2009 and 2011, the percentage of medical admissions with a hospitalist as the attending physician increased by roughly a quarter (from 25.7% to 31.8%). CONCLUSIONS This analysis provides a more current and complete estimate of the use of hospitalists by the Medicare population than is available from prior studies. The ability to identify hospitalists from claims data will facilitate research on the impact of hospitalist use on quality and cost.