Rosalie Malsberger

Effect of Teledermatology on Access to Dermatology Care Among Medicaid Enrollees

IMPORTANCE Access to specialists such as dermatologists is often limited for Medicaid enrollees. Teledermatology has been promoted as a potential solution; however, its effect on access to care at the population level has rarely been assessed. OBJECTIVES To evaluate the effect of teledermatology on the number of Medicaid enrollees who received dermatology care and to describe which patients were most likely to be referred to teledermatology. DESIGN, SETTING, AND PARTICIPANTS Claims data from a large California Medicaid managed care plan that began offering teledermatology as a covered service in April 2012 were analyzed. The plan enrolled 382 801 patients in Californias Central Valley, including 108 480 newly enrolled patients who obtained coverage after the implementation of the Affordable Care Act. Rates of dermatology visits by patients affiliated with primary care practices that referred patients to teledermatology and those that did not were compared. Data were collected from April 1, 2012, through December 31, 2014, and assessed from March 1 to October 15, 2015. MAIN OUTCOMES AND MEASURES The percentage of patients with at least 1 visit to a dermatologist (including in-person and teledermatology visits) and total visits with dermatologists (including in-person and teledermatology visits) per 1000 patients. RESULTS Of the 382 801 patients enrolled for at least 1 day from 2012 to 2014, 8614 (2.2%) had 1 or more visits with a dermatologist. Of all patients who visited a dermatologist, 48.5% received care via teledermatology. Among the patients newly enrolled in Medicaid, 75.7% (1474 of 1947) of those who visited a dermatologist received care via teledermatology. Primary care practices that engaged in teledermatology had a 63.8% increase in the fraction of patients visiting a dermatologist (vs 20.5% in other practices; P < .01). Compared with in-person dermatology, teledermatology served more patients younger vs older than 17 years (2600 of 4427 [58.7%] vs 1404 of 4187 [33.5%]), male patients (1849 of 4427 [41.8%] vs 1526 of 4187 [36.4%]), nonwhite patients (2779 of 4188 [66.4%] vs 1844 of 3478 [53.0%]), and individuals without comorbid conditions (1795 of 2464 [72.8%] vs 1978 of 3024 [65.4%]) (P < .001 for all comparisons). Conditions managed across settings varied; teledermatology physicians were more likely to care for viral skin lesions and acne (3405 of 7287 visits [46.7%]), whereas in-person dermatologists were more likely to care for psoriasis and skin neoplasms (10 062 of 27 347 visits [36.8%]). CONCLUSIONS AND RELEVANCE The offering of teledermatology appeared to improve access to dermatology care among Medicaid enrollees and played an especially important role for the newly enrolled.

Implementation of Medical Homes in Federally Qualified Health Centers

BACKGROUND From 2011 through 2014, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration provided care management fees and technical assistance to a nationwide sample of 503 federally qualified health centers to help them achieve the highest (level 3) medical‐home recognition by the National Committee for Quality Assurance, a designation that requires the implementation of processes to improve access, continuity, and coordination. METHODS We examined the achievement of medical‐home recognition and used Medicare claims and beneficiary surveys to measure utilization of services, quality of care, patients’ experiences, and Medicare expenditures in demonstration sites versus comparison sites. Using difference‐in‐differences analyses, we compared changes in outcomes in the two groups of sites during a 3‐year period. RESULTS Level 3 medical‐home recognition was awarded to 70% of demonstration sites and to 11% of comparison sites. Although the number of visits to federally qualified health centers decreased in the two groups, smaller reductions among demonstration sites than among comparison sites led to a relative increase of 83 visits per 1000 beneficiaries per year at demonstration sites (P<0.001). Similar trends explained the higher performance of demonstration sites with respect to annual eye examinations and nephropathy tests (P<0.001 for both comparisons); there were no significant differences with respect to three other process measures. Demonstration sites had larger increases than comparison sites in emergency department visits (30.3 more per 1000 beneficiaries per year, P<0.001), inpatient admissions (5.7 more per 1000 beneficiaries per year, P=0.02), and Medicare Part B expenditures (

Association Between Patient-Centered Medical Home Capabilities and Outcomes for Medicare Beneficiaries Seeking Care from Federally Qualified Health Centers

37 more per beneficiary per year, P=0.02). Demonstration‐site participation was not associated with relative improvements in most measures of patients’ experiences. CONCLUSIONS Demonstration sites had higher rates of medical‐home recognition and smaller decreases in the number of patients’ visits to federally qualified health centers than did comparison sites, findings that may reflect better access to primary care relative to comparison sites. Demonstration sites had larger increases in emergency department visits, inpatient admissions, and Medicare Part B expenditures. (Funded by the Centers for Medicare and Medicaid Services.)

Evaluation of CMS's Federally Qualified Health Center (FQHC) Advanced Primary Care Practice (APCP) Demonstration: Final Report

BackgroundPatient-centered medical home (PCMH) models of primary care have the potential to expand access, improve population health, and lower costs. Federally qualified health centers (FQHCs) were early adopters of PCMH models.ObjectiveWe measured PCMH capabilities in a diverse nationwide sample of FQHCs and assessed the relationship between PCMH capabilities and Medicare beneficiary outcomes.DesignCross-sectional, propensity score-weighted, multivariable regression analysis.ParticipantsA convenience sample of 804 FQHC sites that applied to a nationwide FQHC PCMH initiative and 231,163 Medicare fee-for-service beneficiaries who received a plurality of their primary care services from these sites.Main MeasuresPCMH capabilities were self-reported using the National Committee for Quality Assurance’s (NCQA’s) 2011 application for PCMH recognition. Measures of utilization, continuity of care, quality, and Medicare expenditures were derived from Medicare claims covering a 1-year period ending October 2011.Key ResultsNearly 88% of sites were classified as having PCMH capabilities equivalent to NCQA Level 1, 2, or 3 PCMH recognition. These more advanced sites were associated with 228 additional FQHC visits per 1000 Medicare beneficiaries (95% CI: 176, 278), compared with less advanced sites; 0.02 points higher practice-level continuity of care (95% CI: 0.01, 0.03); and a greater likelihood of administering two of four recommended diabetes tests. However, more advanced sites were also associated with 181 additional visits to specialists per 1000 beneficiaries (95% CI: 124, 232) and 64 additional visits to emergency departments (95% CI: 35, 89)—but with no differences in inpatient utilization. More advanced sites had higher Part B expenditures (

Who are the men caring for maltreated youth? Male primary caregivers in the child welfare system

111 per beneficiary [95% CI:

Youth victimization profiles and change in mental health symptoms over one year

61,

The Association of Inpatient Occupancy with Hospital-Acquired Clostridium Difficile Infection

158]) and total Medicare expenditures of

Virtual First Responders: the Role of Direct-to-Consumer Telemedicine in Caring for People Impacted by Natural Disasters

353 [95% CI:

Primary Care Visit Regularity and Patient Outcomes: an Observational Study

65,

Utilization of Health Care Services Among Medicare Beneficiaries Who Visit Federally Qualified Health Centers

614]).ConclusionsImplementation of PCMH models in FQHCs may be associated with improved primary care for Medicare beneficiaries. Expanded access to care, in combination with slower development of key PCMH capabilities, may explain higher Medicare expenditures and other types of utilization.