Medicaid Fee Research Articles

US cost-utility model of lenacapavir plus optimized background regimen (OBR) vs fostemsavir plus OBR and ibalizumab plus OBR for people with HIV with multidrug resistance.

Heavily treatment-experienced (HTE) people with HIV (PWH) have limited treatment options owing to multidrug resistance (MDR). Lenacapavir (LEN) is indicated, in combination with other antiretrovirals, for the treatment of adults with MDR HIV-1 experiencing failure of their current antiretroviral regimen because of resistance, intolerance, or safety considerations. To evaluate the cost-utility of LEN in combination with an optimized background regimen (OBR) vs alternative recently approved treatments for HTE PWH, fostemsavir (FTR)+OBR and ibalizumab (IBA)+OBR, for the treatment of PWH with MDR, from a mixed US health care payer perspective. A Markov state-transition model with a lifetime time horizon was developed. Transition probabilities between viral load categories were based on individual participant data from the CAPELLA trial for LEN+OBR and on relative efficacy parameters obtained from indirect treatment comparisons for comparators. Health state utilities were sourced from the literature. Costs included drug acquisition costs, drug administration costs, disease management costs, adverse event costs, AIDS-related event costs, and treatment switching costs and were sourced from red book costs, Medicare and Medicaid fees, and the literature. Costs and outcomes were discounted at 3% annually. The model was used to estimate total and incremental costs, life-years (LYs), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. A deterministic and a probabilistic sensitivity analysis, as well as scenario analyses, were performed to address elements of uncertainty in the model and to explore the robustness of the results. Over a lifetime time horizon, LEN+OBR was associated with the highest absolute QALYs (9.41) and the greatest number of LYs (12.09) compared with FTR+OBR (QALYs: 8.75; LYs: 11.26) and IBA+OBR (QALYs: 8.36; LYs: 10.78). LEN+OBR was also associated with the lowest total lifetime costs of the 3 interventions (LEN+OBR: $1,441,122 [US dollars]; FTR+OBR: $1,504,986; IBA+OBR: $1,524,396) and therefore was dominant over both comparators in the base case. LEN+OBR remained dominant vs FTR+OBR and IBA+OBR across the range of scenarios tested and LEN+OBR had a 99% probability of being cost-effective compared with FTR+OBR and IBA+OBR in the probabilistic sensitivity analysis at a willingness-to-pay threshold of $50,000/QALY. This economic evaluation demonstrated that LEN+OBR provides meaningful increases in QALYs and LYs, and is dominant over a lifetime time horizon, compared with FTR+OBR and IBA+OBR for the treatment of PWH with MDR in the United States.

Medicaid Reimbursement for Common Orthopedic Trauma Procedures is 16.0% Less Compared to Medicare with Substantial Variability Between States.

This study seeks to evaluate the variability of Medicaid reimbursement and compare it to Medicare reimbursement using the 20 most commonly billed orthopedic trauma CPT codes nationwide. The authors anticipate significant variability between states and hypothesize that Medicaid payment will be significantly less than Medicare payment. The top 20 most common orthopedic trauma surgery procedural codes were identified from a previous analysis performed by Haglin et al.1 The Centers for Medicare and Medicaid services physician fee schedule was used to determine reimbursement rates from Medicare, and state Medicaid fee schedules were used to determine reimbursement rates for Medicaid. State Medicaid rates were compared to their corresponding Medicare rates to determine a dollar difference. Additionally, the dollar difference for each CPT code was divided by its respective physician relative value unit (RVU). This was utilized to acknowledge the possible variability in the complexity of orthopedic procedures and the related physician effort. The Medicare Wage Index was used to adjust Medicaid rates based on the cost of living for the state as well. Coefficients of variation were calculated to represent overall variability in Medicaid and Medicare reimbursement rates. The mean reimbursement rates for Medicaid were lower for all 20 procedures compared to Medicare. On average, Medicaid reimbursed 16.0% less than Medicare, and 29.6% less when adjusting for cost-of-living. MCD reimbursed at a higher rate than MCR for all procedures in only nine states (Alaska, Arizona, Arkansas, Montana, Nebraska, New Jersey, New Mexico, and North Dakota, and South Dakota) while 38 states reimbursed at a lower rate than MCR, on average. The coefficient of variation ranged from 0.24 to 0.34 for the Medicaid unadjusted group and from 0.35 to 0.46 for the Medicare Wage-Index adjusted group. In contrast, the Medicare group was consistent at 0.06 for all 20 procedures. The average dollar difference across the 20 CPT codes for Medicaid reimbursement compared to Medicare ranged from -$76.89 to -$225.17, and the dollar difference per relative value unit ranged from -$5.96 to -$15.16. This study found a high amount of variation between state Medicaid reimbursement rates and average rates that were significantly lower than Medicare reimbursement rates for the top twenty most utilized orthopedic trauma CPT codes as identified by Haglin et al. The discrepancy in reimbursement was increased when Medicaid rates were adjusted for state cost-of-living. Level III. See Instructions for Authors for a complete description of levels of evidence.

Did Medicaid Reimbursements Shape the Effects of Medicaid Expansion on Access to Health Care Among the Low-Income Population?

Whether variation in Medicaid reimbursement fees influenced the impacts of the Medicaid expansions is not well understood. We examine whether changes in health care access associated with Medicaid expansion are different in states with comparatively high Medicaid reimbursement rates compared against expanding in states with lower Medicaid reimbursement rates. Using a difference-in-difference-in-difference (DDD or triple-difference) regression approach, we compare relative differences in Medicaid expansion effects between lower and higher reimbursement states. 512,744 low-income adults aged 20-64 in the 2011-2019 Behavioral Risk Factor Surveillance System. Health insurance coverage status, unmet medical needs due to cost, regular source for health care, and a regular/scheduled checkup within the past year. Medicaid expansion has significant and positive impacts on health coverage and access in both high- and low-fee states. In states with fee levels above the median Medicare-to-Medicaid ratios, expanding Medicaid eligibility reduced uninsurance rate by 15.2 percentage point (ppt, p < 0.01), shrank the cost-associated unmet medical need by 10.3 ppt (p < 0.01), improved access to usual source of care by 1.9 ppt (p < 0.1), and increased regular checkup by 14.4 ppt (p < 0.01), while such effects in low-fee states were 11.7 ppt (p < 0.01), 8.3 ppt (p < 0.01), 3.1 ppt (p < 0.1), and 12.3 ppt (p < 0.01), respectively. Our results suggest that Medicaid expansion effect on unmet medical need due to cost in higher-reimbursing states was 2.98 ppt (p < 0.05) larger than in lower-reimbursing states. Evidence suggests modest increases in health care access were more strongly associated with expansions in higher-fee states. Medicaid's fee structure should be considered as a factor influencing large-scale coverage expansions.

A Multi-State Analysis of the Fiscal Impact of Commercial Insurance Coverage for General-Use &amp; Activity-Specific Prosthetic &amp; Orthotic Devices in the United States

Prosthetic and orthotic devices are assistive devices utilized by individuals with limb loss, limb difference, and mobility impairment. Research has shown these devices improve mobility and functionality, independence, and overall quality of life for individuals with disabilities who depend on them. This report focuses on two use types of prosthetic and orthotic devices: general-use and activity-specific. General-use prostheses and orthoses are designed to achieve the basic needs of ambulation and upper-limb functionality. In contrast, activity-specific devices are designed to support higher-intensity physical activities and recreation. Currently, 29 states do not require insurance coverage for general-use prosthetic and orthotic devices, and 45 states do not require insurance coverage for activity-specific devices, hindering individuals with limb loss, limb difference, and mobility impairment from essential life functions, including regular exercise required to prevent chronic illnesses. This study analyzes proposed legislation in 11 states, aiming to expand state-regulated coverage for prosthetic and orthotic devices for the purpose of improving quality of life and longevity of health, including chronic illness prevention. The methodology includes estimating the per member per month (PMPM) and net cost variations per state based on U.S. Census populations, Center of Medicare and Medicaid Services (CMS) Public Use Data Files and state-specific Medicaid fee schedules. The authors hypothesize that expanded insurance coverage could yield long-term social and fiscal benefits to the patient and healthcare systems. Results show PMPM estimates for states pursuing various levels of coverage, encompassing both general-use and activity-specific devices. The analysis conservatively estimates small PMPM increases based on assumptions related to device coverage costs and utilization. The results further emphasize potential overall healthcare savings from insurance coverage for these devices with the implementation of the 11 legislative initiatives, from improved health outcomes, with minimal fiscal impact.

Dental Protraction Versus Surgery for Cleft Lip and Palate: A Budget Impact Analysis.

Class III malocclusion for individuals with cleft lip and palate has historically been managed with surgery. Orthodontic protraction is a noninvasive alternative that may be associated with lower costs. This analysis investigated the budget impact of protraction versus surgery from an institutional perspective. Using a decision tree, analysis was conducted using costs derived from Medicaid reimbursement codes and using actual institutional reimbursement. Probabilities of success, failure, and complications were based on a clinical trial comparing the 2 treatment modalities. One-way and probabilistic sensitivity analyses tested the robustness of results to model parameters. Based on Medicaid fee schedules and failure rates requiring additional surgery, the total cost of protraction was $79,506 versus $172,807 for surgery, resulting in $93,302 cost-savings per patient. The cost and probability of surgery success, as well as the cost of surgery failure and repeat surgery, had the largest impact on these cost-savings. Probabilistic sensitivity analysis showed cost-savings of nearly $92,000 or higher in >50% of simulations. This study showed that protraction is associated with lower costs than surgery and may present a cost-effective alternative to surgery in eligible, appropriate patients.

The effectiveness of collaborative care delivered via telehealth in a pediatric primary care population.

The prevalence of mental health conditions among children and adolescents in the United States has become a pressing concern, exacerbated by the COVID-19 pandemic. Collaborative care is an evidence-based model for identifying and treating depression and anxiety in healthcare settings, with additional promise for remote healthcare delivery. This study aims to evaluate the impact of a telehealth collaborative care model for adolescents with depression and anxiety in pediatric and primary care settings. Secondary analysis was conducted using de-identified national data from Concert Health, a behavioral health medical group offering remote collaborative care across 17 states. Baseline, 90-day, and 120-day assessments of the PHQ-9 and GAD-7 were collected, along with baseline covariates. Stepwise regression analysis was performed to determine the contribution of select covariates to improvement rates. Among the analyzed data, 263 participants had complete PHQ-9 data, and 230 had complete GAD-7 data. In both the PHQ-9 and GAD-7 groups, over 50% of patients experienced treatment success based on success at discharge, as well as 90- and 120-day improvement rates. Predictors of success at discharge for the GAD-7 group included age at enrollment (OR 1.2258, 95% CI 1.01-1.496), clinical touchpoints (OR 1.1469, 95% CI 1.086-1.218), and lower baseline GAD-7 score (OR 0.9319, 95% CI 0.874-0.992). For the PHQ-9 group, Medicaid was significantly associated with not achieving a 50% reduction in PHQ-9 score at 120 days (OR 0.5874, 95% CI 0.349-0.979). Collaborative care has demonstrated its effectiveness in treating adolescent populations, providing an opportunity to expand access to evidence-based behavioral health treatment for young individuals. Notably, collaborative care is already integrated into the Medicaid fee schedule for 22 states and accepted by all commercial payers. Given that individuals often turn to their trusted primary care providers for behavioral health care, offering collaborative care to adolescents can play a crucial role in addressing the ongoing mental health crisis.

Medicaid physician fees and the use of primary care services: evidence from before and after the ACA fee bump.

We examine whether fees paid by Medicaid for primary care affects the use of health care services among adults with Medicaid coverage who have a high school or less than high school degree. The analysis spans the large changes in Medicaid fees that occurred before and after the ACA-mandated fee increase for primary care services in 2013-2014. We use data from the Behavioral Risk Factors Surveillance System and a difference-in-differences approach to estimate the association between Medicaid fees and whether a person has a personal doctor; a routine check-up or flu shot in the past year; whether a woman had a pap test or a mammogram in the past year; whether a person has ever been diagnosed with asthma, diabetes, cardiovascular diseases, cancer, COPD, arthritis, depression, or kidney diseases; and, whether a person reports good-to-excellent health. Estimates indicate that Medicaid fee increases were associated with small increases in the likelihood of having a personal doctor, or receiving a flu shot, although only having a personal doctor remained significant when accounting for multiple hypothesis testing. We conclude that Medicaid fees did not have a major impact on the use of primary care or on the consequences of that care.

The Effectiveness of Collaborative Care in Publicly Insured Populations.

The Centers for Medicare and Medicaid Services covers the cost of collaborative care for Medicare beneficiaries. However, only 24 states cover the costs of collaborative care in their Medicaid programs despite evidence indicating the cost-effectiveness of delivering behavioral health services in primary care. This study examines benchmark data from a behavioral health medical group embedded within primary care practices across the United States using a large dataset of patients treated in collaborative care. The study explores the effectiveness of collaborative care in reducing depression and anxiety symptoms by comparing Medicare, Medicaid, and privately insured populations, seeking to inform the importance of supporting advocacy for continued Medicaid fee adoption for collaborative care.

Prenatally diagnosed congenital heart disease: the cost of maternal care

Objective Little is known regarding the effects of a prenatal diagnosis of congenital heart disease (CHD) on the cost of antenatal and delivery care. We sought to compare the maternal costs of care in pregnancies where the fetus or child was diagnosed prenatally vs. postnatally. Methods Costs of maternal care were determined for pregnancies in which the fetus or child was diagnosed with CHD between 1997 and 2012 in the state of Utah. Cases of CHD were identified via a statewide birth defect surveillance program which included data on the timing of diagnosis, maternal demographic and clinical data, and linked to statewide inpatient maternal hospital discharge records. Antenatal testing costs were determined using Medicaid fee estimates and total facility costs were determined for all hospitalizations including delivery. The association of timing of diagnosis of CHD with costs was analyzed using univariable and multivariable models. Results Of 2128 pregnancies included in the study, 36% had a fetus prenatally diagnosed with CHD. The prenatal diagnosis group was more likely to have a termination or stillbirth and were younger at delivery (gestational age 37.3 vs 38.0 weeks, p < .001). Labor induction and cesarean delivery rates were similar between groups. Antenatal testing and delivery hospitalization costs were higher in the prenatal diagnosis group: $5819 vs $4041 (p < .001) and $10,509 vs $7802 (p < .001), respectively. Patients in the prenatal diagnosis group had longer lengths of hospital stays (3.5 vs 2.4 d, p > .001). After controlling for significant differences between the groups, including lesion severity, the prenatal diagnosis remained directly associated with antenatal testing costs (+$1472), maternal hospitalization costs (+$2713), and maternal hospital length of stay (+1.0 d). Conclusion A prenatal diagnosis of fetal CHD was associated with increased prenatal costs, hospitalization costs, and hospital length of stay for affected pregnant patients.

Medicaid professional fees for treatment of opioid use disorder varied widely across states and were substantially below fees paid by medicare in 2021

BackgroundAs Medicaid is the largest payer for opioid use disorder (OUD) treatment services in the United States, information about Medicaid provider reimbursement is critical, and Medicaid payment policies influence the structure of OUD treatment services for everyone with OUD treatment needs.MethodsWe collected Medicaid professional fees for OUD treatment and related services for the District of Columbia and fifty state Medicaid programs and the Medicare program in 2021. We create three fee indexes related to OUD treatment, with an emphasis on services related to first-line medication treatments in outpatient settings. We then create Medicaid fee indexes and Medicaid-to-Medicare fee indexes.ResultsWeekly Medicaid fee bundles for methadone treatment at OTPs in 2021 varied widely, more than 4-fold across states. The Medicaid-to-Medicare fee index shows that the national average Medicaid fee bundle was 56 percent of Medicare fees for regular methadone treatment at OTPs in 2021. For services related to OUD treatment, Medicaid fees varied up to 5-fold and larger across the components of each of the four services, and Medicaid fees were low relative to Medicare for almost all state services examined. The Medicaid-to-Medicare fee index was 64 percent of Medicare fees in 2021, ranging from 52 percent for evaluation & management to 76 percent for toxicology testing.ConclusionsThere appears to be little justification for such large variation in Medicaid fees across states. In addition, the generally low fees in Medicaid persist despite recent efforts to increase access to opioid use disorder treatment for Medicaid enrollees, and have important implications for access to life-saving treatment during the current opioid overdose crisis.

Mitigating the Impact of Coronavirus Disease-2019 on Child and Family Behavioral Health: Suggested Policy Approaches

Mitigating the Impact of Coronavirus Disease-2019 on Child and Family Behavioral Health: Suggested Policy Approaches

Cost-Effectiveness of a Web-Based Program for Residual Depressive Symptoms: Mindful Mood Balance.

Mindful Mood Balance (MMB) is an effective Web-based program for residual depressive symptoms that prevents relapse among patients with partial recovery from major depressive episodes. This cost-effectiveness analysis was conducted from the health plan perspective alongside a pragmatic randomized controlled trial of MMB. Adults were recruited from behavioral health and primary care settings in a large integrated health system and randomly assigned to MMB plus usual depression care (MMB+UDC) or UDC. Patients had at least one prior major depressive episode; a current score of 5-9 on the Patient Health Questionnaire-9, indicating residual depressive symptoms; and Internet access. Program costs included recruitment, coaching, and MMB licensing. Center for Medicare and Medicaid fee schedules were applied to electronic health record utilization data for psychotropic medications and psychiatric and psychotherapy visits. Effectiveness was measured as depression-free days (DFDs), converted from PHQ-9 scores collected monthly for 1 year. Incremental cost-effectiveness ratios were calculated with various sets of cost inputs. A total of 389 patients (UDC, N=210; MMB+UDC, N=179) had adequate follow-up PHQ-9 measures for inclusion. MMB+UDC patients had 29 more DFDs during follow-up. Overall, the incremental cost of MMB+UDC was $431.54 over 12 months. Incremental costs per DFD gained ranged from $9.63 for program costs only to $15.04 when psychiatric visits, psychotherapy visits, and psychotropic medications were included. MMB offers a cost-effective Web-based program for reducing residual depressive symptoms and preventing relapse. Health systems should consider adopting MMB as adjunctive to traditional mental health care services.

Limited Clinical Utility of Chest Radiography in Asymptomatic Patients after Interventional Radiology-Performed Ultrasound-Guided Thoracentesis: Analysis of 3,022 Consecutive Patients

Abstract Purpose The aim of this study was to report the utility of chest radiography following interventional radiology-performed ultrasound-guided thoracentesis. Materials and Methods A total of 3,998 patients underwent thoracentesis between 2003 and 2018 at two institutions. A total of 3,022 (75.6%) patients were older than 18 years old, underwent interventional radiology-performed ultrasound-guided thoracentesis, and had same-day post-procedure chest radiograph evaluation. Patient age (years), laterality of thoracentesis, procedural technical success, volume of fluid removed (mL), method of post-procedure chest imaging, absence or presence of pneumothorax, pneumothorax size (mm), pneumothorax management measures, and clinical outcomes were recorded. Technical success was defined as successful aspiration of pleural fluid. Post-procedure clinical outcomes included new patient-perceived dyspnea and hypoxia (oxygen saturations &lt; 90% on room air). Costs associated with radiographs were estimated using Medicare and Medicaid fee schedules. Results Mean age was 56.7 ± 15.5 years. Interventional radiology-performed ultrasound-guided thoracentesis was performed on the left (n = 1,531; 50.7%), right (n = 1,477; 48.9%), and bilaterally (n = 14; 0.5%) using 5-French catheters. Technical success was 100% (n = 3,022). Mean volume of 940 ± 550 mL of fluid was removed. Post-procedure imaging was performed in the form of posteroanterior (PA) (2.6%; 78/3,022), anteroposterior (AP) (17.0%; 513/3,022), PA and lateral (77.9%; 2,355/3,022), or PA, lateral, and left lateral decubitus (2.5%; 76/3,022) chest radiographs. Post-procedural pneumothorax was identified in 21 (0.69%) patients. Mean pneumothorax size, measured on chest radiograph as the longest distance from the chest wall to the lung, was 18.8 ± 10.2 mm (range: 5.0–35.0 mm). Of the 21 pneumothoraces, 7 (33.3%) were asymptomatic, resolved spontaneously, and had a mean size of 6.4 ± 2.4 mm. Fourteen pneumothoraces, of mean size 25.0 ± 5.8 mm, required management with a pleural drainage catheter (66.6%). The overall incidence of pneumothorax requiring pleural drainage catheter placement following interventional radiology-performed ultrasound-guided thoracentesis was 0.46% (14/3,022). Of the patients requiring drainage catheter placement, 12/14 (85.7%) and 13/14 (92.9%) had dyspnea and hypoxia, respectively. Potential costs to Medicare and Medicaid, for chest radiographs, in this study, were $27,547 and $10,581, respectively. Conclusion The incidence of clinically significant pneumothorax requiring catheter drainage following interventional radiology-operated ultrasound-guided thoracentesis is exceedingly low (0.46%), and routine post-procedure chest radiographs in asymptomatic patients provide little value. Reserving post-procedure chest radiographs for patients with post-procedure dyspnea or hypoxia will result in more efficient resource utilization and health care cost savings.

Assessment of the Patient Protection and Affordable Care Act’s Increase in Fees for Primary Care and Access to Care for Dual-Eligible Beneficiaries

The Patient Protection and Affordable Care Act (ACA) temporarily increased primary care practitioners' (PCP) Medicaid fees to that of Medicare for 2013 to 2014 (fee bump) to help accommodate potential increases in demand for care with ACA coverage expansion. This also increased fees for PCPs treating dual-eligible Medicare and Medicaid beneficiaries in many states and eliminated payment differentials for dual-eligible vs non-dual-eligible Medicare beneficiaries that could limit access to care. To examine the association between the ACA fee bump and primary care visits for dual-eligible Medicare and Medicaid beneficiaries. This cohort study used a difference-in-difference design and Medicare claims data from 2012 to 2016 to compare changes in visit rates for full-subsidy dual-eligible Medicare and Medicaid beneficiaries vs non-dual-eligible Medicare beneficiaries with low income whose fees did not change. Changes were examined overall and separately in states with temporary, extended, or minimal fee increases for dual-eligible vs non-dual-eligible beneficiaries in 2013 to 2014 (mandatory bump) and 2015 to 2016 (postbump or bump extension) vs 2012 (prebump). The study used linear regression models with beneficiary fixed effects, adjusting for time-changing area and beneficiary characteristics. Statistical analysis was performed from February 2018 to November 2019. ACA-mandated Medicaid fee bump. Primary care visits per 100 beneficiaries overall and visits billed by physicians vs nurse practitioners and physician assistants. The study included 3 052 044 dual-eligible and non-dual-eligible beneficiaries in 2012; 1 516 534 (49.7%) were aged 65 years or younger, 1 797 556 (58.9%) were women, and 1 754 626 (57.5%) had non-Hispanic White race/ethnicity. Overall primary care visit rates for dual-eligible beneficiaries were unchanged or decreased slightly relative to non-dual-eligible beneficiaries during the fee bump (2013-2014) and the postbump or bump extension period (2015-2016) vs baseline. Compared with non-dual-eligible beneficiaries, visit rates with primary care physicians declined more uniformly for dual-eligible beneficiaries across state groups and time periods (difference-in-difference: -0.37 [95% CI, -0.43 to -0.32] visits per 100 beneficiaries in 2013-2014 vs 2012; P < .001; and difference-in-difference: -0.62 [95% CI, -0.68 to -0.56] visits per 100 beneficiaries in 2015-2016 vs 2012; P < .001), whereas visits with nurse practitioners and physician assistants increased over time (difference-in-difference: 0.11 [95% CI, 0.08 to 0.14] visits per 100 beneficiaries in 2013-2014 vs 2012; P < .001; and difference-in-difference: 0.46 [95% CI, 0.43 to 0.50] visits per 100 beneficiaries in 2015-2016 vs 2012; P < .001). These changes, however, were not associated with the timing of the payment changes. The ACA fee bump was not associated with increases in primary care visits for dual-eligible Medicare and Medicaid beneficiaries. Visits for dual-eligible beneficiaries with primary care physicians decreased after the ACA, a decrease that was partially offset by increases in visits with nonphysician clinicians.

A US cost-minimization model comparing ravulizumab versus eculizumab for the treatment of atypical hemolytic uremic syndrome

Aims Ravulizumab, engineered from eculizumab, provides sustained C5 inhibition in atypical hemolytic uremic syndrome (aHUS) while reducing dosing frequency (every 8 vs 2 weeks, respectively). Treatment choice often carries significant financial implications. This study compared the economic consequences of ravulizumab and eculizumab for treating aHUS. Materials and methods A cost-minimization model compared direct medical costs for ravulizumab and eculizumab in treating aHUS, assuming equivalent efficacy and safety, and took a US payer perspective, a lifetime horizon, and a 3.0% cost discount rate. The base case modeled adult and pediatric treatment-naïve populations, with characteristics based on clinical trials, and treatment patterns (duration, discontinuation, re-initiation) derived from eculizumab studies with long-term follow-up. Treatment costs (2019 US$) were based on wholesale drug acquisition costs, Centers for Medicare & Medicaid fee schedules, and published disease management studies. Sensitivity analyses were conducted by adjusting relevant variables. Results Ravulizumab provided lifetime per-patient cost reductions (discounted) of 32.4% and 35.5% vs eculizumab in adult and pediatric base cases, respectively. Total costs for ravulizumab vs eculizumab were $12,148,748 and $17,979,007, respectively, for adults, and $11,587,832 and $17,959,814, respectively, for children. Pre-discontinuation treatment contributed the largest proportion of total costs for ravulizumab (94.8% and 88.0%) and eculizumab (94.8% and 87.8%) in adults and children, respectively. Across sensitivity analyses, ravulizumab provided cost reductions vs eculizumab. Limitations The model included several typical assumptions. Base case patients with more severe stages of chronic kidney disease were assumed not to discontinue treatment, nor to experience an excess mortality risk in either treatment arm, which may not reflect real-world clinical observations. Additionally, rebates and discounts on medication acquisition or administration were not considered. Conclusions In US patients with aHUS, ravulizumab provided cost reductions of 32.4–35.5% vs eculizumab, with a reduced dosing frequency for ravulizumab. The magnitude of reductions was consistent across sensitivity analyses.

New evidence of state variation in Medicaid payment policies for dual Medicare-Medicaid enrollees.

To develop the first longitudinal database of state Medicaid policies for paying the cost sharing in Medicare Part B for services provided to dual Medicare-Medicaid enrollees ("duals") and an index summarizing the impact of these policies on payments for physician office services. Medicaid policy data collected from electronic sources and inquiries with states. We constructed a national database of Medicaid payment policies for the period 2004-2018, consolidating information from online Medicaid policy documents, state laws, and policy data reported to us by state Medicaid programs. Using this database and state Medicaid fee schedules, we constructed a Medicaid payment index for duals. This index represented the proportion of the Medicare allowed amount that physicians would expect to be paid from Medicare and Medicaid for a subset of physician office services (evaluation and management services) based on annual state payment policies and Medicaid fee schedules. In 2018, 42 states had policies to limit Medicaid payments of Medicare cost sharing when Medicaid's fee schedule was lower than Medicare's-an increase from 36 such states in 2004. In the preponderance of states with these policies, combined Medicare and Medicaid payments for evaluation and management services provided to duals averaged 78 percent of the Medicare allowed amount for these services, reflecting relatively low Medicaid fee schedules in these states. In 2013 and 2014, physicians who qualified for the Affordable Care Act's Medicaid "fee bump" were paid 100 percent of the Medicare allowed amount for these services. Medicaid programs vary across states and over time in their payments of cost sharing for physician office services provided to duals. Our database and index can facilitate monitoring of these policies and research on the consequences of policy changes for duals.

The Impact of the ACA Medicaid Fee Bump on Pediatricians’ Participation in Medicaid: Evidence from Massachusetts

Low fees have often been cited as a barrier to provider participation in Medicaid, which limits access to care for enrollees. Under the Affordable Care Act (ACA), Medicaid fees for primary care providers (PCPs) were raised temporarily to that of Medicare fee in 2013‐2014. The existing evidence on whether increasing fees improves the availability of providers is mixed and often relies on self‐reported information from providers. We used the natural experiment created by the ACA fee bump in Massachusetts to examine the impact of the ACA fee bump on pediatricians’ participation in Medicaid. Since Massachusetts expanded Medicaid prior to the ACA, this provides an opportunity to examine the impact of fee increases in a setting of stable coverage levels.We used data from the Massachusetts All Payer Claims Database (MA‐APCD) from 2010‐2013 to identify children (age of 1‐18 years) enrolled in Medicaid, and the National Plan and Provider Enumeration System (NPPES) data to identify Pediatricians using their primary taxonomy codes. We used two main measures of provider participation in Medicaid: (1) the percentage of pediatricians who had at least one outpatient Medicaid claim per year; and (2) among those with at least 1 claim, the number of Medicaid claims per pediatrician per year. In sensitivity analyses, we also examined higher thresholds for number of claims. We used logistic and linear regression models with provider‐level random effects to assess if there were changes in pediatrician participation in Medicaid during the first year of fee bump (2013) vs. the baseline period (2010‐2012), adjusting for providers’ 3‐digit ZIP codes.All Pediatricians (N = 4724) identified in the MA‐APCD provider file linked with NPPES data and children enrolled in Medicaid (N = 772 628).Mean costs per pediatric visit among Medicaid enrollees increased 25% from $89 to $111 (2010‐2012 vs. 2013). In 2010, 45.1% pediatricians in Massachusetts had at least one outpatient Medicaid claim; the mean number of Medicaid claims per pediatrician was 380(SD = 554). The percent of pediatricians with any Medicaid claim increased slightly to 47.3% in 2013, but there was no significant increase in participation associated with the first year of fee bump and participation in multivariate analyses (OR 1.03, 95% CI 0.91, 1.17 for 2013 vs. 2010‐2012). However, the number of outpatient claims per pediatrician per year who participated in Medicaid decreased by 14.3 (95% CI: −23.0, −5.7) in 2013 vs. 2010‐2012. Similar results were obtained from multivariate analyses using higher thresholds for number of claims.Fewer than half of pediatricians in Massachusetts provided outpatient care to Medicaid enrollees in 2010. Despite increases in primary care payments associated with the ACA, pediatricians’ participation in Massachusetts did not increase in the first year of the policy change.The effects of ACA fee bump could have been more muted in the first year given potential delays in implementation. The temporary nature of the policy change could have also limited its effects. Alternative approaches could be needed to increase the availability of providers for low‐income children.Agency for Healthcare Research and Quality.

The Effects of Postpartum Long-Acting Reversible Contraceptive Insertion From the Medicaid Payer Perspective [26J

INTRODUCTION: This Markov model was created to determine the difference in unintended pregnancies, costs, and cost effectiveness with immediate versus standard placement of postpartum long-acting reversible contraception (ppLARC), which includes intrauterine devices (IUDs) and implants. METHODS: This Markov model examines a theoretical cohort of 1,000 women whose obstetrical care was paid for by North Carolina Medicaid and who requested ppLARC prior to discharge from their delivery hospitalization from the perspective of NC Medicaid. Probability inputs came from the literature and cost inputs are from NC Medicaid fee schedules. Markov cycles were weekly with an 18 month time horizon. During the time horizon postpartum, a woman could continue with her current contraceptive method, change to a different method, or become pregnant. Pregnancy is an absorbing state with five different outcomes. Probabilistic sensitivity analyses were conducted on key model parameters. RESULTS: Immediate ppLARC would result in 182 fewer unintended pregnancies and save North Carolina $624,372 over two years. Immediate ppLARC was cost saving, with an ICER of $3,435 saved per unintended pregnancy prevented. In sensitivity analyses, immediate ppLARC remained cost saving except when parameters were varied widely from expected values. CONCLUSION: Immediate post-partum insertion of long-acting reversible contraceptives was found to be associated with cost-savings and fewer unintended pregnancies.

The Effects of Postpartum Long-Acting Reversible Contraceptive Insertion From the Medicaid Payer Perspective [OP03-2C

INTRODUCTION: This model was created to determine the difference in short interval pregnancies, costs, and cost effectiveness with immediate versus standard placement of postpartum long-acting reversible contraception (ppLARC), which includes intrauterine devices and implants. METHODS: This Markov model examines a theoretical cohort of 1,000 women whose obstetrical care was paid for by North Carolina Medicaid (NC Medicaid) and who requested ppLARC prior to discharge from their delivery hospitalization from the perspective of NC Medicaid. Short interval pregnancy was defined as conception prior to 18 months from delivery. Probability inputs came from the literature and cost inputs are from NC Medicaid fee schedules. Markov cycles were weekly with an 18 month time horizon. During the time horizon postpartum, a woman could continue with her current contraceptive method, change to a different method, or become pregnant. Pregnancy is an absorbing state with five different outcomes. Probabilistic sensitivity analyses were conducted on key model parameters. RESULTS: Immediate ppLARC would result in 182 fewer unintended short interval pregnancies and save North Carolina $624,372 over 18 months. Immediate ppLARC was cost saving, with an incremental cost-effectiveness ratio of $3,435 saved per short interval pregnancy prevented. In sensitivity analyses, immediate ppLARC remained cost saving except when parameters were varied widely from expected values. CONCLUSION: Immediate post-partum insertion of long-acting reversible contraceptives was associated with cost-savings and fewer short interval pregnancies.

Is Primary Care A Substitute or Complement for Other Medical Care? Evidence from Medicaid.

It is widely believed that Medicaid reimbursement for primary care is too low and that these low fees adversely affect access to healthcare for Medicaid recipients. In this article, we exploit changes in Medicaid physician fees for primary care to study the response of primary care visits and services that are complements/substitutes with primary care, including emergency department, hospitalization, prescription drugs, and imaging. Results from our study indicate that higher Medicaid fees for primary care have modest effects. Among non-blind and non-disabled adults, we find that a 25% (or $10) increase in Medicaid fees for primary care is associated with approximately a 5% of a standard deviation increase in the number of primary care visits. For the same group, we also find that the fee increase is associated with an increase in the probability of having any primary care visits of approximately 3 percentage points. For children, changes in Medicaid fees are not significantly related to the number of primary care visits. In terms of other types of care, we find some evidence that Medicaid fees for primary care are associated with prescription drug use, and no evidence that primary care fees are associated with the use of emergency department, inpatient services, or imaging. Overall, our evidence provides, at best, limited support for the large effects of Medicaid fees on service provision sometimes asserted in policy discussions.