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Medicaid, the primary source of insurance coverage for disadvantaged Americans, was originally designed as a temporary safety-net program. No studies have used long-run data to assess the recent use of the program by beneficiaries.To assess patterns of short- and long-term enrollment among beneficiaries, using a 10-year longitudinal panel of Michigan Medicaid eligibility data.Primary analyses assessing trends in Medicaid enrollment among cohorts of existing and new beneficiaries.Administrative records from Michigan Medicaid for the period 2011 to 2020.3.97 million Medicaid beneficiaries.Short- and long-term enrollment in the program.The sample includes 3.97 million unique beneficiaries enrolled at some point between 2011 and 2020. Among a cohort of 1.23 million beneficiaries enrolled in 2011, over half (53%) were also enrolled in Medicaid in June 2020, spending, on average, two-thirds of that period (67%) on Medicaid. These beneficiaries, however, experienced substantial lapses in coverage, as only 25% were continuously enrolled throughout the period. Enrollment was less stable when assessed from the perspective of newly enrolled beneficiaries, of whom only 37% remained enrolled at the end of the study period.Primary estimates from a single state.For many beneficiaries, Medicaid has served as their primary source of coverage for at least a decade. This pattern would justify increasing investments in the program to improve long-term health outcomes.Self-funded.

ImportanceLittle is known about small-area variations in health care spending and utilization across the 3 major funders of health care in the US: Medicare, Medicaid, and private insurers.ObjectiveTo measure regional health spending and utilization across Medicare, Medicaid, and the privately insured; to observe whether there are regions that are simultaneously low spending for all 3 payers; and to determine what factors are correlated with regional spending and utilization by payer.Design, Setting, and ParticipantsObservational cross-sectional analysis of the US health system in 2016 and 2017 for 241 of 306 hospital referral regions (HRRs) and 2 states. Participants include individuals with employer-sponsored coverage from Aetna, Humana, or UnitedHealth; individuals with Medicaid fee-for-service coverage in 2016 and 2017; and individuals with Medicare coverage. The analysis was carried out from January 2020 to May 2022.Main Outcomes and MeasuresSpending per beneficiary and inpatient days per beneficiary by payer and overall.ResultsThe data include 25 381 167 individuals with employer-sponsored coverage, 69 891 299 with Medicaid coverage in 2016 and 2017, and 26 711 426 individuals with Medicare fee-for-service coverage. The percentage of enrollees who identified as female was 54.1% in the Medicaid program, 56.2% in the Medicare program, and 50.4% in private insurance. The mean (SD) age was 26.9 (21.8) years for Medicaid and 75.0 (7.9) years for Medicare enrollees; for private insurance enrollees, just age brackets were reported: 18 to 24 years (15.9%), 25 to 34 years (24.2%), 35 to 44 years (21.3%), 45 to 54 years (20.8%), and 55 to 64 years (17.8%). In 2017, the mean (SD) HRR-level spending per beneficiary was $4441 ($710) for private insurance, $10 281 ($1294) for Medicare, and $6127 ($1428) for Medicaid. Across HRRs, the correlation coefficients and 95% CIs were 0.020 (−0.106 to 0.146; P = .76) for private insurance and Medicare spending, 0.213 (0.090 to 0.330; P P P P P Conclusions and RelevanceThese findings suggest that payer-specific factors are correlated with health spending variation among Medicare beneficiaries, Medicaid beneficiaries, and the commercially insured and that payer-specific policies will be necessary to improve efficiency in the US health sector.

BACKGROUND: Medicaid managed care plans change provider networks frequently, yet there is no evidence about the performance of exiting providers relative to those that remain. OBJECTIVES: To investigate the association between provider cost and quality and network exit. DESIGN: Observational study with provider network directory data linked to administrative claims from managed care plans in Tennessee’s Medicaid program during the period 2010–2016. PARTICIPANTS: 1,966,022 recipients assigned to 9593 unique providers. MAIN MEASURES: Exposures were risk-adjusted total costs of care and nine measures from the Healthcare Effectiveness Data and Information Set (HEDIS) were used to construct a composite annual indicators of provider performance on quality. Outcome was provider exit from a Medicaid managed care plan. Differences in quality and cost between providers that exited and remained in managed care networks were estimated using a propensity score model to match exiting to nonexiting providers. KEY RESULTS: Over our study period, we found that 21% of participating providers exited at least one of the Medicaid managed care plans in Tennessee. As compared with providers that remained in networks, those that exited performed 3.8 percentage points [95% CI, 2.3, 5.3] worse on quality as measured by a composite of the nine HEDIS quality metrics. However, 22% of exiting providers performed above average in quality and cost and only 29% of exiting providers had lower than average quality scores and higher than average costs. Overall, exiting providers had lower aggregate costs in terms of the annual unadjusted cost of care per-member-month − $21.57 [95% CI, − $41.02, − $2.13], though difference in annual risk-adjusted cost per-member-month was nonsignificant. CONCLUSIONS: Providers exiting Medicaid managed care plans appear to have lower quality scores in the year prior to their exit than the providers who remain in network. Our study did not show that managed care plans disproportionately drop high-cost providers. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-05784-4) contains supplementary material, which is available to authorized users.

ImportanceAmid efforts in the US to promote health equity, there is a need to assess recent progress in reducing excess deaths and years of potential life lost among the Black population compared with the White population.ObjectiveTo evaluate trends in excess mortality and years of potential life lost among the Black population compared with the White population.Design, setting, and participantsSerial cross-sectional study using US national data from the Centers for Disease Control and Prevention from 1999 through 2020. We included data from non-Hispanic White and non-Hispanic Black populations across all age groups.ExposuresRace as documented in the death certificates.Main outcomes and measuresExcess age-adjusted all-cause mortality, cause-specific mortality, age-specific mortality, and years of potential life lost rates (per 100 000 individuals) among the Black population compared with the White population.ResultsFrom 1999 to 2011, the age-adjusted excess mortality rate declined from 404 to 211 excess deaths per 100 000 individuals among Black males (P for trend P for trend = .98) and increased in 2020 to 395—rates not seen since 2000. Among Black females, the rate declined from 224 excess deaths per 100 000 individuals in 1999 to 87 in 2015 (P for trend P for trend = .71) and in 2020 rates increased to 192—levels not seen since 2005. The trends in rates of excess years of potential life lost followed a similar pattern. From 1999 to 2020, the disproportionately higher mortality rates in Black males and females resulted in 997 623 and 628 464 excess deaths, respectively, representing a loss of more than 80 million years of life. Heart disease had the highest excess mortality rates, and the excess years of potential life lost rates were largest among infants and middle-aged adults.Conclusions and relevanceOver a recent 22-year period, the Black population in the US experienced more than 1.63 million excess deaths and more than 80 million excess years of life lost when compared with the White population. After a period of progress in reducing disparities, improvements stalled, and differences between the Black population and the White population worsened in 2020.

Administrative records indicate that more than half of the 80 million Medicaid enrollees identify as belonging to a racial and ethnic minority group. Despite this, disparities within the Medicaid program remain understudied. For example, we know of no studies examining racial differences in Medicaid spending, a potential measure of how equitably state resources are allocated.To examine whether and to what extent there are differences in health care spending and utilization between Black and White enrollees in Medicaid.This cross-sectional study used calendar year 2016 administrative data from 3 state Medicaid programs and included 1 966 689 Black and White Medicaid enrollees. Analyses were performed between January 28, 2021, and October 18, 2021.Self-reported race.Rates and racial differences in health care spending and utilization (including Healthcare Effectiveness Data and Information Set [HEDIS] access measures).Of 1 966 689 Medicaid adults and children (mean [SD] age, 20.3 [17.1] years; 1 119 136 [56.9%] female), 867 183 (44.1%) self-identified as non-Hispanic Black and 1 099 506 (55.9%) self-identified as non-Hispanic White. Results were adjusted for age, sex, Medicaid eligibility category, zip code, health status, and usual source of care. On average, annual spending on Black adult (19 years or older) Medicaid enrollees was $317 (95% CI, $259-$375) lower than White enrollees, a 6% difference. Among children (18 years or younger), annual spending on Black enrollees was $256 (14%) lower (95% CI, $222-$290). Adult Black enrollees also had 19.3 (95% CI, 16.78-21.84), or 4%, fewer primary care encounters per 100 enrollees per year compared with White enrollees. Among children, the differences in primary care utilization were larger: Black enrollees had 90.1 (95% CI, 88.2-91.8) fewer primary care encounters per 100 enrollees per year compared with White enrollees, a 23% difference. Black enrollees had lower utilization of most other services, including high-value prescription drugs, but higher emergency department use and rates of HEDIS preventive screenings.In this cross-sectional study of US Medicaid enrollees in 3 states, Black enrollees generated lower spending and used fewer services, including primary care and recommended care for acute and chronic conditions, but had substantially higher emergency department use. While Black enrollees had higher rates of HEDIS preventive screenings, ensuring equitable access to all services in Medicaid must remain a national priority.

ImportanceRacial and ethnic disparities in delayed medical care for reasons that are not directly associated with the cost of care remain understudied.ObjectiveTo describe trends in racial and ethnic disparities in barriers to timely medical care among adults during a recent 20-year period.Design, Setting, and ParticipantsThis was a serial cross-sectional study of 590 603 noninstitutionalized adults in the US using data from the National Health Interview Survey from 1999 to 2018. Data analyses were performed from December 2021 through August 2022.ExposuresSelf-reported race, ethnicity, household income, and sex.Main Outcomes and MeasuresTemporal trends in disparities regarding 5 specific barriers to timely medical care: inability to get through by telephone, no appointment available soon enough, long waiting times, inconvenient office or clinic hours, and lack of transportation.ResultsThe study cohort comprised 590 603 adult respondents (mean [SE] age, 46.00 [0.07] years; 329 638 [51.9%] female; 27 447 [4.7%] Asian, 83 929 [11.8%] Black, 98 692 [13.8%] Hispanic/Latino, and 380 535 [69.7%] White). In 1999, the proportion of each race and ethnicity group reporting any of the 5 barriers to timely medical care was 7.3% among the Asian group; 6.9%, Black; 7.9%, Hispanic/Latino; and 7.0%, White (P > .05 for each difference compared with White individuals). From 1999 to 2018, this proportion increased across all 4 race and ethnicity groups (by 5.7, 8.0, 8.1, and 5.9 percentage points [pp] among Asian, Black, Hispanic/Latino, and White individuals, respectively; P P = .03 and P = .001, respectively). There was no significant difference in prevalence between Asian and White individuals. There was a significant increase in the difference in prevalence between Black individuals and White individuals who reported delaying care because of long waiting times at the clinic or medical office and because of a lack of transportation (1.5 pp and 1.8 pp; P = .03 and P = .01, respectively). In addition, the difference in prevalence between Hispanic/Latino and White individuals who reported delaying care because of long waiting times increased significantly (2.6 pp; P Conclusions and RelevanceThe findings of this serial cross-sectional study of data from the National Health Interview Survey suggest that barriers to timely medical care in the US increased for all population groups from 1999 to 2018, with associated increases in disparities among race and ethnicity groups. Interventions beyond those currently implemented are needed to improve access to medical care and to eliminate disparities among race and ethnicity groups.

Key Points Question Are higher-performing hospitals more likely to advertise their services directly to consumers? Findings In this cross-sectional study of more than 4500 acute care hospitals per year, almost half advertised their services to consumers, yet there was no clear association between advertising and objective performance measures. Hospitals that advertised were more likely to have more net assets and income. Meaning The results of this cross-sectional study suggest that advertising is not an effective means to inform consumers about quality; instead, it may mislead consumers and undermine, not complement, public reporting efforts., This cross-sectional study uses data from the Centers for Medicare & Medicaid Services to assess whether higher-performing hospitals are more likely to advertise their services directly to consumers., Importance Hospital advertising has been touted as a tool to improve consumer decision-making, but little is known about its association with objective measures of hospital quality. Objective To document recent trends in hospital advertising in the US and examine the association between concurrent measures of hospital advertising and quality. Design, Setting, and Participants Retrospective cross-sectional study of all general acute care hospitals operating in the US between January 2008 and December 2016. Data were analyzed from December 6, 2019, to July 15, 2020. Exposure Annualized advertising spending for each hospital as measured by a market research firm. Main Outcomes and Measures Four composites of hospital performance from the Centers for Medicare & Medicaid Services Hospital Compare database were used: risk-standardized mortality rate, risk-standardized readmission rate, Consumer Assessment of Healthcare Providers & Systems (CAHPS) Overall Patient Experience Rating (scale of 1-5; higher scores indicate a more positive patient experience rating), and overall 5-star rating. Linear models adjusted for hospital bed size, hospital revenue, and geographic census region. Results The study sample included, on average, 4569 general acute care hospitals per year between 2008 and 2016. During this time, approximately half of acute care hospitals (2239 of 4569 [49%]) advertised their services to consumers and spent a total of $3.39 billion. Relative to hospitals that never advertised, advertising hospitals were more likely to be nonprofit facilities (mean [SD], 66% [47%] vs 51% [50%]; P

Background Hospitals across the United States are pursuing strategies to reduce avoidable readmissions but the evidence on how best to accomplish this goal is mixed, with no specific clinical practice shown to reduce readmissions consistently. Changes to hospital organizational practices, a key component of context, also may be critical to improving performance on readmissions, but this has not been studied. Objective The aim of this study was to understand how high-performing hospitals improved risk-stratified readmission rates, and whether their changes to clinical practices and organizational practices differed from low-performing hospitals. Design This was a qualitative study of 10 hospitals in which readmission rates had decreased (n=7) or increased (n=3). Participants A total of 82 hospital staff drawn from hospitals that had participated in the State Action on Avoidable Readmissions quality improvement initiative. Results High-performing hospitals were distinguished by several organizational practices that facilitated readmissions reduction, that is, collective habits of action or interpretation shared by organization members. First, high-performing hospitals reported focused efforts to improve collaboration across hospital departments. Second, they helped postacute providers improve care by sharing the hospital's clinical and quality improvement expertise and data. Third, high performers enthusiastically engaged in trial and error learning to reduce readmissions. Fourth, they emphasized that readmissions represented bad outcomes for patients, de-emphasizing the role of financial penalties. Both high-performing and low-performing hospitals had implemented most clinical practice changes commonly recommended to reduce readmissions. Conclusions Our findings highlight several organizational practices that hospitals may be able to use to enhance the effectiveness of their readmissions reduction efforts.

Primary care site may play an important role in cardiovascular disease prevalence; however, the distribution of risk factors and outcomes across care sites is not known. In this study, a cross-sectional analysis of 21,778 adult participants from the National Health and Nutrition Examination Survey (NHANES; 1999 to 2008) using multivariate logistic regression was conducted to assess the relation between site of usual care and disease prevalence. Patients' self-reported histories of several chronic conditions (hypertension, diabetes, and hypercholesterolemia), awareness of chronic conditions, and associated cardiovascular events (angina, coronary heart disease, cardiovascular disease, myocardial infarction, and stroke) were examined. After adjustment for demographic and health care utilization characteristics, there were no significant differences in the prevalence of diabetes or hypercholesterolemia among patients receiving usual care at private doctors' offices, hospital outpatient clinics, community-based clinics, and emergency rooms (ER). However, participants without usual sources of care and those receiving usual care at ERs had significantly lower awareness of their chronic conditions than participants at other sites. The odds of having a history of each of the adverse cardiovascular events ranged from 2.21 to 4.18 times higher for patients receiving usual care at ERs relative to private doctors' offices. In conclusion, participants who report using ERs as their usual sites of care are disproportionately more likely to have histories of poor cardiovascular outcomes and are more likely to be unaware of having hypertension or hypercholesterolemia. As health care reform takes place and millions more begin seeking care, it is imperative to ensure access to longitudinal care sites designed for continuous disease management.

The relative effectiveness of strategies to recruit minority patients, populations traditionally difficult to engage in research, for focus groups is unclear. We conducted a systematic review of all peer-reviewed focus group studies targeting Black and/or Hispanic participants with diabetes, hypertension, asthma, and/or cardiovascular disease reported in Pubmed, MEDLINE, and CINAHL from January 1993 through August 2009. Reviewers extracted data on each study's characteristics, methods, and outcomes. Forty-five studies were eligible. While most described recruitment strategies, only 21 presented any metric of their success in recruiting participants. Among studies with high recruitment success rates, no discernable trends regarding effectiveness of recruitment strategies were found, largely due to variation in reporting of the use of incentives and follow-up mechanisms. Increased rigor is necessary for describing methodology of focus group research in the literature. It is incumbent upon researchers to ensure clear and detailed methodology in qualitative articles.

Nationally, a higher proportion of the medically underserved than of the general population suffer from hypertension. Poorer adherence to recommended therapies (includ- ing medication regimens, salt intake reduction, and regular visits with provider) has been linked to poorer blood pressure control. To identify whether differences in adherence are associated with racial/ethnic and socioeconomic characteristics, we administered a sur- vey to 141 African American and non-Hispanic White hypertensive patients within two hospital-based clinics in an urban setting in the Northeast U.S. There were no differences in adherence to follow-up appointments or dietary recommendations between racial/ ethnic or income groups. However, there were differences between groups in adherence to medication regimens, with African Americans and lower-income groups significantly more likely to be non-adherent to medication regimens. When treating patients or implementing interventions aimed at improving adherence, special attention should be paid to African Americans and patients from low-income communities.

Importance Medicaid enrollees typically report worse access to care than other insured populations. Expansions in Medicaid through less restrictive income eligibility requirements and the resulting influx of new enrollees may further erode access to care for those already enrolled in Medicaid. Objective To assess the effect of previous Medicaid expansions on self-reported access to care and the use of emergency department services by Medicaid enrollees. Design, Setting, and Participants Quasi-experimental difference-in-differences design among 1714 adult Medicaid enrollees in 10 states that expanded Medicaid between June 1, 2000, and October 1, 2009, and 5097 Medicaid enrollees in 14 bordering control states that did not expand Medicaid. Main Outcomes and Measures Self-reported access to care and annualized emergency department use. Results Among states expanding their Medicaid program for adults, the mean income eligibility level increased from 82.6% to 144.2% of the federal poverty level. Income eligibility in matched control states remained constant at 77.1% of the federal poverty level. The proportion of adults reporting being enrolled in Medicaid increased from 7.2% to 8.8% in expansion states and from 6.1% to 6.4% in matched control states. In Medicaid program expansion states, the proportion of Medicaid enrollees reporting poor access to care declined from 8.5% before the expansion to 7.3% after the expansion. In matched control states, the proportion of Medicaid enrollees reporting poor access to care remained constant at 5.3%. The proportion of enrollees reporting any emergency department use decreased from 41.2% to 40.1% in expansion states and from 37.3% to 36.1% in matched control states. In the period following expansions, newly eligible enrollees reported poorer access to care than previously enrolled beneficiaries, although the overall difference between groups did not reach statistical significance. Conclusions and Relevance We found no evidence that expanding the number of individuals eligible for Medicaid coverage eroded perceived access to care or increased the use of emergency services among adult Medicaid enrollees.

Medication reconciliation at transitions in care is a national patient safety goal, but its effects on important patient outcomes require further evaluation. We sought to measure the impact of an information technology-based medication reconciliation intervention on medication discrepancies with potential for harm (potential adverse drug events [PADEs]).We performed a controlled trial, randomized by medical team, on general medical inpatient units at 2 academic hospitals from May to June 2006. We enrolled 322 patients admitted to 14 medical teams, for whom a medication history could be obtained before discharge. The intervention was a computerized medication reconciliation tool and process redesign involving physicians, nurses, and pharmacists. The main outcome was unintentional discrepancies between preadmission medications and admission or discharge medications that had potential for harm (PADEs).Among 160 control patients, there were 230 PADEs (1.44 per patient), while among 162 intervention patients there were 170 PADEs (1.05 per patient) (adjusted relative risk [ARR], 0.72; 95% confidence interval [CI], 0.52-0.99). A significant benefit was found at hospital 1 (ARR, 0.60; 95% CI, 0.38-0.97) but not at hospital 2 (ARR, 0.87; 95% CI, 0.57-1.32) (P = .32 for test of effect modification). Hospitals differed in the extent of integration of the medication reconciliation tool into computerized provider order entry applications at discharge.A computerized medication reconciliation tool and process redesign were associated with a decrease in unintentional medication discrepancies with potential for patient harm. Software integration issues are likely important for successful implementation of computerized medication reconciliation tools.