FFS Medicaid Research Articles

Changes in Medicaid Fee-for-Service Benefit Design for Substance Use Disorder Treatment During the Opioid Crisis, 2014 to 2021

Medicaid is the largest payer of substance use disorder treatment in the US and plays a key role in responding to the opioid epidemic. However, as recently as 2017, many state Medicaid programs still did not cover the full continuum of clinically recommended care. To determine whether state Medicaid fee-for-service (FFS) programs have expanded coverage and loosened restrictions on access to substance use disorder treatment in recent years. In 2014, 2017, and 2021, a survey on coverage for substance use disorder treatment was conducted among state Medicaid programs and the District of Columbia with FFS programs. This survey was completed by Medicaid program directors or knowledgeable staff. Data analysis was performed in 2022. The following were calculated for a variety of substance use disorder treatment services (individual and group outpatient, intensive outpatient, short-term and long-term residential, recovery support, inpatient treatment and detoxification, and outpatient detoxification) and medications (methadone, oral and injectable naltrexone, and buprenorphine): (1) the percentage of Medicaid FFS programs covering these services and medications and (2) the percentage of Medicaid FFS programs using utilization management policies, such as copayments, prior authorizations, and annual maximums. This study had response rates of 92% in 2014 and 2017 (47 of 51 states) and 90% in 2021 (46 of 51 states). For the 2021 wave, data are reported for the 38 non-managed care organization plan-only states. Between 2017 and 2021, coverage of individual and group outpatient treatment increased to 100% of states, and use of annual maximums for medications decreased to 3% or less (n ≤ 1). However, important gaps in coverage persisted, particularly for more intensive services: 10% of Medicaid FFS programs (n = 4) did not cover intensive outpatient treatment, 13% (n = 5) did not cover short-term residential care, and 33% (n = 13) did not cover long-term residential care. Use of utilization controls, such as copays, prior authorizations, and annual maximums, decreased but continued to be widespread. In this survey study of state Medicaid FFS programs, increases in coverage and decreases in use of utilization management policies over time were observed for substance use disorder treatment and medications. However, these findings suggest that some states still lag behind and impose barriers to treatment. Future research should work to identify the long-term ramifications of these barriers for patients.

Observational Analysis of the Costs Associated with Acute Treatment of Breakthrough Migraine Attacks in Medicaid Patients Using Preventive Therapies.

Medications for preventive treatment of migraine reduce migraine frequency, usually measured by a reduction in monthly migraine days (MMD), but generally do not eliminate the need for acute treatment. To assess the economic impact of treatment-related reductions in frequency, methodological guidance recommends capturing cost differences along the spectrum of MMD. Characterize monthly migraine medication costs along the spectrum of MMD for patients using calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) for prevention. Medicaid State Drug Utilization Data (SDUD) were used to identify formulations and per-unit costs for oral, intranasal, and parenteral migraine-specific medications for acute and preventive treatment used by fee-for-service (FFS) Medicaid enrollees in 2020. National drug codes of relevant therapies were used to match SDUD to formulation characteristics including substance, route of administration, and branded/generic marketing status. Mean per-unit cost and the formulation's share of total prescriptions were estimated. Monthly medication costs were modeled based on formulations' per-unit costs and frequency of acute medication use during clinical trials of CGRP mAbs. In the SDUD, there were 563,338 prescriptions for migraine-specific acute medications; triptans accounted for 97.37%. Triptan formulations prescribed were 83.78% oral tablet, 10.89% orally disintegrating tablet, 2.60% intranasal, and 2.73% parenteral. Dihydroergotamine accounted for < 1% of total prescriptions and had the highest per-unit cost ($443.50, branded intranasal). There were 97,119 prescriptions for CGRP mAbs, the majority for erenumab (45.73%) or galcanezumab (45.24%). Modeled monthly acute and preventive medication costs ranged from approximately $550 in patients with the fewest MMD treated with oral triptans to > $1500 in patients with the most MMD treated with dihydroergotamine. In consideration of the migraine-specific acute medications used in FFS Medicaid 2020, for patients using CGRP mAbs for prevention, medication costs may vary significantly with the number of breakthrough attacks treated per month and the type of migraine-specific acute therapy used.

Coverage and Prior Authorization Policies for Medications for Opioid Use Disorder in Medicaid Managed Care

Medicaid is a key policy lever to improve opioid use disorder treatment, covering approximately 40% of Americans with opioid use disorder. Although approximately 70% of Medicaid beneficiaries are enrolled in comprehensive managed care organization (MCO) plans, little is known about coverage and prior authorization (PA) policies for medications for opioid use disorder (MOUD) in these plans. To compare coverage and PA policies for buprenorphine, methadone, and injectable naltrexone across Medicaid MCO plans and fee-for-service (FFS) programs and across states. This cross-sectional study analyzed MOUD data from 266 Medicaid MCO plans and FFS programs in 38 states and the District of Columbia in 2018. For each medication, the percentages of MCO plans and FFS programs that covered the medication without PA, covered the medication with PA, and did not cover the medication were calculated, as were the percentages of MCO, FFS, and all (MCO and FFS) beneficiaries who were covered with no PA, covered with PA, and not covered. In addition, MCO plan coverage and PA policies were mapped by state. Analyses were conducted from January 1 through May 31, 2022. Coverage and PA policies were compared for MOUD in 266 MCO plans and 39 FFS programs, representing approximately 70 million Medicaid beneficiaries. Overall, FFS programs had more generous MOUD coverage than MCO plans. However, a higher percentage of FFS programs imposed PA for the 3 medications (47.0%) than did MCOs (35.9%). Furthermore, although most Medicaid beneficiaries were enrolled in a plan that covered MOUD, 53.2% of all MCO- and FFS-enrolled beneficiaries were subject to PA. Results also showed wide state variation in MCO plan coverage and PA policies for MOUD and the percentage of Medicaid beneficiaries subject to PA. This cross-sectional study found variation in MOUD coverage and PA policies across Medicaid MCO plans and FFS programs and across states. Thus, Medicaid beneficiaries' access to MOUD may be heavily influenced by their state of residency and the Medicaid plan in which they are enrolled. Left unaddressed, PA policies are likely to remain a barrier to MOUD access in the nation's Medicaid programs.

Associations Between Copays, Coverage Limits for Naloxone, and Prescribing in Medicaid.

Aims:To describe naloxone dispensing in Medicaid fee-for-service (FFS) and examine relationships between copays and coverage limits for naloxone and its dispensing rates.Methods:Cross-sectional study using Medicaid FFS State Drug Utilization Data to quantify the use of naloxone in 2018. The primary outcomes of this study were the proportion of naloxone prescriptions relative to all prescriptions and all opioid prescriptions dispensed in each state. We obtained drug benefit design information from the Medicaid Behavioral Health Services Database. The primary analysis examined the influence of copays (yes/no), copay amounts, and coverage limits on medication dispensing using simple linear regression, excluding states with no measurable use or less than 5% Medicaid FFS.Results:We found substantial variability across 50 states and DC in the proportion of prescriptions dispensed for Narcan and generic naloxone. We found a positive relationship between copay and copay amount and dispensing of generic naloxone. However, a sensitivity analysis including the broadest possible cohort of states failed to confirm this relationship. We found no other relationships between copays or coverage limits and dispensing of any naloxone formulation.Conclusions:Substantial variation exists between the rates of naloxone dispensing across the US for Medicaid patients, but we did not find a meaningful relationship between plan design and dispensing. Whether drug benefit designs in Medicaid influence naloxone use requires further evaluation to avoid limiting access to this life-saving medication.

Difference in Hospital Utilization Within the First 12Months Among Low-Birth-Weight Infants in Medicaid Managed Care Versus Fee-for-Service: A Regression Discontinuity Study.

To examine the effect of Medicaid managed care (MMC) versus Medicaid fee-for-service (FFS) on emergency department (ED) use and hospitalization during the first 6 and 12months of life among low-birth-weight (LBW) infants. We used the New York City Office of Vital Statistics-Statewide Planning and Research Cooperative System (OVS-SPARCS) dataset to identify 9135 LBW infants born to female Medicaid beneficiaries in New York City from January 2008-March 2012. We applied a robust regression discontinuity framework using a New York State Medicaid policy in effect at that time. This policy automatically enrolled infants born to female Medicaid beneficiaries to Medicaid managed care (MMC) or Medicaid fee-for-service (FFS) based on their birth weight (less than 1200g vs. 1200-2500g) during the first 6months of their lives. LBW infants in MMC had an average 0.16% points higher probability of being hospitalized within the first year of their lives than those in Medicaid FFS (p-value = 0.04). More research is necessary to understand possible differences in healthcare utilization between MMC and FFS participants with high health risks.

Medicaid managed care and preventable emergency department visits in the United States.

ObjectivesIn the United States the percentage of Medicaid enrollees in some form of Medicaid managed care has increased more than seven-fold since 1990, e.g., up from 11% in 1991 to 82% in 2017. Yet little is known about whether and how this major change in Medicaid insurance affects how recipients use hospital emergency rooms. This study compares the performance of Medicaid health maintenance organizations (HMOs) and fee-for-service (FFS) Medicaid regarding the occurrence of potentially preventable emergency department (ED) use.MethodsUsing data from the 2003–2015 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the non-institutionalized US population, we estimated multivariable logistic regression models to examine the relationship between Medicaid HMO status and potentially preventable ED use. To accommodate the composition of the Medicaid population, we conducted separate repeated cross-sectional analyses for recipients insured through both Medicaid and Medicare (dual eligibles) and for those insured through Medicaid only (non-duals). We explicitly addressed the possibility of selection bias into HMOs in our models using propensity score weighting.ResultsWe found that the type of Medicaid held by a recipient, i.e., whether an HMO or FFS coverage, was unrelated to the probability that an ED visit was potentially preventable. This finding emerged both among dual eligibles and among non-duals, and it occurred irrespective of the adopted analytical strategy.ConclusionsWithin the U.S. Medicaid program, Medicaid HMO and FFS enrollees are indistinguishable in terms of the occurrence of potentially preventable ED use. Policymakers should consider this finding when evaluating the pros and cons of adopting Medicaid managed care.

Pediatric outpatient utilization by differing Medicaid payment models in the United States

BackgroundIn the United States (US), Medicaid capitated managed care costs are controlled by optimizing patients’ healthcare utilization. Adults in capitated plans utilize primary care providers (PCP) more than emergency departments (ED), compared to fee-for-service (FFS). Pediatric data are lacking. We aim to determine the association between US capitated and FFS Medicaid payment models and children’s outpatient utilization.MethodsThis retrospective cohort compared outpatient utilization between two payment models of US Medicaid enrollees aged 1–18 years using Truven’s 2014 Marketscan Medicaid database. Children enrolled > 11 months were included, and were excluded for eligibility due to disability/complex chronic condition, lack of outpatient utilization, or provider capitation penetration rate < 5% or > 95%. Negative binomial and logistic regression assessed relationships between payment model and number of visits or odds of utilization, respectively.ResultsOf 711,008 children, 66,980(9.4%) had FFS and 644,028(90.6%) had capitated plans. Children in capitated plans had greater odds of visits to urgent care, PCP-acute, and PCP-well-child care (aOR 1.21[95%CI 1.15–1.26]; aOR 2.07[95%CI 2.03–2.13]; aOR 1.86 [95%CI 1.82–1.91], respectively), and had lower odds of visits to EDs and specialty care (aOR 0.82 [95%CI 0.8–0.83]; aOR 0.61 [95%CI 0.59–0.62], respectively), compared to FFS.ConclusionsThe majority of children in this US Medicaid population had capitated plans associated with higher utilization of acute care, but increased proportion of lower-cost sites, such as PCP-acute visits and UC. Health insurance programs that encourage capitated payment models and care through the PCP may improve access to timely acute care in lower-cost settings for children with non-complex chronic conditions.

Impact of Removing Medicaid Fee-for-Service Hepatitis C Virus (HCV) Treatment Restrictions on HCV Provider Experience with Medicaid Managed Care Organizations in New York City.

Immediately after the approval of direct-acting antiviral medications for the treatment of hepatitis C virus (HCV) in 2013, state Medicaid programs limited access to these expensive treatments based on liver disease stage, absence of active alcohol or substance use, and prescriber limitations. New York State fee-for-service (FFS) Medicaid eliminated these requirements in May 2016, but the effect on providers and patients obtaining prior authorization (PA) from Medicaid managed care organizations (MCOs) was unknown. We used a mixed methods approach to assess whether the removal of HCV treatment restrictions was associated with changes in Medicaid MCOs' PA approval processes and length of time to treatment initiation at two large urban New York City provider organizations participating in Project INSPIRE, an HCV care coordination demonstration project. At baseline, the top criteria for clinic care coordinators ranking MCOs as being "most difficult" were liver staging criteria, delayed treatment, and requiring a urine toxicology test. At follow-up, liver staging criteria were replaced by medication formulary limitations. Univariate analysis of the Project INSPIRE participant data suggests a decrease in the percentage of participants with insurance/PA-related treatment delays pre- versus post-policy change (23% versus 15%, p value = 0.02). Interrupted time series analysis found a 2 percentage point decrease (p value = 0.02) in the proportion of PAs each month with insurance-related treatment delays that was attributable to policy change. These results from two urban clinics indicate New York State FFS Medicaid's policy change for HCV treatment may have been associated with some changes in Medicaid MCO PA decisions, but MCO PA denials and treatment delays were still observed "on the ground" by clinic staff.

Is enrollment in a Medicaid health maintenance organization associated with less preventable hospitalizations?

IntroductionThe objective of this study is to compare the performance of Medicaid health maintenance organizations (HMOs) and fee-for-service (FFS) Medicaid regarding the prevalence of potentially preventable hospitalizations, a recognized measure of outpatient care quality.MethodsThis study used nationally representative data on non-institutionalized Medicaid recipients, ages 18–64, from the 2003–2012 Medical Expenditure Panel Survey. Separate analyses are conducted for recipients insured through both Medicaid and Medicare (“dual eligibles”) and recipients whose only health insurance is Medicaid (“non-duals”). In each group the occurrence of potentially preventable hospitalizations is measured, and then survey-weighted multivariable logistic regression models are fit to quantify the relationship between Medicaid HMO status and the occurrence of such stays. The possibility of selection bias into HMOs is considered and explicitly addressed in model estimation using propensity score methods.ResultsAdjusting for covariates and confounders dual eligible enrolled in Medicaid managed care are more likely to have a potentially preventable hospitalization relative to those covered under FFS Medicaid (survey weighted logit model OR = 1.72, 95% CI = 0.98–3.03; propensity score weighted logit model OR = 1.87, 95% CI = 1.06–3.28). In contrast, the odds ratios did not differ among non-duals in Medicaid HMOs versus FFS Medicaid.ConclusionThese findings suggest that, at least for dual eligibles, the quality of outpatient care in Medicaid HMOs may be worse than under FFS Medicaid. Better and more streamlined clinical preventive approaches for this high risk and vulnerable population might be required in Medicaid HMOs.

Oregon's Coordinated Care Organization Experiment: Are Members' Experiences of Care Actually Changing?

In 2012, Oregon embarked on an ambitious plan to redesign financing and care delivery for Medicaid. Oregon's Coordinated Care Organizations (CCOs) are the first statewide effort to use accountable care principles to pay for Medicaid benefits. We surveyed 8,864 Medicaid-eligible participants approximately 1 year before and 12 months after CCO implementation to assess the impact of CCOs on member-reported outcomes. We compared changes in outcomes over time between Medicaid CCO members, Medicaid fee-for-service (FFS) members, and those who were uninsured. After 1 year, Medicaid beneficiaries enrolled in CCOs reported better access to care, better quality care, and better connections to primary care than Medicaid FFS or uninsured persons. We did not find early evidence of improvements in preventive care and screenings or in ED utilization. Although these are early indicators, results suggest that Oregon's delivery system transformation is having a positive impact on patient experience outcomes.

Peering Behind the Veil: Trends in Types of Contracts Between Private Health Plans and Hospitals

Contracting between private health plans and hospitals has been described as “chaos behind a veil of secrecy.” Contract types — e.g. discounted charges versus per diems — profoundly influence providers’ incentives and health plan spending, but remain largely hidden. We develop a novel algorithm that classifies inpatient claims as one of three contract types — discounted charges, fixed rates, or per diems — and apply it to the 2009-2014 Colorado All Payer Claims Database. Of $1.9 billion in payments by private health plans for inpatient care in Colorado, $1.1 billion could be classified, and, of classifiable payments, 42% were fixed rates, 41% were discounted charges, and 16% were per diems. From 2009 to 2014, the share of private payments classified as fixed rates increased sharply in Colorado, from 11% to 43%, while discounted charges declined from 69% to 29%. We also describe the distribution of contract types across types of hospitals and clinical conditions, and payers. To test the validity of our algorithm, we apply it to Colorado Medicare fee-for-service (FFS) claims (2014 only), and Colorado Medicaid FFS claims (2009-2014)–both — both of those programs are known primarily to pay for hospital inpatient care using fixed rates. Reassuringly, our algorithm classifies more than three quarters of both Medicare and Medicaid FFS payments as fixed rates, and exceptions to the fixed-rate classification align with known special payment provisions.

Trends in Medicaid fee-for-service outpatient drug utilization, expenditures, and pharmacy reimbursement rates (2010–2012)

Purpose: To assess drug utilization and expenditure trends in Medicaid fee-for-service program during the period 2010 – 2012 in the United States of America. Methods: A retrospective, descriptive analysis of the trend in drug utilization and expenditures in the Medicaid fee-for-service (FFS) program was performed using Medicaid state drug utilization data provided by Centers for Medicare and Medicaid Services (CMS) in the United States. Descriptive analyses were performed for all variables in the study. Association between prescription-drug utilization and reimbursement rate was examined using a linear regression model. Results: The results indicate that prescription-drug utilization of Medicaid FFS program decreased by 20 % during the period (2010 – 2012) as also drug expenditure during the same period. Although constituting nearly 70 % and about 75 % of the total drug utilization in 2010 and 2012, respectively, generics represent only around 18 % of the total drug expenditures. No statistically significant association was found between total expenditures and the reimbursement rate. Conclusion: FFS Medicaid drug expenditures decreased from 2010 to 2012 mainly due to a reduction in the total number of prescriptions as also the prices of generic drugs. Thus, higher utilization of generic drugs may offer substantial savings to Medicaid programs at the state level. Keywords: Fee-for-service programs, Medicaid program, Generic drug utilization; Branded drugs, Patient Protection and Affordable Care Act

Polypharmacy and Multimorbidity Among Medicaid Enrollees: A Multistate Analysis.

The purpose of this study is to explore the associations between polypharmacy and multimorbidity using conventional and novel measures of polypharmacy. In this cross-sectional study, data on fee-for-service (FFS) Medicaid enrollees with at least 1 chronic condition and aged 18-64 years (N = 38,329) were derived from the 2010 Medicaid Analytic eXtract (MAX) files of Maryland and West Virginia. Polypharmacy, by the authors' novel definition, was determined as simultaneous use of ≥5 drugs for a consecutive period of 60 days. Multimorbidity was defined as having ≥2 chronic conditions based on the US Department of Health and Human Services framework. The association between multimorbidity and polypharmacy was examined with chi-square tests and logistic regression. Polypharmacy prevalence was estimated at 50.9% using the novel definition, as compared to 16.7% and 64.9% for the 2 commonly used conventional measures, respectively. For all 3 definitions, individuals with multimorbidity were more likely to have polypharmacy than those without multimorbidity (P < 0.001). The authors also consistently found, using all definitions, that those who were older, female, white, and eligible for Medicaid because of cash assistance were more likely to have polypharmacy (all P < 0.001). Polypharmacy was highly prevalent and significantly associated with multimorbidity among Medicaid FFS enrollees irrespective of the definitions used. The new measure may provide a more comprehensive and accurate estimation of polypharmacy than the conventional measures. These findings suggest the need for a paradigm shift from disease-specific care to patient-centered collaborative care to manage patients with multimorbidity and polypharmacy.

Comparison of Medicaid Payments Relative to Medicare Using Inpatient Acute Care Claims from the Medicaid Program: Fiscal Year 2010-Fiscal Year 2011.

To compare Medicaid fee-for-service (FFS) inpatient hospital payments to expected Medicare payments. Medicaid and Medicare claims data, Medicare's MS-DRG grouper and inpatient prospective payment system pricer (IPPS pricer). Medicaid FFS inpatient hospital claims were run through Medicare's MS-DRG grouper and IPPS pricer to compare Medicaid's actual payment against what Medicare would have paid for the same claim. Average inpatient hospital claim payments for Medicaid were 68.8 percent of what Medicare would have paid in fiscal year 2010, and 69.8 percent in fiscal year 2011. Including Medicaid disproportionate share hospital (DSH), graduate medical education (GME), and supplemental payments reduces a substantial proportion of the gap between Medicaid and Medicare payments. Medicaid payments relative to expected Medicare payments tend to be lower and vary by state Medicaid program, length of stay, and whether payments made outside of the Medicaid claims process are included.

Medicare and Medicaid enrollment and outside hospitalizations among HIV-infected and uninfected veterans engaged in VA care: a retrospective cohort study.

BackgroundMany veterans engaged in care with the Veterans Administration (VA) health system are also enrolled in Medicare and/or Medicaid and may receive care both inside and outside of the VA. Use of dual health systems has been associated with worse outcomes. Veterans with HIV may have different rates of Medicare and Medicaid enrollment and may be at greater risk of poor outcomes related to non-VA use. This study compares the frequency and factors associated with Medicare and/or Medicaid enrollment and non-VA use in an HIV-infected and uninfected population of veterans.MethodsWe used data from the VA and Center for Medicare & Medicaid Services from 2004 and 2005 to determine the frequency of Medicare and/or Medicaid enrollment among a cohort of HIV-infected and uninfected veterans engaged in VA care. We then restricted the cohort to veterans enrolled in fee-for-service (FFS) Medicare and/or Medicaid with at least one hospitalization and identified characteristics associated with non-VA hospital admissions.ResultsHIV-infected veterans had higher rates of Medicare and/or Medicaid enrollment than uninfected veterans (38% vs. 33%, p < 0.01), though the opposite was true when our sample was limited to veterans 65 years and older (53% vs. 70%, p < 0.0 1). Among veterans enrolled in the VA and FFS Medicare and/or Medicaid, veterans with HIV had greater illness severity and more frequent hospitalizations, but were less likely to be hospitalized outside the VA (48% vs. 54%, p < 0.01). HIV infection was associated with lower odds of outside hospitalization (OR = 0.76 [95% CI: 0.68, 0.85]).ConclusionsVeterans with HIV have higher rates of Medicare and/or Medicaid enrollment, but lower odds of non-VA hospitalization. The VA integrated model of HIV care may discourage outside use among HIV-infected veterans.

Patterns of Cervical Cancer Screening, Diagnosis, and Follow-up Treatment in a State Medicaid Fee-for-Service Population

Despite being a screening-amenable cancer, cervical cancer is the third most common genital cancer among white women and the most common among African American women. The study objective was to use administrative claims data for CC disease surveillance among recipients enrolled in a state Medicaid fee-for-service (FFS) program. West Virginia (WV) Medicaid FFS administrative claims data for female recipients aged 21-64 years from 2003 to 2008 were used for this study. All medical and prescription claims were aggregated to reflect each recipient's medical care and prescription drug utilization. The yearly prevalence of Pap smear testing declined from 23.9% in 2003 to 15.8% in 2008 in the Medicaid FFS population. During the 6-year study period, persistence with Pap smear testing was low; 41.8% of recipients received no Pap smear testing. Only 73.1% of recipients received Pap smear testing during the year prior to their CC or precancerous cervical lesions (PCL) diagnosis. The likelihood of a CC diagnosis increased with a decrease in Pap smear testing persistence. Only 10.1% of recipients received appropriate follow-up care following a diagnosis of high-grade PCL; only 31.5% of the recipients received appropriate follow-up care for low-grade PCL diagnosis. Although CC preventive services such as screening and PCL follow-up care are covered under Medicaid programs, underutilization of these services by recipients in the Medicaid FFS population is a concern. Results of this study emphasize the need to address disparities in screening and appropriate PCL follow-up care among recipients in the Medicaid FFS population.

PMS40 Medication Adherence among Patients with Rheumatoid Arthritis

The main objective of this study was to assess the medication adherence among individuals with rheumatoid arthritis (RA) enrolled in a state Medicaid fee-for-service (FFS) program. Factors influencing medication adherence were identified. Lastly, the role of adherence in influencing the utilization of acute care services (hospitalization/emergency room visit) was ascertained. The target population included nonelderly adult recipients (21-64 years) who were continuously enrolled in the Mississippi Medicaid FFS program from January 1, 2006 to December 31, 2007. Recipients who had a medical services claim with a primary or secondary diagnosis of RA in calendar year 2006 were identified. Medication adherence (measured as proportion of days covered (PDC)) was determined using calendar year 2007 data. Recipients with adherence (PDC) ≥80% were classified as adherent. Logistic regression analyses were used to determine factors predicting medication adherence and the effect of adherence on acute care services utilization. Roughly 20% of recipients with RA were adherent. Older age (odds ratio (OR) = 1.031; p<0.005), white race (OR= 1.684; p<0.005), and lower Charlson comorbidity index (CCI) score (OR= 0.785; p<0.005) were significant predictors of adherence. Adherence did not have a significant association with acute care services utilization after controlling for demographic and disease-related covariates. Only one in five Medicaid recipients with RA were found to be adherent. Lower levels of adherence among individuals with RA could contribute to poor outcomes in these individuals over time. Policy makers should undertake intervention programs aimed at increasing medication adherence in this underprivileged population.

Declining mammography screening in a state Medicaid Fee-for-Service program: 1999-2008.

To evaluate and compare annual and biennial mammography screening rates across age, race, and geographic location (rural-urban) and to determine mammography screening persistence over 10 years among women enrolled in the West Virginia (WV) Medicaid Fee-for-Service (FFS) program. The WV Medicaid FFS administrative claims data for women recipients aged 40-64 from 1999 to 2008 were used for study purposes. Annual and biennial screening rates and persistence with screening were determined for women who were continuously enrolled in the WV Medicaid FFS program for respective calendar years. A steady decline in the annual and biennial screening rates over a 10-year period (1999-2008) was observed among women recipients aged 40-64 years in the WV Medicaid FFS program, and screening persistence was also lower. Both annual and biennial screening rates and persistence varied by different demographic characteristics. Although mammography screening services are covered under Medicaid programs, underuse persists as a major concern. The results of this study emphasize the need to identify and address barriers to mammography screening in low-income rural populations.

Use and cost of psychotropic drugs among recipients with autism in a state Medicaid fee‐for‐service programme

There has been a significant increase in the prevalence of autism in the USA in the past few decades. The purpose of this study was to provide recent estimates of psychotropic drug use and costs among individuals with autism enrolled in Medicaid programme. A cross-sectional analysis of 2007 Mississippi (MS) Medicaid fee-for-service (FFS) programme administrative-claims data was performed. Study sample included recipients (<65 years) who had a medical services claim with a diagnosis of autism in 2007. Psychotropic drug patterns of use and costs were studied. Factors predicting the use of psychotropic drugs were identified using logistic regression analyses. Average number and cost of psychotropic drug claims per recipient were reported. Costs were reported from the perspective of MS Medicaid. In 2007, there were 1330 recipients with a diagnosis of autism in MS Medicaid FFS programme. Among these recipients, 66.32% had a claim for psychotropic drug during the year. Roughly 39% of recipients with autism had a claim for antipsychotics, 31.58% for stimulants, 19.55% for antidepressants, 19.40% for other psychotropics and 14.81% for anxiolytics/hypnotics/sedatives. Results from regression analyses highlighted variation in psychotropic drug use by demographic and co-morbid factors. There were a total of 12,618 claims for psychotropic drugs filled by recipients with autism in 2007, at an average of 14 (±12) claims per recipient. The total cost of these claims paid for by MS Medicaid FFS programme was ∼$2 million. Antipsychotics accounted for more than half (∼58%) of the total costs, and had the highest average cost per claim ($291 ± 205). The results of this study indicate a high use of psychotropic drugs among individuals with autism enrolled in a state Medicaid programme. There is an urgent need to study the risk-benefit profile of these drugs in this growing population. Psychotropic drug use was found to vary by demographic and co-morbid factors. Among the different classes of psychotropic drugs, antipsychotics were the most commonly used and had the highest cost per claim.

Prevalence, Healthcare Utilization, and Costs of Breast Cancer in a State Medicaid Fee-for-Service Program

The purpose of this study was to determine the prevalence, medical services and treatment utilization, and costs associated with breast cancer in a socioeconomically underprivileged population covered by a state Medicaid fee-for-service (FFS) program. We analyzed the West Virginia (WV) Medicaid FFS administrative claims data for women recipients 21-64 years of age enrolled continuously in the program during the calendar year 2005. Breast cancer-related medical services and treatment use and costs were calculated for women recipients with breast cancer. The excess burden of breast cancer was calculated by comparing the all-cause healthcare utilization and costs among women recipients with breast cancer to a matched control group of women recipients without breast cancer. Healthcare costs incurred during the 1-year study period were calculated from the perspective of state Medicaid. Cost estimates in the study excluded out-of-pocket expenses and indirect costs of breast cancer. In 2005, the prevalence of breast cancer in the WV Medicaid FFS program was 22.7/1000. More than 98% of breast cancer-related medical services utilization occurred in the office setting. Approximately 73% of women recipients with breast cancer had at least one claim for breast cancer treatment, with hormone therapy being the most common (55.1%) treatment. The all-cause healthcare costs were significantly higher for women recipients with breast cancer compared to those without breast cancer ($16,345 vs. $13,027, p<0.001). Consistent with our expectations, breast cancer diagnosis among women recipients in the WV Medicaid FFS program was found to be associated with higher all-cause healthcare use and costs compared to women recipients in the matched control group. The excess cost burden associated with breast cancer could be attributed to higher office visit, emergency room visit, and prescription medication use among recipients with breast cancer.