Brian K. Bruen

The States' Next Challenge — Securing Primary Care for Expanded Medicaid Populations

Many of the U.S. states with the largest anticipated Medicaid expansions are also the ones that have less primary care capacity. These states could face surging demand from the newly insured population without having sufficient primary care resources available.

Accessibility of long-acting reversible contraceptives (LARCs) in Federally Qualified Health Centers (FQHCs) ☆

OBJECTIVE(S) This study examines the on-site availability of long-acting reversible contraception (LARC) methods, defined here as intrauterine devices and contraceptive implants, at Federally Qualified Health Centers (FQHCs). We also describe factors associated with on-site availability and specific challenges and barriers to providing on-site access to LARC as reported by FQHCs. STUDY DESIGN An original survey of 423 FQHC organizations was fielded in 2011. RESULTS Over two thirds of FQHCs offer on-site availability of intrauterine devices yet only 36% of FQHCs report that they offer on-site contraceptive implants. Larger FQHCs and FQHCs receiving Title X Family Planning program funding are more likely to provide on-site access to LARC methods. Other organizational and patient characteristics are associated with the on-site availability of LARC methods, though this relationship varies by the type of method. The most commonly reported barriers to providing on-site access to LARC methods are related to the cost of stocking or supplying the drug and/or device, the perceived lack of staffing and training, and the unique needs of special populations. CONCLUSION Our findings indicate that patients seeking care in small FQHC organizations, FQHCs with limited dedicated family planning funding and FQHCs located in rural areas may have fewer choices and limited access to LARC methods on-site. IMPLICATIONS Despite the presumed widespread coverage of contraceptives for women as a result of provisions in the Affordable Care Act, there is a limited understanding of how FQHCs may redesign their practices to provide on-site availability of LARC methods. This study sheds light on the current state of practice and challenges related to providing LARC methods in FQHC settings.

Health care reform and women's insurance coverage for breast and cervical cancer screening.

Introduction The Patient Protection and Affordable Care Act of 2010 (ACA) will increase insurance coverage for US citizens and for breast and cervical cancer screening through insurance expansions and regulatory changes. The primary objective of this study was to estimate the number of low-income women who would gain health insurance after implementation of the ACA and thus be able to obtain cancer screening. A secondary objective was to estimate the size and characteristics of the uninsured low-income population and the number of women who would still need National Breast and Cervical Cancer Early Detection Program (NBCCEDP) services. Methods We used the nationally representative 2009 American Community Survey to estimate the determinants of insurance status for women in Massachusetts, assuming full implementation of the ACA. We extrapolated findings to simulate the effects of the ACA on each state. We used individual-level predicted probabilities of being uninsured to generate estimates of the number of women who would gain health insurance after implementation of the ACA and to predict demand for NBCCEDP services. Results Approximately 6.8 million low-income women would gain health insurance, potentially increasing the annual demand for cancer screenings initially by about 500,000 mammograms and 1.3 million Papanicolaou tests. Despite a 60% decrease in the number of low-income uninsured women, the NBCCEDP would still serve fewer than one-third of the estimated number of women eligible for services. The NBCCEDP-eligible population would comprise a larger number of women with language and literacy-related barriers to care. Conclusion Implementation of the ACA would increase insurance coverage and access to cancer screening for millions of women, but the NBCCEDP will remain essential for the millions who will remain uninsured.

Scope of family planning services available in Federally Qualified Health Centers

OBJECTIVES Federally Qualified Health Centers (FQHCs) are a major and growing source of primary care for low-income women of reproductive age; however, only limited knowledge exists on the scope of family planning care they provide and the mechanisms for delivery of these essential reproductive health services, including family planning. In this paper, we report on the scope of services provided at FQHCs including on-site provision, prescription only and referral options for the range of contraceptive methods. STUDY DESIGN An original survey of 423 FQHC organizations was fielded in 2011. RESULTS Virtually all FQHCs reported that they provide at least one contraceptive method (99.8%) at one or more clinical sites. A large majority (87%) of FQHCs report that their largest primary care site prescribes oral contraceptives plus one additional method category of contraception, with oral contraception and injectables being the most commonly available methods. Substantial variation is seen among other methods such as intrauterine devices (IUDs), contraceptive implants, the patch, vaginal ring and barrier methods. For all method categories, Title-X-funded sites are more likely to provide the method, though, even in these sites, IUDs and implants are much less likely to be provided than other methods. CONCLUSION There is clearly wide variability in the delivery of family planning services at FQHCs in terms of methods available, level of counseling, and provision of services on-site or through prescription or referral. Barriers to provision likely include cost to patients and/or additional training to providers for some methods, such as IUDs and implants, but these barriers should not limit on-site availability of inexpensive methods such as oral contraceptives. IMPLICATIONS With the expansion of contraceptive coverage under private insurance as part of preventive health services for women, along with expanded coverage for the currently uninsured, and the growth of FQHCs as the source of care for women of reproductive age, it is critical that women seeking family planning services at FQHCs have access to a wide range of contraceptive options. Our study both highlights the essential role of FQHCs in providing family planning services and also identifies remaining gaps in the provision of contraception in FQHC settings.

Impact of health insurance expansions on nonelderly adults with hypertension

Introduction Hypertension is a risk factor for cardiovascular disease (CVD), the leading cause of death in the United States. The treatment and control of hypertension is inadequate, especially among patients without health insurance coverage. The Affordable Care Act offered an opportunity to improve hypertension management by increasing the number of people covered by insurance. This study predicts the long-term effects of improved hypertension treatment rates due to insurance expansions on the prevalence and mortality rates of CVD of nonelderly Americans with hypertension. Methods We developed a state-transition model to simulate the lifetime health events of the population aged 25 to 64 years. We modeled the effects of insurance coverage expansions on the basis of published findings on the relationship between insurance coverage, use of antihypertensive medications, and CVD-related events and deaths. Results The model projected that currently anticipated health insurance expansions would lead to a 5.1% increase in treatment rate among hypertensive patients. Such an increase in treatment rate is estimated to lead to 111,000 fewer new coronary heart disease events, 63,000 fewer stroke events, and 95,000 fewer CVD-related deaths by 2050. The estimated benefits were slightly greater for men than for women and were greater among nonwhite populations. Conclusion Federal and state efforts to expand insurance coverage among nonelderly adults could yield significant health benefits in terms of CVD prevalence and mortality rates and narrow the racial/ethnic disparities in health outcomes for patients with hypertension.

Increased Use of Dental Services by Children Covered by Medicaid: 2000-2010

This report analyzes the use of dental services by children enrolled in Medicaid from federal fiscal years (FFY) 2000 to 2010. The number and percent of children receiving dental services under Medicaid climbed continuously over the decade. In FFY 2000, 6.3 million children ages 1 to 20 were reported to receive some form of dental care (either preventive or treatment); the number more than doubled to 15.4 million by FFY 2010. Part of the increase was because the overall number of children covered by Medicaid rose by 12 million (50%), but the percentage of children who received dental care climbed appreciably from 29.3% in FFY 2000 to 46.4% in FFY 2010. In that same time period, the number of children ages 1 to 20 receiving preventive dental services climbed from a reported 5.0 million to 13.6 million, while the percentage of children receiving preventive dental services rose from 23.2% to 40.8%. For children ages 1 to 20 who received dental treatment services, the reported number rose from 3.3 million in FFY 2000 to 7.6 million in FFY 2010. The percentage of children who obtained dental treatment services increased from 15.3% to 22.9%. In FFY 2010, about one sixth of children covered by Medicaid (15.7%) ages 6-14 had a dental sealant placed on a permanent molar. While most states have made steady progress in improving childrens access to dental care in Medicaid over the past decade, there is still substantial variation across states and more remains to be done.

Changes In Medicaid Prescription Volume And Use In The Wake Of Medicare Part D Implementation

Implementation of the Medicare drug benefit resulted in a major shift of prescription drug spending from Medicaid to Medicare. Data indicate that Medicaid programs experienced substantial changes in the volume and types of prescriptions used by enrollees. Medicaid prescription volume and total payments to pharmacies dropped by almost 50 percent in 2006. Generic dispensing rates increased 4.6 percentage points nationally. The mix of drug classifications also shifted, reflecting the younger makeup of the population that remains eligible for Medicaid prescription drug benefits. Still, patterns of use reflect the major mental and physical health needs of Medicaid enrollees.

Continuous-Eligibility Policies Stabilize Medicaid Coverage For Children And Could Be Extended To Adults With Similar Results

A key method of stabilizing Medicaid coverage is to provide beneficiaries with twelve months of continuous eligibility. Following the passage of the Childrens Health Insurance Program Reauthorization Act in 2009, seven states adopted the continuous-eligibility option for children. That policy change led to a 1.8-percentage-point increase in the average length of child enrollment during fiscal year 2010 and increased annual costs for children by about 2.2 percent. The Medicaid and CHIP Payment and Access Commission has recommended offering states the option of giving adults twelve-month continuous eligibility for Medicaid. Our findings suggest that continuous eligibility could promote more stable coverage for adults enrolled in Medicaid at a modest cost.

Potentially preventable dental care in operating rooms for children enrolled in Medicaid

BACKGROUND In this study, the authors examined the prevalence and cost of care for children enrolled in Medicaid for potentially preventable dental conditions who receive surgical care in hospital operating rooms (ORs) or ambulatory surgery centers (ASCs). METHODS The authors analyzed Medicaid data from 8 states to find cases in which children aged 1 to 20 years received surgical care in ORs or ASCs in 2010 and 2011 for potentially preventable diagnoses, as defined with diagnostic codes. RESULTS For 6 states with complete data, there were 26,373 cases in 2011 in which children received OR or ASC surgical care for potentially preventable conditions. These cases represent approximately 0.5% of all children enrolled in Medicaid in these states and approximately 1% of children enrolled in Medicaid who received any dental care. There were

The potential employment impact of health reform on working-age adults with disabilities

68 million in total Medicaid payments for these cases, with an average of