Medicaid Rates Research Articles

A Decade Long Analysis of Healthcare Disparities and Uterine Artery Embolization: An Exploration of Social Determinants of Health

To determine the extent that social determinants of health have on uterine artery embolization (UAE) utilization for treatment of symptomatic uterine fibroids. In this IRB-exempt study, data from the 2011-2020 National Inpatient Sample was used to identify patients with ICD-9 and -10 codes of uterine fibroids who underwent UAE. Data collected included: patient's demographics (race/ethnicity, income, insurance status) and procedure location (geographic region, hospital setting). Results are presented in percentage (UAE procedures per variable) and analyzed using Chi-square test. UAE utilization by race/ethnicity demonstrated the following distribution: Non-Hispanic Blacks (45.6%), Non-Hispanic Whites (28.1%), Hispanics (14.2%) and Asians (5.7%). The lowest quartile for income experienced no change in utilization (27.8%), while the highest quartile gradually decreased across the decade (2011:26.7%, 2020:19.0%, p=0.01). The Northeast region of the US (49.0% in 2011) was superseded by the South (34.8% in 2020) as the dominant geographic region for UAE. The main insurance statuses were private (55.5%) and Medicaid (26.2%), with Medicaid rates increasing throughout the decade (2011:18.2%, 2020: 28.6%, p < 0.001). Urban teaching hospitals accounted for the highest rates of total UAE (82.3%), compared to urban non-teaching (16.0%) and rural hospitals (1.2%). Over the past decade, UAE has been performed in a relatively equitable fashion on the basis income, with improved utilization within the Medicaid population and throughout the geographic regions of the US. When accounting for US population representation and unequal disease burden, Non-Hispanic Blacks demonstrated a greater-than-expected utilization of UAE, compared to lower-than-expected rates among Non-Hispanic Whites.

Regional differences in reimbursement rates from Medicare, Medicaid, and FAIR Health across common procedures for neurological surgeons.

FAIR Health-a nonprofit, state-funded database-was created as an independent repository of healthcare claims paid data to address allegations of price fixing. Many insurers have forced physicians to negotiate payments based on Medicare rates, rather than utilizing FAIR Health. The authors' objective was to provide an overview of regional differences in reimbursement rates per several sample neurosurgical Current Procedural Terminology (CPT) codes and to compare Medicare, Medicaid, and usual, customary, and reasonable rates via FAIR Health rate estimates. The authors compared FAIR Health rates for three common neurosurgical CPT codes: 61510 (removal of bone from skull for removal of upper brain tumor), 22630 (fusion of lower spine bones with removal of disc, posterior approach, single interspace), and 62223 (creation of a brain fluid drainage shunt, ventriculoperitoneal, ventriculopleural, or other terminus), with Medicare and Medicaid reimbursement to evaluate differences in five different regions in the US. Medicare and Medicaid reimbursement rates were consistently and significantly lower than FAIR Health in-network rates across all three CPT codes evaluated (p < 0.001 for all). Significant regional differences exist per census data in median age, median income, employment rates, and degree of health coverage (p < 0.001, p = 0.002, p = 0.002, and p = 0.001, respectively). Reimbursement estimates were found to have regional variation: Medicare/Medicaid rates were significantly lower than FAIR Health in-network rates for all codes across regions with a region-based interaction for reimbursement for code 62223 (p = 0.020). Medicare and Medicaid rates did not significantly vary across regions. Inherent differences exist between cities and states, including median income, employment rates, and health coverage. Despite geographic cost practice indices for Medicare and state-specific production of Medicaid, Medicaid/Medicare reimbursement rates did not vary across regions but were consistently and significantly lower than FAIR Health estimates throughout the US. Locale-specific variation in FAIR Health may further indicate a better accounting of regional differences in cost of practice.

Insurance acceptance and cash pay rates for psychotherapy in the US.

Cost and insurance coverage remain important barriers to mental health care, including psychotherapy and mental health counseling services ("psychotherapy"). While data are scant, psychotherapy services are often delivered in private practice settings, where providers frequently do not take insurance and instead rely on direct pay. In this cross-sectional analysis, we use a large national online directory of 175 083 psychotherapy providers to describe characteristics of private practice psychotherapy providers who accept and do not accept insurance, and assess self-reported private pay rates. Overall, about one-third of private practice psychotherapists did not accept insurance, with insurance acceptance varying substantially across states. We also found significant session rate differentials, with Medicaid rates being on average 40% lower than reported cash pay rates, which averaged $143.26 a session. Taken together, low insurance acceptance across a broad swath of mental health provider types means that access to care is disproportionately reliant on patients' ability to afford out-of-pocket payments-even when covered by insurance. While our findings are descriptive and may not be representative of all US psychotherapists, they add to scant existing knowledge about the cash pay market for an important mental health service that has experienced increased use and demand over time.

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

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

Medicaid Reimbursement for Total Hip and Knee Arthroplasty: A State-by-State Analysis Compared With Medicare

BackgroundMedicare (MCR) reimbursement for arthroplasty procedures has been declining, but little has been reported on Medicaid (MCD) reimbursement. We sought to determine MCD reimbursement rates using state MCD data for nine arthroplasty procedure codes and compare them to MCR rates. MethodsThe Centers for Medicare & Medicaid Services physician fee schedule was used to collect MCR reimbursement rates, and state MCD fee schedules were accessed to collect MCD rates for nine procedures encompassing primary and revision hip and knee arthroplasty surgery. State MCR and MCD rates were compared to determine the mean dollar difference and dollar difference per relative value unit. A cost of living adjustment was performed using the Medicare Wage Index for each state. Coefficients of variation were calculated for each state to determine overall variability between the two systems. ResultsThe mean reimbursement rates for MCD were lower for eight of the nine codes used in the study. Medicaid reimbursed physicians an average of 11.3% less overall and 23.1% less when adjusted for cost of living. The amount of variability in the MCR rates was low with a consistent coefficient of variation of 0.06, but was higher in the MCD rates with a range of 0.26 to 0.29 in the unadjusted rates and 0.34 to 0.37 in the adjusted rates. There was a mean $6.73 decreased reimbursement per relative value unit for MCD procedures. ConclusionsFor the most common arthroplasty procedures, MCD reimbursed physicians less than MCR on average. MCD also demonstrated increased variability when compared to MCR rates between states.

Association of Managed Medicaid Plans and Cancer Stage at Diagnosis

Managed care organizations provide insurance to many Medicare (Advantage) and Medicaid beneficiaries and seek to maintain quality while controlling provider networks, utilization, and costs. In prior research, patients with Medicare Advantage plans had restricted access to care, including at cancer centers, and had higher mortality after cancer surgery than patients with traditional Medicare. Over 80% of Medicaid patients nationally are enrolled in managed care plans; despite their prevalence, there is a paucity of evidence regarding the quality of cancer care provided by these plans. We examined associations of state-level managed Medicaid rates and cancer stage at diagnosis. Adults ages 18-64 years with Medicaid coverage diagnosed with cancer from 2007-2016 were identified from Surveillance, Epidemiology, and End Results program data covering 12 states. Note that 2016 was the last year with unsuppressed insurance status data. Year-varying state-level rates of types of managed Medicaid plans (comprehensive risk-based managed care, limited benefit plans, and primary care case management) were obtained from the Medicaid and CHIP Payment and Access Commission and categorized in quartiles. The association of state levels of each type of managed Medicaid plan with localized stage diagnoses was evaluated using multivariable linear probability models with cluster-robust standard errors (state clusters) accounting for state fixed effects, year fixed effects, age, sex, race, metropolitan residence, marital status, county-level income and education, state Medicaid expansion status, and cancer type. A total of 229,227 Medicaid patients were identified. The average state-level rates of comprehensive managed care, limited benefit, and primary care case management plans were 47%, 47%, and 5.6%, respectively. In adjusted analyses, relative to states with <20% of Medicaid recipients enrolled in comprehensive managed care plans, states with 40-80% (-2.07 percentage points, 95% CI = -3.31 to -0.83, P = .001) and >80% (-1.49, 95% CI = -2.49 to -0.50, P = .003) had fewer localized stage diagnoses. States with >2% relative to 0-1% of recipients enrolled in primary care case management plans had more localized stage diagnoses (1.02, 95% CI = 0.27 to 1.77, P = .008). States with higher levels of limited benefit plans had more localized stage diagnoses (P = .011), though associations were attenuated with increasing levels (20-40%: 1.22; 40-80%: 0.53; >80%: 0.40). Patterns were similar across most cancer types. The prevalence and type of Medicaid managed care plans are associated with early-stage cancer diagnoses. Higher levels of comprehensive managed care plans were associated with fewer early diagnoses, raising concerns about barriers to symptom evaluation and diagnostic workup. In contrast, higher levels of primary care case management plans were associated with more early diagnoses, potentially through streamlined care coordination.

Medicare Reimbursement Rates: Too Much or Too Little? What Are Our Options?

In recent decades, Medicare reimbursement rates have continued to fall behind general inflation rates while the number of beneficiaries has continued to rise. To compensate for lagging Medicare and Medicaid rates, cost shifts have increased the financial burden on private payers and patients. With impending increases in inflation caused by current historical events, reform is necessary. Otherwise, increasing number of physicians will likely be forced to limit the number of Medicare patients in their practices. However, the 2022 annual March Report released by MedPAC continued to recommend that Congress freeze physician payments in 2023. Various policy solutions have been considered, including single-payer systems, all-payer systems, and public options. Examples of such systems exist in specific states, including Maryland, Washington, and Colorado, and can provide insight on how these policies might fare if applied to the entire country. Overall, Medicare needs reform involving a stronger focus on a pay-for-value approach.

Medicaid rates to psychiatrists lag, with wide variation among states

Medicaid payment rates for psychiatric services continue to lag behind comparable Medicare reimbursement in most states, with wide variation in rates across the country, a newly published study reported. While low payment rates are thought to contribute to a shortage of psychiatrists treating low‐income patients, the study's researchers suggest that simply increasing reimbursement rates might not be enough to shore up the workforce.

Collaborative Care Model Gaining Traction in North Carolina

Collaborative Care Model Gaining Traction in North Carolina

The Reality of Commercial Payer-Negotiated Rates in Cleft Lip and Palate Repair.

Commercial payer-negotiated rates for cleft lip and palate surgery have not been evaluated on a national scale. The aim of this study was to characterize commercial rates for cleft care, both in terms of nationwide variation and in relation to Medicaid rates. A cross-sectional analysis was performed of 2021 hospital pricing data from Turquoise Health, a data service platform that aggregates hospital price disclosures. The data were queried by CPT code to identify 20 cleft surgical services. Within- and across-hospital ratios were calculated per CPT code to quantify commercial rate variation. Generalized linear models were used to assess the relationship between median commercial rate and facility-level variables and between commercial and Medicaid rates. There were 80,710 unique commercial rates from 792 hospitals. Within-hospital ratios for commercial rates ranged from 2.0 to 2.9 and across-hospital ratios ranged from 5.4 to 13.7. Median commercial rates per facility were higher than Medicaid rates for primary cleft lip and palate repair ($5492.20 versus $1739.00), secondary cleft lip and palate repair ($5429.10 versus $1917.00), and cleft rhinoplasty ($6001.00 versus $1917.00; P < 0.001). Lower commercial rates were associated with hospitals that were smaller ( P < 0.001), safety-net ( P < 0.001), and nonprofit ( P < 0.001). Medicaid rate was positively associated with commercial rate ( P < 0.001). Commercial rates for cleft surgical care demonstrated marked variation within and across hospitals, and were lower for small, safety-net, or nonprofit hospitals. Lower Medicaid rates were not associated with higher commercial rates, suggesting that hospitals did not use cost-shifting to compensate for budget shortfalls resulting from poor Medicaid reimbursement.

COVID-19 INTENSIFIED HOME CARE WORKFORCE CHALLENGES

Abstract The COVID-19 pandemic affected home care workers in several important ways. The purpose of this study was to detail the challenges faced and the state and federal policy responses implemented to address those challenges. We conducted scans of federal and state policies enacted during the pandemic, home care agency practices described in media reports and the literature, and interviews with 25 stakeholders. Some challenges encountered were entirely new and resulted directly from the pandemic, such as limited access to personal protective equipment due to workers not being recognized as “essential.” In other cases, the pandemic worsened long-standing challenges, such as recruitment and retention. State policy responses included Medicaid rate increases, hazard pay, and changes to staff training requirements. Federal policy responses included disaster relief funding as well as allowing non-physician practitioners to order services. Stakeholders suggested additional policy changes will be needed to address ongoing challenges experienced by this workforce.

Commercial Price Variation for Breast Reconstruction in the Era of Price Transparency

Breast reconstruction is costly, and negotiated commercial rates have been hidden from public view. The Hospital Price Transparency Rule was enacted in 2021 to facilitate market competition and lower health care costs. Breast reconstruction pricing should be analyzed to evaluate for market effectiveness and opportunities to lower the cost of health care. To evaluate the extent of commercial price variation for breast reconstruction. The secondary objective was to characterize the price of breast reconstruction in relation to market concentration and payer mix. This was a cross-sectional study conducted from January to April 2022 using 2021 pricing data made available after the Hospital Price Transparency Rule. National data were obtained from Turquoise Health, a data service platform that aggregates price disclosures from hospital websites. Participants were included from all hospitals with disclosed pricing data for breast reconstructive procedures, identified by Current Procedural Terminology (CPT) code. Price variation was measured via within- and across-hospital ratios. A mixed-effects linear model evaluated commercial rates relative to governmental rates and the Herfindahl-Hirschman Index (health care market concentration) at the facility level. Linear regression was used to evaluate commercial rates as a function of facility characteristics. A total of 69 834 unique commercial rates were extracted from 978 facilities across 335 metropolitan areas. Commercial rates increased as health care markets became less competitive (coefficient, $4037.52; 95% CI, $700.12 to $7374.92; P = .02; for Herfindahl-Hirschman Index [HHI] 1501-2500, coefficient $3290.21; 95% CI, $878.08 to $5702.34; P = .01; both compared with HHI ≤1500). Commercial rates demonstrated economically insignificant associations with Medicare and Medicaid rates (Medicare coefficient, -$0.05; 95% CI, -$0.14 to $0.03; P = .23; Medicaid coefficient, $0.14; 95% CI, $0.07 to $0.22; P < .001). Safety-net and nonprofit hospitals reported lower commercial rates (coefficient, -$3269.58; 95% CI, -$3815.42 to -$2723.74; P < .001 and coefficient, -$1892.79; -$2519.61 to -$1265.97; P < .001, respectively). Extra-large hospitals (400+ beds) reported higher commercial rates compared with their smaller counterparts (coefficient, $1036.07; 95% CI, $198.29 to $1873.85, P = .02). Study results suggest that commercial rates for breast reconstruction demonstrated large nationwide variation. Higher commercial rates were associated with less competitive markets and facilities that were large, for-profit, and nonsafety net. Privately insured patients with breast cancer may experience higher premiums and deductibles as US hospital market consolidation and for-profit hospitals continue to grow. Transparency policies should be continued along with actions that facilitate greater health care market competition. There was no evidence that facilities increase commercial rates in response to lower governmental rates.

Delays in access to an Alzheimer’s treatment for individuals dually eligible for Medicare and Medicaid in the U.S.

AbstractBackgroundPrior research has predicted substantial wait times for access to a disease‐modifying Alzheimer’s treatment because of the combination of a highly prevalent disease and a complex diagnostic process. Access could be particularly limited for individuals dually eligible for Medicare and Medicaid in the U.S. in some states. Medicaid programs cover Medicare cost‐sharing requirements for their indigent members, but under the so‐called “lesser of” policy, states may elect to pay only up to the Medicaid rate which is typically less than the Medicare rate. In states with that policy, providers will only receive the lower Medicaid rate, which is known to reduce appointment availability. We estimate the effect of the policy on wait times.MethodWe use a Markov model to predict wait times for dually eligible and regular Medicare beneficiaries. Counts of both groups by age, sex and states came from Census data and Medicare enrollment records, specifics of each state’s Medicaid policy from published data and inquiries to states, and prevalence and incidence data as well as price elasticity of supply from published data.ResultAt total of 35 states and the District of Columbia have a “lesser of” policy and pay less than the Medicare rate for elective specialty care. The average wait time for dually eligibles is between 5.9 and 48.5 months with an average of 17.5 compared to between 3.6 and 42.5 with an average of 13.8 for regular Medicare beneficiaries in those states. Conversely, wait times are indistinguishable in states without that policy, as Figure 1 illustrates. As Figure 2 shows, the difference means that duals have a 30.3% higher average wait times than regular Medicare beneficiaries with a range of 61.2% in DC and 1.2% in Georgia.ConclusionThe “lesser of” policy is likely to reduce access for the socio‐economically disadvantaged group of dually eligibles, who also suffer from a higher disease burden. The delays would translate into avoidable disease progression and mortality, raising concerns about health equity.

Practice patterns of postgraduate trained dentists in the United States

Postgraduate dental (PGD) primary care training has grown significantly. This study examines the individual, educational, community, and policy factors that predict practice patterns of PGD-trained dentists. Individual dentist records from the 2017 American Dental Association Masterfile, with indicators of Medicaid participation and practice in a Federally Qualified Health Center (FQHC), were linked to postdoctoral training, community/practice location, and state policy factors. Generalized logistic models, adjusted for these factors, were used to predict PGD-trained dentists: (1a) serving Medicaid children, (1b) accepting new Medicaid patients, and (2) working in an FQHC. Individual attributes that predicted serving Medicaid children included all race/gender combinations (vs. White females), and foreign-trained dentists and contractors/employees/associates (vs. practice owners). Black women are most likely to work in an FQHC. Residency attributes that predicted serving Medicaid children and working in an FQHC were Health Resources and Services Administration postdoctoral funding and being community based. Dentists practicing in rural or high-poverty communities were more likely to serve Medicaid children and work at FQHCs. States with higher levels of graduate medical education investment, higher Medicaid rates, and more generous adult dental Medicaid benefits increased the likelihood of serving Medicaid children, while states with more expansive adult dental Medicaid benefits increased the likelihood of working in an FQHC. Federal training investment in PGD education combined with Medicaid payment and coverage policies can strongly impact access to dental care for vulnerable populations. Yet, oral health equity cannot be achieved without increasing dentist workforce diversity.

Pancreatic cancer among Pacific Islanders: a comprehensive analysis of an understudied racial group

ABSTRACT Objective Racial disparities in care and outcome have been demonstrated for several cancers, but it is not clear that a similar discrepancy exists for pancreatic cancer. Furthermore, there are limited data describing the pancreatic cancer experience of Pacific Islanders. The primary objective of this study was to analyze the clinical characteristics, treatment, and outcomes of Pacific Islander patients with pancreatic cancer. Design We obtained data for a consecutive sample of pancreatic adenocarcinoma patients who presented to the largest hospital in Hawaii from 1 January 2000, through 31 December 2019. Analyses were performed for the entire population and separately for patients who had their cancer resected. Overall survival was calculated by the Kaplan–Meier method. Cox proportional hazards regression models were constructed to determine the prognostic capacity of clinical and pathologic factors. Results A total of 1040 patients were included in the final analysis. Pacific islanders presented at a significantly younger age compared to Whites or Asians and had the highest Medicaid rate. There were no statistically significant racial differences in stage at presentation or treatments. We did not demonstrate an association between race and survival on univariate analysis, nor after adjusting for demographic and tumor factors. Age, stage, and treatment were significantly associated with survival for both univariate and multivariate analyses. Conclusion We did not demonstrate disparate outcomes among Pacific Islanders with pancreatic cancer. This is likely due in part to the absence of a screening test and the notable poor prognosis of pancreatic adenocarcinoma. Furthermore, equity in treatment may have contributed to racial parity in survival.

Variation in prices for an evidence-based pediatric preventive service.

To examine variation in prices paid by private medical insurers for fluoride varnish applications in medical settings, a newly reimbursed service that few children receive. Private-insurance medical claims from Connecticut, Maine, New Hampshire, and Rhode Island (2016-2018). We examined prices paid for fluoride varnish by private insurers and compared these to prices paid by Medicaid. Private claims for fluoride varnish during medical visits for children aged 1-5 years. State Medicaid rates for fluoride varnish were obtained from the American Academy of Pediatrics. Prices paid for fluoride varnish by private insurers varied within and across states, ranging from less than $5 to $50. Median prices closely followed Medicaid rates in three of the four states. In states covering a package of fluoride varnish plus additional preventive oral health services during medical visits, combined Medicaid rates were nearly double the median price paid by private insurers. Fluoride varnish is a recommended service, but few children receive it. Price variation may contribute to the low uptake of this service. Ensuring sufficient Medicaid and private insurance rates could increase fluoride varnish applications in medical settings and improve oral health.

Abstract P234: Stroke in Texas: Leveraging Population Level Data to Inform Public Health

Introduction: We studied variation in stroke rates, post-discharge health services, and outcomes across payors in Texas. Methods: Claims for 48,331 stroke patients in 2016 and hospital data covering 58,114 discharges were analyzed. Prevalence and incidence rates per region were reported as a variation from the state mean by payor type (Medicaid, Medicare and Commercial). Stroke overall, ischemic stroke, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage are reported. Stroke outcomes are reported for the following measures: Discharges to rehabilitation, 30-Day Follow-Up with neurologist, death within 45 days Results: Among all payors, east Texas had the highest incidence and prevalence of ischemic stroke (Fig) but Northern Texas had the highest incidence of ICH among Medicaid and Commercial payors. Medicaid patients showed the greatest increases across ages and displayed a higher prevalence rate among those aged 40-64 than the 65+ group. Medicaid had a higher rate for each age group when compared to commercial. Within Medicaid and commercial, the 0-17 age had a very high rate of death from ischemic stroke (121/1000 and 83/1000, respectively), greater than any of the other age bands except over age 65; these high rates were not observed in ICH. Commercial and Medicaid patients had low rates of discharge to rehabilitation compared with Medicare (354/1000, 130/1000, 424/1000, respectively). Outpatient follow-up rates with a neurologist were low: Medicaid rates were very low compared to Commercial and Medicare (22/1000, 387/1000, 267/1000, respectively). Conclusion: Statewide review revealed dramatic variation in regional rates across all payors and ages. Graphic display and public reporting of statewide data on stroke through population level transparency can be leveraged to identify areas of risk, intervention strategies, and inform public health policy.

Contextualizing Medicaid reimbursement rates for abortion procedures

ObjectiveLow Medicaid reimbursement rates have been cited as a key threat to abortion clinic sustainability in the United States. This study examines differences between Medicaid and Medicare reimbursements for abortion and miscarriage management procedures under a fee-for-service (FFS) model. Study designUsing 2017 Medicaid and Medicare Physician fee schedules, we extracted reimbursement data for the two most commonly-billed abortion procedures and two miscarriage management procedures for 45 states and the District of Columbia (DC). We compared Medicaid and Medicare reimbursement rates for each procedure by state. ResultsMedicaid reimbursement rates for both procedures varied widely across the states. Medicaid rates for second-trimester abortion procedures had the widest range; $79–$626. Median Medicaid reimbursement rates were lower than median Medicare rates for first- and second-trimester abortion procedures. Median reimbursement rates for first-trimester induced abortion were lower than median reimbursement rates for miscarriage management for both Medicaid and Medicare. ConclusionOur findings indicate that Medicaid reimbursement rates for abortion are low; the median patient cost for a first- and second-trimester abortion have been reported as $490 and $750, respectively. Median Medicaid reimbursement rates for a first- and second-trimester abortion covers approximately 37% and 41% of patient costs for a first- and second-trimester abortion. Further, while induced abortion procedures are similar to miscarriage management procedures, Medicaid and Medicare reimbursement rates are lower for first- and second-trimester abortion procedures. Implication statementEnsuring reimbursement rates are closely aligned with procedural costs bolsters provider willingness to accept Medicaid. Data that highlights the potential impact of fee-for-service reimbursement rates on healthcare provision and ultimately patient access can help inform healthcare policies. This is especially important as more states consider expanding Medicaid coverage of abortion.

Comparison of Management and Outcomes of Acute Heart Failure Hospitalization in Medicaid Beneficiaries Versus Privately Insured Individuals

Medicaid expansion in terms of its eligibility and federal funding has led to improved healthcare access in previously uninsured individuals. However, proposed lower Medicaid rates have unintentionally led to lower utilization of substantial life-saving therapies and poor outcomes compared with private insurance. We examined heart failure (HF) management, in-hospital mortality, and resource utilization in Medicaid and privately insured individuals hospitalized with HF. The authors screened the National Inpatient Sample from January 2012 to September 2015 for HF hospitalizations with Medicaid or private insurance as the primary payer. The authors identified a total of 226,265 and 292,070 patients with HF hospitalizations with Medicaid and private insurance, respectively. In propensity-matched cohort of 155,790 hospitalizations in each group, Medicaid beneficiaries with HF hospitalization had lower rates of intra-aortic balloon pump/left ventricular assist device/extracorporeal membrane oxygenation utilization (0.6 vs 0.9%; odds ratio [OR] 0.64; 95% confidence interval [CI] 0.59 to 0.69), heart transplantation (0.15 vs 0.44%; OR 0.35; 95% CI 0.30 to 0.40), implantable cardioverter-defibrillator/cardiac resynchronization therapy/permanent pacemaker (3.3 vs 3.9%; OR 0.84; 95% CI 0.81 to 0.87), and had higher rates of in-hospital mortality (1.9 vs 1.7%; OR 1.12; 95% CI 1.07 to 1.19) compared with privately insured individuals (p <0.001 for both). In conclusion, Medicaid recipients with HF hospitalizations had a lower rate of device utilization, heart transplantation, and a higher rate of in-hospital mortality compared with the privately insured sector. Further studies are needed to explore and understand the variation in the outcomes of HF hospitalizations stratified by insurance status.

CONSISTENT ASSIGNMENT: AN UPDATE ON THE QUALITY IMPACT

The association of consistent assignment of Nurse Aides (NAs) with nursing home quality indicators is examined. Consistent assignment is defined as the same caregivers consistently caring for the same residents almost (80% of their shifts) every time they are on duty. Data used came from a survey of nursing home administrators, Nursing Home Compare, the Certification and Survey Provider Enhanced Reporting (CASPER) data, and the Area Resource File. All of the data was from 2015, and included 3,550 facilities. Several multivariate logistic regression models (using GEE) were used, including staffing variables (turnover, agency use, staffing levels), facility factors (size, ownership, occupancy rate), and market characteristics (competition, Medicaid rates). An average of 77% of nursing homes reported using at least some level of consistent assignment; although some were at low levels. In the multivariate analyses, accepted levels of consistent assignment were used. Turnover and family satisfaction quality were significantly (p<.01) better in facilities with the highest levels of consistent NA assignment. 7 of the 9 Quality Measures and 3 of the 5 Five-Star measures examined were significantly (p<.01) better in facilities with the highest levels of consistent NA assignment. Consistent assignment has developed as a preferred practice in nursing homes based on little empirical evidence. The findings presented here provide substantial justification for the use of this staffing practice for NAs.