Medicaid Managed Care Program Research Articles

Latent Class Analysis of Social Needs in Medicaid Population and Its Impact on Risk Adjustment Models

Background: A growing number of US states are implementing programs to address the social needs (SNs) of their Medicaid populations through managed care contracts. Incorporating SN might also improve risk adjustment methods used to reimburse Medicaid providers. Objectives: Identify classes of SN present within the Medicaid population and evaluate the performance improvement in risk adjustment models of health care utilization and cost after incorporating SN classes. Research Design: A secondary analysis of Medicaid patients during the years 2018 and 2019. Latent class analysis (LCA) was used to identify SN classes. To evaluate the impact of SN classes on measures of hospitalization, emergency (ED) visits, and costs, logistic and linear regression modeling for concurrent and prospective years was used. Model performance was assessed before and after incorporating these SN classes to base models controlling for demographics and comorbidities. Subjects: 262,325 Medicaid managed care program patients associated with a large urban academic medical center. Results: 7.8% of the study population had at least one SN, with the most prevalent being related to safety (3.9%). Four classes of SN were determined to be optimal based on LCA, including stress-related needs, safety-related needs, access to health care–related needs, and socioeconomic status–related needs. The addition of SN classes improved the performance of concurrent base models’ AUC (0.61 vs. 0.58 for predicting ED visits and 0.61 vs. 0.58 for projecting hospitalizations). Conclusions: Incorporating SN clusters significantly improved risk adjustment models of health care utilization and costs in the study population. Further investigation into the predictive value of SN for costs and utilization in different Medicaid populations is merited.

Changing high-risk asthma in Memphis through partnership: Results from the CHAMP program

BackgroundChildren in metro Shelby County, Tennessee, have disproportionally high asthma-related health care resource use (HRU) compared with those in other regions in Tennessee. ObjectiveTo describe the goals, logistics, and outcomes of the Changing High-Risk Asthma in Memphis through Partnership (CHAMP) program implemented to improve pediatric asthma care in Shelby County. MethodsCHAMP established a multidisciplinary team with dedicated medical staff and community health workers, implemented a 24/7 call line to improve access to care, established a patient data registry to address fragmented care, assigned community health educators to improve asthma education and social needs, and partnered with services to address environmental triggers and social determinants of health. Patients eligible for CHAMP are Shelby County residents aged 2 to 18 years with high-risk asthma enrolled in Tennessee's Medicaid managed care program. Health care resource use outcomes 1-year pre- and post-CHAMP enrollment were analyzed for patients who had completed 1 year of CHAMP between January 2013 and December 2022. The 24/7 call line data between November 2013 and December 2022 were analyzed. ResultsCHAMP has enrolled 1348 children; 945 have completed 1 year (63% male; 90% identified as Black). At 1-year post-CHAMP enrollment, patients had 58%, 68%, 42%, and 53% reductions in emergency department visits, inpatient and observation visits, urgent care visits, and total asthma exacerbations, respectively. The number of asthma exacerbations per patient significantly decreased from 2.97 to 1.40 at 1-year post-CHAMP enrollment. Of the calls made to the 24/7 call line, 58% occurred after hours and 52% led to issue resolution without a medical facility visit. ConclusionCHAMP successfully decreased asthma HRU in children with high-risk asthma in Shelby County by implementing initiatives that targeted barriers to asthma care.

Abstract A125: Effects of Medicaid managed care on cancer staging: Evidence from Pennsylvania's mandatory Medicaid managed care program

Abstract Introduction: Cancer contributes disproportionately to the disease burden among adult Medicaid beneficiaries, underscoring a need for early cancer detection to improve cancer outcomes. One policy development within Medicaid that may influence the timeliness of cancer detection is the use of managed care. Medicaid managed care (MMC) programs may promote early-stage diagnosis through their emphasis on care coordination, disease screening, and primary care management. However, little research has examined the impact of MMC and cancer staging. Therefore, we estimated the effects of implementing mandatory MMC on early vs. late-stage diagnosis among incident cancer cases insured by Medicaid in Pennsylvania. Methods: We included non-elderly adults aged 21 to 64 diagnosed with solid tumors in the Pennsylvania cancer registry (2010-2018). To ascertain insurance and MMC status, we linked the sample to their inpatient/outpatient hospital discharge records (containing payer information for the visit) within one month of diagnosis. We leveraged a natural experiment arising from county-level variation in the implementation of a mandatory MMC program in Pennsylvania. Using a stacked difference-in-differences (DD) design to account for staggered treatment timing, we analyzed changes in the stage of diagnosis among incident cancer cases in counties that newly transitioned to mandatory MMC in 2012/2013 (“treated”), before and after the transition. We compared changes in these treated counties to contemporaneous changes among counties that had mandatory MMC in operation since 1997 (“controls”). We estimated incident case-level linear probability DD models and controlled for patient demographics (age, sex, race/ethnicity, rurality, and area deprivation index), county-level healthcare resources (constructed using the Area Resources Files), and county- and year-quarter-by-stack fixed effects. Results: We found a significant reduction in late-stage diagnosis of 3.9 percentage-points, or pp (95% CI: -7.2, -0.5; P = .023; baseline mean: 55.9%) in the treated counties vs. control counties, before and after the transition. The effect of mandatory MMC were driven by a greater reduction in late-stage diagnosis in screening-amenable cancer cases (DD: -5.5 pp; 95% CI: -10.4, -0.6; P =.027), especially breast and cervical cancer cases (DD: -8.9, 95% CI; -16.8, -0.9, P = .029). Conclusions: Mandatory MMC was associated with a reduced probability of late-stage diagnosis, particularly for screening-amenable cancers, suggesting that care coordination and primary care management may contribute to early detection of cancer in Medicaid. However, late-stage diagnosis was still highly prevalent among Medicaid beneficiaries, both before and after the transition to mandatory MMC. Medicaid programs and managed care organizations should continue to carefully monitor cancer screening and design strategies to reduce barriers to screening. Citation Format: Youngmin Kwon, Howard B. Degenholtz, Bruce L. Jacobs, Eric T. Roberts, Lindsay M. Sabik. Effects of Medicaid managed care on cancer staging: Evidence from Pennsylvania's mandatory Medicaid managed care program [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A125.

Organizational Health Literacy and Health Among New York State Medicaid Members.

The definition of health literacy has recently expanded beyond the idea of individual skills to include the system and environment the individual interacts with to receive care, known as organizational health literacy (OHL). However, neither the prevalence of OHL nor the impact of OHL on individuals' perceptions of their health and healthcare have been examined in New York's Medicaid managed care population. This study aimed to estimate the prevalence of organizational health literacy in the New York State (NYS) Medicaid Managed Care (MMC) program. A brief measure to assess organizational health literacy was developed from responses to two questions in the 2018 NYS Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Generalized Estimating Equation models were developed to analyze the association between organizational health literacy and three aspects of perceptions of health and health care, controlling for demographic differences and clustering effects from health insurance plans. Missing data were handled using multiple imputation. Among 3,598 members included in the study, 20% of the MMC members reported inadequate organizational health literacy. These members were more likely to be older, less educated, from racial and ethnic minority groups, and less fluent with English. They are more likely to have poorer self-reported health (odds ratio [OR] 1.49), lower perceived access to health care (OR 6.97), and lower satisfaction with their health care (OR 6.49) than members who did not report inadequate organizational health literacy. Our results suggest that a proportion of the NYS MMC population faces inadequate organizational health literacy, which can present a barrier to health care access and result in patients having a significantly poorer health care experience. Using an existing data source that is part of existing data collection allows for routine assessment of organizational health literacy, which can help inform health plans about areas for potential improvement. [HLRP: Health Literacy Research and Practice. 2023;7(3):e154-e164.].

Asthma outcomes in pediatric patients with 30-day follow-up after an asthma hospitalization in a Medicaid-managed care program

Background National asthma guidelines recommend an outpatient follow-up after hospitalization for asthma. Our aim is determine if a follow-up visit within 30 days after an asthma hospitalization impacts risk for re-hospitalization and emergency department visits for asthma within the following year. Methods This was a retrospective cohort study of claims data of Texas Children’s Health Plan (a Medicaid managed care program) members age 1 to <18 years and hospitalized for asthma between January 1, 2012, and December 31, 2018. Primary outcomes were days to re-hospitalization and emergency department visit between 30 days and 365 days following the index hospitalization. Results We identified 1,485 children age 1 to <18 years hospitalized for asthma. Comparing those with a 30 day follow-up to those without, there was no difference in days to re-hospitalization (adjusted hazard ratio 1.23, 95% Confidence Interval (CI) 0.74–2.06) or emergency department visit for asthma (aHR 1.08, 95% CI 0.88–1.33). Inhaled corticosteroid and short acting beta agonist dispensing were greater in the group completing the 30 day follow-up (means of 2.8 and 4.8 respectively for those with follow-up, 1.6 and 3.5 respectively for those without, p < 0.0001). Conclusion Having a follow-up outpatient visit within 30 days of an asthma hospitalization is not associated with a decrease in asthma re-hospitalization or emergency department visit in the 30–365 day period following the index hospitalization. Non-adherence to regular use of inhaled corticosteroid medication was high in both groups. These findings suggest need for improvement in the quality and quantity of post hospital asthma follow-up.

CMS sets parameters for services to meet social needs in Medicaid

The federal Centers for Medicare &amp; Medicaid Services (CMS) this month offered states additional guidance on incorporating services to address unmet health‐related social needs into their Medicaid managed care programs. The Jan. 4 document for state Medicaid directors presents guidelines for the use of services provided to enrollees in lieu of a service being covered in a Medicaid state plan.

IMPLEMENTATION AND IMPACT OF MANAGED LONG-TERM SERVICES AND SUPPORTS IN PENNSYLVANIA

Abstract In 2018, Pennsylvania began implementing a mandatory Medicaid managed care program called Community HealthChoices (CHC). CHC replaces the 1915(c) aging waiver and 4 other waiver programs that covered adults with disabilities and people with acquired brain injury. The new program covers people receiving long-term services and supports (LTSS) in both nursing homes and home and community-based settings as well as people dually eligible for both Medicaid and Medicare. The program is administered by 3 managed care organizations (MCOs) that are obligated to coordinate with Medicaid Behavioral Health, Medicare Advantage and D-SNP plans. The MCOs are incentivized to serve people with LTSS needs in community-based settings by increasing access to HCBS and supporting transitions from nursing homes back into the community. This symposium will present findings from a comprehensive, mixed-methods evaluation of the program. Drawing from our qualitative interviews with key stakeholders and examination of program materials, we will describe some of the challenges of the implementation process. Next, we will share findings from interviews with cohorts of participants conducted before and after implementation of the new program. Next, we will present findings from analysis of Medicaid claims data to examine changes in use of home and community-based services as well as overall rebalancing. Finally, we will present both qualitative and quantitative data on person-centered service planning- a critical requirement for HCBS programs.

The Influence of National Standards on Medicaid Managed Care Programs: Implications for Children and Youth with Special Health Care Needs.

To improve services and assure predictable costs of care for Children and Youth with Special Health Care Needs (CYSHCN), state Title V and Medicaid programs are cooperating to reconceive care systems including contracting arrangements with managed care organizations (MCOs). This article describes how a consensus-based framework, the National Standards for Systems of Care for CYSHCN, influenced the redesign of two state Medicaid managed care programs: a statewide managed care plan for children with medical complexity in Florida and a regional accountable care program serving children and adults in Colorado. Data are drawn from a recent evaluation of the National Standards, which define the core components of a comprehensive, coordinated, and family-centered system of care for CYSHCN. The authors synthesized insights from documents and semi-structured interviews with national and state stakeholders. The states used the National Standards in different ways. Florida translated the Standards into contract provisions and holds its MCO accountable to performance targets specific to CYSHCN. In Colorado, the Standards had an indirect influence on contract provisions with regional accountable entities (RAEs) and the state's oversight of EPSDT, which helps ensure that RAEs meet their obligations to CYSHCN. Managed care leaders viewed the Standards as an impetus to sharpen quality improvement and foster whole-person care. The National Standards offer a flexible framework to help states design Medicaid managed care programs and improve systems of care for CYSHCN. States can learn from one another's experiences applying the Standards in the context of their policy environments.

Impact of Statewide Mandatory Medicaid Managed Care (SMMC) Programs on Hospital Obstetric Outcomes.

The state of Florida implemented mandatory managed care for Medicaid enrollees via the Statewide Medicaid Managed Care (SMMC) program in April of 2014. The objective of this study was to examine the impact of the implementation of the SMMC program on the access to care and quality of maternal care for Medicaid enrollees, as measured by several hospital obstetric outcomes. The primary data source for this retrospective observational study was the Hospital Cost and Utilization Project (HCUP) all-payer State ED (SED) visit and State Inpatient Databases (SIDs) from 2010 to 2017. The primary health outcomes for obstetric care were primary cesarean, preterm birth, postpartum preventable ED visits, postpartum preventable readmissions, and vaginal delivery after cesarean (VBAC) rates. Using difference-in-differences (DID) estimation, selected health outcomes were examined for Florida residents with Medicaid beneficiaries (treatment) and the commercially insured population (comparison), before and after the implementation of SMMC. Improvement in disparities for racial/ethnic minority Medicaid enrollees was estimated relative to whites, compared to the relative change among commercially insured patients. From the DID estimation, the findings showed that SMMC is statistically significantly associated with a higher reduction in primary cesarean rates, preterm births, preventable postpartum ED visits, and readmissions among Medicaid beneficiaries relative to their commercially insured counterparts. However, this study did not find any significant reduction in racial/ethnic disparities in obstetric outcomes. In general, this study highlights the impact of SMMC implementation on obstetric outcomes in Florida and provides important insights and potential scope for improvement in obstetric care quality and associated racial/ethnic disparities.

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.

Partnering to Improve Pediatric Asthma Quality.

Partnering to Improve Pediatric Asthma Quality.

Mental health service utilization review patterns in a Medicaid managed care program.

The current study investigated mental health utilization review (UR) clinical service authorization requests, denials, and reasons for denial in a statewide Medicaid managed care organization (MMCO) program. Retrospective analysis of utilization review data reported by MMCOs in New York State. Data from the utilization review practices of 15 MMCOs were collected and analyzed for calendar years 2017 and 2018. The data reported are specific to mental health services and include the number of authorization requests, number of clinical denials, and the reasons specified for each denial. Analyses were undertaken to determine the UR denial rates and most common reasons for denials. A total of 264,901 requests for inpatient mental health service authorizations and 53,687 requests for outpatient mental health service authorizations were made in 2017 and 2018. Of these, 1.5% of inpatient authorization requests and 0.4% of outpatient authorization requests were denied for reasons related to medical necessity. The most common reason for inpatient mental health service denials was that the patient no longer met the standard for the requested level of care. Low UR denial rates warrant further examination of the relationship between UR and both quality of care and patient outcomes in mental health care. With the substantial resources spent on UR, findings could point to areas of potential reforms to the system that may minimize these costs and improve care for patients with mental illness.

Evaluation of a pediatric asthma high-risk scoring algorithm.

Identification of patients with asthma at increased risk for hospitalization and emergency department (ED) visits presents opportunity for intervention. Retrospective analysis of computerized health plan claims data. Texas Children's Health Plan, a large Medicaid managed care program, developed an asthma risk scoring algorithm using the clinically relevant parameters of hospitalization for asthma, ED visits for asthma, short-acting β agonist medication dispensing, inhaled corticosteroid medication dispensing, number of prescribing providers, loss to follow-up, and oral corticosteroid dispensing. The risk score performance was evaluated using 2016-2018 risk scores to predict 2017-2019 asthma hospitalizations and ED visits. We identified 107,811 unique members aged 1 to less than 18 years with an asthma diagnosis. For those aged 3 to less than 18 years, the area under the receiver operating characteristic curve (AUC) for risk score predicting hospitalization ranged from 0.72 to 0.79. For those aged 1 to less than 3 years, the AUC ranged from 0.65 to 0.69. Those with a risk score of 1 or greater accounted for 20% to 23% of pediatric members 3 to less than 18 years with asthma but 53% to 56% of asthma hospitalizations in the follow-up year. Sixteen to eighteen percent of those aged 3 to less than 18 years with a risk score of 9 or greater were hospitalized in the follow-up year. Texas Children's Health Plan asthma risk score stratifies risk of asthma hospitalization and ED visits for Medicaid-insured children. The risk score performs better for children aged 3 to less than 18 years than for those aged 1 to less than 3 years.

Individual health insurance reforms in the U.S.: Expanding interstate markets, Medicare for all, or Medicaid for all?

To help enhancing affordability and availability in the U.S. individual health insurance markets, we evaluate whether expanding interstate markets is associated with efficiency improvement, and the potentials of “Medicaid for All” and “Medicare for All”. This research aims to provide insights and evidence for data-driven decision making in reforming individual health insurance markets and optimizing individual health insurance operations. We employ traditional, non-oriented slack-based, order-α partial frontier, bootstrapped bias-corrected, and modified context-dependent data envelopment analysis (DEA) models, as well as generalized linear, Tobit, and residual inclusion regression models. We find that higher competition or expansion is not associated with higher consumer efficiency or societal efficiency. Our results also indicate that, in minimizing premiums or expenses given enrollment and utilization of medical services, individual health plans are less efficient than Medicaid managed care plans, but more efficient than Medicare Advantage plans. Our findings imply that, for individual plans, expanding interstate markets is not accompanied with lower premiums or expenses without the sacrifice of medical services. This research suggests that it should be advisable to structure individual health insurance markets following the Medicaid managed care model but not the Medicare Advantage model. To “Medicaid-ize” individual markets, we propose to structure the individual coverage in two layers: a conditionally subsidized Medicaid managed care program with mandatory essential benefits, and an unsubsidized “Medicaid Supplement” program for optional additional coverages.

Parity Is Not Enough! Mental Health, Managed Care, and Medicaid

This Commentary describes limitations of mental health parity requirements in ensuring access to insurance coverage for mental health treatment. It then surveys regulatory options employed by states in Medicaid managed care programs as supplements to parity that can further reduce the risk of inappropriate denials of coverage.

Washington’s State Innovation Models (SIM) Project: Effects of Primary Care and Behavioral Health Integration on Participating Organizations

The Triple Aim is a framework designed by the Institute for Healthcare Improvement (IHI), aimed at enhancing health system performance. The IHI Triple Aim is defined by three components: improving population health, improving quality of care, and reducing per capita health care costs. Section 3021 of the Affordable Care Act (ACA) altered section 1115A of the Social Security Act, establishing the Center for Medicare and Medicaid Innovation (CMMI). Through CMMI, Medicaid and Medicare programs can test models to improve care, lower cost, and support patient‐centered practice. The State Innovation Models (SIM) initiative is one of these major reform models and is designed to test new payment approaches that address the Triple Aim.In Washington State, SIM Payment Model 1 (PM1) assists the transition from the traditional Medicaid payment system, with separate contracts for physical and behavioral health services, to a unified managed care model wherein each Medicaid managed care organization has single contract for delivering physical and behavioral health services. The primary goal is to incorporate behavioral health benefits into the capitated Medicaid managed care program so that beneficiaries have access to the full complement of physical and behavioral health services through a single integrated managed care plan. Our purpose is to evaluate stakeholders’ perspectives regarding the impact of the SIM PM1 initiative on participating payers, providers, and support agencies.The lead qualitative investigator contacted a purposive sample of clinical and administrative executives via email between June 2017 and October 2019. A total of 23 informants (n = 23) representing 11 organizations participated in a combination of face‐to‐face and telephonic interviews. Semi‐structured interviews were conducted using a single questionnaire aligned with an organization theory‐based conceptual framework, and each lasted 37 to 70 minutes.The research team identified health service payers (MCOs), behavioral health and primary care providers, and supporting agencies (eg, public health, crisis services, associations) participating in the development and/or implementation of PM1 physical‐behavioral health care integration initiative.PM1 implementation efforts required extensive consideration of organizational needs as well as agency‐based integration techniques. Integration depended on external and internal contributing factors, which informed and guided changes to the organization theory‐based conceptual framework. Efforts were influenced by a combination of external and internal factors, such as regional leadership and partnerships as well as each entity’s unique capacity to engage in organizational learning. While stakeholders expressed wide‐ranging opinions about the initiative and its effects, informants’ perspectives aligned largely by organization type. Thematically, findings included (a) organizational change management; (b) key priorities and approaches; (c) common facilitators and barriers to integration; (d) lessons learned; and (e) sustainability.Contextual factors influence organizations’ unique approaches to adoption and implementation of physical and behavioral health care integration policy. Value‐based policy implementation is a learning process. As such, organizations must hone their approaches to services delivered over time.When setting priorities for value‐based contracting, policy makers and health system leaders should consider the contextual and organizational factors that influence implementation, and should explore payment and purchasing structures that allow for flexibility and learning, particularly during early implementation.The study was funded by the Centers for Medicare and Medicaid Services.

Impacts of family-informed care for people with disabilities enrolled in Medicaid managed care

ABSTRACT This paper explores the impact of family-informed care on Medicaid enrollees with disabilities’ unmet needs for medical services and long-term services and supports (LTSS) and family members’ appraisal of the services received by those enrollees within a Medicaid managed care program in one Midwestern state. Families play an important role in the lives of people with disabilities. However, little is understood about the relationship between unmet needs of people with disabilities and the degree to which their family informs the care they receive. Regression analyses were performed on 700 surveys that were partially completed by a Medicaid enrollee with a disability and partially by a family member. After controlling for enrollee and family demographics/factors and family involvement in day-to-day activities, family members who reported higher levels of the family-informed care had higher appraisals of the services received by enrollees and those enrollees reported fewer unmet medical and LTSS needs. Findings highlight the importance of including family members in healthcare decision-making within social policies and programs, such as Medicaid managed care. Additional research is needed to promote best practices in family-informed care when desired by adults with disabilities.

Parity is Not Enough! Mental Health, Managed Care, and Medicaid.

This commentary describes limitations of mental health parity requirements in ensuring access to insurance coverage for mental health treatment and surveys regulatory options employed by states in Medicaid managed care programs as supplements to parity that can further reduce the risk of inappropriate denials of coverage.

Iowa community pharmacies’ experiences with Medicaid managed care

ObjectivesTo describe Iowa community pharmacies’ experiences and satisfaction with the transition to Medicaid managed care and conduct a qualitative evaluation of the effect of Medicaid managed care on 3 independent community pharmacies. DesignCross-sectional descriptive study. Mixed methods were used: the quantitative phase was a mailed survey and the qualitative phase involved interviews. Setting and participantsThe mail survey was sent to Iowa-registered community pharmacies whose names and addresses were obtained from the Iowa Board of Pharmacy website. Interviews with pharmacists and other pharmacy staff were conducted at 3 Iowa independent community pharmacies. Outcome measuresPharmacy satisfaction and experiences with the Iowa Medicaid managed care program. ResultsThe 265 returned surveys yielded a 27.4% response rate. Eight pharmacists and pharmacy staff were interviewed in the qualitative phase. Mean satisfaction with the Medicaid managed care organizations (MCOs) was 3.1 on a scale of 1-7, with 1 being extremely dissatisfied, and 7 being extremely satisfied. Respondents were most satisfied with the ease of joining the plans’ pharmacy networks (mean = 4.1) and least satisfied with the availability of payment for nondispensing-related services (2.3), plans’ communication with patients (2.7), and plans’ communication with pharmacies (3.0). Pharmacies also reported problems with patients’ access to prescriptions. The MCOs ranked lowest in satisfaction when compared with the largest private payer, the largest Medicare Part D plan, and the previous state-run Medicaid program. The themes that emerged from the interviews were as follows: confusion caused by multiple MCOs, plan-communication challenges, product-coverage challenges, problems related to durable medical equipment, and payment challenges. ConclusionThe transition from a state-run fee-for-service Medicaid program to Medicaid managed care in Iowa created many challenges for community pharmacies. Different procedures and product coverage across the 3 MCOs were particularly problematic.

Prescribing Associated with High-Risk Opioid Exposures Among Non-cancer Chronic Users of Opioid Analgesics: a Social Network Analysis.

The continued rise in fatalities from opioid analgesics despite a steady decline in the number of individual prescriptions directing ≥ 90 morphine milligram equivalents (MME)/day may be explained by patient exposures to redundant prescriptions from multiple prescribers. We evaluated prescribers' specialty and social network characteristics associated with high-risk opioid exposures resulting from single-prescriber high-daily dose prescriptions or multi-prescriber discoordination. Retrospective cohort study. A cohort of prescribers with opioid analgesic prescription claims for non-cancer chronic opioid users in an Illinois Medicaid managed care program in 2015-2016. Per prescriber rates of single-prescriber high-daily-dose prescriptions or multi-prescriber discoordination. For 2280 beneficiaries, 36,798 opioid prescription claims were submitted by 3532 prescribers. Compared to 3% of prescriptions (involving 6% of prescribers and 7% of beneficiaries) that directed ≥ 90 MME/day, discoordination accounted for a greater share of high-risk exposures-13% of prescriptions (involving 23% of prescribers and 24% of beneficiaries). The following specialties were at highest risk of discoordinated prescribing compared to internal medicine: dental (incident rate ratio (95% confidence interval) 5.9 (4.6, 7.5)), emergency medicine (4.7 (3.8, 5.8)), and surgical subspecialties (4.2 (3.0, 5.8)). Social network analysis identified 2 small interconnected prescriber communities of high-volume pain management specialists, and 3 sparsely connected groups of predominantly low-volume primary care or emergency medicine clinicians. Using multivariate models, we found that the sparsely connected sociometric positions were a risk factor for high-risk exposures. Low-volume prescribers in the social network's periphery were at greater risk of intended or discoordinated prescribing than interconnected high-volume prescribers. Interventions addressing discoordination among low-volume opioid prescribers in non-integrated practices should be a priority. Demands for enhanced functionality and integration of Prescription Drug Monitoring Programs or referrals to specialized multidisciplinary pain management centers are potential policy implications.