Thomas H. A. Meath

Comparison of Low-Value Care in Medicaid vs Commercially Insured Populations.

IMPORTANCE Reducing unnecessary tests and treatments is a potentially promising approach for improving the value of health care. However, relatively little is known about whether insurance type or local practice patterns are associated with delivery of low-value care. OBJECTIVES To compare low-value care in the Medicaid and commercially insured populations, test whether provision of low-value care is associated with insurance type, and assess whether local practice patterns are associated with the provision of low-value care. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of claims data from the Oregon Division of Medical Assistance Programs and the Oregon All-Payer All-Claims database included Medicaid and commercially insured adults aged 18 to 64 years. The study period was January 1, 2013, through December 31, 2013. MAIN OUTCOMES AND MEASURES Low-value care was assessed using 16 claims-based measures. Logistic regression was used to test the association between Medicaid vs commercial insurance coverage and low-value care and the association between Medicaid and commercial low-value care rates within primary care service areas (PCSAs). RESULTS This study included 286 769 Medicaid and 1 376 308 commercial enrollees in 2013. Medicaid enrollees were younger (167 847 [58.5%] of Medicaid enrollees were aged 18-34 years vs 505 628 [36.7%] of those with commercial insurance) but generally had worse health status compared with those with commercial insurance. Medicaid enrollees were also more likely to be female (180 363 [62.9%] vs 702 165 [51.0%]) and live in a rural area (120 232 [41.9%] vs 389 964 [28.3%]). A total of 10 304 of 69 338 qualifying Medicaid patients (14.9%; 95% CI, 14.6%-15.1%) received at least 1 low-value service during 2013; the corresponding rate for commercially insured patients was 35 739 of 314 023 (11.4%; 95% CI, 11.3%-11.5%). No consistent association was found between insurance type and low-value care. Compared with commercial patients, Medicaid patients were more likely to receive low-value care for 10 measures and less likely to receive low-value care for 5 others. For 7 of 11 low-value care measures, Medicaid patients were significantly more likely to receive low-value care if they resided in a PCSA with a higher rate of low-value care for commercial patients. CONCLUSIONS AND RELEVANCE Oregon Medicaid and commercially insured patients received moderate amounts of low-value care in 2013. No consistent association was found between insurance type and low-value care. However, Medicaid and commercial rates of low-value care were associated with one another within PCSAs. Low-value care may be more closely related to local practice patterns than to reimbursement generosity or insurance benefit structures.

Early Performance in Medicaid Accountable Care Organizations: A Comparison of Oregon and Colorado

Importance Several state Medicaid reforms are under way, but the relative performance of different approaches is unclear. Objective To compare the performance of Oregon’s and Colorado’s Medicaid Accountable Care Organization (ACO) models. Design, Setting, and Participants Oregon initiated its Medicaid transformation in 2012, supported by a

Disparities in Alcohol, Drug Use, and Mental Health Condition Prevalence and Access to Care in Rural, Isolated, and Reservation Areas: Findings From the South Dakota Health Survey

1.9 billion investment from the federal government, moving most Medicaid enrollees into 16 Coordinated Care Organizations, which managed care within a global budget. Colorado initiated its Medicaid Accountable Care Collaborative in 2011, creating 7 Regional Care Collaborative Organizations that received funding to coordinate care with providers and connect Medicaid enrollees with community services. Data spanning July 1, 2010, through December 31, 2014 (18 months before intervention and 24 months after intervention, treating 2012 as a transition year) were analyzed for 452 371 Oregon and 330 511 Colorado Medicaid enrollees, assessing changes in outcomes using difference-in-differences analyses of regional focus, primary care homes, and care coordination. Oregon’s Coordinated Care Organization model was more comprehensive in its reform goals and in the imposition of downside financial risk. Exposures Regional focus, primary care homes, and care coordination in Medicaid ACOs. Main Outcomes and Measures Performance on claims-based measures of standardized expenditures and utilization for selected services, access, preventable hospitalizations, and appropriateness of care. Results In a total of 782 882 Medicaid enrollees, 45.0% were male, with mean (SD) age 16.74 (14.41) years. Standardized expenditures for selected services declined in both states during the 2010-2014 period, but these decreases were not significantly different between the 2 states. Oregon’s model was associated with reductions in emergency department visits (−6.28 per 1000 beneficiary-months; 95% CI, −10.51 to −2.05) and primary care visits (−15.09 visits per 1000 beneficiary-months; 95% CI, −26.57 to −3.61), improvements in acute preventable hospital admissions (−1.01 admissions per 1000 beneficiary-months; 95% CI, −1.61 to −0.42), 3 of 4 measures of access (well-child visits, ages 3-6 years, 2.69%; 95% CI, 1.20% to 4.19%; adolescent well-care visits, 6.77%; 95% CI, 5.22% to 8.32%; and adult access to preventive ambulatory care, 1.26%; 95% CI, 0.28% to 2.25%), and 1 of 4 measures of appropriateness of care (avoidance of head imaging for uncomplicated headache, 2.59%; 95% CI, 1.35% to 3.83%). Conclusions and Relevance Two years into implementation, Oregon’s and Colorado’s Medicaid ACO models exhibited similar performance on standardized expenditures for selected services. Oregon’s model, marked by a large federal investment and movement to global budgets, was associated with improvements in some measures of utilization, access, and quality, but Colorado’s model paralleled Oregon’s on several other metrics.

Adverse Childhood Experiences (ACE) among American Indians in South Dakota and Associations with Mental Health Conditions, Alcohol Use, and Smoking

PURPOSE Research on urban/rural disparities in alcohol, drug use, and mental health (ADM) conditions is inconsistent. This study describes ADM condition prevalence and access to care across diverse geographies in a predominantly rural state. METHODS Multimodal cross-sectional survey in South Dakota from November 2013 to October 2014, with oversampling in rural areas and American Indian reservations. Measures assessed demographic characteristics, ADM condition prevalence using clinical screenings and participant self-report, perceived need for treatment, health service usage, and barriers to obtaining care. We tested for differences among urban, rural, isolated, and reservation geographic areas, controlling for participant age and gender. FINDINGS We analyzed 7,675 surveys (48% response rate). Generally, ADM condition prevalence rates were not significantly different across geographies. However, respondents in isolated and reservation areas were significantly less likely to have access to primary care. Knowledge of treatment options was significantly lower in isolated regions and individuals in reservation areas had significantly lower odds of reporting receipt of all needed care. Across the sample there was substantial discordance between ADM clinical screenings and participant self-reported need; 98.1% of respondents who screened positive for alcohol or drug misuse and 63.8% of respondents who screened positive for a mental health condition did not perceive a need for care. CONCLUSION In a predominantly rural state, geographic disparities in ADM conditions are related to differences in access as opposed to prevalence, particularly for individuals in isolated and reservation areas. Educational interventions about ADM condition characteristics may be as important as improving access to care.

Changes in pain intensity after discontinuation of long-term opioid therapy for chronic noncancer pain

Abstract:Objectives. To assess the prevalence of Adverse Childhood Experiences (ACEs) and their association with behavioral health in American Indian (AI) and non-AI populations in South Dakota. Methods. We included the validated ACE questionnaire in a statewide health survey of 16,001 households. We examined the prevalence of ACEs and behavioral health conditions in AI and non-AI populations and associations between ACEs and behavioral health. Results. Compared with non-AIs, AIs displayed higher prevalence of ACEs including abuse, neglect, and household dysfunction and had a higher total number of ACEs. For AIs and non-AIs, having six or more ACEs significantly increased the odds for depression, anxiety, PTSD, severe alcohol misuse, and smoking compared with individuals with no ACEs. Conclusions. American Indians in South Dakota experience more ACEs, which may contribute to poor behavioral health. Preventing and mitigating the effects of ACEs may have a significant impact on health disparities in AI populations.

Clinician Referrals for Non-opioid Pain Care Following Discontinuation of Long-term Opioid Therapy Differ Based on Reasons for Discontinuation.

Abstract Little is known about changes in pain intensity that may occur after discontinuation of long-term opioid therapy (LTOT). The objective of this study was to characterize pain intensity after opioid discontinuation over 12 months. This retrospective U.S. Department of Veterans Affairs (VA) administrative data study identified N = 551 patients nationally who discontinued LTOT. Data over 24 months (12 months before and after discontinuation) were abstracted from VA administrative records. Random-effects regression analyses examined changes in 0 to 10 pain numeric rating scale scores over time, whereas growth mixture models delineated pain trajectory subgroups. Mean estimated pain at the time of opioid discontinuation was 4.9. Changes in pain after discontinuation were characterized by slight but statistically nonsignificant declines in pain intensity over 12 months after discontinuation (B = −0.20, P = 0.14). Follow-up growth mixture models identified 4 pain trajectory classes characterized by the following postdiscontinuation pain levels: no pain (average pain at discontinuation = 0.37), mild clinically significant pain (average pain = 3.90), moderate clinically significant pain (average pain = 6.33), and severe clinically significant pain (average pain = 8.23). Similar to the overall sample, pain trajectories in each of the 4 classes were characterized by slight reductions in pain over time, with patients in the mild and moderate pain trajectory categories experiencing the greatest pain reductions after discontinuation (B = −0.11, P = 0.05 and B = −0.11, P = 0.04, respectively). Pain intensity after discontinuation of LTOT does not, on average, worsen for patients and may slightly improve, particularly for patients with mild-to-moderate pain at the time of discontinuation. Clinicians should consider these findings when discussing risks of opioid therapy and potential benefits of opioid taper with patients.

Level of Reconciliation Payments by Safety-Net Hospital Status Under the First Year of the Comprehensive Care for Joint Replacement Program

ABSTRACTBackgroundLittle is known about pain care offered to patients discontinued from long-term opioid therapy (LTOT) by their prescriber due to aberrant behaviors versus other reasons.ObjectiveThis study aimed to compare rates of non-opioid analgesic pharmacotherapy initiation and clinician referrals for non-pharmacologic pain treatment, complementary and integrative pain therapies, and specialty mental health and substance use disorder treatment between patients discontinued from opioid therapy due to aberrant behaviors versus other reasons.DesignThe design included retrospective manual electronic health record review and administrative data abstraction.ParticipantsPatients were sampled from a national cohort of US Department of Veterans Affairs patients prescribed continuous opioid therapy in 2011 who subsequently discontinued opioid therapy in 2012. The study sample comprised 509 patients discontinued from LTOT by opioid-prescribing clinicians.Main MeasuresThe primary independent variable was reason for discontinuation of LTOT (aberrant behaviors versus other reasons). Pain care dichotomous outcomes included clinician use of an opioid taper; initiating new non-opioid analgesic pharmacotherapy; and referrals for non-pharmacologic pain treatment, complementary and integrative pain therapies, and specialty mental health and substance use disorder treatment.Key ResultsWe observed low rates of opioid taper (15% of patients), initiations of new or modifications of existing non-opioid analgesic pharmacotherapy (45% of patients), and clinician referrals for non-pharmacologic pain treatment (58% of patients) and complementary and integrative therapies (25% of patients). Patients discontinued due to aberrant behaviors, relative to patients discontinued for other reasons, were more likely to receive opioid tapers (adjusted OR = 5.60, 95% CI = 2.10–14.93), receive new non-opioid analgesic medications or dose changes to an existing non-opioid analgesic medications (adjusted OR = 2.61, 95% CI = 1.59–4.29), or be referred for specialty substance use disorder treatment (adjusted OR = 7.39, 95% CI = 3.76–14.53).ConclusionsThese findings highlight the variability in referral rates for different types of non-opioid pain treatments and challenges accessing specific types of pain care.

Patient satisfaction with a hospital’s arts-enhanced environment as a predictor of the likelihood of recommending the hospital

This study uses data from the Comprehensive Care for Joint Replacement program to assess the level of Medicare reconciliation payments and examine these levels by hospital size and teaching hospital status to understand hospital performance.

Reasons for discontinuation of long-term opioid therapy in patients with and without substance use disorders

Abstract Background: A multi-component arts initiative was instituted at a non-metropolitan, five-hospital healthcare system. This study examined whether patients’ satisfaction with the hospital arts-enhanced environment was associated with their likelihood to recommend the hospital. Methods: A survey was mailed to a random sample of patients who had been discharged from the five hospitals between 2010 and 2012. Survey items included standard HCAHPS and other questions. Logistic regression was used to identify predictors of patients’ likelihood to recommend. Results: Patients’ ratings of the hospital’s arts environment significantly predicted their likelihood to recommend. Other predictors included demographic variables, provider characteristics, and room conditions. Conclusions: This is one of the first studies to demonstrate that patients’ positive experiences with an arts-enhanced hospital environment are statistically predictive of a higher likelihood of recommending the hospital to others. Modest investment to develop an arts-enhanced environment is recommended for boosting HCAHPS scores and maximizing Medicare reimbursement rates.