Medicaid Managed Care Research Articles

Medicaid Managed Care Prior Authorization For Buprenorphine Tied To State Partisanship And Health Plan Profit Status, 2018.

Buprenorphine is among the most effective drugs for treating opioid use disorder, yet only a quarter of Americans who need it receive it. Requiring prior authorization has been identified as an important barrier to buprenorphine access. However, the practice remains widespread in Medicaid-the largest insurer of Americans with opioid use disorder. In this study, we examined how prior authorization for buprenorphine is related to plan structure and state political environment, using data on all 266 comprehensive Medicaid managed care plans active in 2018. We found substantial variation in prior authorization use across states, with all plans requiring prior authorization in eleven states and no plans requiring it in thirteen other states. We found that for-profit plans and those located in Republican states were more likely to impose prior authorization policies. Our findings suggest that managed care plans' decisions regarding use of prior authorization may be shaped by internal pressures to control costs, as well as by differing partisan stances regarding the need to prevent criminal diversion of buprenorphine.

Access, Utilization, and Quality of Behavioral Health Integration in Medicaid Managed Care

Many states have moved from models that carve out to those that carve in or integrate behavioral health in their Medicaid managed care organizations (MCOs), but little evidence exists about the effect of this change. To assess the association of the transition to integrated managed care (IMC) in Washington Medicaid with health services use, quality, health-related outcomes, and measures associated with social determinants of health. This cohort study used difference-in-differences analyses of Washington State's 2014 to 2019 staggered rollout of IMC on claims-based measures for enrollees in Washington's Medicaid MCO. It was supplemented with interviews of 24 behavioral health agency leaders, managed care administrators, and individuals who were participating in the IMC transition. The data were analyzed between February 1, 2023, and September 30, 2023. Claims-based measures of utilization (including specialty mental health visits and primary care visits); health-related outcomes (including self-harm events); rates of arrests, employment, and homelessness; and additional quality measures. This cohort study included 1 454 185 individuals ages 13 to 64 years (743 668 female [51.1%]; 14 306 American Indian and Alaska Native [1.0%], 132 804 Asian American and Pacific Islander [9.1%], 112 442 Black [7.7%], 258 389 Hispanic [17.8%], and 810 304 White [55.7%] individuals). Financial integration was not associated with changes in claims-based measures of utilization and quality. Most claims-based measures of outcomes were also unchanged, although enrollees with mild or moderate mental illness experienced a slight decrease in cardiac events (-0.8%; 95% CI, -1.4 to -0.2), while enrollees with serious mental illness experienced small decreases in employment (-1.2%; 95% CI -1.9 to -0.5) and small increases in arrests (0.5%; 95% CI, 0.1 to 1.0). Interviews with key informants suggested that financial integration was perceived as an administrative change and did not have substantial implications for how practices delivered care; behavioral health agencies lacked guidance on how to integrate care in behavioral health settings and struggled with new contracts and regulatory policies that may have inhibited the ability to provide integrated care. The results of this cohort study suggest that financial integration at the MCO level was not associated with significant changes in most measures of utilization, quality, outcomes, and social determinants of health. Additional support, including monitoring, training, and funding, may be necessary to drive delivery system changes to improve access, quality, and outcomes.

Improving Diabetes Control in a Medicaid Managed Care Population With Complex Needs.

People enrolled in Medicaid managed care who struggle with diabetes control often have complex medical, behavioral, and social needs. Here the authors report the results of a program designed to partner with primary care teams to address those needs. A nonprofit organization partnered with a Medicaid managed care plan and a Federally Qualified Health Center in California to enroll people with A1cs >9% in a 12-month program. The program team included a community health worker, certified diabetes care and education specialist/registered dietitian, behavioral health counselor, and registered nurse. They developed patient-led action plans, connected patients to community resources, and supported behavior changes to improve diabetes control. Baseline assessments of behavioral health conditions and social needs were collected. Monthly A1c values were tracked for participants and a comparison group. Of the 51 people enrolled, 83% had at least 1 behavioral health condition. More than 90% reported at least 1 unmet social need. The average monthly A1c among program participants was 0.699 lower than the comparison group post-enrollment (P = .0008), and the disparity in A1c between Hispanic and non-Hispanic White participants at enrollment declined. Participants had high levels of unmet medical, behavioral, and social needs. Addressing these needs resulted in a rapid and sustained improvement in A1c control compared to non-enrollees and a reduction in disparity of control among Hispanic participants. By partnering with a primary care team, a program external to Federally Qualified Health Center primary care can improve clinical outcomes for people with complex needs living with diabetes.

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.

The Need for Transparency in Medicaid Managed Care: Section 1115 Waiver Requirements as a Blueprint.

Medicaid plays a significant role in the health care space, providing insurance coverage to nearly one quarter of the U.S. population. In recent years, managed care organizations have taken on an increasingly prominent role in the Medicaid space, and in many instances have become the sole insurance option for Medicaid recipients. The scale and method of implementation for managed care programs has varied widely from state to state. This Note discusses the many methods by which a state can enact managed care within its Medicaid program, and summarizes the challenges with assessing the success of such programs. It proposes a uniform approach to managed care reporting requirements designed to increase transparency and accountability across state lines, and in turn ensure quality care for Medicaid managed care beneficiaries.

Hospital Prices in Medicaid Managed Care

This cross-sectional study uses hospitals’ self-disclosed pricing information to characterize Medicaid managed care hospital prices.

Trends in Influenza Vaccination Rates among a Medicaid Population from 2016 to 2021.

Seasonal influenza is a leading cause of death in the U.S., causing significant morbidity, mortality, and economic burden. Despite the proven efficacy of vaccinations, rates remain notably low, especially among Medicaid enrollees. Leveraging Medicaid claims data, this study characterizes influenza vaccination rates among Medicaid enrollees and aims to elucidate factors influencing vaccine uptake, providing insights that might also be applicable to other vaccine-preventable diseases, including COVID-19. This study used Medicaid claims data from nine U.S. states (2016-2021], encompassing three types of claims: fee-for-service, major Medicaid managed care plan, and combined. We included Medicaid enrollees who had an in-person healthcare encounter during an influenza season in this period, excluding those under 6 months of age, over 65 years, or having telehealth-only encounters. Vaccination was the primary outcome, with secondary outcomes involving in-person healthcare encounters. Chi-square tests, multivariable logistic regression, and Fisher's exact test were utilized for statistical analysis. A total of 20,868,910 enrollees with at least one healthcare encounter in at least one influenza season were included in the study population between 2016 and 2021. Overall, 15% (N = 3,050,471) of enrollees received an influenza vaccine between 2016 and 2021. During peri-COVID periods, there was an increase in vaccination rates among enrollees compared to pre-COVID periods, from 14% to 16%. Children had the highest influenza vaccination rates among all age groups at 29%, whereas only 17% were of 5-17 years, and 10% were of the 18-64 years were vaccinated. We observed differences in the likelihood of receiving the influenza vaccine among enrollees based on their health conditions and medical encounters. In a study of Medicaid enrollees across nine states, 15% received an influenza vaccine from July 2016 to June 2021. Vaccination rates rose annually, peaking during peri-COVID seasons. The highest uptake was among children (6 months-4 years), and the lowest was in adults (18-64 years). Female gender, urban residency, and Medicaid-managed care affiliation positively influenced uptake. However, mental health and substance abuse disorders decreased the likelihood. This study, reliant on Medicaid claims data, underscores the need for outreach services.

A Medicaid-Funded Statewide Diabetes Quality Improvement Collaborative: Ohio 2020‒2022.

We used a collective impact model to form a statewide diabetes quality improvement collaborative to improve diabetes outcomes and advance diabetes health equity. Between 2020 and 2022, in collaboration with the Ohio Department of Medicaid, Medicaid Managed Care Plans, and Ohio's seven medical schools, we recruited 20 primary care practices across the state. The percentage of patients with hemoglobin A1c greater than 9% improved from 25% to 20% over two years. Applying our model more broadly could accelerate improvement in diabetes outcomes. (Am J Public Health. 2023;113(12):1254-1257. https://doi.org/10.2105/AJPH.2023.307410).

New Opportunities to Strengthen Medicaid Managed Care Network Adequacy Standards

This Viewpoint discusses new standards proposed by the Centers for Medicare & Medicaid Services for ensuring that Medicare managed care networks meet enrollees’ needs.

State-Level Variation in Medicaid Managed Care Enrollment and Specialty Care for Publicly Insured Children

Medicaid and Children's Health Insurance Program cover almost 50% of children with special health care needs (CSHCN). CSHCN often require specialty services and have been increasingly enrolled in Medicaid managed care (MMC) plans, but there is a dearth of recent national studies on specialty care access among publicly insured children and particularly CSHCN. To provide recent, nationwide evidence on the association of MMC penetration with specialty care access among publicly insured children, with a special focus on CSHCN. This cross-sectional study used nationally representative data from the 2016 to 2019 National Survey of Children's Health to identify publicly insured children in 41 states that administered comprehensive managed care organizations for Medicaid. Data analysis was performed from May 2022 to March 2023. Form CMS-416 data were used to measure state-year level share of Medicaid-enrolled children who were covered by MMC (ie, MMC penetration). Measures of specialty care access included whether, in the past year, the child had (1) any visit to non-mental health (MH) specialists, (2) any visit to MH professionals, and (3) any unmet health care needs and (4) whether the caregiver ever felt frustrated getting services for their child. Logistic regression models were used to examine the association of MMC penetration with specialty care access among all publicly insured children, and separately for CSHCN and non-CSHCN. Among 20 029 publicly insured children, 7164 (35.8%) were CSHCN, 9537 (48.2%) were female, 4110 (37.2%) were caregiver-reported Hispanic, and 2812 (21.4%) were caregiver-reported non-Hispanic Black (all percentages are weighted). MMC was not associated with significant changes in any visit to non-MH specialists and unmet health care needs. In addition, MMC penetration was positively associated with caregiver frustration among all children (adjusted odds ratio, 1.23; 95% CI, 1.03-1.48; P = .02) and was negatively associated with any visit to MH professionals among CSHCN (adjusted odds ratio, 0.75; 95% CI, 0.58-0.98; P = .04). In this cross-sectional study evaluating MMC and specialty care access for publicly insured children, increased MMC enrollment was not associated with improved specialty care access for publicly insured children, including CSHCN. MMC was associated with less access to specialties like MH and increased frustrations among caregivers seeking services for their children.

Trends in Repeat Opioid Analgesic Prescription Utilization for Acute Pain in Children: 2013–2018

Our study examined the change in repeat opioid analgesic prescription trends in children and adolescents experiencing acute pain between 2013 and 2018. Eligible individuals were children and adolescents between 1 and 17 years of age enrolled in a Medicaid Managed Care plan and filled an incident opioid analgesic prescription from 2013 to 2018. A repeat opioid prescription was defined as receiving a subsequent opioid prescription within 30 days from the end of the incident opioid prescription. A generalized linear regression analysis was conducted to examine changes in repeat opioid analgesic dispensing over time at quarterly intervals from January 1, 2013, to December 31, 2018. The cohort comprised 17,086 children and adolescents receiving an incident opioid analgesic. Of these, 1780 (10.4%) filled a repeat opioid analgesic prescription. There was a significant decline in the repeat opioid analgesic trend from 11.5% in Q1 2013 to 9.6% in Q4 2018. Stratified analyses by age, sex, and race and ethnicity in a sub-cohort of patients undergoing surgical procedures showed that a significant decline in repeat opioid utilization over time has been observed in all racial/ethnic groups stratified by age and sex, with the most significant decline found in non-Hispanic White children and Hispanic adolescents. At the end of the 6-year follow-up, the racial and ethnic variations in repeat opioid utilization associated with surgical procedures had significantly reduced in children yet persisted among adolescents. Approximately 10% of incident pediatric opioid analgesic recipients received a repeat opioid prescription. There has been a moderate but steady decline (∼7% per quarter) in repeat opioid analgesic utilization between 2013 and 2018.

Is There Variation in Time to and Type of Treatment for Hip Osteoarthritis Based on Insurance?

BackgroundDisparities in care access based on insurance exist for total hip arthroplasty (THA), but it is unclear if these lead to longer times to surgery. We evaluated whether rates of THA versus nonoperative interventions (NOI) and time to THA from initial hip osteoarthritis (OA) diagnosis vary by insurance type. MethodsUsing a national claims database, patients who had hip OA undergoing THA or NOI from 2011 to 2019 were identified and divided by insurance type: Medicaid-managed care; Medicare Advantage; and commercial insurance. The primary outcome was THA incidence within 3 years after hip OA diagnosis. Multivariable logistic regression models were created to assess the association between THA and insurance type, adjusting for age, sex, region, and comorbidities. ResultsMedicaid patients had lower rates of THA within 3 years of initial diagnosis (7.4 versus 10.9 or 12.0%, respectively; P < .0001) and longer times to surgery (297 versus 215 or 261 days, respectively; P < .0001) compared to Medicare Advantage and commercially-insured patients. In multivariable analyses, Medicaid patients were also less likely to receive THA (odds ratio (OR) = 0.62 [95% confidence intervals (CI): 0.60 to 0.64] versus Medicare Advantage, OR = 0.63 [95% CI: 0.61 to 0.64] versus commercial) or NOI (OR = 0.92 [95% CI: 0.91 to 0.94] versus Medicare Advantage, OR = 0.81 [95% CI: 0.79 to 0.82] versus commercial). ConclusionsMedicaid patients experienced lower rates of and longer times to THA than Medicare Advantage or commercially-insured patients. Further investigation into causes of these disparities, such as costs or access barriers, is necessary to ensure equitable care.

Use of and barriers to adopting standardized social risk screening tools in federally qualified health centers during the first year of the COVID-19 pandemic.

To describe the national rate of social risk factor screening adoption among federally qualified health centers (FQHCs), examine organizational factors associated with social risk screening adoption, and identify barriers to utilizing a standardized screening tool in 2020. 2020 Uniform Data System, a 100% sample of all US FQHCs (N = 1375). We used multivariable linear probability models to assess the association between social risk screening adoption and key FQHC characteristics. We used descriptive statistics to describe variations in screening tool types and barriers to utilizing standardized tools. We thematically categorized open-ended responses about tools and barriers. None. In 2020, 68.9% of FQHCs screened patients for any social risk factors. Characteristics associated with a greater likelihood of screening adoption included having high proportions of patients best served in a language other than English (18.8 percentage point [PP] increase, 95% CI: 6.0, 31.6) and being larger in size (10.3 PP increase, 95% CI: 0.7, 20.0). Having higher proportions of uninsured patients (14.2 PP decrease, 95% CI: -25.5, -0.3) and participating in Medicaid-managed care contracts (7.3 PP decrease, 95% CI: -14.2, -0.3) were associated with lower screening likelihood. Among screening FQHCs, the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) was the most common tool (47.1%). Among non-screening FQHCs, common barriers to using a standardized tool included lack of staff training to discuss social issues (25.2%), inability to include screening in patient intake (21.7%), and lack of funding for addressing social needs (19.2%). Though most FQHCs screened for social risk factors in 2020, various barriers have prevented nearly 1 in 3 FQHCs from adopting a screening tool. Policies that provide FQHCs with resources to support training and workflow changes may increase screening uptake and facilitate engagement with other sectors.

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.].

How Does Medicaid Managed Care Address the Needs of Beneficiaries with Opioid Use Disorders? A Deep Dive into Contract Design.

Many people who experience opioid use disorder rely on Medicaid. The high penetration of managed care systems into Medicaid raises the importance of understanding states' expectations regarding coverage, access to care, and health system performance and effectively elevates agreements between states and plans into blueprints for coverage and care. Federal law broadly regulates these structured agreements while leaving a high degree of discretion to states and plans. In this study, researchers reviewed the provisions of 15 state Medicaid managed care contract related to substance use disorder (SUD) treatment to identify whether certain elements of SUD treatment were a stated expectation and the extent to which the details of those expectations varied across states in ways that ultimately could affect evaluation of performance and health outcomes. We found that while all states include SUD treatment as a stated contract expectation, discussions around coverage of specific services and nationally recognized guidelines varied. These variations reflect key state choices regarding how much deference to afford their plans in coverage design and plan administration and reveal important differences in purchasing expectations that could carry implications for efforts to examine similarities and differences in access, quality, and health outcomes within managed care across the states.

Results of Immediate Postpartum Long Acting Reversible Contraception Provision After Expanded Reimbursement Policy Implementation at an Academic Medical Institution.

Immediate postpartum (IPP) Long Acting Reversible Contraception (LARC) is effective in reducing short birth spacing, which is highest among minoritized and younger women with lower socioeconomic status. The structural barrier of cost for pregnant people who desire IPP LARC insertion was alleviated in 2016 when New York State provided statewide reimbursement for Medicaid recipients. Analyses of existing electronic medical records (EMR) were conducted on women who received IPP LARC between 3/2/17 and 9/2/19 at two hospitals after a term delivery, defined as gestational age 37 0/7 weeks or greater. Descriptive and bivariate statistics, including chi-square tests and Fischer's exact tests, based on cell sizes, were calculated using SAS (version9.4). Prior to the study period, IPP LARC was not placed in these hospitals. After reimbursement policy changes, electronic medical record data identified 501 women with full term delivery and IPP LARC placed, of which the majority were single (82.8%), Black (49.1%), and had public insurance (Medicaid and Medicaid Managed Care) (79.2%). Removing structural economic barriers for people using public insurance may increase health equity in contraceptive access and choice.

Elaborate biologic approval process delays care of patients with moderate-to-severe asthma.

mAbs (biologics) are indicated in patients with poorly controlled moderate-to-severe asthma. The process of prior authorization and administration of a biologic requires exceptional commitment from clinical teams. Our aim was to evaluate the process of approval and administration of biologics for asthma and determine the most common reasons associated with denials of biologics and delays in administration. We examined the records of patients with asthma who were prescribed biologics from January 2018 to January 2020 at 2 centers, Montefiore Medical Center (Bronx, NY) and Scripps Clinics (San Diego, Calif). Demographics, insurance information, and details on the approval process were collected. After querying of electronic health records, the records of 352 and 70 patients with moderate-to-severe asthma were included from Montefiore and Scripps, respectively. Most patients at Montefiore (58.2%) were insured under Managed Care Medicaid (MC Medicaid), whereas most patients at Scripps (61.4%) had commercial insurance. The median times from prescription to administration of a biologic were similar: 34 days (interquartile range [IQR]= 18-63 days) and 34 days (IQR= 22.5-56.0 days) (P= .97) for Montefiore and Scripps, respectively. However, the median approval time for Montefiore was 6 days (IQR= 1-20 days) and that for Scripps was 22 days (IQR= 10-36 days) (P< .001). Approval times for prescriptions requiring appeals were significantly longer than for prescriptions approved after the initial submission: 23 days versus 2.5 days and 40.5 days versus 15.5 days (for Montefiore and Scripps, respectively [P< .001 for both]). Lengthy appeals contribute to delays between prescribing and administering a biologic. Site-specific practices and insurance coverage influence approval timing of the biologics for asthma.

State Policy and the Breadth of Buprenorphine-Prescriber Networks in Medicaid Managed Care.

Provider networks in Medicaid Managed Care (MMC) play a crucial role in ensuring access to buprenorphine, a highly effective treatment for opioid use disorder. Using a difference-in-differences approach that compares network breadth across provider specialties and market segments within the same state, we investigated the association between three Medicaid policies and the breadth of MMC networks for buprenorphine prescribers: Medicaid expansion, substance use disorder (SUD) network adequacy criteria, and SUD carveouts. We found that both Medicaid expansion and SUD network adequacy criteria were associated with substantially increased breadth in buprenorphine-prescriber networks in MMC. In both cases, we found that the associations were largely driven by increases in the network breadth of primary care physician prescribers. Our findings suggest that Medicaid expansion and SUD network adequacy criteria may be effective strategies at states' disposal to improve access to buprenorphine.

Disparities in Treatment of Closed Distal Radius Fractures in Patients Aged 18–64 Years and ≥65 Years by Insurance Type

Type of and time to definitive treatment for distal radius fractures can influence the outcomes. The impact of social determinants of health (eg, insurance type) on distal radius fracture care remains unknown despite having health equity implications. Thus, we evaluate the association between insurance type and rate of surgery, the time to surgery, and the complication rate for distal radius fractures. We conducted a retrospective cohort study using the PearlDiver Database. We identified adults with closed distal radius fractures. Patients were divided into subgroups by age (18-64 years, 65+ years) and further stratified on the basis of the insurance type (Medicare Advantage, Medicaid-managed care, and commercial). The primary outcome was the rate of surgical fixation. Secondary outcomes included the time to surgery and 12-month complication rates. Logistic regression modeling was used to calculate the odds ratios for each outcome, adjusting for age, sex, geographic region, and comorbidities. In patients aged ≥65 years, a lower proportion of Medicaid patients underwent surgery within 21 days of diagnosis compared with Medicare or commercially insured patients (12.1% vs 15.9% or 17.5%, respectively). Complication rates did not differ between Medicaid and other insurance types. In patients aged <65 years, fewer Medicaid patients underwent surgery compared with commercially insured patients (16.2% vs 21.1%). However, in this younger group, Medicaid patients had higher adjusted odds of malunion/nonunion (adjusted odds ratio [aOR]= 1.39 [95% CI, 1.31-1.47]) and subsequent repair (aOR= 1.38 [95% CI, 1.25-1.53]). Although older Medicaid patients experienced lower surgical rates, this may not lead to differential clinical outcomes. However, Medicaid patients aged <65 years experienced lower surgical rates that correlated with the increased rates of malunion or nonunion. In younger patients with a closed distal radius fracture and Medicaid insurance, system and patient-directed efforts should be considered to address delayed time to surgery and a higher odds for malunion/nonunion.

Cigna Policy Change on Modifier QZ Payment

Payment & Practice Management| April 2023 Cigna Policy Change on Modifier QZ Payment Helen Olkaba, MS Helen Olkaba, MS Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor April 2023, Vol. 87, 31. https://doi.org/10.1097/01.ASM.0000925008.28735.94 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Cite Icon Cite Get Permissions Search Site Citation Helen Olkaba; Cigna Policy Change on Modifier QZ Payment. ASA Monitor 2023; 87:31 doi: https://doi.org/10.1097/01.ASM.0000925008.28735.94 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: modifiers Effective March 12, 2023, Cigna will reduce payment on services reported with modifier QZ by 15%. Modifier QZ identifies services provided by CRNAs without medical direction of a physician. According to Cigna, this was done to align payment with other advanced practice providers (e.g., nurse practitioners). Cigna will only implement this policy change on its commercial lines of business but not on its Medicare Advantage or Medicaid Managed Care lines of business. At this point, it is hard to determine the impact of this payment cut on business models that anesthesia practices are using. ASA will be monitoring the long-term implications of this policy change on anesthesia practices. This policy change makes it important for you to have a clearer understanding of what is considered medical direction versus what is considered medical supervision and the billing modifiers that are associated with them. In order to qualify for medically directed service... You do not currently have access to this content.