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THE HRRP AND OBSERVATION HOSPITALIZATIONS The omission of observation hospitalizations from the HRRP "rehospitalization" metric is perhaps the most obvious shortcoming that has emerged.[[6], [8]] Although counterintuitive, hospitalization is not synonymous with inpatient admission. Eliminating observation stays as a separate hospital visit status entirely - meaning all hospital stays would simply be considered hospital inpatient admissions - would be a significant improvement, but this degree of policy shift would have far-reaching implications and is unlikely to happen. According to the MedPAC, from 2006 to 2016, outpatient services increased by 49.0% while inpatient discharges decreased by 21.8%.[15] Although observation is only one type of outpatient service, observation hospital care is nonetheless a significant portion of hospital outpatient services. Both studies included only index inpatient stays, followed by observation I or i inpatient stays within 30 days of the index inpatient stay. [Extracted from the article]

Policy PointsLow‐value care is common in clinical practice, leading to patient harm and wasted spending. Much of this low‐value care stems from the use of medical device‐based procedures.We describe here a novel academic‐policymaker collaboration in which evidence‐based clinical coverage for device‐based procedures is implemented through prior authorization‐based policies for Louisiana's Medicaid beneficiary population.This process involves eight steps: 1) identifying low‐value medical device‐based procedures based on clinical evidence review, 2) quantifying utilization and reimbursement, 3) reviewing clinical coverage policies to identify opportunities to align coverage with evidence, 4) using a low‐value device selection index, 5) developing an evidence synthesis and policy proposal, 6) stakeholder engagement and input, 7) policy implementation, and 8) policy evaluation. This strategy holds significant potential to reduce low‐value device‐based care. [ABSTRACT FROM AUTHOR]

Policy PointsAs essential access points to primary care for almost 29 million US patients, of whom 47% are Medicaid enrollees, health centers are positioned to implement the population health management necessary in value‐based payment (VBP) contracts.Primary care payment reform requires multiple payment methodologies used together to provide flexibility to care providers, encourage investments in infrastructure and new services, and offer incentives for achieving better health outcomes.State policy and significant financial incentives from Medicaid agencies and Medicaid managed care plans will likely be required to increase health center participation in VBP, which is consistent with broader state efforts to expand investment in primary care. Context: Efforts are ongoing to advance value‐based payment (VBP), and health centers serve as essential access points to comprehensive primary care services for almost 29 million people in the United States. Therefore, it is important to assess the levels of health center participation in VBP, types of VBP contracts, characteristics of health centers participating in VBP, and variations in state policy environments that influence VBP participation. Methods: This mixed methods study combined qualitative research on state policy environments and health center participation in VBP with quantitative analysis of Uniform Data System and health center financial data in seven vanguard states: Oregon, Washington, California, Colorado, New York, Hawaii, and Kentucky. VBP contracts were classified into three layers: base payments being transformed from visit‐based to population‐based (Layer 1), infrastructure and care coordination payments (Layer 2), and performance incentive payments (Layer 3). Findings: Health centers in all seven states participated in Layer 2 and Layer 3 VBP, with VBP participation growing from 35% to 58% of all health centers in these states from 2013 to 2017. Among participating health centers, the average percentage of Medicaid revenue received as Layer 2 and Layer 3 VBP rose from 6.4% in 2013 to 9.1% in 2017. Oregon and Washington health centers participating in Layer 1 payment reforms received most of their Medicaid revenue in VBP. In 2017, VBP participation was associated with larger health center size in four states (P <.05), and higher average number of days cash on hand (P <.05) in three states. Conclusions: A multilayer payment model is useful for implementing and monitoring VBP adoption among health centers. State policy, financial incentives from Medicaid agencies and Medicaid managed plans, and health center–Medicaid collaboration under strong primary care association and health center leadership will likely be required to increase health center participation in VBP. [ABSTRACT FROM AUTHOR]

Objective: To examine the qualitative literature on low‐income women's perspectives on the barriers to high‐quality prenatal and postpartum care. Data Sources and Study Setting: We performed searches in PubMed, Web of Science, Embase, SocIndex, and CINAHL for peer‐reviewed studies published between 1990 and 2021. Study Design: 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. Data Collection/Extraction Methods: Two reviewers independently assessed studies for inclusion, evaluated study quality, and extracted information on study design and themes. Principal Findings: 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. Conclusions: 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. [ABSTRACT FROM AUTHOR]

BACKGROUND: Parental Medicaid eligibility has been shown to be linked to positive academic and school outcomes for children. However, the impact of adult Medicaid expansion on children's school absenteeism is largely unexplored in the literature. The aim of this study was to examine whether Medicaid expansion for adults under the Affordable Care Act (ACA), affected school absenteeism of children. METHODS: This study used data from the National Survey of Children's Health 2016 to 2017 and the difference‐in‐differences method. RESULTS: The decrease in the predicted probability of missing 11 or more school days in Louisiana, after Medicaid expansion, among school‐going children from low‐income families, was greater by 18 percentage points (p =.007), as compared to the decrease in the predicted probability of missing 11 or more school days in the neighboring nonexpansion states of Texas and Mississippi. CONCLUSION: The positive impacts of Medicaid expansion are not limited to adults, but also extend to children's school absenteeism. [ABSTRACT FROM AUTHOR]

Background: Chronic ventilator use in Tennessee nursing homes surged following 2010 increases in respiratory care payment rates. Tennessee's Medicaid program implemented multiple policies between 2014 and 2017 to promote ventilator liberation in 11 nursing homes, including quality reporting, on‐site monitoring, and pay‐for‐performance incentives. Methods: Using repeated cross‐sectional analysis of Medicare and Medicaid nursing home claims (2011–2017), hospital discharge records (2010–2017), and nursing home quality reports (2015–2017), we examined how service use changed as Tennessee implemented policies designed to promote ventilator liberation in nursing homes. We measured the annual number of nursing home patients with ventilator‐related service use; discharge destination of ventilated inpatients and percent of nursing home patients liberated from ventilators. Results: Between 2011 and 2014, the number of Medicare SNF and Medicaid nursing home patients with ventilator use increased more than sixfold. Among inpatients with prolonged mechanical ventilation, discharges to home decreased as discharges to nursing homes increased. As Tennessee implemented policy changes, ventilator‐related service use moderately declined in nursing homes from a peak of 198 ventilated Medicare SNF patients in 2014 to 125 in 2017 and from 182 Medicaid patients with chronic ventilator use in 2014 to 145 patients in 2017. Nursing home weaning rates peaked at 49%–52% in 2015 and 2016, but declined to 26% by late 2017. Median number of days from admission to wean declined from 81 to 37 days. Conclusions: This value‐based approach demonstrates the importance of designing payment models that target key patient outcomes like ventilator liberation. [ABSTRACT FROM AUTHOR]