Medicaid Policy Changes Research Articles

7525 Impact of Medicaid Policy Change on CGM Uptake in a Federally Qualified Health Center

Abstract Disclosure: W. Solorzano: None. L. Scarlett: None. K.P. Santiago Mangual: None. J. Borrell: None. B. Brumley: None. M. Tavares: None. C. Santana: None. T. Moin: None. E.M. Everett: None. Background: Despite the numerous benefits of CGMs in diabetes management, studies have consistently reported inequities in CGM use in racial-ethnic minorities, lower socioeconomic status, and with public insurance. In January 2022, a new California Medicaid policy switched coverage of CGMs from a Durable Medical Equipment benefit to a pharmacy benefit, creating less stringent insurance related criteria for CGM approval. We aim to evaluate the utilization of CGM use after the aforementioned policy change in an urban, multi-centered, federally qualified health center. Methods: We performed a retrospective study of patients with diabetes seen by diabetes NPs in three different clinics from January 1, 2022, through June 30, 2023. We excluded patients not managed on insulin. Patients were stratified by CGM status (current user, former user, never user). We used descriptive statistics to report patient demographics and clinical characteristics. Chi-squared test was used to evaluate differences between groups. We performed multivariate logistic regression to evaluate predictors of never using CGM. Results: We identified 239 patients who met inclusion criteria. They were primarily between the ages of 45-64 (60%), female (57%), Hispanic (84%), Spanish speaking (70%), and on Medicaid insurance (63%). Majority had a diagnosis of type 2 diabetes (93%) and managed on basal insulin plus other antidiabetic medication(s) (48%) with a mean HbA1c ≥ 10% (31%). At the end of the study period, 37% were current CGM users, 13% were former users and 51% were never users. Almost all (98%) of those who used CGMs started after January 2022.There was a statistically significant difference between CGM groups and treatment regimen (p = 0.000), insurance type (p = 0.000), type of diabetes (p = 0.000), and clinic site (p = 0.029). There was no statistically significant association between age, birth sex, race, primary language, or mean Hba1c. Most current and former users were/are on Freestyle Libre 2 (61% and 93%, respectively). Among never users, 55% had no discussion about CGM use documented in their charts. In an adjusted analysis, insurance type was the strongest predictor of never using CGM. Those without insurance on a county program, My Health LA (OR 15.5, 95% CI 3.7-65.6) or self-pay (OR 10.0, 95% CI 1.77-56.3) were more likely to be a never user. Conclusion: In an underserved population with diabetes, insurance status was the primary barrier to CGM use as demonstrated by the large uptake of CGM use after the policy change and that insurance status was the largest predictor of use. Additional studies are needed to evaluate other barriers impacting CGM uptake and adherence, clinical impact of CGM use, and patient experience. This will improve the utilization and adherence of this diabetes technology in this patient population who historically experiences more challenges with diabetes and obtaining optimal glycemic control. Presentation: 6/1/2024

Medicaid policy changes are set to allow coverage for some health services for youth in custody: what should pediatricians know?

Medicaid policy changes are set to allow coverage for some health services for youth in custody: what should pediatricians know?

259 Medicaid Policy Changes to Improve Chronic Kidney Disease Care in Michigan

259 Medicaid Policy Changes to Improve Chronic Kidney Disease Care in Michigan

Opioid use disorder treatment and the role of New Jersey Medicaid policy changes: perspectives of office-based buprenorphine providers

ABSTRACT Background: In the US, seventy percent of drug-related deaths are attributed to opioids. In response to the ongoing opioid crisis, New Jersey’s (NJ) Medicaid program implemented the MATrx model to increase treatment access for Medicaid participants with opioid use disorder (OUD). The model’s goals include increasing the number of office-based treatment providers, enhancing Medicaid reimbursement for certain treatment services, and elimination of prior authorizations for OUD medications. Objectives: To explore office-based addiction treatment providers’ experiences delivering care in the context of statewide policy changes and their perspectives on treatment access changes and remaining barriers. Methods: This qualitative study used purposive sampling to recruit office-based New Jersey medications for opioid use disorder (MOUD) providers . Twenty-two providers (11 females, 11 males) discussed treatment experiences since the policy changes in 2019, including evaluations of the current state of OUD care in New Jersey and perceived outcomes of the MATrx model policy changes. Results: Providers reported the MOUD climate in NJ improved as Medicaid implemented policies intended to reduce barriers to care and increase treatment access. Elimination of prior authorizations was noted as important, as it reduced provider burden and allowed greater focus on care delivery. However, barriers remained, including stigma, pharmacy supply issues, and difficulty obtaining injectable or non-generic medication formulations. Conclusion: NJ policies may have improved access to care for Medicaid beneficiaries by reducing barriers to care and supporting providers in prescribing MOUD. Yet, stigma and lack of psychosocial supports still need to be addressed to further improve access and care quality.

P070Short-interval births among patients choosing immediate postpartum long-acting reversible contraception (ipp larc) after tennessee medicaid policy change

<h3>Objectives</h3> This project aimed to determine the impact of immediate postpartum long-acting reversible contraception (LARC) IPP LARC on short-interval birth (SIB) at our institution among publicly insured patients after a Medicaid policy change in November 2017. <h3>Methods</h3> State birth certificate records (BCR) for 2015–2020 (n=483,006) were obtained and matched by SSN, date of birth, and name with hospital delivery records. SIB was defined as a birth within 24 months of a previous birth. Between July 2018 and December 2018, 276 patients received IPP LARC (44.2% intrauterine device (IUD) and 55.8% implants); 261 patients were identified in BCR and included in this analysis. <h3>Results</h3> From 2018 to 2020, BCR demonstrated the SIB rate among publicly insured patients at our institution was 24.9%. Among the 261 patients who received IPP LARC, at delivery, 88 (33.7%) were nulliparous and 173 (66.3%) were multiparous. Of the multiparous patients, 41 (23.7%) had a SIB (mean 16.5 months) preceding this delivery. Of the IPP LARC placed, 18% were adolescents (≤ 20 years old), 17.7% were Hispanic, 88.1% were White, 10% were Black, 8.4% of women had diabetes and 15.3% had diagnosed hypertension. Of the patients that received IPP LARC, 11 (4.2%) had a SIB (mean 18 months) identified in the BCR by the end of 2020. Of the 11 patients who had a SIB, the majority (54.5%) had one living child and 27.2% were ≤ 20 years old. <h3>Conclusions</h3> Despite the known increased risk of expulsion of IPP IUDs, SIB was significantly decreased with IPP LARC in the population studied. More work on the impact of this policy change is planned.

A systematic review of the qualitative literature on barriers to high-quality prenatal and postpartum care among low-income women.

To examine the qualitative literature on low-income women's perspectives on the barriers to high-quality prenatal and postpartum care. We performed searches in PubMed, Web of Science, Embase, SocIndex, and CINAHL for peer-reviewed studies published between 1990 and 2021. A systematic review of qualitative studies with participants who were currently pregnant or had delivered within the past 2 years and identified as low-income at delivery. Two reviewers independently assessed studies for inclusion, evaluated study quality, and extracted information on study design and themes. We identified 34 studies that met inclusion criteria, including 23 focused on prenatal care, 6 on postpartum care, and 5 on both. The most frequently mentioned barriers to prenatal and postpartum care were structural. These included delays in gaining pregnancy-related Medicaid coverage, challenges finding providers who would accept Medicaid, lack of provider continuity, transportation and childcare hurdles, and legal system concerns. Individual-level factors, such as lack of awareness of pregnancy, denial of pregnancy, limited support, conflicting priorities, and indifference to pregnancy, also interfered with the timely use of prenatal and postpartum care. For those who accessed care, experiences of dismissal, discrimination, and disrespect related to race, insurance status, age, substance use, and language were common. Over a period of 30 years, qualitative studies have identified consistent structural and individual barriers to high-quality prenatal and postpartum care. Medicaid policy changes, including expanding presumptive eligibility, increased reimbursement rates for pregnancy services, payment for birth doula support, and extension of postpartum coverage, may help overcome these challenges.

Reduction of Long-Term Opioid Prescribing for Back Pain in Community Health Centers After a Medicaid Policy Change.

Beginning around 2011, innumerable policies have aimed to improve pain treatment while minimizing harms from excessive use of opioids. It is not known whether changing insurance coverage for specific conditions is an effective strategy. We describe and assess the effect of an innovative Oregon Medicaid back/neck pain coverage policy on opioid prescribing patterns. This retrospective cohort study uses electronic health record data from a network of community health centers (CHCs) in Oregon to analyze prescription opioid dose changes among patients on long-term opioid treatment (LOT) affected by the policy. Of the 1,789 patients on LOT at baseline, 41.6% had an average daily dose of <20 morphine milligram equivalents (MME), 32.3% had ≥20 to <50 MME, 14.5% had ≥50 to <90 MME, and 11.6% ≥90 MME. Around half of each group discontinued opioids within the 18-month policy period. Those who discontinued did so gradually (average of 11 months) regardless of starting dosage. Predictors of discontinuation included: diagnosis of opioid use disorder, older, non-Hispanic white, and less medical complexity. Regardless of starting opioid dose, nearly half of patients affected by the 2016 Oregon Medicaid back/neck pain treatment policy no longer received opioid prescriptions by the end of the 18-month study period; another 30% decreased their dose. Gradual dose reduction was typical. These outcomes suggest that the policy impacted opioid prescribing. Understanding patient experiences resulting from such policies could help clinicians and policy makers navigate the complex balance between potential harms and benefits of LOT.

The ACA Medicaid Expansion And Perinatal Insurance, Health Care Use, And Health Outcomes: A Systematic Review.

The Affordable Care Act (ACA) Medicaid expansion increased Medicaid eligibility for low-income adults regardless of their pregnancy or parental status. Variation in states' adoption of this expansion created a natural experiment to study the effects of expanding public insurance on insurance coverage, health care use, and health outcomes during preconception, pregnancy, and postpartum. We conducted a systematic review of relevant literature on this topic, analyzing twenty-four studies published between January 2014 and April 2021. We found that the ACA Medicaid expansion increased preconception and postpartum Medicaid coverage with corresponding declines in uninsurance, private insurance coverage, and insurance churn. There was limited evidence that Medicaid expansion increased perinatal health care use or improved infant birth outcomes overall, although some studies reported reduced racial and ethnic disparities in rates of prenatal and postpartum visit attendance, maternal mortality, low birthweight, and preterm births. Stronger data collection on preconception and postpartum outcomes with sufficient sample sizes to stratify by race and ethnicity is needed to assess the full impact of the ACA and emerging Medicaid policy changes, such as the postpartum Medicaid extension.

Time trends in emergency department use among adults with intellectual and developmental disabilities

BackgroundEmergency Department (ED) visits are common among adults with intellectual and developmental disabilities (IDD). However, little is known about how ED use has varied over time in this population, or how it has been affected by recent Medicaid policy changes. ObjectiveTo examine temporal trends in ED use among adult Medicaid members with IDD in eight states that ranged in the extent to which they had implemented state-level Medicaid policy changes that might affect ED use. MethodsWe conducted repeated cross-sectional analyses of 2010–2016 Medicaid claims data. Quarterly analyses included adults ages 18–64 years with IDD (identified by diagnosis codes) who were continuously enrolled in Medicaid for the past 12 months. We assessed change in number of ED visits per 1000 member months from 2010 to 2016 overall and interacted with state level policy changes such as Medicaid expansion. ResultsStates with no Medicaid expansion experienced an increase in ED visits (linear trend coefficient: 1.13, p < 0.01), while states operating expansion via waiver had a much smaller (non-significant) increase, and states with ACA-governed expansion had a decrease in ED visits (linear trend coefficient: 1.17, p < 0.01). Other policy changes had limited or no association with ED visits. ConclusionsMedicaid expansion was associated with modest reduction or limited increase in ED visits compared to no expansion. We found no consistent decrease in ED visits in association with other Medicaid policy changes.

Analysis of Postpartum Uptake of Long-Acting Reversible Contraceptives Before and After Implementation of Medicaid Reimbursement Policy.

The postpartum period is a time of high unmet contraception need. Providing long-acting reversible contraception (LARC), particularly in the immediate postpartum period, is one strategy to meet contraceptive needs. This practice may also prevent unintended and short interpregnancy interval pregnancies. In recent years, state Medicaid programs have implemented reimbursement policies for LARC use in the inpatient setting. The purpose of this study was to assess the uptake of inpatient postpartum LARCs at a large urban hospital with a sizable Medicaid population, before and after policy implementation. Using billing records from January 2015 and December 2017, we extracted data on patient demographics and LARC uptake before Medicaid policy change (2015) and after policy change (2016 and 2017). Implant and intrauterine device insertions were classified as inpatient postpartum (0-7days after birth), outpatient postpartum (1-8weeks after) or interval (9+ weeks after). In the 3-year study period, 2091 LARC insertions occurred, of which 700 (33.5%) were inpatient postpartum, 429 (20.5%) outpatient postpartum, and 962 (46.0%) interval. After policy implementation, inpatient postpartum LARC insertions increased from 2.6 per 100 deliveries to 16.8 per 100 deliveries. Significant differences in uptake were seen in Black and Hispanic populations. The number of outpatient postpartum LARCs remained stable and tubal sterilizations decreased. Implementation of reimbursement policies contributed to a sharp uptake of inpatient postpartum LARCs. Improved access to effective, reversible contraception could reduce the number of unplanned and short interpregnancy interval pregnancies, ultimately lowering rates of maternal morbidity and mortality.

Coverage of immediate postpartum long-acting reversible contraception has improved birth intervals for at-risk populations

In 2012, South Carolina revised the Medicaid policy to cover reimbursement for immediate postpartum long-acting reversible contraception. Immediate postpartum long-acting reversible contraception may improve health outcomes for populations at risk with a subsequent short-interval pregnancy. We examined the impact of the Medicaid policy change on the initiation of long-acting and reversible contraception (immediate postpartum and postpartum) within key populations. We determined whether immediate postpartum long-acting and reversible contraception use varied by adequate prenatal care (>7 visits), metropolitan location, and medical comorbidities. We also tested the association of immediate postpartum and postpartum long-acting, reversible contraception on interpregnancy interval of less than 18 months. We conducted a historical cohort study of live births among Medicaid recipients in South Carolina between 2010 and 2017, 2 years before and 5 years after the policy change. We used birth certificate data linked with Medicaid claims. Our primary outcome was immediate postpartum long-acting and reversible contraception, and our secondary outcome was short interpregnancy interval. We characterize trends in long-acting and reversible contraception use and interpregnancy interval over the study period. We used logistic regression models to test the association of key factors (rural, inadequate prenatal care, and medical comorbidities) with immediate and outpatient postpartum long-acting and reversible contraception following the policy change and to test the association of immediate postpartum and postpartum long-acting and reversible contraception with short interpregnancy interval. Our sample included 187,438 births to 145,973 women. Overall, 44.7% of the sample was white, with a mean age of 25.0 years. A majority of the sample (61.5%) was multiparous and resided in metropolitan areas (79.5%). The odds of receipt of immediate postpartum long-acting and reversible contraception use increased after the policy change (adjusted odds ratio, 1.39, 95% confidence interval, 1.34-1.43). Women with inadequate prenatal care (adjusted odds ratio, 1.50, 95% confidence interval, 1.31-1.71) and medically complex pregnancies had higher odds of receipt of immediate postpartum long-acting and reversible contraception following the policy change (adjusted odds ratio, 1.47, 95% confidence interval, 1.29-1.67) compared with women with adequate prenatal care and normal pregnancies. Women residing in rural areas were less likely to receive immediate postpartum long-acting and reversible contraception (adjusted odds ratio, 0.36, 95% confidence interval, 0.30-0.44) than women in metropolitan areas. Utilization of immediate postpartum long-acting and reversible contraception was associated with a decreased odds of a subsequent short interpregnancy interval (adjusted odds ratio, 0.62, 95% confidence interval, 0.44-0.89). Women at risk of a subsequent pregnancy and complications (inadequate prenatal care and medical comorbidities) are more likely to receive immediate postpartum long-acting and reversible contraception following the policy change. Efforts are needed to improve access in rural areas.

Massachusetts Community-Based Organization Perspectives on Medicaid Redesign

The purpose of the study is to investigate how community-based organizations perceive Medicaid policy changes to address the social determinants of health. This study included 46 key informant interviews, representing 44 community-based organizations across Massachusetts conducted from September 2017 to March 2018. The interviews were designed to collect community-based organizations' perceptions of Medicaid policy changes. An Advisory Board was empaneled for feedback on data collection and analysis. Massachusetts was chosen as a study site in light of explicit policy efforts to incentivize healthcare organizations to take a more active role in social determinants of health, most notably through the creation of Medicaid Accountable Care Organizations. The community-based organizations expressed optimism about future partnerships with healthcare organizations. This optimism existed alongside the recognition that healthcare organizations and community-based organizations can have conflicting agendas, including misaligned outcomes of interest and timelines. Community-based organizations struggled to define a clear strategy for partnership in the face of incomplete information about how the final Medicaid redesign would proceed and what healthcare providers would be looking for in a partner. Changes to Medicaid policy can catalyze interest in partnership between healthcare organizations and community-based organizations. To minimize the impact of conflicting agendas, policymakers and healthcare leadership should ensure community-based organizations are part of strategy development and social service program implementation. This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Long-acting reversible contraceptive utilization after policy change increasing device reimbursement to wholesale acquisition cost in Louisiana

Unintended pregnancies, occurring in nearly 1 out of every 2 (45%) pregnancies in the United States, are associated with adverse health and social outcomes for the infant and the mother. The risk of unintended pregnancies is significantly reduced when women use long-acting reversible contraceptives, namely intrauterine devices and implants. Inadequate reimbursement for long-acting reversible contraceptive devices may be an access barrier to long-acting reversible contraceptive uptake. In 2014, the Louisiana Department of Health Bureau of Health Services Financing implemented a policy change that increased the Medicaid reimbursement rates for acquiring long-acting reversible contraceptive devices to the wholesale acquisition cost. To examine the association of a Medicaid policy change that increased the long-acting reversible contraceptive device reimbursement rate to the wholesale acquisition cost (ie, price set by the manufacturers) on long-acting reversible contraceptive uptake among women at risk for unintended pregnancy. This retrospective, repeated cross-sectional study used 2013-2015 Louisiana Medicaid claims data and contraceptive provision measures to assess associations between patient (age, race, urban/rural residence, postpartum status) and provider (urban/rural location, specialty) characteristics and long-acting reversible contraceptive uptake among contraceptive users (N= 193,623) using bivariate and logistic regression analyses. After long-acting reversible contraceptive reimbursement increased, there was a 2-fold likelihood increase in use in 2015 vs 2013 (odds ratio, 2.08; 95% confidence interval, 1.69-2.55). Long-acting reversible contraceptive uptake was more likely across all patient and provider subgroups in 2015 vs 2013 but notably among patients receiving contraceptive care from family planning clinics (odds ratio, 3.93; 95% confidence interval, 2.34-6.62). Removal of a provider-level financial barrier to long-acting reversible contraceptive provision was associated with increased long-acting reversible contraceptive uptake among women at risk for unintended pregnancy. Efforts to improve long-acting reversible contraceptive access should focus on equitable healthcare reimbursement for healthcare providers of reproductive-aged women.

Impact of medicaid policy changes on immigrant parents.

During the 1990s and early 2000s many states expanded Medicaid eligibility for parents particularly after the 1996 welfare reform. At the same time, welfare reform also put in place policies that limited the eligibility of recent immigrants for public programs including Medicaid. This paper evaluates the effects of these changes in Medicaid eligibility policy on the private and public health insurance coverage of immigrants as well as the overall insurance rate. It also looks at the effect on health care use and measures of health status. The findings indicate a significant increase in Medicaid coverage and an increase in the proportion insured overall with negligible crowd-out of private insurance. There is also an increase in the use of health care services. In the case of permanent residents, there is a diminished response to Medicaid eligibility changes possibly due to a "chilling effect".

Physicians in Print: Letters to the Editor and the Medicaid Expansion

Abstract The June 2012 Supreme Court decision on Medicaid expansion provides insight into how physicians and the general public engaged with the political and policy-making process. This study assesses the making of public statements on Medicaid policy, through analyzing letters to the editor published in one hundred newspapers across the United States. A total of 2,792 individual letters to the editor were coded for their stance, use of evidence, use of personal experience, and framing of the Medicaid expansion. Both the general public and physicians expressed support for expansion in their letters, but physicians were more likely to emphasize the role of Medicaid expansion at improving the quality of care and saving lives. Additionally, physicians were more likely to cite evidence and personal experiences while framing their position on Medicaid expansion. There is no evidence of a shift in stance on Medicaid expansion after the election of Donald Trump, and Medicaid policy changes made by the new administration highlight the importance of the public engaging in the political and policy-making process of Medicaid.

Screening for Sexually Transmitted Infections After Cervical Cancer Screening Guideline and Medicaid Policy Changes: A Population-based Analysis.

Sexually transmitted infection (STI) screening prevents complications and is cost-effective. Annual screening is recommended in sexually active women below 25 years and older women at increased risk. Cervical cancer (CC) screening guideline changes in 2009 and 2012 recommended less frequent screening, causing concern that STI screening would decrease. Pennsylvania Medicaid implemented a family planning program in 2007 which covered women's health services (including STI testing) for uninsured women. It is unclear how STI screening was affected by these countervailing forces. The main objective of this study was to assess STI screening before and after CC screening guideline changes and family planning program implementation, and to determine factors associated with STI screening. This study was an observational cross-sectional study of Pennsylvania Medicaid administrative claims from 2007 to 2013. Sixteen-year-old to 30-year-old women enrolled in Pennsylvania Medicaid. Annual STI screening, defined as receipt of ≥1 STI test in respective 1-year periods. Our population included 1,226,079 women-years for 467,143 women. STI screening increased by 48% between 2007 and 2011, and stabilized by 2013. Odds for STI screening were higher among black compared with white women [adjusted odds ratio (AOR), 2.56; 95% confidence interval (CI), 2.60-3.10]; Hispanic compared with non-Hispanic women (AOR, 1.42; 95% CI, 1.39-1.46); family planning program enrollees (AOR, 1.42; 95% CI, 1.40-1.45); and urban compared with rural residents (AOR, 1.05; 95% CI, 1.03-1.06). STI screening dramatically increased between 2007 and 2011. Potential reasons are family planning program implementation, increased urine/vaginal testing, and reporting improvements. It is reassuring that STI screening did not decrease despite CC screening guideline changes. Between 2011 and 2013, rates stabilized at 45% among all women and 60% among sexually active women below 25 years, suggesting opportunities for improvement.

Medicaid Coverage of Smoking Cessation Counseling and Medication Is Underutilized for Pregnant Women.

Policies to promote smoking cessation among Medicaid-insured pregnant women have the potential to assist a significant proportion of pregnant smokers. In 2010, Kansas Medicaid began covering smoking cessation counseling for pregnant smokers. Our aim was to evaluate the use of smoking cessation benefits provided to pregnant women as a result of the Kansas Medicaid policy change that provided reimbursement for physician-provided smoking cessation counseling. We examined Kansas Medicaid claims data to estimate rates of delivery of smoking cessation treatment to Medicaid-insured pregnant women in Kansas from fiscal year 2010 through 2013. We analyzed the number of pregnant women who received physician-provided smoking cessation counseling indicated by procedure billing codes (ie, G0436 and G0437) and medication (ie, nicotine replacement therapy, bupropion, or varenicline) located in outpatient managed care encounter and fee-for-service claims data. We estimated the number of Medicaid-insured pregnant smokers using the national smoking prevalence (14%) in this population and the number of live births reported in Kansas. Annually from 2010 to 2013, approximately 27.2%-31.6% of pregnant smokers had claims for nicotine replacement therapy, bupropion, or varenicline. Excluding claims for bupropion, a medication commonly prescribed to treat depression, claims ranged from 9.3% to 11.1%. Following implementation of Medicaid coverage for smoking cessation counseling, less than 1% of estimated smokers had claims for counseling. This low claims rate suggests that simply changing policy is not sufficient to ensure use of newly implemented benefits, and that there probably remain critical gaps in smoking cessation treatment. This study evaluates the use of Medicaid reimbursement for smoking cessation counseling among low-income pregnant women in Kansas. We describe the Medicaid claims rates of physician-provided smoking cessation counseling for pregnant women, an evidence-based and universally recommended treatment approach for smoking cessation in this population. Our findings show that claims rates for smoking cessation benefits in this population are very low, even after policy changes to support provision of cessation assistance were implemented. Additional studies are needed to determine whether reimbursement is functioning as intended and identify potential gaps between policy and implementation of evidence-based smoking cessation treatment.

Effect of Medicaid Policy Changes on Medication Adherence: Differences by Baseline Adherence.

In 2001, the North Carolina (NC) Medicaid program reduced the number of days prescription supply that enrollees could fill from 100 days to 34 days and increased copayments for brand-name medications. Previous work has shown that a change in these policies led to a decrease in medication adherence from 2.9 to 8.0 percentage points in specific populations with chronic conditions. Studies have also shown that days supply limits and copayment increases have heterogeneous effects based on enrollees' baseline characteristics, including baseline adherence. However, this phenomenon has not been studied in the Medicaid population. We undertook this study to assess the heterogeneous effect of the NC Medicaid policy changes in groups with varying levels of baseline adherence. To examine whether restrictions on days supply had heterogeneous effects in subgroups defined by medication adherence before the policy changes. A partial difference-in-difference-in-differences model with fixed effects was used to compare medication adherence before and after the NC Medicaid policy changes among Medicaid enrollees subject to the policy changes because of their use of long prescriptions (> 40 days) as compared with (a) NC Medicaid enrollees using short prescriptions (< 40 days) before policy adoption, as well as (b) Medicaid enrollees in Georgia restricted to a 31 days supply through the study period. Medicaid enrollees were included if they filled a prescription for 1 of the following medication classes: antihypertensives, lipid-lowering drugs, or antipsychotics. The effect of the policy changes on medication adherence, calculated using the proportion of days covered (PDC) each quarter by baseline adherence level and clinical condition group, was studied. Average adherence levels over the 18-month prechange period were used to stratify individuals into 3 baseline adherence groups: fully adherent (PDC ≥ 80%), partially adherent (50%-79%), and nonadherent (PDC ≤ 50%). Enrollees fully adherent at baseline observed a 2.0 (P = 0.001) and 1.2 (P < 0.001) percentage-point decline in adherence for the lipid-lowering drug and antihypertensive cohorts, respectively, in the period after the policy changes. The nonadherent and partially adherent cohorts in the statin group observed an increase in adherence by 1.7-2.6 (P < 0.05) percentage points in the post-index period. Adherence changes after cost containment policies have a heterogeneous effect on individuals with varying baseline adherence in the Medicaid population. Individuals fully adherent at baseline decreased adherence following policy changes, while individuals partially adherent and nonadherent at baseline either had no change or showed increases in adherence, possibly because of increased contact with pharmacists and clinicians required by shorter prescription lengths. Managed care strategies to control costs should take into consideration the heterogeneity of responses by the enrollees to these policies. Furthermore, policies that consider baseline characteristics of enrollees may be more effective in improving adherence. This study was partly funded by a grant from the Robert Wood Johnson Foundation for use in data creation. Maciejewski was supported by a Research Career Scientist Award from the Department of Veterans Affairs (RCS 10-391) and owns stock in Amgen. Farley reports consultancy fees from Daiichi Sankyo outside of the conduct of this study. The other authors report no financial or other conflicts of interest related to the subject of this article. The views expressed in this article are those of the authors and do not reflect the position or policy of the Centers for Medicare & Medicaid Services, University of North Carolina at Chapel Hill, Department of Veteran Affairs, or Duke University. Study design and concept were contributed by Amin and Domino, along with Farley and Maciejewski. Domino collected the data, and data interpretation was performed primarily by Amin, along with Domino, with assistance from Farley and Maciejewski. The manuscript was primarily written by Amin, along with Domino, and revised by all the authors.

Impact of Wisconsin Medicaid Policy Change on Dental Sealant Utilization.

In September 2006, Wisconsin Medicaid changed its policy to allow nondentists to become certified Medicaid providers and to bill for sealants in public health settings. This study examined changes in patterns of dental sealant utilization in first molars of Wisconsin Medicaid enrollees associated with a policy change. The Electronic Data Systems of Medicaid Evaluation and Decision Support for Wisconsin from 2001 to 2009. Retrospective claims data analysis of Wisconsin Dental Medicaid for children aged 6-16years. A total of 479,847 children followed up for 1,441,300 person-years with 64,546 visits were analyzed. The rate of visits for sealants by dentists increased significantly from 3 percent per year prepolicy to 11 percent per year postpolicy, and that of nondentists increased from 18 percent per year to 20 percent after the policy change, but this was not significant. Non-Hispanic blacks had the lowest visit rates for sealant application by dentists and nondentists pre- and postpolicy periods. The Wisconsin Medicaid policy change was associated with increased rates of visits for dental sealant placement by dentists. The rate of visits with sealant placements by nondentists increased at the same rate pre- and postpolicy change.

Behavioral Health Screening among Massachusetts Children Receiving Medicaid

To assess the impact of a Massachusetts Medicaid policy change (the Children's Behavioral Health Initiative; CBHI, which required and reimbursed behavioral health [BH] screening with standardized tools at well child visits and developed intensive home- and community-based BH services) on primary care practice examining the relationship of BH screening to subsequent BH service utilization. Using a repeated cross-sectional design, our 2010 and 2012 Medicaid study populations each included 2000 children/adolescents under the age of 21 years. For each year, the population was randomly selected and stratified into 4 age groups, with 500 members selected per group. Two data sources were used: medical records and Medicaid claims. The CBHI had a large impact on formal BH screening and treatment utilization among children/adolescents enrolled in Medicaid. Screening increased substantially (73%: 2010; 74%: 2012) since the baseline/premandate period (2007) when only 4% of well child visits included a formal screen. BH utilization increased among those formally screened but decreased among those with informal assessments. CBHI implementation transformed the relationship between primary care and BH services. Changes in regulation and payment resulted in widespread BH screening in Massachusetts primary care practices caring for children/adolescents on Medicaid.