Managed Care Organizations Research Articles

Impact of Social Needs in Electronic Health Records and Claims on Health Care Utilization and Costs Risk-Adjustment Models Within Medicaid Population.

Patients enrolled in Medicaid have significantly higher social needs (SNs) than others. Using claims and electronic health records (EHRs) data, managed care organizations (MCOs) could systemically identify high-risk patients with SNs and develop population health management interventions. Impact of SNs on models predicting health care utilization and costs was assessed. This retrospective study included claims and EHRs data on 39,267 patients younger than age 65 years who were continuously enrolled during 2018-2019 in a Medicaid-managed care plan. SN marker was developed suggesting presence of International Classification of Diseases, 10th revision codes in any of the 5 SN domains. Impact of SN marker was compared across demographic and 2 diagnosis-based (ie, Charlson and Adjusted Clinical Groups risk score) prediction models of emergency department (ED) visit and hospitalizations, and total, medical, and pharmacy costs. After combining data sources, prevalence of documented SN marker increased from 11% and 13% to 18% of the study population across claims, EHRs, and both combined, respectively. SN marker improved predictions of demographic models for all utilization and total costs outcomes (area under the curve [AUC] of ED model increased from 0.57 to 0.61 and R2 of total cost model increased from 10.9 to 12.2). In both diagnosis-based models, adding SN marker marginally improved outcomes prediction (AUC of ED model increased from 0.65 to 0.66). This study demonstrated feasibility of using claims and EHRs data to systematically capture SNs and incorporate in prediction models that could enable MCOs and policy makers to adjust and develop effective population health interventions.

North Carolina's six BH MCOs unite on foster care services plan

North Carolina's six behavioral health managed care organizations (MCOs) have launched the N.C. Child and Family Improvement Initiative as a collective first move to providing an alternative to a proposed statewide foster‐care services plan, the Winston‐Salem Journal reported on June 4. Although spokespersons for the MCOs provided few details last week about the initiative, they expect “the immediate improvements resulting from this partnership will be fully functional before the planned Dec. 1, 2022 launch of the North Carolina Department of Health's Behavioral Health and Intellectual/Developmental Disabilities Tailored Plans, an integrated care plan for people with serious behavioral health care needs, substance use disorder and/or disabilities. The MCOs said a primary goal of the initiative is to demonstrate their ability “to implement a statewide model to ensure seamless access to quality care for these children and families regardless of where they live in North Carolina. For those children with very complex behavioral health needs, often inclusive of intellectual/developmental disabilities needs, there are regularly challenges in securing needed treatment. Severe provider capacity issues and workforce shortages across the state have exacerbated these challenges.” The MCOs said their plan will address concern expressed by state legislators, county departments of social services, providers and families of service recipients.

A Tale of Two Trials: A Comparative Case Study of Successful versus Terminated Home-Based Palliative Care Trials.

Background: In 2007 we published a trial of home-based palliative care (HBPC) conducted in a managed care organization (MCO) that found significant improvements in patient satisfaction with health care, rates of home deaths, and reductions in health care use and costs. A decade later, we undertook a similar trial of HBPC within accountable care organizations (ACOs) funded by the Patient-Centered Outcomes Research Institute. This trial tested the same model using similar eligibility criteria and recruitment strategies as the earlier trial, yet it failed to achieve its enrollment targets. Objectives: To understand key differences in the trials that contributed to the success of one and failure of the other. Methods: We conducted a comparative case study of the original MCO HBPC trial and the subsequent ACO HBPC trial. Two researchers familiar with both trials reviewed both quantitative and qualitative data obtained from previous analyses and publications to develop a rich, in-depth understanding of each study. Results: We identified four differences that explain in large part why the ACO trial failed while the MCO trial succeeded. These differences center on the trials' setting, target populations, outreach strategies, and providers' understanding of palliative care. Discussion: Our findings demonstrate the challenges in conducting research in complex health care systems and how physician and setting structures along with target population and lack of general palliative care knowledge can influence the success of research. Conclusion: Future HBPC trials must consider the strengths and weaknesses of trial design factors when partnering with multiple health care organizations. ClinicalTrials.gov Identifier: NCT03128060.

State Expectations and Medicaid Managed Care Organizations' Efforts to Address the Social Needs of Medicaid Enrollees.

Existing work on states' efforts to address the social needs of Medicaid enrollees indicate the implementation of several state-level strategies to move Medicaid Managed Care Organizations (MMCOs) toward the provision of whole-person care. However, less is known about how these expectations drive MMCOs' SDOH efforts. To address this gap, we interviewed representatives of eight MMCOs (N=28) and 12 state Medicaid offices (N=17). Participants described varying state-implemented instruments for encouraging an SDOH-focus among MMCOs, including both coercive (e.g., contractual mandates) and subtle approaches (e.g., request for proposal process and performance measurement expectations). However, regardless of states' expectations, MMCOs, driven by organizational and industry-related factors, recognized the importance of addressing SDOH as part of a holistic approach to health care. Collectively, regulatory pressures, organizational strategy, and market forces influenced MMCOs' efforts to address SDOH leading to a normalization of their role in addressing members' social needs within a medical paradigm.

Long-term reoperation risk after apical prolapse repair in female pelvic reconstructive surgery

Although several different apical suspension procedures are available to women with pelvic organ prolapse, data on long-term efficacy and safety profiles are limited. The primary aim of this study was to analyze longitudinal reoperation risk for recurrent prolapse among the 4 apical suspension procedures over 2 to 15 years. Secondary aims included evaluation of all-cause reoperation, defined as a repeated surgery for the indications of recurrent prolapse and adverse events, and total retreatment rate, which included a repeated treatment with another surgery or a pessary. This was a multicenter, retrospective cohort study within Kaiser Permanente Southern California that included women who underwent sacrocolpopexy, uterosacral ligament suspension, sacrospinous ligament fixation, or colpocleisis from January 2006 through December 2018. Women who underwent concomitant rectal prolapse repair or vaginal prolapse repair with mesh augmentation were excluded. Data were abstracted using procedural and diagnostic codes through July 2021, with manual review of 10% of each variable. Patient demographics and pessary use were compared using analysis of variance or chi square tests for continuous and categorical variables, respectively. Time-to-event analysis was used to contrast reoperation rates. A Cox regression model was used to perform an adjusted multivariate analysis of the following predictors of reoperation for recurrence: index surgery, concomitant procedures, patient demographics, baseline comorbidities, and year of index surgery. Censoring events included exit from the health maintenance organization and death. The cohort included 9681 women with maximum follow-up of 14.8 years. The overall incidence of reoperation for recurrent prolapse was 7.4 reoperations per 1000 patient-years, which differed significantly by type of apical suspension (P<.0001). The incidence of reoperation was lower after colpocleisis (1.4 events per 1000 patient-years) and sacrocolpopexy (4.8 events per 1000 patient-years) when compared with uterosacral ligament suspension (9 events per 1000 patient-years) and sacrospinous ligament fixation (13.9 events per 1000 patient-years). All pairwise comparisons between procedures were significant (P=.0003-.0018) after correction for multiplicity, except for uterosacral ligament suspension or uterosacral ligament hysteropexy vs sacrospinous ligament fixation or sacrospinous ligament hysteropexy (P=.05). The index procedure was the only significant predictor of reoperation for recurrence (P=.0003-.0024) on multivariate regression analysis. Reoperations for complications or sequelae (overall 2.9 events per 1000 patient-years) also differed by index procedure (P<.0001) and were highest after sacrocolpopexy (4.4 events per 1000 patient-years). The incidence of all-cause reoperation for recurrence and adverse events after sacrocolpopexy, however, was comparable to that of the other reconstructive procedures (P=.1-.4) in pairwise comparisons with Bonferroni correction. Similarly, frequency of pessary use differed by index procedure (P<.0001) and was highest after sacrospinous ligament fixation at 9.3% (43/464). Among nearly 10,000 patients undergoing prolapse surgery within a large managed care organization, colpocleisis and sacrocolpopexy offered the most durable obliterative and reconstructive prolapse repairs, respectively. All-cause reoperation rates were lowest after colpocleisis by a large margin, but similar among reconstructive apical suspension procedures.

Opioid prescribing patterns in a commercially insured population

BackgroundClaims data evaluations have advanced our understanding about patient risk factors and predictors for opioid misuse and aid in patient identification. However, less evidence is available to guide the identification of prescribers with at-risk prescribing practices. Thus, an algorithm was developed to identify prescribers with outlying patterns of opioid prescriptions in a managed care organization. MethodsA retrospective analysis used enrollment, prescription, and medical claims data from September-December 2019 to identify prescribers of schedule II, III or IV opioid analgesic medications. Criteria were used to characterize these prescribers as frequent, continuous, and/or high-dose prescribers of opioids. ResultsFor prescribers with > 25 patients with any prescriptions, the algorithm identified 5136 prescribers who had prescribed at least one opioid. This group of prescribers accounted for 53.9% of the total opioids prescribed and wrote an average of 6.5 opioid prescriptions per prescriber during a 3-month period. There were 629 prescribers (12.2%) that had prescribed an opioid to ≥ 50% of their population (frequent prescribers); 493 prescribers (9.6%) that had prescribed >185 day-supply of opioids within 6 months to 10% or more of their population (continuous prescribers); 147 prescribers (2.9%) that had prescribed an average daily MME > 90 mg to ≥ 10% of their population in the most recent 90 days (high-dose prescribers); and 47 prescribers (0.9%) that met all three criteria. ConclusionsThe algorithm identified a targeted prescriber group to employ resources to mitigate opioid misuse and abuse. Flexible criteria for frequent, continuous, and/or high-dose prescribing allows tailoring to the needs of different managed care organizations.

Directory Accuracy and Timely Access in Maryland's Medicaid Managed Care Program.

We assessed provider directory accuracy and timely access in Maryland's Medicaid managed care program, using annual surveys from the annual random and representative provider surveys conducted on behalf of the Maryland Department of Health for 2018 and 2019. Based on 3,262 calls to 2,002 providers in 2018 and 2,739 calls to 2,033 providers in 2019, we found that provider directories are highly inaccurate. Insurance coverage could only be verified for 46% of the listed providers in 2018 and 56% of the listed providers in 2019. Among providers whose insurance participation was verified, beneficiaries were able to schedule timely general care appointments in 90% of verified providers in 2018 and 85% of verified providers in 2019; slightly more than 70% of appointments were scheduled on the first call. The success rate for urgent care appointments was lower but improved substantially once alternative providers were accounted for. Even for verified providers, timely access standards were often not met, particularly for general care. We also note the substantial variation across managed care organizations and across years. Our findings raise concerns from both an enrollee as well as a broader policy perspective. More oversight and enforcement are necessary to guarantee access to care.

Association of Counseling and Psychotherapy on Retention in Medication for Addiction Treatment Within a Large Medicaid Population.

Buprenorphine/naloxone is an effective medication for the treatment of opioid use disorder. Unlike methadone, which can only be dispensed in federally waived clinics and which must be combined with specific psychosocial treatment, buprenorphine can be dispensed by individual prescribers who have completed an 8-hour training program, with no requirement that patients receive concomitant psychotherapy. The objective of this study is to quantify the association of counseling and psychotherapy on retention in treatment. We also examine the effect of buprenorphine dosage on retention. We examined a cohort of 4987 members of a not-for-profit managed care organization serving Medicaid members in 41 counties in Pennsylvania. This cohort was selected from all members who had a full year without any medication for opioid use disorder followed by initiation of treatment with buprenorphine/naloxone in 2016 to 2017 and who remained Medicaid eligible for at least 80% of the following 2 years. Outcomes were estimated using inverse probability weighted propensity scores. The addition of counseling and psychotherapy within the first 8 weeks of treatment was associated with greater total retention in treatment and there was a dose-response relationship. A 16 mg/d or greater dose of buprenorphine was also associated with greater retention. These results provide support for an integrated approach to treating people with an opioid use disorder, through a combination of buprenorphine pharmacotherapy and targeted counseling and psychotherapy within the first 2 months of treatment.

Moving Publicness Forward: Merging Moulton and Merritt’s Frameworks to Examine Managed Care Organizations

Abstract Publicness work focuses on the unique characteristics that make an organization more, or less, public, and dates back to the late 70s. Despite the range of publicness research that exists, the characteristics explored remain largely unchanged. However, merging Merritt’s (2019) primary influences that make an organization public and Moulton’s (2009) realized publicness frameworks provides the structure necessary to explore a broader conceptualization of organizational publicness. This study pushes theory forward by considering aspects of publicness beyond political authority-specific characteristics and uses behavioral health managed care organizations (MCOs) as the tool for exploration. This work outlines propositions, offers metrics that can be used in future studies, and explores how the framework can be valuable and what it might reveal in organizational settings beyond MCOs.

ASCP, PQA, and AMDA: A Collaboration Using Quality Measures to Advocate for Best Senior Care

View Large Image Figure ViewerDownload Hi-res image Download (PPT)The American Society of Consultant Pharmacists (ASCP) is a membership association that was founded in 1969 to represent pharmacists and other health care professionals who work with older adults. ASCP’s mission is “to promote healthy aging by empowering pharmacists with education, resources, and innovative opportunities” (“ASCP: Empowering Pharmacists; Transforming Aging,” https://www.ascp.com/page/about). The Pharmacy Quality Alliance (PQA) is a nonprofit and consensus-based “national quality organization dedicated to improving medication safety, adherence, appropriate use” (“About PQA,” https://www.pqaalliance.org/our-story). They provide medication management services through performance measurement, research, and education, and are in a public-private partnership with the Centers for Medicare & Medicaid Services (see “PQA Measure Development Process, Version 4.0,” Oct. 25, 2021, https://bit.ly/369SPRx). The relationships between PQA and ASCP and between ASCP and AMDA – The Society for Post-Acute and Long-Term Care Medicine highlight the benefits of collaboration to optimize patient care. By aligning the clinical and financial goals among these organizations to improve outcomes, this model of collaboration has demonstrated its value for successful results. As a PQA member organization, ASCP works with PQA in multiple ways. ASCP contributes subject matter expertise during measure development and maintenance. ASCP also serves in an advisory role as measures are vetted and finalized for adoption to support measure implementation strategies via its professional relationships. ASCP’s interest in promoting adoption of measures is inclusive of the regulatory level by government agencies and at the grassroots level with allied pharmacy organizations and their membership. ASCP’s consultant pharmacists partner with other ASCP members and any aligned health care team members, including facility data collection providers (e.g., Minimum Data Set [MDS] coordinators) to ensure education about measures and accuracy in the data coding process. Additionally, they provide traditional medication regimen review services, comprehensive medication reviews for Medicare D beneficiaries in post-acute and long-term care, additional residential care settings, and novel emerging community and telehealth practices. One example of how ASCP has collaborated with PQA to provide subject matter expertise on a specific PALTC concern is the “Antipsychotic Use in Persons with Dementia (APD)” measure, which “evaluates the percentage of individuals with dementia with a prescription claim for an antipsychotic medication without evidence of a psychotic disorder or related condition.” It was also “adapted for the long-term care setting using MDS data” (“PQA Measures Overview,” Sept. 23, 2021, https://bit.ly/3oUKx6w). ASCP also collaborated with PQA to understand the intent of the current APD quality measure and identify opportunities for continued quality improvement, which informed ASCP’s policy and position statement on the “Use of Antipsychotic Medications in Nursing Facility Residents” (Apr. 1, 2018, https://bit.ly/3HZLH8u). The position statement aligns the partnership and mission of ASCP with that of AMDA. ASCP members work closely with their facility clients at the corporate ownership, medical leadership, and administrative executive levels to complement the entity’s focus on quality measures. ASCP consultant pharmacists, ASCP member provider pharmacies, and pharmacy managed care organizations ensure alignment with these mutual goals. They work side by side with the Society’s members to ensure that quality measures are shared, strategized, and implemented to ensure individual providers are held accountable for meeting the goals. Finally, the partnership between ASCP and the Society uses publicly collected data on outcomes statistics related to the measures and compares performance with benchmark state and national averages. Data indicators of poor performance become a focus for attention, including the use of vehicles such as facility Quality Assurance Performance Improvement (QAPI) activities. “PQA’s mission to optimize health by advancing the quality of medication use is supported by collaboration with ASCP,” said PQA Chief Quality and Innovation Officer Lisa Hines, PharmD, CPHQ. “Our work together and ASCP’s collaboration with AMDA enhances our strategies and ability to promote safe and appropriate medication use for older adults.” The information presented is a selective summary of publicly available information and is accurate as of the date of writing. Please consult the sources for complete reference information. Dr. Manzi has been a licensed pharmacist since 1990 and a Board Certified Geriatric Pharmacist since 1998. She is the director of LTC clinical services at Managed Health Care Associates, Inc. The views expressed in this article are those of the author(s) alone and not of Managed Health Care Associates, Inc. Robert C. Accetta is the president/owner of Rivercare Consulting, LLC. A Board-Certified Geriatric Pharmacist, Rob currently serves on the Board of Directors of the American Society of Consultant Pharmacists (ASCP). He is a graduate of St. John’s University College of Pharmacy and Health Sciences in New York.

Retrospective Evaluation Of Suspected Vs. Confirmed Transthyretin Amyloid Cardiomyopathy (ATTR-CM) Cases

<h3>Intoduction</h3> Transthyretin amyloidosis (ATTR) is a progressive and potentially fatal disease which results from the accumulation of misfolded amyloid fibrils in various organs and tissues. The deposition of these fibrils in the heart can lead to transthyretin amyloid cardiomyopathy (ATTR-CM). Literature reports that this disease is often misdiagnosed as heart failure or a variety of other conditions due to otherwise non-specific symptoms. For these reasons, the true prevalence of ATTR-CM is not well known. It has been estimated there are approximately 100,000 people in the United States living with ATTR-CM, and only one to two percent of these patients have been diagnosed. The primary objective of this study was to determine both the suspected and confirmed numbers of hereditary ATTR (hATTR) and wild-type ATTR (wtATTR) cases within a large managed care organization in western Pennsylvania. The secondary objective was to determine (in the suspected ATTR-CM population) the percentage of patients who had a cardiologist visit during the study period. <h3>Hypothesis</h3> The hypothesis of this evaluation is that there may be many undiagnosed members with ATTR-CM due to the presence of certain medical conditions commonly associated with the disease. <h3>Methods</h3> : This retrospective review of pharmacy and medical claims included UPMC Health Plan members ages 65 and older who were continuously enrolled from March 1, 2019 through February 29, 2020 with both pharmacy and medical benefits through UPMC Health Plan. Members were included in the suspected ATTR-CM population who had a select diagnosis of heart failure and at least one of the 10 medical condition combinations that are commonly associated with ATTR-CM during the study period; this population excluded patients with a diagnosis of ATTR-CM. The confirmed ATTR-CM population included patients with at least one ICD-10 code for either wtATTR or hATTR during the study period. <h3>Results</h3> 183,580 continuously enrolled members who were 65 and older during the study period were reviewed. Of these members, 11,928 had a diagnosis of heart failure. 986 members were identified for the suspected ATTR-CM population with a mean age of 80 (SD 7.68). Each combination group had more female than male matches. In the suspected ATTR-CM population, 94% of patients had a cardiologist visit during the study period. Separately, as a comparison, there were 214 members who had a confirmed diagnosis of ATTR-CM. <h3>Conclusion</h3> Both cardiovascular and non-cardiovascular medical conditions typically associated with ATTR-CM were common among members ≥ 65 years of age with heart failure; therefore, ATTR-CM may be underdiagnosed in this patient population.

Pilot Testing a Series of Value-Based Care Training Courses.

PurposeThe US healthcare system currently emphasizes volume of services over value. To facilitate changing to a value-based care model, one managed care organization developed a series of online courses designed to teach clinicians value-based care principles and practices. A pilot test was conducted to obtain feedback regarding course content and design, so the courses could be revised prior to their launch.Patients and MethodsA representative cross section of the courses’ target audience (n = 50) was recruited to participate in the pilot test, and data were collected through an online survey. Descriptive statistics were calculated for responses to close-ended survey questions, and affinity analysis was performed on responses to open-ended survey questions. Issues identified were then categorized as urgent/not urgent with respect to course revision.ResultsNearly a quarter (24%) of respondents indicated that the course contained incorrect or misleading information. Other responses noted inconsistencies in course content, eg, misspelled or mispronounced words, slides that were hard to read, etc.ConclusionThis study demonstrates how a pilot test was used as part of a formative assessment to improve course content and design. During a pilot test, attention should be paid to making it easy for participants to provide feedback.

The effect on dental care utilization from transitioning pediatric Medicaid beneficiaries to managed care.

Compared to the fee‐for‐service (FFS) model, the managed care delivery system has the potential to improve health care management, increase provider accountability, and support better monitoring of health care quality. However, managed care organizations may attempt to control costs by curbing utilization among Medicaid beneficiaries or reducing reimbursement for Medicaid services. It is an empirical question whether managed care increases or decreases utilization of services. Using detailed pediatric public insurance dental claims data from 2016 through 2018, we examined whether the transition from FFS to managed care affects rates of dental care utilization. Between 2016 and 2018, Indiana, Missouri and Nebraska transitioned pediatric Medicaid beneficiaries from public dental fee‐for‐service programs to private managed care entities. Using an extended two‐way fixed‐effects estimation framework, we found that dental managed care leads to a decline in dental care utilization, especially when compared to states that maintain FFS provision of Medicaid dental services.

Barriers and Facilitators to Peer Support Services for Patients With Opioid Use Disorder in the Emergency Department.

There is a high prevalence of opioid use disorder in the United States, and emergency departments (EDs) play multiple vital roles in providing care to help these patients with achieving sobriety, one of which is the application of peer recovery services. This technical report discusses the utilization of peer recovery supporters in the ED and associated barriers. They include but are not limited to the difficult hiring process, referral process challenges for certain populations, difficulty with follow-up data collection, retention of peer recovery supporters, and a lack of ED provider awareness. This article also discussed strategies to address these barriers. Examples include simplifying hospital onboarding processes for peer recovery supporters, obtaining grants to utilize peer recovery services, and using managed care organizations to facilitate follow-up data collection, ED provider education, and discharge planning.

COVID-19 and social determinants of health: Medicaid managed care organizations' experiences with addressing member social needs.

BackgroundThe significant adverse social and economic impact of the COVID-19 pandemic has cast broader light on the importance of addressing social determinants of health (SDOH). Medicaid Managed Care Organizations (MMCOs) have increasingly taken on a leadership role in integrating medical and social services for Medicaid members. However, the experiences of MMCOs in addressing member social needs during the pandemic has not yet been examined.AimThe purpose of this study was to describe MMCOs’ experiences with addressing the social needs of Medicaid members during the COVID-19 pandemic.MethodsThe study was a qualitative study using data from 28 semi-structured interviews with representatives from 14 MMCOs, including state-specific markets of eight national and regional managed care organizations. Data were analyzed using thematic analysis.ResultsFour themes emerged: the impact of the pandemic, SDOH response efforts, an expanding definition of SDOH, and managed care beyond COVID-19. Specifically, participants discussed the impact of the pandemic on enrollees, communities, and healthcare delivery, and detailed their evolving efforts to address member nonmedical needs during the pandemic. They reported an increased demand for social services coupled with a significant retraction of community social service resources. To address these emerging social service gaps, participants described mounting a prompt and adaptable response that was facilitated by strong existing relationships with community partners.ConclusionAmong MMCOs, the COVID-19 pandemic has emphasized the importance of addressing member social needs, and the need for broader consideration of what constitutes SDOH from a healthcare delivery standpoint.

Anticipated efficiencies, real costs: Medicaid managed care organizations and the pharmacy benefit.

The Affordable Care Act led an additional 15 states to begin contracting with comprehensive, risk-based managed care organizations (MCOs) to administer pharmacy benefits for Medicaid beneficiaries between 2010 and 2017. Reasons for this shift included concerns about administering complex benefits for an influx of new beneficiaries, assumptions about the cost-saving potential of privately run managed care, and a desire for budget predictability. As drug prices increased during the past decade, the way that state pharmacy benefits were administered via MCOs affected the ability of states to meet the needs of their Medicaid beneficiaries. Here, we review the advantages and limitations of 2 strategies that give states more centralized control over management of the pharmacy benefit: excluding the pharmacy benefit from MCO contracts and aligning preferred drug lists across beneficiary types. We propose that centralizing utilization management tools, aligning incentives for managed care payers with the needs of patients and Medicaid programs, and the ability to implement formulary exclusions may enable states to achieve savings and better meet the needs of beneficiaries. DISCLOSURES: No funding supported the writing of this Viewpoints article. Kesselheim is supported by grants from Arnold Ventures. Bendicksen has nothing to disclose.

Care Management Intervention to Address Determinants of Health for Individuals With Multiple Behavioral Health Readmission.

To examine the effectiveness of a care management intervention to decrease readmissions and to better understand clinical and social determinants associated with readmission. Inpatient mental health (MH) and substance use disorder (SUD) facilities, nonhospital SUD withdrawal management and rehabilitation facilities. The authors identified 3,950 Medicaid-enrolled individuals who received the intervention from licensed clinical staff of a behavioral health managed care organization; 2,182 individuals were eligible but did not receive the intervention, for treatment as usual (TAU). We used logistic regression to examine factors associated with readmission. Determinants of readmission were summarized through descriptive tests. The intervention was associated with lower readmissions to SUD facilities compared with TAU (6.0% vs. 8.6%, p = .0002) and better follow-up to aftercare. Controlling for clinical differences between groups, regression results found increased odds of readmission for male gender (odds ratio [OR]: 1.33; 95% confidence interval [CI]: 1.16-1.52, p < .0001) and dual MH and SUD diagnoses (OR: 1.52; CI: 1.29-1.79, p < .0001). Prior inpatient and case management services were also associated with increased odds for readmission. In the regression model, the intervention was not associated with decreased odds for readmission. Individuals with readmission (n = 796) were more likely to report being prescribed psychotropic medication and having housing difficulties and less likely to report having a recovery plan than those without readmission. Characteristics of Medicaid populations with hospitalization may contribute to readmission, which may be mitigated through care management intervention.

Assessment of Handicapping Labio-Lingual Deviation index scoring methods and their effect on orthodontic treatment coverage by Medicaid.

The purpose of this study was to assess the validity and reliability of Handicapping Labio-Lingual Deviation index (HLDI) scoring methods as calculated by digital models (DM) and visual inspection (VI) and their agreement to either meet or fail to meet the Medicaid coverage threshold. An additional objective was to assess the agreement with Medicaid managed care organizations (MCO) coverage decisions. The study included the orthodontic records of 401 patients who applied for Medicaid coverage. Two methods were used to calculate HLDI scores: (1) Measurements derived from DMs using OrthoCAD software; and (2) VI of intraoral photographs. The levels of agreement between the two methods and the Medicaid coverage decision by a MCO were evaluated. The study results show a high level of agreement between the two HLDI calculation methods, DM and VI evaluation methods(Cramer's V=0.812). The agreement on coverage decisions (eligible/not eligible) between VI methods and the official MCO decision was Cramer's V=0.318. The agreement on coverage decisions between the DM method and the official MCO decision was Cramer's V=0.318. MCO assessment results of the patients using HLDI showed low agreement with the results obtained by DM and VI scoring methods used in this study. The Illinois Medicaid system is apparently using unknown factors other than the HLDI score when determining when approving or disapproving orthodontic coverage. MCO decisions on eligibility for orthodontic treatment coverage were not consistent with patients' treatment needs.

Managing prior approval for site-of-service referrals: an algorithmic approach

ObjectivesMany payers and health care providers are either currently using or considering use of prior authorization schemes to redirect patient care away from hospital outpatient departments toward free-standing ambulatory surgical centers owing to the payment differential between these facilities. In this work we work with a medium size payer to develop and lay out a process for analysis of claims data that allows payers to conservatively estimate potential savings from such policies based on their specific case mix and provider network.Study DesignWe analyzed payment information for a medium-sized managed care organization to identify movable cases that can reduce costs, estimate potential savings, and recommend implementation policy alternatives.MethodsWe analyze payment data, including all professional and institutional fees over a 15-month period. A rules-based algorithm was developed to identify episodes of care with at least one alternate site for each episode, and potential savings from a site-of-service policy.ResultsData on 64,884 episodes of care were identified as possible instances that could be subject to the policy. Of those, 7,679 were found to be attractive candidates for movement. Total projected savings was approximately $8.2 million, or over $1,000 per case.ConclusionsInstituting a site-of-service policy can produce meaningful savings for small and medium payers. Tailoring the policy to the specific patient and provider population can increase the efficacy of such policies in comparison to policies previously established by other payers.

Cost and Utilization Impacts of a Medicaid Managed Care Organization's Behavioral Health Wraparound Program.

Wraparound programs that provide comprehensive evidence-based outpatient treatment, transportation, social services, and housing supports have shown promise for improving clinical behavioral health-related outcomes to reduce the need for institutionalized care; however, the majority of evidence is based on wraparound programs for children. This study examined the impact of a wraparound program for adult Medicaid managed care organization members with serious mental health or substance use disorders on health care costs and utilization. This retrospective observational study used 2013-2018 claims data collected from a large Medicaid managed care organization operating in multiple states. We used an intention-to-treat difference-in-difference study design to examine the association of the wraparound with costs and utilization. Adult Medicaid members with an emergency department (ED) or inpatient visit for a behavioral health condition (index visit) were eligible for the study. Outcomes included all-cause and behavioral health-related costs and utilization during follow-up after the index visit's admission date. Outcomes were calculated overall, as well as separately by inpatient, ED, and outpatient/wraparound settings. We found that during the first post-admission month, the wraparound program was associated with 27.6 percentage points (PP) and 27.2 PP reductions in the number of behavioral health-related inpatient nights and costs, respectively. However, during subsequent months (median follow-up ranging from 7 to 10months) there were no associations with per-member-per-month total all-cause or behavioral health-related costs. Nonetheless, the wraparound program was associated with 12.3 PP reduction in all-cause cost during the entire study period among a subset of members who were high cost at the baseline. Reduced hospital utilization and costs during the first month of wraparound services were fully counteracted by outpatient, housing, and other wraparound services costs during the following months. This indicates the importance of proper payment arrangements with value-based contracting or performance targets with wraparound services providers to align the objective of reducing inpatient use. Future wraparound programs may consider a more focused recruitment from high-cost members with complex care needs. However, our estimates were conservative given that it's from a single Medicaid managed care organization's perspective and some benefit from investing in addressing social needs may be realized in longer term (beyond our study period). States' Medicaid programs may consider the longer-term cost and broader, societal benefit of wraparound investment.