Maryland Medicaid Research Articles

Addressing housing-related social needs for Medicaid beneficiaries: a qualitative assessment of Maryland’s Medicaid §1115 waiver program

BackgroundWhile health care payers are increasingly considering approaches that help support stable and affordable housing for their beneficiaries, experience with these initiatives is limited. Through its §1115 HealthChoice waiver, Maryland Medicaid has begun experimenting with programs designed to pay for housing and tenancy support/case management services. This study investigates barriers and facilitators to the success of Maryland’s pilot program initiative — Assistance in Community Integration Services (ACIS).MethodsThe study focused on key stakeholders employed by the four Lead Entities that currently participate in the ACIS program. The stakeholders included members of each Lead Entity’s administration, direct service providers, state and local government officials, and case managers from local hospitals. The convenience sample was selected through an initial list of stakeholders and was supplemented using snowball sampling methods. Interviews were audio recorded and turned into transcripts via Otter.ai and then analyzed using NVivo by two independent reviewers.ResultsA total of 23 interviews were conducted between February 2022 and May 2022, representing a broad range of stakeholders across different Maryland geographies. A total of 4 themes were identified through the course of the interviews. Stakeholders identified difficulty finding housing for the target population in a tight housing market, challenges with communication within the program and with its clients, and problems with non-healthcare providers documenting services for reimbursement. At the same time, ACIS was seen as creating opportunities for organizations to work together across siloes in meeting client needs.ConclusionsThe findings of this study helps to highlight Medicaid §1115 waivers as a novel approach to using Medicaid funds to support tenancy-based services, such as ACIS and to improve the lives of individuals while reducing healthcare costs. Implementation of the ACIS program in Maryland has been a resounding success in helping individuals obtain and sustain stable housing. However, continued efforts to align capacity with demand, streamline billing and reimbursement and improve communication with clients and across partners will need to be prioritized. The program also highlights the growing need to address root causes of housing insecurity including the limited supply of affordable housing.

A Novel Approach to PDMP Reporting: Adapting Opioid Quality Measures to PDMP Data.

The SUPPORT Act provided resources for developing prescription drug monitoring programs (PDMPs) capable of reporting on four specific opioid quality measures. Therefore, the objective of this pilot study was to map, test, and adapt these claims-based opioid quality measures specified for health plan performance to PDMP data for state-level performance. Maryland PDMP and claims from Maryland Medicaid beneficiaries continuously enrolled from April 1, 2019, to March 31, 2020. The measure rates as specified using claims data are closely aligned with the measure rates when mapped and adapted to PDMP data. The Concurrent Use of Opioids and Benzodiazepines measure rates were 14.49% and 15.31%, the OHD rates were 12.44% and 13.54%, the OHDMP rates were 0.01% and 0.40%, and the Use of Opioids from Multiple Providers in Persons Without Cancer rates were 0.12% and 3.03% for the claims-based and adapted measures, respectively. This is a novel application that may be replicated in other states to support quality improvement and can have a measurable effect on stemming the drug abuse epidemic. This will facilitate data sharing of the opioid quality measure reporting within the Maryland PDMP and stakeholders responsible for caring for Maryland Medicaid beneficiaries. Owing to the encouragement by the Centers for Medicare and Medicaid Services, other states' PDMPs may require the adaptation of these measures. This will open the door for innovative state-level policy and practice interventions. The quantification of outcomes related to these measures will inform our learning healthcare system and help support the Quintuple Aim.

The Role of Dementia and Residential Service Agency Characteristics in the Care Experiences of Maryland Medicaid Home and Community-Based Service Participants and Family and Unpaid Caregivers.

In Maryland, residential service agencies deliver Medicaid Home and Community-Based Services (HCBS) to older adults with disabilities through direct care workers (e.g., personal care aides). Leveraging survey data from residential service agency administrators, linked to interRAI Home Care assessments for 1144 participants, we describe agency characteristics, and participant and family caregiver experiences by participant dementia status. Most (61.7%) participants experienced low social engagement, and roughly 10.0% experienced a hospitalization or emergency room visit within 90days. Few (14.4%) participants were served by agencies requiring dementia-specific direct care worker training, and most were served by agencies offering supplemental services, or in which direct care workers helped with health information technology (81.2% and 72.8%, respectively). Few caregivers reported negative care experiences. Participants with dementia and those served by agencies with training and support more often reported negative care experiences. Findings lay the foundation for future longitudinal and embedded interventions within Medicaid HCBS.

Designing optimal recommended budgeting thresholds for a Medicaid program.

To develop and test a methodology for optimally setting automatic auditing thresholds to minimize administrative costs without encouraging overall budget growth in a state Medicaid program. Two-stage optimization using administrative Maryland Medicaid plan-of-service data from fiscal year (FY) 2019. In the first stage, we use an unsupervised machine learning method to regroup acuity levels so that plans of service with similar spending profiles are grouped together. Then, using these regroupings, we employ numerical optimization to estimate the recommended budget levels that could minimize the number of audits across those groupings. We simulate the effects of this proposed methodology on FY 2019 plans of service and compare the resulting number of simulated audits with actual experience. Using optimal regrouping and numerical optimization, this method could reduce the number of audits by 10.4% to 36.7% relative to the status quo, depending on the search space parameters. This reduction is a result of resetting recommended budget levels across acuity groupings, with no anticipated increase in the total recommended budget amount across plans of service. These reductions are driven, in general, by an increase in recommended budget level for acuity groupings with low variance in plan-of-service spending and a reduction in recommended budget level for acuity groupings with high variance in plan-of-service spending. Using machine learning and optimization methods, it is possible to design recommended budget thresholds that could lead to significant reductions in administrative burden without encouraging overall cost growth.

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.

The actual, long-term cost of intentional injury care among a cohort of Maryland Medicaid recipients.

Intentional injury (both self-harm and interpersonal) is a major cause of morbidity and mortality, yet there are little data on the per-person cost of caring for these patients. Extant data focus on hospital charges related to the initial admission but does not include actual dollars spent or follow-up outpatient care. The Affordable Care Act has made Medicaid the primary payor of intentional injury care (39%) in the United States and the ideal source of cost data for these patients. We sought to determine the total and per-person long-term cost (initial event and following 24 months) of intentional injury among Maryland Medicaid recipients. Retrospective cohort study of Maryland Medicaid claims was performed. Recipients who submitted claims after receiving an intentional injury, as defined by the International Classification of Diseases, Tenth Revision, between October 2015 and October 2017, were included in this study. Subjects were followed for 24 months (last participant enrolled October 2017 and followed to October 2019). Our primary outcome was the dollars paid by Medicaid. We examined subgroups of patients who harmed themselves and those who received repeated intentional injury. Maryland Medicaid paid $11,757,083 for the care of 12,172 recipients of intentional injuries between 2015 and 2019. The per-person, 2-year health care cost of an intentional injury was a median of $183 (SD, $5,284). These costs were highly skewed: min, $2.56; Q1 = 117.60, median, $182.80; Q3 = $480.82; and max, $332,394.20. The top 5% (≥95% percentile) required $3,000 (SD, $6,973) during the initial event and $8,403 (SD, $22,024) per served month thereafter, or 55% of the overall costs in this study. The long-term, per-person cost of intentional injury can be high. Private insurers were not included and may experience different costs in other states. Economic and Value Based Evaluations; level III.

Predictors of cancer screening among Black and White Maryland Medicaid enrollees with serious mental illness.

Cancer is the second leading cause of death for people with serious mental illness (SMI), such as schizophrenia and bipolar disorder. People with SMI receive cancer screenings at lower rates than the general population. We sought to identify factors associated with cancer screening in a publicly insured population with SMI and stratified by race, a factor itself linked with differential rates of cancer screening. We used Maryland Medicaid administrative claims data (2010-2018) to examine screening rates for cervical cancer (N = 40,622), breast cancer (N = 9818), colorectal cancer (N = 19,306), and prostate cancer (N = 4887) among eligible Black and white enrollees with SMI. We examined individual-level socio-demographic and clinical factors, including co-occurring substance use disorder, medical comorbidities, psychiatric diagnosis, obstetric-gynecologic and primary care utilization, as well as county-level characteristics, including metropolitan status, mean household income, and primary care workforce capacity. Generalized estimating equations with a logit link were used to examine the characteristics associated with cancer screening. Compared with white enrollees, Black enrollees were more likely to receive screening for cervical cancer (AOR: 1.18; 95% CI: 1.15-1.22), breast cancer (AOR: 1.27; 95% CI: 1.19-1.36), and colorectal cancer (AOR: 1.07; 95% CI: 1.02-1.13), while similar rates were observed for prostate cancer screening (AOR: 1.06; 95% CI: 0.96-1.18). Primary care utilization and longer Medicaid enrollment were positively associated with cancer screening while co-occurring substance use disorder was negatively associated with cancer screening. Improving cancer screening rates among populations with SMI should focus on facilitating continuous insurance coverage and access to primary care.

Association Between Enrollment in Maryland's Behavioral Health Homes and Use of Outpatient Mental Health Services.

This study examined the association between enrollment in Maryland's behavioral health home (BHH) program and use of outpatient mental health services among people with serious mental illness. The study sample, drawn from Maryland Medicaid administrative claims data from 2012 through 2017, included 12,232 individuals ages 21-64 with a serious mental illness who were enrolled in a BHH (N=3,319) or never enrolled (N=8,913). A marginal structural modeling approach with inverse probability of treatment weighting was used to examine the association between BHH enrollment and outpatient mental health utilization, measured as the number of visits per 3-month period. BHH enrollment was associated with 0.8 additional outpatient mental health visits per 3-month period, or approximately three additional visits annually. A specialty mental health system-based health home model with a primary goal of improving access to general medical care was associated with increased use of outpatient mental health services.

Behavioral health home impact on transitional care and readmissions among adults with serious mental illness.

To evaluate the impact of Maryland's behavioral health homes (BHHs) on receipt of follow-up care and readmissions following hospitalization among Medicaid enrollees with serious mental illness (SMI). Maryland Medicaid administrative claims for 12232 individuals. Weighted marginal structural models were estimated to account for time-varying exposure to BHH enrollment and time-varying confounders. These models compared changes over time in outcomes among BHH and comparison participants. Outcome measures included readmissions and follow-up care within 7 and 30days following hospitalization. Eligibility criteria included continuous enrollment in Medicaid for the first two years of the study period; 21-64years; and use of psychiatric rehabilitation services. Over three years, BHH enrollment was associated with 3.8 percentage point (95% CI: 1.5, 6.1) increased probability of having a mental health follow-up service within 7days of discharge from a mental illness-related hospitalization and 1.9 percentage point (95% CI: 0.0, 3.9) increased probability of having a general medical follow-up within 7days of discharge from a somatic hospitalization. BHHs had no effect on probability of readmission. BHHs may improve follow-up care for Medicaid enrollees with SMI, but effects do not translate into reduced risk of readmission.

Sharing the cure: Building primary care and public health infrastructure to improve the hepatitis C care continuum in Maryland.

In 2014, trained healthcare provider capacity was insufficient to deliver care to an estimated 70 000 persons in Maryland with chronic hepatitis C virus (HCV) infection. The goal of Maryland Community Based Programs to Test and Cure Hepatitis C, a public health implementation project, was to improve HCV treatment access by expanding the workforce. Sharing the Cure (STC) was a package of services deployed 10/1/14-9/30/18 that included enhanced information technology and public health infrastructure, primary care provider training and practice transformation. Nine primary care sites enrolled. HCV clinical outcomes were documented among individuals who presented for care at sites and met criteria for HCV testing including risk factor or birth cohort (born between 1945 and 1965) based testing. Fifty-three providers completed the STC training. STC providers identified 3237 HCV antibody-positive patients of which 2624 (81%) were RNA+. Of those HCV RNA+, 1739 (66%) were staged, 932 (36%) were prescribed treatment, 838 (32%) started treatment, 721 (27%) completed treatment and 543 (21%) achieved cure. Among 1739 patients staged, 693 (40%) patients had a liver fibrosis assessment score<F2, rendering them ineligible for treatment under Maryland Medicaid guidelines. HCV RNA testing among HCV antibody-positive people increased from 40% (baseline) to 95% among STC providers. Of 554 patients with virologic data reported, 543 (98%) achieved cure. Primary care practices can effectively serve as HCV treatment centers to expand treatment access. However, criteria by insurance providers in Maryland were a major barrier to treatment.

Sheppard Pratt Opens Virtual Walk-In Clinic to All Marylanders

Back to table of contents Previous article Next article CommunityFull AccessSheppard Pratt Opens Virtual Walk-In Clinic to All MarylandersMark MoranMark MoranSearch for more papers by this authorPublished Online:16 Jun 2020https://doi.org/10.1176/appi.pn.2020.6b14AbstractThe American Hospital Association’s (AHA) Center for Health Innovation cites numerous ways hospitals and health systems are adapting to meet the pandemic. AHA offers tools and resources to hospitals to cope with COVID-19 and serve their communities.Maryland residents experiencing a psychiatric emergency—that’s anyone anywhere in the “Old Line” State—can find “virtual urgent care” through the Sheppard Pratt Health System in Towson, Md.The Sheppard Pratt Virtual Crisis Walk-In Clinic is a novel extension of psychiatric/medical care in the midst of a global pandemic that has transformed telehealth from a sometimes used tool in the physician toolkit—mainly reserved for rural areas of the country or other unusual circumstances—to the common currency of nearly every consult that does not require hospitalization.“With the spread of COVID-19, we realized many people may be cut off from their usual source of care,” says Harsh Trivedi, M.D.Sheppard Pratt“With the spread of COVID-19, we realized many people may be cut off from their usual source of care” as hospitals and the medical community mobilize to meet the pandemic, said Harsh Trivedi, M.D., CEO of Sheppard Pratt. “Our solution has been to use telehealth to extend urgent care into the community to anyone in the state experiencing a psychiatric emergency. We are used to evaluating 6,000 to 7,000 patients in our walk-in clinic every year. Now people can get the same timely care at Sheppard Pratt virtually.”The Virtual Crisis Walk-In Clinic is available to any individual living in Maryland. It is open Monday to Friday, 10 a.m. to 9 p.m., and Saturdays, 1 p.m. to 4 p.m.Deepak Prabhakar, M.D., M.P.H., director of outpatient services at Sheppard Pratt, told Psychiatric News that in the first four days of the clinic’s virtual existence (beginning on April 6), more than 40 people received consults. These individuals—they do not have to be patients at Sheppard Pratt’s outpatient clinics—received an evaluation and then connected with therapists.“Pandemic or no pandemic, a quarter of our population has always been struggling with these issues,” says Deepak Prabhakar, M.D., M.P.H. “The fact that such a large population is at risk of losing employment and access to care further complicates their disorders.”Jason PutscheHe said the clinic website surfaces in common Google searches. Once at the website, prospective patients can call the Sheppard Pratt outpatient services phone number or fill out an online form requesting a consult. Within minutes, Prabhakar and staff with the clinic receive an email about a new patient, who will then be contacted and connected with an online therapist. Individuals needing medication, or refills of medication, receive a consult with a physician or nurse practitioner.He said a handful of individuals have been admitted to the hospital. The clinic also has a mobile team that can transport individuals without transportation from their homes to the hospital in Towson.The Virtual Crisis Walk-In Clinic participates with Maryland Medicaid and Medicare and major insurers. “As a mission-based organization we have a mechanism for taking in patients who are uninsured,” Prabhakar said.Sheppard Pratt’s virtual walk-in clinic is one example of the way hospitals and health systems are adapting to the unprecedented challenge of COVID-19. The American Hospital Association’s (AHA) Center for Health Innovation microsite lists a variety of steps being taken by health systems on their own or in tandem with the private sector. AHA’s Update and Resources on Novel Coronavirus (COVID-19) offers tools and resources for hospitals and health systems.At Sheppard Pratt, patients using the virtual clinic report COVID-related problems with mental health, as well as exacerbations of psychiatric disorders that pre-date the pandemic. A typical presenting complaint, Prabhakar said, might be something like this: “I don’t know if I can go through this. I’ve had depression and now my treatment has been disrupted.”He said, “A quarter of our population [in Maryland] has always been struggling with these issues, and now they are being buried by COVID. Everyone is paying attention to COVID. But pandemic or no pandemic, the fact that such a large population is at risk of losing employment and access to care further complicates their disorders.” ■The website for the Sheppard Pratt Virtual Crisis Walk-In Clinic is here.The website of the American Hospital Association Center for Health Innovation is here.The AHA’s Update and Resources on Novel Coronavirus (COVID-19) is posted here. ISSUES NewArchived

Effects of Maryland's Affordable Care Act Medicaid Health Home Waiver on Quality of Cardiovascular Care Among People with Serious Mental Illness.

Nineteen US states and D.C. have used the Affordable Care Act Medicaid health home waiver to create behavioral health home (BHH) programs for Medicaid beneficiaries with serious mental illness (SMI). BHH programs integrate physical healthcare management and coordination into specialty mental health programs. No studies have evaluated the effects of a BHH program created through the Affordable Care Act waiver on cardiovascular care quality among people with SMI. To study the effects of Maryland's Medicaid health home waiver BHH program, implemented October 1, 2013, on quality of cardiovascular care among individuals with SMI. Retrospective cohort analysis using Maryland Medicaid administrative claims data from July 1, 2010, to September 30, 2016. We used marginal structural modeling with inverse probability of treatment weighting to account for censoring and potential time-dependent confounding. Maryland Medicaid beneficiaries with diabetes or cardiovascular disease (CVD) participating in psychiatric rehabilitation programs, the setting in which BHHs were implemented. To qualify for psychiatric rehabilitation programs, individuals must have SMI. The analytic sample included BHH and non-BHH participants, N = 2605 with diabetes and N = 1899 with CVD. Healthcare Effectiveness Data and Information Set (HEDIS) measures of cardiovascular care quality including annual receipt of diabetic eye and foot exams; HbA1c, diabetic nephropathy, and cholesterol testing; and statin therapy receipt and adherence among individuals with diabetes, as well as HEDIS measures of annual receipt of cholesterol testing and statin therapy and adherence among individuals with CVD. Relative to non-enrollment, enrollment in Maryland's BHH program was associated with increased likelihood of eye exam receipt among individuals with SMI and co-morbid diabetes, but no changes in other care quality measures. Additional financing, infrastructure, and implementation supports may be needed to realize the full potential of Maryland's BHH to improve cardiovascular care for people with SMI.

Association Between the Maryland Medicaid Behavioral Health Home Program and Cancer Screening in People With Serious Mental Illness.

This study evaluated the association of the Maryland Medicaid behavioral health home (BHH) integrated care program with cancer screening. Using administrative claims data from October 2012 to September 2016, the authors measured cancer screening among 12,176 adults in Maryland's psychiatric rehabilitation program who were eligible for cervical (N=6,811), breast (N=1,658), and colorectal (N=3,430) cancer screening. Marginal structural modeling was used to examine the association between receipt of annual cancer screening and whether participants had ever enrolled in a BHH (enrolled: N=3,298, 27%; not enrolled: N=8,878, 73%). Relative to nonenrollment, BHH enrollment was associated with increased screening for cervical and breast cancer but not for colorectal cancer. Predicted annual rates remained low, even in BHHs. Despite estimates of improvements in cervical and breast cancer screening after BHH implementation, cancer screening rates remained suboptimal. Broader cancer screening interventions are needed to improve cancer screening for people with mental illness.

The effects of the Maryland Medicaid Health Home Waiver on Emergency Department and inpatient utilization among individuals with serious mental illness

ObjectiveThe Maryland Medicaid health home program, established through the Affordable Care Act's Medicaid health home waiver, integrates primary care services into specialty mental health programs for adults with serious mental illness (SMI). We evaluated the effect of this program on all-cause, physical, and behavioral health emergency department (ED) and inpatient utilization. MethodUsing marginal structural modeling to control for time-invariant and time-varying confounding, we analyzed Medicaid administrative claims data for 12,232 enrollees with SMI from October 1, 2012 to December 31, 2016; 3319 individuals were enrolled in a BHH and 8913 were never enrolled. ResultsHealth home enrollment was associated with reduced probability of all-cause (PP: 0.23 BHH enrollment vs. 0.26 non-enrollment, p < 0.01) and physical health ED visits (PP: 0.21 BHH enrollment vs. 0.24 non-enrollment, p < 0.01) and no effect on inpatient admissions per person-three-month period. ConclusionThese results suggest the Maryland Medicaid health home waiver's focus on supporting physical health care coordination by specialty mental health programs may be preventing ED visits among adults with SMI, although effect sizes are small.

The Policy Ecology of Behavioral Health Homes: Case Study of Maryland's Medicaid Health Home Program.

Behavioral health homes, shown to improve receipt of evidence-based medical services among people with serious mental illness in randomized clinical trials, have had limited results in real-world settings; nonetheless, these programs are spreading rapidly. To date, no studies have considered what set of policies is needed to support effective implementation of these programs. As a first step toward identifying an optimal set of policies to support behavioral health home implementation, we use the policy ecology framework to map the policies surrounding Maryland's Medicaid behavioral health home program. Results suggest that existing policies fail to address important implementation barriers.

Oral Health Literacy and Dental Care among Low-Income Pregnant Women.

Objectives: In this study, we sought to determine the impact of oral health literacy (OHL) on use of prenatal dental care and knowledge, understanding, and practices related to preventing dental caries (tooth decay) among low-income pregnant women in Maryland. Methods: We conducted a mixed methods study using a survey and a structured guide for one-on-one interviews or focus groups. The study included 117 pregnant women and was conducted between July 2016 and April 2018 in Maryland. Results: Respondents had a low level of OHL. Maryland Medicaid covers prenatal dental care, but only 53% of participants reported seeing a dentist during their pregnancy. Most women were unaware of the Medicaid dental program for pregnant women and the importance of prenatal dental care. They could not afford care if there was an associated cost and had difficulty finding a Medicaid dental provider. Importantly, they lacked understanding of how to prevent caries and did not practice behaviors to prevent this disease. Conclusions: To decrease caries rates, policies and programs must be implemented to increase the OHL of low-income pregnant women because the OHL of caregivers is associated with their children's oral health status.

Incidence of Lyme Disease Diagnosis in a Maryland Medicaid Population, 2004-2011.

The epidemiology of Lyme disease has been examined utilizing insurance claims from privately insured individuals; however, it is unknown whether reported patterns vary among the publicly insured. We examined trends in incidence rates of first Lyme disease diagnosis among 384,652 Maryland Medicaid recipients enrolled from July 2004 to June 2011. Age-, sex-, county-, season-, and year-specific incidence rates were calculated, and mixed-effects multiple logistic regression models were used to study the relationship between Lyme disease diagnosis and these variables. The incidence rate in our sample was 97.65 cases per 100,000 person-years (95% confidence interval (CI): 91.53, 104.06), and there was a 13% average annual increase in the odds of a Lyme disease diagnosis (odds ratio = 1.13, 95% CI: 1.09, 1.17; P < 0.001). Incidence rates for males and females were not significantly different, though males were significantly more likely to be diagnosed during high-season months (relative risk (RR) = 1.24, 95% CI: 1.06, 1.44) and less likely to be diagnosed during low-season months (RR = 0.63, 95% CI: 0.46, 0.87) than females. Additionally, adults were significantly more likely than children to be diagnosed during low-season months (RR = 1.59, 95% CI: 1.19, 2.12). While relatively rare in this study sample, Lyme disease diagnoses do occur in a Medicaid population in a Lyme-endemic state.

Measuring Variation Across Dimensions of Integrated Care: The Maryland Medicaid Health Home Model.

Despite the proliferation of initiatives to integrate services for people with serious mental illness (SMI), measures of distinct dimensions of integration, such as spatial arrangement and care team expertise, are lacking. Such measures are needed to support organizations' assessment of progress toward integrated service delivery. We developed measures characterizing integration of behavioral, somatic, and social services to operationalize the integrated care dimensions conceived by the Agency for Healthcare Research and Quality. In a survey fielded to 46 Maryland Medicaid health homes (response rate: 96%) serving adults with SMI during 2015-2016, we found that these measures provided a useful description of variation across dimensions of integration.

A Cost Analysis of Universal versus Targeted Cholesterol Screening in Pediatrics

To compare the number of children needed to screen to identify a case of childhood dyslipidemia and estimate costs under universal vs targeted screening approaches. We constructed a decision-analytic model comparing the health system costs of universal vs targeted screening for hyperlipidemia in US children aged 10 years over a 1-year time horizon. Targeted screening was defined by family history: dyslipidemia in a parent and/or early cardiovascular disease in a first-degree relative. Prevalence of any hyperlipidemia (low-density lipoprotein [LDL] ≥130 mg/dL) and severe hyperlipidemia (LDL ≥190 mg/dL or LDL ≥160 mg/dL with family history) were obtained from published estimates. Costs were estimated from the 2016 Maryland Medicaid fee schedule. We performed sensitivity analyses to evaluate the influence of key variables on the incremental cost per case detected. For universal screening, the number needed to screen to identify 1 case was 12 for any hyperlipidemia and 111 for severe hyperlipidemia. For targeted screening, the number needed to screen was 7 for any hyperlipidemia and 49 for severe hyperlipidemia. The incremental cost per case detected for universal compared with targeted screening was $1980 for any hyperlipidemia and $32 170 for severe hyperlipidemia. Our model suggests that universal cholesterol screening detects hyperlipidemia at a low cost per case, but may not be the most cost-efficient way to identify children with severe hyperlipidemia who are most likely to benefit from treatment.

An innovative model to coordinate healthcare and social services for people with serious mental illness: A mixed-methods case study of Maryland's Medicaid health home program.

We conducted a case study examining implementation of Maryland's Medicaid health home program, a unique model for integration of behavioral, somatic, and social services for people with serious mental illness (SMI) in the psychiatric rehabilitation program setting. We conducted interviews and surveys with health home leaders (N=72) and front-line staff (N=627) representing 46 of the 48 total health home programs active during the November 2015-December 2016 study period. We measured the structural and service characteristics of the 46 health home programs and leaders' and staff members' perceptions of program implementation. Health home program structure varied across sites: for example, 15% of programs had co-located primary care providers and 76% had onsite supported employment providers. Most leaders and staff viewed the health home program as having strong organizational fit with psychiatric rehabilitation programs' organizational structures and missions, but noted implementation challenges around health IT, population health management, and coordination with external providers. Maryland's psychiatric rehabilitation-based health home is a promising model for integration of behavioral, somatic, and social services for people with SMI but may be strengthened by additional policy and implementation supports, including incentives for external providers to engage in care coordination with health home providers.