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Persons who contract COVID-19 are at risk of developing post-acute sequelae of SARS-CoV-2 (PASC). The objective of this study was to describe the incidence of PASC in a pediatric Medicaid population. Using a retrospective cohort of children enrolled in New York State Medicaid Managed Care we compared incident diagnoses between children with a positive laboratory test for SARS-CoV-2 in 2021 to children without a positive test in 2021 and children with a viral respiratory diagnosis in 2019. Logistic regression models estimated adjusted odds ratios using the Cohen's d statistic to assess the strength of associations. Most unadjusted incidence of clinical outcomes were less than 1% for all cohorts. Relative to the 2021 comparison cohort, significant increases among SARS-CoV-2 cases were observed in sequela of infectious disease conditions, general signs and symptoms, and pericarditis and pericardial disease and for the 2019 comparison, sequela of infectious disease conditions and suicidal ideation. However, associations were mostly determined to be weak or marginal. In this low socioeconomic status pediatric population, incidence of new clinical sequelae was low with mostly weak or marginal increases associated with SARS-CoV-2 infection. Though the incidence was low, some outcomes may be severe. Observed associations may have been impacted by pandemic behavior modification including social distancing policies., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objective: To examine changes in late- versus early-stage diagnosis of cancer associated with the introduction of mandatory Medicaid managed care (MMC) in Pennsylvania., Data Sources and Study Setting: We analyzed data from the Pennsylvania cancer registry (2010-2018) for adult Medicaid beneficiaries aged 21-64 newly diagnosed with a solid tumor. To ascertain Medicaid and managed care status around diagnosis, we linked the cancer registry to statewide hospital-based facility records collected by an independent state agency (Pennsylvania Health Care Cost Containment Council)., Study Design: We leveraged a natural experiment arising from county-level variation in mandatory MMC in Pennsylvania. Using a stacked difference-in-differences design, we compared changes in the probability of late-stage cancer diagnosis among those residing in counties that newly transitioned to mandatory managed care to contemporaneous changes among those in counties with mature MMC programs., Data Collection/extraction Methods: N/A., Principal Findings: Mandatory MMC was associated with a reduced probability of late-stage cancer diagnosis (-3.9 percentage points; 95% CI: -7.2, -0.5; p = 0.02), particularly for screening-amenable cancers (-5.5 percentage points; 95% CI: -10.4, -0.6; p = 0.03). We found no significant changes in late-stage diagnosis among non-screening amenable cancers., Conclusions: In Pennsylvania, the implementation of mandatory MMC for adult Medicaid beneficiaries was associated with earlier stage of diagnosis among newly diagnosed cancer patients with Medicaid, especially those diagnosed with screening-amenable cancers. Considering that over half of the sample was diagnosed with late-stage cancer even after the transition to mandatory MMC, Medicaid programs and managed care organizations should continue to carefully monitor receipt of cancer screening and design strategies to reduce barriers to guideline-concordant screening or diagnostic procedures., (© 2024 Health Research and Educational Trust.)

Over 70% of Medicaid beneficiaries are enrolled in Medicaid managed care (MMC). MMC provider networks therefore represent a critical determinant of access to the Medicaid program. Many MMC insurers also participate in commercial insurance markets where prices are high, and some insurers exercise considerable market power. In this paper, we examined the relationship between commercial insurer market power and MMC physician network breadth using linked national enrollment data and provider directory data. Insurers with more commercial market power had broader Medicaid physician networks. Insurers with over 30% market share had 37.3% broader Medicaid networks than insurers in the same county that had no commercial market share. These differences were driven by greater breadth among primary care providers, as well as other specialists including OB/GYNs, surgeons, neurologists, and cardiologists. Commercial insurance market power may have spillovers on access to care for MMC beneficiaries., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Importance: Millions of economically disadvantaged children depend on Medicaid for dental care, with states differing in whether they deliver these benefits using fee-for-service or capitated managed care payment models. However, there is limited research examining the association between managed care and the accessibility of dental services., Objective: To estimate the association between the adoption of managed care for dental services in Florida's Medicaid program and nontraumatic dental emergency department visits and associated charges., Design, Setting, and Participants: This cohort study used an event-study difference-in-differences design, leveraging Florida Medicaid's staggered adoption of managed care to examine its association with pediatric nontraumatic dental emergency department visits and associated charges. This study included all Florida emergency department visits from 2010 to 2014 in which the patient was 17 years or younger, the patient was a Florida resident, Medicaid paid for the visit, and a primary or secondary International Classification of Diseases, Ninth Revision, code was used to classify a nontraumatic dental condition. Analyses were conducted between May 2023 and April 2024., Exposure: The county of residence transitioning Medicaid dental services from fee-for-service to a fully capitated managed care program managed by a dental plan., Main Outcomes and Measures: The rate of nontraumatic dental emergency department visits per 100 000 pediatric Medicaid enrollees and the associated mean charges per visit. Nontraumatic dental emergency department visits are a well-documented proxy for access to dental care. Data on emergency department visit counts came from the Florida Agency for Health Care Administration. Medicaid population denominators were derived from the American Community Survey's 5-year estimates., Results: Among the 34 414 pediatric nontraumatic dental emergency department visits that met inclusion criteria across Florida's 67 counties, the mean (SD) age of patients was 8.11 (5.28) years, and 50.8% of patients were male. Of these, 10 087 visits occurred in control counties and 24 327 in treatment counties. Control counties generally had lower rates of NTDC ED visits per 100 000 enrollees compared with treatment counties (123.5 vs 132.7). Over the first 2.5 years of implementation, the adoption of managed care was associated with an 11.3% (95% CI, 4.0%-18.4%; P = .002) increase in nontraumatic dental emergency department visits compared with pre-implementation levels. There was no evidence that the average charge per visit changed., Conclusions and Relevance: In this cohort study, Florida Medicaid's adoption of managed care for pediatric dental services was associated with increased emergency department visits for children, which could be associated with decreased access to dental care.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services is a Medicaid benefit for children that addresses their health problems before they become advanced, debilitating, and expensive. We conducted a retrospective cross-sectional analysis of pediatric beneficiaries (newborn to younger than 21 years) enrolled in a Medicaid managed care organization to examine the factors associated with EPSDT screening services completion. We obtained 2018 administrative claims data for beneficiaries continuously enrolled for a minimum of 90 days (n=156,108). Completion of EPSDT screening services among our Medicaid managed care beneficiaries was low. Those having more emergency department visits and hospitalizations, having family medicine practitioners as primary care physicians, belonging to the racial/ethnic group Asian/Pacific Islander/Hawaiian/Alaskan Native/Native American, and 18 to younger than 21 years age group were less likely than others to complete EPSDT services. Our results provide information on segments of pediatric beneficiaries that can be targeted to increase EPSDT screening services completion.

Background: The significant adverse social and economic impact of the COVID-19 pandemic has cast broader light on the importance of addressing social determinants of health (SDOH). Medicaid Managed Care Organizations (MMCOs) have increasingly taken on a leadership role in integrating medical and social services for Medicaid members. However, the experiences of MMCOs in addressing member social needs during the pandemic has not yet been examined., Aim: The purpose of this study was to describe MMCOs' experiences with addressing the social needs of Medicaid members during the COVID-19 pandemic., Methods: The study was a qualitative study using data from 28 semi-structured interviews with representatives from 14 MMCOs, including state-specific markets of eight national and regional managed care organizations. Data were analyzed using thematic analysis., Results: Four themes emerged: the impact of the pandemic, SDOH response efforts, an expanding definition of SDOH, and managed care beyond COVID-19. Specifically, participants discussed the impact of the pandemic on enrollees, communities, and healthcare delivery, and detailed their evolving efforts to address member nonmedical needs during the pandemic. They reported an increased demand for social services coupled with a significant retraction of community social service resources. To address these emerging social service gaps, participants described mounting a prompt and adaptable response that was facilitated by strong existing relationships with community partners., Conclusion: Among MMCOs, the COVID-19 pandemic has emphasized the importance of addressing member social needs, and the need for broader consideration of what constitutes SDOH from a healthcare delivery standpoint., Competing Interests: NO authors have competing interests.

Objective: To measure the impact of Medicaid managed long-term services and supports (MLTSS) on nursing home (NH) quality and rebalancing., Data Sources/study Setting: This study analyzes secondary data from annual NH recertification surveys and the minimum dataset (MDS) in three states that implemented MLTSS: Massachusetts (2001-2007), Kansas and Ohio (2011-2017)., Study Design: We utilized a difference-in-difference approach comparing NHs in border counties of states that implemented MLTSS with a control group of NHs in neighboring border counties in states that did not implement MLTSS. Sensitivity analyses included a triple-difference model (stratified by Medicaid payer mix) and a within-state comparison. We examined changes in six NH-level outcomes (percentage of low-care NH residents, facility occupancy, and four NH quality measures) after MLTSS implementation., Data Collection/extraction Methods: For each state, all freestanding NHs in border counties were included, as were NHs in neighboring counties located in other states. Information on low-care residents was aggregated to the NH level from MDS data, then combined with Online Survey Certification and Reporting (OSCAR) and Certification and Survey Provider Enhanced Reporting (CASPER) data., Principal Findings: MLTSS had no statistically significant effects on NH quality outcomes in Massachusetts or Kansas. In Ohio, MLTSS led to an increase of 0.21 nursing hours per resident day [95% CI: 0.03, 0.40], and a decrease of 1.47 deficiencies [95% CI: -2.52, -0.42] and 9.38 deficiency points [95% CI: -18.53, -0.24] per certification survey. After MLTSS, occupancy decreased by 1.52 percentage points [95% CI: -2.92, -0.12] in Massachusetts, but increased by 3.17 percentage points [95% CI: 0.36, 5.99] in Ohio. We found no effect on low-care residents in any state. Findings were moderately sensitive to the choice of comparator group., Conclusion: The study provides little evidence that MLTSS reduces quality of care, occupancy, or the percentage of low-care residents in NHs., (© 2021 Health Research and Educational Trust.)

Importance: Although there is no pharmacological treatment for autism spectrum disorder (ASD) itself, behavioral and pharmacological therapies have been used to address its symptoms and common comorbidities. A better understanding of the medications used to manage comorbid conditions in this growing population is critical; however, most previous efforts have been limited in size, duration, and lack of broad representation., Objective: To use a nationally representative database to uncover trends in the prevalence of co-occurring conditions and medication use in the management of symptoms and comorbidities over time among US individuals with ASD., Design, Setting, and Participants: This retrospective, population-based cohort study mined a nationwide, managed health plan claims database containing more than 86 million unique members. Data from January 1, 2014, to December 31, 2019, were used to analyze prescription frequency and diagnoses of comorbidities. A total of 26 722 individuals with ASD who had been prescribed at least 1 of 24 medications most commonly prescribed to treat ASD symptoms or comorbidities during the 6-year study period were included in the analysis., Exposures: Diagnosis codes for ASD based on International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision., Main Outcomes and Measures: Quantitative estimates of prescription frequency for the 24 most commonly prescribed medications among the study cohort and the most common comorbidities associated with each medication in this population., Results: Among the 26 722 individuals with ASD included in the analysis (77.7% male; mean [SD] age, 14.45 [9.40] years), polypharmacy was common, ranging from 28.6% to 31.5%. Individuals' prescription regimens changed frequently within medication classes, rather than between classes. The prescription frequency of a specific medication varied considerably, depending on the coexisting diagnosis of a given comorbidity. Of the 24 medications assessed, 15 were associated with at least a 15% prevalence of a mood disorder, and 11 were associated with at least a 15% prevalence of attention-deficit/hyperactivity disorder. For patients taking antipsychotics, the 2 most common comorbidities were combined type attention-deficit/hyperactivity disorder (11.6%-17.8%) and anxiety disorder (13.1%-30.1%)., Conclusions and Relevance: This study demonstrated considerable variability and transiency in the use of prescription medications by US clinicians to manage symptoms and comorbidities associated with ASD. These findings support the importance of early and ongoing surveillance of patients with ASD and co-occurring conditions and offer clinicians insight on the targeted therapies most commonly used to manage co-occurring conditions. Future research and policy efforts are critical to assess the extent to which pharmacological management of comorbidities affects quality of life and functioning in patients with ASD while continuing to optimize clinical guidelines, to ensure effective care for this growing population.

Objective: To evaluate the impact of the Health and Recovery Plan (HARP), a capitated special needs Medicaid managed care product that fully integrates physical and behavioral health delivery systems in New York State., Data Sources: 2013-2019 claims and encounters data on continuously enrolled individuals from the New York State Medicaid data system., Study Design: We used a difference-in-difference approach with inverse probability of exposure weights to compare service use outcomes in individuals enrolled in the HARP versus HARP eligible comparison group in two regions, New York City (NYC) pre- (2013-2015) versus post- (2016-2018) intervention periods, and rest of the state (ROS) pre- (2014-2016) versus post- (2017-2019) intervention periods., Data Collection/extraction Methods: Not applicable., Principal Findings: HARPs were associated with a relative decrease in all-cause (RR = 0.78, 95% CI 0.68-0.90), behavioral health-related (RR = 0.76, 95% CI 0.60-0.96), and nonbehavioral-related (RR = 0.87, 95% CI 0.78-0.97) stays in the NYC region. In the ROS region, HARPs were associated with a relative decrease in all-cause (RR = 0.87, 95% CI 0.80-0.94) and behavioral health-related (RR = 0.80, 95% CI 0.70-0.91) stays. Regarding outpatient visits, the HARPs benefit package were associated with a relative increase in behavioral health (RR = 1.21, 95% CI 1.13-1.28) and nonbehavioral health (RR = 1.08, 95% CI 1.01-1.15) clinic visits in the NYC region. In the ROS region, the HARPs were associated with relative increases in behavioral health (RR = 1.47, 95% CI 1.32-1.64) and nonbehavioral health (RR = 1.17, 95% CI 1.11-1.25) clinic visits., Conclusions: Compared to patients with similar clinical needs, HARPs were associated with a relative increase in services used and led to a better engagement in the HARPs group regardless of the overall decline in services used pre- to postperiod., (© 2021 Health Research and Educational Trust.)

Objective: To evaluate the effect of a forced disruption to Medicaid managed care plans and provider networks on health utilization and outcomes for children with persistent asthma., Data Sources: Medicaid managed care administrative claims data from 2013 to 2016, obtained from a southeastern state., Study Design: A difference-in-difference analysis compared patients' outpatient, inpatient, and emergency department (ED) utilization and receipt of recommended services before and after implementation of a statewide redistribution of patients among nine managed care plans., Data Collection/extraction Methods: Enrollment data for children with asthma were linked to the administrative claims. Children were included if they had a diagnosis of persistent asthma in 2013 and if they were enrolled continuously throughout 2014-2016., Principal Findings: Among the 28 537 children with asthma, 26% were forced to switch their managed care plan after the redistribution. Of these, 67% also switched their primary care provider (PCP). Relative to those who remained in their plan, disruption was associated with an additional 2.1 percentage-point decrease in the number of children who had an outpatient visit per quarter [95%CI -2.8, -1.3], from 71% to 66% (compared to plan stayers: 74% to 71%). Among children experiencing a change to their plan, there was overall a decrease in the proportion of children receiving an asthma-specific visit per quarter, but there was less of a decrease in children that also changed their PCP [1.6 percentage points, 95%CI 0.7, 2.5], from 9.7% to 8.3% (compared to those who did not switch their PCP: 12% to 8.6%). Indicators of asthma care quality and emergent care utilization were not significantly different between the two periods., Conclusions: While there was a decrease in the number of outpatient visits associated with forced disruption of Medicaid managed care plans for children with persistent asthma, there were no consistent associations with worse asthma quality performance or higher emergent health care utilization., (© 2021 Health Research and Educational Trust.)

Background: Opioids are generally an inappropriate acute pain management strategy in children, particularly because of the risk for diversion and subsequent misuse and abuse., Objectives: To examine associations between Medicaid plan type [coordinated care organization (CCO), managed care (MC), fee-for-service (FFS)] and whether a child received an opioid prescription., Research Design: Secondary analysis of Oregon Medicaid data (January 1, 2016 to December 31, 2017)., Subjects: Medicaid-enrolled children ages 0-17 (N=200,169)., Measures: There were 2 outcomes: whether a child received an opioid prescription from (a) any health provider or (b) from a visit to the dentist. Predictor variables included Medicaid plan type, age, sex, race, and ethnicity., Results: About 6.7% of children received an opioid from any health provider and 1.2% received an opioid from a dentist visit. Children in a CCO were significantly more likely than children in a MC (P<0.01) or FFS (P=0.02) plan to receive an opioid from any health provider. Children in a CCO were also significantly more likely than children in MC or FFS to receive an opioid from a dentist visit (P<0.01)., Conclusions: Pediatric opioid prescriptions vary by plan type. Future efforts should identify reasons why Medicaid-enrolled children in a CCO plan are more likely to be prescribed opioids., Competing Interests: One of the authors (J.B.) is employed by Anthem Inc. as a Senior Health Information Consultant for commercially insured employers with no involvement in business related to Medicaid. The remaining authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The United States currently has more confirmed cases of COVID-19 than any other country in the world. Given the variability in COVID-19 testing and prevention capability, identifying factors associated with mortality in patients requiring mechanical ventilation is critical. This study aimed to identify which demographics, comorbidities, markers of disease progression, and interventions are associated with 30-day mortality in COVID-19 patients requiring mechanical ventilation., Methods: Adult patients with a confirmed diagnosis of COVID-19 admitted to one of the health system's intensive care units and requiring mechanical ventilation between March 9, 2020 and April 1, 2020, were included in this observational cohort study. We used Chi-Square and Mann-Whitney U tests to compare patient characteristics between deceased and living patients and multiple logistic regression to assess the association between independent variables and the likelihood of 30-day mortality., Results: We included 85 patients, of which 20 died (23.5%) within 30 days of the first hospital admission. In the univariate analysis, deceased patients were more likely ≥60 years of age (p < 0.001), non-Hispanic (p = 0.026), and diagnosed with a solid malignant tumor (p = 0.003). Insurance status also differed between survivors and non-survivors (p = 0.019). Age ≥60 and malignancy had a 9.5-fold (95% confidence interval 1.4-62.3, p = 0.020) and 5.8-fold higher odds ratio (95% confidence interval 1.2-28.4, p = 0.032) for 30-day mortality after adjusted analysis using multivariable logistic regression, while other independent variables were no longer significant., Conclusions: In our observational cohort study of 85 mechanically ventilated COVID-19 patients, age, and a diagnosis of a solid malignant tumor were associated with 30-day mortality. Our findings validate concerns for the survival of elderly and cancer patients in the face of the COVID-19 pandemic in the United States, where testing capabilities and preventative measures have been inconsistent. Preventative efforts geared to patients at risk for intensive care unit mortality from COVID-19 should be explored.

Importance: Enrollment in Medicaid managed care plans has increased rapidly, particularly in national commercial insurance plans. Whether the type of managed care plan is associated with the use of health services for Medicaid beneficiaries is unknown., Objective: To compare the use of outpatient and acute care between Medicaid enrollees randomly assigned to a national commercial managed care plan or a local Medicaid-focused managed care plan., Design, Setting, and Participants: This natural experiment of a cohort of Medicaid enrollees randomly assigned to 2 managed care plans in a Northeastern US state was conducted from June 30, 2009, to June 30, 2013. Statistical analysis was performed from September 1, 2019, to August 30, 2020., Interventions: Assignment to a Medicaid-focused insurance plan or a commercial managed care plan., Main Outcomes and Measures: Outpatient visits, emergency department visits, and total inpatient and ambulatory care-sensitive hospitalizations., Results: A total of 8010 patients were included in the analysis: 4737 were assigned to a Medicaid-focused plan (2795 female [59.0%]; mean [SD] age, 17.8 [3.2] years) and 3273 to a commercial managed care plan (1915 female [58.5%]; mean [SD] age, 17.9 [3.3] years). Those randomly assigned to the Medicaid-focused plan had a mean (SD) of 6.67 (9.18) annual outpatient visits per person, and those assigned to the commercial plan had a mean (SD) of 8.36 (11.77) annual outpatient visits per person (adjusted absolute difference, 1.72 [95% CI, 1.31-2.13]; 22% relative difference). The increased use of outpatient visits in the commercial plan was associated with an increase in specialty care visits (mean [SD], 2.34 [6.31] visits in Medicaid-focused plan vs 3.75 [9.32] visits in commerical plan; adjusted absolute difference, 1.43 visits [95% CI, 1.25-1.56 visits]; 61% relative difference). Mean (SD) annual emergency department visits were 0.49 (1.39) per person in the Medicaid-focused plan and 0.51 (1.40) in the commercial plan (adjusted absolute difference, 0.02 [95% CI, -0.02 to 0.05]). Mean (SD) annual inpatient admissions were 0.067 (0.45) per person in the Medicaid-focused plan and 0.069 (0.53) in the commercial plan (adjusted absolute difference, 0.003 [95% CI, -0.01 to 0.02]). Plan assignment was not significantly associated with ambulatory care-sensitive admissions. Results were consistent in instrumental variables analyses that accounted for disenrollment and switching., Conclusions and Relevance: Compared with Medicaid managed care enrollees assigned to a Medicaid-focused plan, those assigned to a commercial plan had more outpatient visits, particularly for specialty care, but had similar rates of emergency department visits and hospitalizations. These findings suggest that the type of managed care plan may be associated with health services use and spending among Medicaid beneficiaries and that random assignment may help states understand how well different plans perform for enrollees.

Objective: To estimate the health-related quality of life (HRQoL) and health utilities among asthma patients with and without comorbid allergies in a managed care population. Methods: This was a retrospective analysis of patient survey responses and pharmacy claims from the Observational Study of Asthma Control and Outcomes (OSACO). Patients ≥12 years-old with persistent asthma received four identical surveys between April-2011 and December-2012. The presence of allergy was identified by a positive response to a survey question about hay fever/seasonal allergies and ≥1 diagnosis-related ICD-9-CM code(s) for allergic conditions. HRQoL instruments included generic utility (EQ-5D-3L [including VAS]), asthma-specific utility (AQL-5D) and asthma-specific health status (Mini Asthma Quality of Life Questionnaire [MiniAQLQ]). Median regression was used for utility scores and Least Squares regression for MiniAQLQ, adjusting for sociodemographic characteristics and smoking. Results: Of the 2681 asthmatics who completed the first survey in the OSACO study, 971 had comorbid allergies. After adjusting for covariates, asthma patients with comorbid allergies had significantly lower MiniAQLQ scores than patients without allergies (-0.489 [95% CI -0.570, -0.409]; p  < 0.01), with the greatest decrement/impairment observed for the environmental stimuli domain (-0.729 [95% CI -0.844, -0.613]; p  < 0.01). Utility scores were also statistically significantly lower for asthma patients with comorbid allergies compared to those without allergies (EQ-5D, -0.031 [95% CI -0.047, -0.015]; AQL-5D, -0.036 [95% CI -0.042, -0.029]; p  < 0.01 each). Conclusions: The presence of allergies with persistent asthma is associated with a significant deleterious impact on several different measures of HRQoL.

Objective: This study evaluated whether access to and engagement in substance use disorder treatment has improved from 2010 to 2016., Methods: Data submitted by commercial and Medicaid health plans, representing over 163 million beneficiaries from 2010 to 2016, were analyzed., Results: For commercial plans, identification increased (from 1.0% to 1.6%, p<0.001), the initiation rate declined (from 41.9% to 33.7%, p<0.001), and the engagement rate also declined (from 15.8% to 12.1%, p<0.001). The decline in the initiation and engagement rates could not be explained by the increasing identification rates. For Medicaid plans, the identification rate increased (from 3.3% to 6.7%, p<0.001), and the initiation and engagement rates were unchanged., Conclusions: Although an increasing proportion of health plan members are being identified with substance use disorders, the majority of these individuals are not engaging in treatment.

Abstracts: To examine the impact of increased managed care activity on 30-day readmission and mortality for acute myocardial infarctions and congestive heart failure in U.S. hospitals following the managed care backlash against managed care cost containment practices.The Centers for Medicare and Medicaid Services (CMS) Hospital Compare files, CMS Hospital Cost Report, CMS Medicare Advantage Enrollment files, and Health Resources and Services Administration Area Resource File data for the period 2008 to 2011 were used to construct the study sample. Multivariate fixed effects regression with robust standard errors, hospital fixed effects, and year fixed effects were used to estimate the impact of managed care penetration on adverse cardiovascular outcomes. Our primary outcome measures were readmission and mortality for patients discharged with acute myocardial infarction and congestive heart failure for acute, non-federal hospitals with emergency rooms. To examine effects of hospital ownership status, not-for-profit hospitals were compared to proprietary hospitals.The main analysis revealed that an increase in managed care penetration was associated with a decline in both 30-day readmission and mortality for acute myocardial infarction and congestive heart failure. In the hospital ownership analysis, only the acute myocardial infarction results for proprietary hospitals was statistically significant. All hospital types reported similar congestive heart failure trends as the full sample; however, proprietary hospitals reported greater declines in readmission and mortality.Increased managed care activity is associated with reductions in hospital readmission and mortality following the legislative and consumer backlash against managed care, with differential impacts across hospital ownership type. These finding highlights the important role of managed care in creating quality improvements in the delivery of care in the hospital setting.

Background: Health insurance reimbursement structure has evolved, with patients becoming increasingly responsible for their health care costs through rising out-of-pocket expenses. High levels of cost sharing can lead to delays in access to care, influence treatment decisions, and cause financial distress for patients., Methods: Patients undergoing the most common outpatient reconstructive plastic surgery operations were identified using Truven MarketScan databases from 2009 to 2017. Total cost of the surgery paid to the insurer and out-of-pocket expenses, including deductible, copayment, and coinsurance, were calculated. Multivariable generalized linear modeling with log link and gamma distribution was used to predict adjusted total and out-of-pocket expenses. All costs were inflation-adjusted to 2017 dollars., Results: The authors evaluated 3,165,913 outpatient plastic and reconstructive surgical procedures between 2009 and 2017. From 2009 to 2017, total costs had a significant increase of 25 percent, and out-of-pocket expenses had a significant increase of 54 percent. Using generalized linear modeling, procedures performed in outpatient hospitals conferred an additional $1999 in total costs (95 percent CI, $1978 to $2020) and $259 in out-of-pocket expenses (95 percent CI, $254 to $264) compared with office procedures. Ambulatory surgical center procedures conferred an additional $1698 in total costs (95 percent CI, $1677 to $1718) and $279 in out-of-pocket expenses (95 percent CI, $273 to $285) compared with office procedures., Conclusions: For outpatient plastic surgery procedures, out-of-pocket expenses are increasing at a faster rate than total costs, which may have implications for access to care and timing of surgery. Providers should realize the increasing burden of out-of-pocket expenses and the effect of surgical location on patients' costs when possible.

Background/objectives: Although there is a strong cross-sectional association between dependence in activities of daily living (ADLs) and decreased mental health, it is largely unknown how the loss of specific ADLs, or the combination of ADLs, influences mental health outcomes. We examined the effect of ADL independence on mental health among participants in a large survey of Medicare managed care recipients., Design/setting: Retrospective cohort study., Participants: A total of 104,716 participants in cohort 17 of the Medicare Health Outcomes Survey, who completed the baseline and follow-up surveys in 2014 and 2016., Measurements: Linear regression models estimated the effects of loss of ADL independence on change in Mental Component Summary (MCS) score., Results: In an adjusted model, loss of independence in eating, bathing, dressing, and toileting were associated with three- to four-point declines in MCS, suggesting meaningful worsening. In a model that also included all six ADLs, loss of independence in each ADL was associated with declines in MCS, with the largest effects for eating and bathing. MCS decreased by 1.3 per each additional summative loss of ADL independence (P < .001)., Conclusion: Loss of ADL independence was associated with large declines in mental health, with personal care activities showing the largest effects. Additional research can help to characterize the causes of ADL loss, to explore how older adults cope with it, and to identify ways of maximizing resilience. J Am Geriatr Soc 68:1301-1306, 2020., (© 2020 The American Geriatrics Society.)

Medicaid is integral to public health because it insures one in five Americans and half of the nation's births. Nearly two-thirds of all Medicaid recipients are currently enrolled in a health maintenance organization (HMO). Proponents of HMOs argue that they can lower costs while maintaining access and quality. We critically reviewed 32 studies on Medicaid managed care (2011-2019). Authors reported state-specific cost savings and instances of increased access or quality with implementation or redesign of Medicaid managed-care programs. Studies on high-risk populations (e.g., disabled) found improvements in quality specific to a state or a high-risk population. A unique model of managed care (i.e., the Oregon Health Plan) was associated with reduced costs and improved access and quality, but results varied by comparison state. New trends in the literature focused on analysis of auto-assignment algorithms, provider networks, and plan quality. More analysis of costs jointly with access/quality is needed, as is research on managing long-term care among elderly and disabled Medicaid recipients.

Research agendas play valuable roles in clearly identifying high-priority topics that reflect potential to improve health care quality. The purpose of this report is to present work completed by the Academy of Managed Care Pharmacy (AMCP) and AMCP Foundation Joint Research Committee. This committee set forth to develop a research agenda for our 2 organizations that focuses on critical evidence needs in managed care pharmacy. This document reviews results from 2 surveys that were conducted to better understand unmet research needs within managed care pharmacy and to inform professional efforts of managed care pharmacists. The first survey collected qualitative data from key opinion leaders (KOLs) regarding the top evidentiary gaps in managed care pharmacy and barriers to closing those gaps. The second survey was sent to AMCP members and AMCP Foundation stakeholders, used a mixed methods quantitative-qualitative design, and incorporated concepts from initial KOL responses. The key outcome from these proceedings is the research agenda, which identifies and prioritizes 4 evidentiary gaps in managed care pharmacy: (1) real-world evidence to inform managed care pharmacy decision making, (2) value-based models in managed care pharmacy to address total cost of care, (3) impact of benefit design or utilization management strategies on patient outcomes, and (4) impact of direct patient care services provided by managed care pharmacy on patient outcomes. The agenda was intended to be broad and will evolve over time. AMCP and the AMCP Foundation hope that this research agenda inspires the AMCP membership, researchers, and funding agencies to close these gaps in knowledge and understanding. DISCLOSURES: Chairs and members of the Joint Research Committee oversaw and conducted the work outlined in this report with the support of AMCP and the AMCP Foundation. No outside funding was received. Gembarski, Couto, Wilson, and Eichenbrenner declare no conflicts of interest, real or apparent, with any product or service mentioned in this report. Gembarski is employed by BCBS Michigan; Couto is employed by Cigna; Wilson is employed by HealthCore, a wholly owned subsidiary of Anthem; and Eichenbrenner is employed by the AMCP Foundation.

Objective : Use claims data to examine the cost benefit of the Community Asthma Initiative (CAI), a Boston area nurse-supervised community health worker (CHW) asthma home-visiting program. Methods : The reduction in asthma treatment costs was assessed using Massachusetts claims data from one Medicaid Managed Care Organization (MCO) in the north east that included all costs between January 1, 2011 and December 31, 2016. The data was used to determine asthma-related utilization cost reductions between 1 year pre- and 1, 2 and 3 years post-intervention. The cost reductions for 45 CAI patients and 45 cost-matched comparison patients were measured. Return on investment (ROI) was computed as the difference in cost reduction for CAI patients and a cost-matched comparison population divided by CAI program cost. Results : The excess reduction in per patient asthma-related utilization costs among CAI patients compared to the comparison population was $806 ( p  = 0.047), $1,253 ( p  = 0.01) and $1,549 ( p  = 0.005) between 1 year pre- and 1, 2 and 3 years post-intervention. These yielded adjusted ROI's of 0.31, 0.78 and 1.37 after 1, 2 and 3 years post-CAI intervention. Conclusions : The reduction in asthma utilization costs of a home visit program by nurse-supervised CHWs exceeds program costs. The findings support the business case for the provision of secondary prevention of home-based asthma services through reimbursement from payers or integration into Accountable Care Organizations (ACOs).

Objective: To estimate the maternity-related cost of health care services in women with and without severe maternal morbidity (SMM)., Methods: Women with a live inpatient birth in the calendar year 2013 were identified in the MarketScan ® Commercial and Medicaid health insurance claims databases. Costs were defined as the amounts paid by insurers plus out-of-pocket and third-party payments. Costs were calculated as total maternity-related costs and categorized as prenatal, delivery, and postpartum costs. SMM was identified using the CDC algorithm of 25 ICD-9 diagnostic and procedural codes. Variables associated with higher delivery costs were determined by multivariable linear regression analysis., Results: A total of 750 women met the criteria for SMM in the Commercial population. The total, per-patient mean costs of care for women without and with SMM were $14,840 and $20,380, respectively. Delivery hospitalization costs were 76-77% of total mean costs for women without and with SMM. A total of 99 women met the criteria for SMM in the Medicaid population. The total, per-patient mean costs of care for women without and with SMM were $6894 and $10,134, respectively. Delivery costs were 71-72% of total costs. Variables independently predictive of increased delivery costs in both Commercial and Medicaid populations were delivery by cesarean section, multifetal gestation, gestational hypertension/preeclampsia, and obstetric infection., Conclusions: The occurrence of SMM was associated with an increase in maternity-related costs of 37% in the Commercial and 47% in the Medicaid population. Some of the factors associated with increased delivery hospitalization costs may be prevented.

Background: In 2009 health insurers AOK and Bosch BKK introduced the "FacharztProgramm Kardiologie" - a program for coordinated ambulatory cardiology care in the German state of Baden-Württemberg. It aims for efficient, medical guideline-oriented cardiology care to reduce avoidable hospitalizations as well as costs of care. A high number of cardiologists participate and the program has served as blueprint for programs in other medical fields. With many prerequisites and conditions involved, its implementation cannot be expected to be self-directed. Still, only little data on the actual implementation exists. We aimed to determine to what extent medical specialists and cooperating general practitioners implemented the program, which components they adapted, and which contextual factors they deemed relevant., Methods: We collected data from primary care practices of medical specialists and general practitioners within Baden-Württemberg. Qualitative data was obtained through structured telephone interviews with participating and non-participating medical specialists as well as general practitioners cooperating with the program and general practitioners not cooperating. Interviews were analyzed through content-structuring qualitative content analyses via MAXQDA. Quantitative data was obtained using anonymous written questionnaires completed by participating and non-participating medical specialists as well as general practitioners cooperating with the program. Analyses were performed using SPSS Statistics, mainly with regard to differences within and between groups of physicians., Results: Most components of the program regarding medical care were well implemented. However, access to medical care was not completely as intended due to high numbers of patients participating in the program and prioritization by physicians. Procedures for communication and cooperation between medical specialists and general practitioners were only partially adhered to and standardized communication was not implemented. A range of regional and practice-related contextual factors influenced implementation and outcomes., Conclusions: Implementation of this program was mixed. Contextual factors posed individual challenges to participating physicians which can't be captured by an encompassing program. Both control mechanisms and tailoring of the program to medical care seem needed., Trial Registration: Though not a clinical study, we deemed registration appropriate to ensure transparency. The study has been registered as a non-interventional observation study at the German Clinical Trials Register under ID: DRKS00013070.

Objectives: To identify care needs among Medicaid and Medicare patients in an all-condition care management program involving case managers (CMs) and community health workers (CHWs), and to examine the relationship between intervention intensity and healthcare utilization., Study Design: Retrospective longitudinal evaluation of managed care-hired CMs and CHWs based at 8 primary care sites participating in the Johns Hopkins Community Health Partnership (J-CHiP)., Methods: Patients at high risk for hospitalization were enrolled in J-CHiP. CMs provided care coordination and CHWs addressed barriers to care. Four program intensity categories were created: low CM-low CHW, low CM-high CHW, high CM-low CHW, and high CM-high CHW. We evaluated the adjusted relative risk (RR) of emergency department (ED) visits, hospitalizations, and 30-day hospital readmissions pre- and post enrollment in the program using CM documentation, electronic health record data, and insurance claims., Results: Among 1408 Medicaid and 2196 Medicare patients, the predominant barriers to care were lack of transportation, unstable housing, medication payment, and healthy food access. Among Medicaid and Medicare patients, high CM-high CHW and high CM-low CHW intensities were associated with a higher adjusted risk of hospitalization and 30-day hospital readmission after program implementation compared with low CM-low CHW intensity. Among patients with low CM-high CHW intensity, Medicaid patients had a higher risk of readmission (RR, 1.47; P = .016) and Medicare patients had a higher risk of ED visit (RR, 1.33; P = .001) post program implementation., Conclusions: In this longitudinal evaluation of an all-condition, unstructured, managed care organization-led program, preprogram trajectories of healthcare utilization rates among patients increased rather than decreased after program implementation, especially among patients receiving the highest care management program intensity.

Objective: To examine the impact of Oregon's Coordinated Care Organizations (CCOs), an accountable care model for Oregon Medicaid enrollees implemented in 2012, on neonatal and infant mortality., Data Sources: Oregon birth certificates linked with death certificates, and Medicaid/CCO enrollment files for years 2008-2016., Study Design: The sample consisted of the pre-CCO birth cohort of 135 753 infants (August 2008-July 2011) and the post-CCO birth cohort of 148 650 infants (August 2012-December 2015). We used a difference-in-differences probit model to estimate the difference in mortality between infants enrolled in Medicaid and infants who were not enrolled. We examined heterogeneous effects of CCOs for preterm and full-term infants and the impact of CCOs over the implementation timeline. All models were adjusted for maternal and infant characteristics and secular time trends., Principal Findings: The CCO model was associated with a 56 percent reduction in infant mortality compared to the pre-CCO level (-0.20 percentage points [95% CI: -0.35; -0.05]), and also with a greater reduction in infant mortality among preterm infants compared to full-term infants. The impact on mortality grew in magnitude over the postimplementation timeline., Conclusions: The CCO model contributed to a reduction in mortality within the first year of birth among infants enrolled in Medicaid., (© Health Research and Educational Trust.)

Background: Type 2 diabetes mellitus (T2DM) is a chronic condition with a high economic burden as well as drug treatments that have not all demonstrated effects on longevity. Managed care organizations want to improve health outcomes in these complex patients but lack actionable evidence to make informed decisions on which therapies are most effective among their members and may also control total health care spending., Objective: To produce actionable evidence by identifying antidiabetic treatments that are effective and may reduce total cost of care in various risk groups of patients with T2DM, using insurance claims data that includes medical claims and pharmacy dispensing data among members of Horizon Blue Cross Blue Shield of New Jersey with T2DM., Methods: We identified patients with T2DM in longitudinal claims data from Horizon between 2014 and 2017 with demographic and enrollment information, inpatient and outpatient diagnoses and procedures, and pharmacy dispensing. Outcomes included myocardial infarction, heart failure (HF), stroke, percutaneous revascularization, health care services utilization, and plan costs (i.e., medical, pharmacy, and total cost of care). After propensity score decile adjustment on over 20 covariates, we evaluated the effectiveness and safety of second-line antidiabetic treatment that included sodium-glucose co-transporter-2 (SGLT-2) inhibitors, sulfonylureas (SUs), dipeptidyl peptidase-4 (DPP-4) inhibitors, and glucagon-like peptide-1 (GLP-1) receptor agonists., Results: Among 115,308 members with T2DM, the most common comorbidities were cardiovascular risk factors, including hyperlipidemia (56%), hypertension (50%), and existing cardiovascular disease (CVD; 55%). Among members receiving dual antidiabetic treatment (n = 20,204), the most prevalent treatments were metformin plus the following second-line medications: SUs (42%), DPP-4 inhibitors (29%), SGLT-2 inhibitors (10%), or GLP-1 receptor agonists (3%). Approximately 20% of members accounted for 79% of total cost of care, with an average of $9,605 per member per year (PMPY). Compared with SU initiation and after propensity score decile adjustment, new users of SGLT-2 inhibitors had a reduced risk for HF hospitalization (HR = 0.35, 95% CI = 0.13-0.89), hypoglycemia, albuminuria, microvascular disease, and metabolic failure. Among SGLT-2 inhibitor initiators with established CVD, the savings in total cost of care compared with SU initiators was $5,520 per member over an average treatment duration of 6 months and an approximate savings of $11,000 PMPY if patients persisted on treatment for 12 months., Conclusions: In the Horizon membership, we confirmed that SGLT-2 inhibitors reduce HF hospitalizations, resulting in reduced medical spending and savings in total cost of care. Regulatory-grade analytics of local data provided the confidence to encourage increased SGLT-2 inhibitor use to produce better outcomes and save total cost of care despite higher pharmacy spending., Disclosures: This research did not receive outside funding; however, Aetion has since begun a contractual relationship with Horizon Blue Cross Blue Shield of New Jersey. Garry, Petruski-Ivleva, Cheever, and Rajan are employees of and have stock options in Aetion, a company that makes software for the analysis of real-world data. Eapen was an employee of Aetion during the implementation of this study. Rassen is an employee of and has ownership interest in Aetion. Murk is a consultant to Aetion of which he owns equity. Schneeweiss is a consultant to WHISCON and to Aetion, of which he also owns equity. He is the principal investigator of investigator-initiated grants to the Brigham and Women's Hospital from Bayer, Genentech, Boehringer Ingelheim, and Vertex. Gambino is an employee and officer at Horizon Blue Cross and Blue Shield of New Jersey. He was recently appointed to a board observer position at Aetion, as Horizon has small equity interest in Aetion. Jan is an employee of Rutgers State University and Horizon Blue Cross Blue Shield of New Jersey and has no conflict of interest or association with Aetion or any pharmaceutical company. Jang and Rubin are employees of Horizon Blue Cross and Blue Shield of New Jersey and have no conflict of interest or association with Aetion. This work was presented as a poster at AMCP Nexus 2018, October 22-25, 2018, in Orlando, FL; as part of a continuing education session at the AMCP Managed Care & Specialty Pharmacy 2019 Annual Meeting in San Diego, CA, March 25-28, 2019; as invited podium presenter at the Blue Cross Blue Shield 2019 National Summit conference in Grapevine, TX, April 29-May 2, 2019; and was accepted for a podium presentation at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 2019 annual conference in New Orleans, LA, May 18-22, 2019, where it won an award for Best Podium Presentation.

Objectives: Ankle radiography in the pediatric emergency department exposes a radiosensitive population to harmful ionizing radiation and is costly to health care systems. This study aimed to determine if ankle injuries in children could be managed safely and effectively without radiography., Methods: This prospective study enrolled 94 patients with ankle injuries between July 14, 2015, and December 16, 2015. Participating clinicians filled out a tick-box questionnaire describing their predicted diagnosis and management. In March 2016, we looked retrospectively at TRAK to determine how these patients were actually managed and compared this with the predictions., Results: Agreement was calculated for the predicted and actual presence of a fracture, with a κ value of 0.433. The intraclass correlation coefficient was calculated to determine interrater reliability between predicted management and actual management, showing an average score of 0.801. Of the 16 patients found to be Low Risk Ankle Rule positive, none were found to have high-risk fractures., Conclusions: This study found that radiographs are necessary for the management of pediatric ankle injuries. However, there is scope to reduce radiography by implementing the Low Risk Ankle Rule.

Aim: To evaluate clinical comorbidities and steroid use as risk factors for central serous retinopathy (CSR)., Methods: Using national insurance databases, we conducted a case-control study of beneficiaries with an incident diagnosis of CSR between 2007 and 2015 (n=35 492) and randomly selected controls matched on age-based and sex-based propensity scores (n=1 77 460)., Results: The mean age (SD) of cases was 49.1 (12.2) years, and the majority (69.2%) were male. Cases were more likely to have received steroids in the past year (OR 1.14, 95% CI 1.09 to 1.19, p<0.001) and to have comorbid Cushing's syndrome (OR 2.19, 95% CI 1.33 to 3.59, p=0.002), age-related macular degeneration (OR 5.24, 95% CI 5.00 to 5.49, p<0.001), diabetic macular oedema (OR 2.05, 95% CI 1.71 to 2.47, p<0.001) and diabetes mellitus (OR 1.44, 95% CI 1.33 to 1.56, p<0.001). Glaucoma was associated with lower odds of CSR (OR 0.54, 95% CI 0.51 to 0.56, p<0.001). Patients with other previously hypothesised risk factors (including essential hypertension, pregnancy, other autoimmune disease, sleep disorders, Helicobacter pylori infection and gastro-oesophageal reflux disease) had lower odds of CSR., Conclusions: Male middle-aged patients with recent steroid exposure were significantly more likely to develop CSR. Other risk factors include diabetes mellitus, diabetic macular oedema and age-related macular degeneration. Other previously hypothesised risk factors did not appear to confer increased risk. More research is needed to confirm and examine underlying pathophysiology., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The study examined factors associated with uptake of behavioral therapy among children with attention-deficit hyperactivity disorder (ADHD)., Methods: Insurance claims data from 2008-2014 (MarketScan) were reviewed to examine associations between behavioral therapy use and demographic, patient, family, and provider factors. The association between ADHD medication use and future uptake of behavioral therapy was examined with logistic regression adjusted for covariates found to affect behavioral therapy use., Results: Among 827,396 youths with ADHD, under 50% received any billable behavioral therapy services over the 7 years. ADHD severity, gender, region of residence, assessment year, comorbid behavioral disorders, and behavioral therapy use by siblings were significantly associated with behavioral therapy use (p<0.001). Parent psychopathology and sibling medication use was not. Children prescribed ADHD medication were 2.5 times less likely than those not prescribed medication to use behavioral therapy, even after adjustment for severity of behavioral health symptoms and other covariates (odds ratio [OR]= 0.41, 95% confidence interval [CI]=.40-.41, p<0.001). Effects of medication use were stronger for future uptake of behavioral therapy (OR=0.25, 95% CI =0.24-0.25, p<.001). The impact of medication use on behavioral therapy use was equally strong for children under age 6 and for older children and did not weaken after release of 2011 guidelines recommending behavioral therapy as the initial ADHD treatment for young children., Conclusions: Multiple systems, family, patient and provider factors affected behavioral therapy uptake. ADHD medication was a robust and potentially modifiable factor. It may be advisable to engage families in behavioral therapy prior to initiation of ADHD medication.

TRICARE is the military's health plan that provides coverage to 9.4 million active duty and retired uniformed services personnel and their family members. The TRICARE pharmacy benefit has undergone many changes in the last decade. These changes include assigning newly approved drugs to nonformulary status after regulatory approval, the addition of weight loss medications to the benefit, channel management point-of-service requirements for some medications, and copay increases. Several initiatives have resulted in significant cost avoidance to the Department of Defense (DoD). The purpose of this article is to discuss the changes to the TRICARE pharmacy benefit, describe the continual challenges, and estimate cost savings associated with implementation of these changes. DoD implemented its 3-tier Uniform Formulary in 2005. Since then, many changes have been enacted, including more extensive use of prior authorization, step therapy, and quantity limits; coverage of over-the-counter medications; the retail refund program; coverage of vaccines and smoking cessation agents; mandatory mail/military treatment facility requirements; rapid review and initial nonformulary status for newly approved innovator drugs; revisions to the compounded drug benefit; initial deployment of a new medical record system; coverage of weight loss medications; and the ability to exclude medications from the Uniform Formulary. Although the TRICARE pharmacy benefit has evolved significantly, the focus remains on the beneficiaries, with an overall goal of providing integrated, affordable, and high quality health services for the Military Health System. Challenges for the future include maximizing clinical effectiveness in the face of rising pharmaceutical costs and cost avoidance, while supporting the needs of TRICARE beneficiaries. DISCLOSURES: No outside funding supported this study. The authors declare no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. The information discussed here represents the views of the authors and does not necessarily reflect the views of the Defense Health Agency (DHA), the Department of Defense (DoD), or the Departments of the Army, Navy, and Air Force. The authors have nothing to disclose that presents a potential conflict of interest.

Objective: This study examined the performance of health plans on two HEDIS measures: metabolic monitoring of children and adolescents prescribed an antipsychotic and use of first-line psychosocial care for children and adolescents prescribed an antipsychotic for a nonindicated use. Plan characteristics and other contextual factors that may be associated with health plan performance were examined to identify potential strategies for improving care., Methods: The study population included 279 commercial and 169 Medicaid health plans that voluntarily submitted data for care provided in 2016. Bivariate associations between performance on the two measures and each plan characteristic (eligible population size, region, profit status, model type, and operating in a state with legislation on prior authorization for antipsychotics) were examined. Main-effects multivariable linear regression models were used to examine the combined association of plan characteristics with each measure., Results: Performance rates on both measures were comparable for commercial and Medicaid plans. Among commercial plans, not-for-profit plans outperformed for-profit plans on both measures. Commercial and Medicaid plans in the North performed significantly better on the metabolic monitoring measure. Commercial plans in the South and Medicaid plans in the West performed significantly worse on the first-line psychosocial care measure. Plans operating in states requiring prior authorization performed significantly better on the metabolic monitoring measure., Conclusions: This study identified key plan characteristics and other contextual factors associated with health plan performance on quality measures related to pediatric antipsychotic prescribing. Findings suggest that quality measures, in conjunction with policies such as prior authorization, can encourage better care delivery to vulnerable populations.

Background: Robust evidence is lacking on optimal timing of statin administration and its impact on patient outcomes., Objective: This study aims to evaluate among incident statin users the relationship between those prescribed evening vs. daily dosing instructions, medication adherence, and changes in low-density lipoprotein cholesterol (LDL-c)., Design: This is an observational cohort study at Sutter Health, a community-based healthcare system, 2010-2016., Participants: Patients were ≥ 35 years of age as of the first statin prescription (baseline), with 12 to 36 months of electronic health record activity before and after baseline. Incident use was defined as no statin prescription in 12 months prior to baseline., Main Measures: Differences in medication adherence (proportion of days covered ≥ 0.80) over 12 months from baseline and mean change in LDL-c between 12 and 24 months from baseline were measured using regression modeling, adjusting for baseline demographics and clinical, prescriber, and statin characteristics., Key Results: Among 31,252 patients with valid statin prescriptions between 2010 and 2016, 5099 eligible incident statin users (mean age, 63 years) were identified, of whom 53% were prescribed evening and 47% daily dosing instructions. No difference in likelihood of statin adherence over 12 months was observed for evening vs. daily dosing (adjusted odds ratio [OR] 0.90; 95% CI 0.75, 1.08). No differences were observed in mean change in LDL-c (adjusted mean difference 1.42 mg/dL; 95% CI - 1.02, 3.89) or likelihood of attaining LDL-c < 70 mg/dL (adjusted OR 0.83; 95% CI 0.67, 1.04) for evening vs. daily dosing over a mean of 19 months follow-up., Conclusions: Among incident statin users from a real-world clinical setting, those with daily and evening dosing instructions had similar adherence rates and mean changes in LDL-c. Given potential clinical equipoise for evening and daily dosing, clinicians should consider patient-tailored statin dosing instructions to reduce potentially unnecessary regimen complexity.

Objective: To examine the impact of a Medicaid-serving pediatric accountable care organization (ACO) on health service use by children who qualify for Medicaid by virtue of a disability under the "aged, blind, and disabled" (ABD) eligibility criteria., Data Sources/study Setting: We evaluated a 2013 Ohio policy change that effectively moved ABD Medicaid children into an ACO model of care using Ohio Medicaid administrative claims data for years 2011-2016., Study Design: We used a difference-in-difference design to examine changes in patterns of health care service use by ABD-enrolled children before and after enrolling in an ACO compared with ABD-enrolled children enrolled in non-ACO managed care plans., Data Collection/extraction Methods: We identified 17 356 children who resided in 34 of 88 counties as the ACO "intervention" group and 47 026 ABD-enrolled children who resided outside of the ACO region as non-ACO controls., Principal Findings: Being part of the ACO increased adolescent preventative service and decreased use of ADHD medications as compared to similar children in non-ACO capitated managed care plans. Relative home health service use decreased for children in the ACO., Conclusions: Our overall results indicate that being part of an ACO may improve quality in certain areas, such as adolescent well-child visits, though there may be room for improvement in other areas considered important by patients and their families such as home health service., (© Health Research and Educational Trust.)

Near misses and unsafe conditions have become more serious for patients in emergency departments (EDs). We aimed to search the near misses and unsafe conditions that occurred in an ED to improve patient safety.This was a retrospective analysis of a 10-year observational period from January 1, 2007 to December 31, 2016. We gained access to the adverse event notification forms (AENFs) sent to the hospital quality department from the ED. Patient age, sex, and date of presentation were recorded. The near misses and unsafe conditions were classified into 7 types: medication errors, falls, management errors, penetrative-sharp tool injuries, incidents due to institution security, incidents due to medical equipment, and forensic events. The outcome of these events was recorded.A total of 220 AENF were reported from 294,673 ED visits. The median age of the 166 patients was 60 (21-95) years. Of these, 57.1% of the patients were females and 47.9% were males. The most commonly reported events were medication errors (32.7%) and management errors (27.3%). The median age of falling patients was 67.5 years. The nurse-patient ratio between 2007 to 2011 and 2011 to 2016 were 1/10 and 1/7, respectively. We found that when this ratio increased, the adverse events results were less significant (P < .003).This was the 1st study investigating the adverse events in ED in Turkey. The reporting ratio of 0.07% for the total ED visits was too low. This showed that adverse events were under-reported.

Objectives: To evaluate the patterns of clinical service use for long-term nursing home residents enrolled in UnitedHealthcare's Medicare Advantage Institutional Special Needs Plans (I-SNPs), which provide on-site direct coordinated care for beneficiaries through the use of advanced practice clinicians., Study Design: Observational analysis of 8052 I-SNP members and 12,982 Medicare fee-for-service (FFS) long-term nursing home residents across 13 states., Methods: Multivariate analyses were performed to compare rates of emergency department (ED), inpatient, and skilled nursing facility (SNF) use between I-SNP members and Medicare FFS long-term nursing home residents., Results: In comparison with FFS institutionalized Medicare beneficiaries, I-SNP members had 51% lower ED use, 38% fewer hospitalizations, and 45% fewer readmissions, whereas their SNF use was 112% higher., Conclusions: "At-risk" models, administered through specialized Medicare Advantage plans, that invest in clinical management in the nursing home setting have the potential to allow individuals to receive care on-site and avoid costly inpatient transfers.

Objectives: To inform state Medicaid programs and managed care organizations, as well as to build their capacity to serve enrollees with complex needs related to serious mental illness (SMI)., Study Design: Quantitative and qualitative analyses of survey results from a sample of Medicaid enrollees with SMI in Kansas in 2016 and 2017 (N = 189)., Methods: Surveys were conducted by telephone or in person at community mental health centers. Analyses of descriptive statistics from closed-item responses and coded transcripts were used to identify major themes in open-item responses., Results: Respondents reported high rates of comorbid physical and mental health conditions and current or past tobacco use. Most were unemployed, and some were homeless or living in unstable conditions. Participants indicated a need for better information and communication; improved access to prescriptions, dental care, reliable transportation, medical supplies, and equipment; and a wider physician/provider network. They wanted care coordinators to provide more frequent and responsive contact, better information about benefits and resources, and help navigating the system., Conclusions: Individuals with chronic and complex conditions can be challenging for managed care organizations to support, especially Medicaid enrollees with SMI, who experience high rates of comorbid physical health conditions and complex healthcare needs. To the extent that managed care organizations can help this population navigate their coverage and use more of the available benefits, barriers to care and unmet needs can be reduced or eliminated and outcomes subsequently improved.

Objectives: To observe any change in ambulatory care utilization after switching from Medicaid fee-for-service (FFS) to Medicaid managed care (MC)., Study Design: We conducted a statewide longitudinal study of 21,048 adult Medicaid beneficiaries in New York State who switched from FFS to MC in 2011 or 2012, with 2 sets of controls (n = 21,048 with continuous FFS; n = 21,048 with continuous MC) who were matched on age, gender, dual-eligible status, and number of chronic conditions., Methods: We measured ambulatory care utilization in the 12 months before and 12 months after the switch date, using regression to adjust for case mix and account for matching., Results: Overall, switching from Medicaid FFS to Medicaid MC was associated with greater absolute decreases over time in ambulatory visits and providers compared with controls (-1.49 visits vs continuous FFS and -1.60 visits vs continuous MC; each P <.0001; -0.10 providers vs continuous FFS and -0.12 providers vs continuous MC; each P <.0001). The subset of switchers with 5 or more chronic conditions had the greatest absolute decreases in visits (-5.88 visits vs continuous FFS and -5.98 visits vs continuous MC; each P <.0001) and providers (-1.37 providers vs continuous FFS and -1.39 providers vs continuous MC; each P <.0001). Significant decreases in visits and providers were also observed for switchers with 3 to 4 chronic conditions but not for those with 0 to 2 chronic conditions., Conclusions: Switching from Medicaid FFS to Medicaid MC was associated with a decrease in ambulatory utilization, especially for the sickest patients.

People with intellectual and developmental disabilities (IDD) are frequent users of health services. We examined how their service utilization of emergency department (ED), inpatient hospitalization, and primary care physicians changed as they transitioned from fee-for-service to Medicaid managed care (MMC). Our results showed that MMC reduced the utilization of all of these services. A substantial decrease in ED visits was associated with the reduction in visits due to mental/behavioral health conditions and conditions that could be nonemergent and manageable with the community-based health services. These findings suggest that health service utilization of people with IDD is related not only to their health needs, but also to the delivery model that provides their health services.

Background: Lupus is a chronic autoimmune and incurable rheumatic disease and has a global prevalence of 3.2-517.5 cases per 100,000 people. However, currently there is no knowledge regarding the actual direct cost of patients with lupus to healthcare systems in developing countries. This study aimed to determine the direct cost of lupus care in Colombia., Methods: To identify patients with lupus, claims data of 2 years from two health insurers were subjected to an algorithm according to International Statistical Classification of Diseases and Related Health Problems 10th Revision codes. Multivariate linear regression analyses were used to assess the direct cost of lupus care., Results: The average annual per-patient, all-claims, all-cause direct cost was $2355; this is approximately 9 times the average annual premium received by health insurers for covering the public benefits package. Approximately 50% of direct costs are not included in the public benefits package. The incidence of one or more condition is 98.4%. The direct cost incurred by patients with two comorbidities was 1.8 times more, with three chronic conditions was 1.9 times more and with six chronic conditions was 4.5 times more than that incurred by patients with only lupus., Conclusions: The direct cost of lupus care in the developing world may be higher than expected; in addition, access to healthcare may not be equal for the entire population.

Objectives: To illustrate methods using administrative data on patients with diabetes that can offer a foundation for using network analyses in managed care., Study Design: The study used an administrative claims database to analyze patients with diabetes in a large health plan in Hawaii in 2010., Methods: The networks were explored graphically and analyzed at several levels of complexity. Levels ranged from major components comprising the majority in the networks to smaller, highly connected cliques to communities of patients and physicians grouped by a network algorithm. The attributes of patients linked by seeing the same primary physicians were evaluated using an exponential random graph model that predicted links in the network., Results: The study included 41,941 patients with diabetes of Native Hawaiian (16.3%), Filipino (14.2%), Japanese (46.7%), white (11.2%), and other (11.6%) ethnicity. About half were 65 years or older. When examined by Hawaiian island of residence, at least 95% of patients and at least 78% of physicians belonged to loosely connected major components within a network. Smaller communities of patients, identified by being closely linked together, averaged 150 to 177 patients; communities of physicians averaged 3 to 8 physicians. The average numbers of patients sharing physicians and physicians sharing patients were greater on the island of Oahu than on the rural neighboring islands. Patients of the same ethnicity were significantly more likely to share the same primary physician., Conclusions: Network analyses reveal structures and links that health plans could leverage to strengthen quality improvement and disease management programs.

Objective: To document differences among racial/ethnic/gender groups in specialty behavioral health care (BH) utilization/expenditures; examine whether these differences are driven by probability vs intensity of treatment; and identify whether differences are explained by socioeconomic status (SES)., Data Source: The cohort consists of adults continuously enrolled in Optum plans with BH benefits during 2013., Study Design: We modeled each outcome using linear regressions among the entire sample stratified by race/ethnicity, language and gender. Then, we estimated logistic regressions of the probability that an enrollee had any spending/use in a given service category (service penetration) and linear regressions of spending/use among the user subpopulation (treatment intensity). Lastly, all analyses were rerun with SES controls., Data Collection: This study links administrative data from a managed BH organization to a commercial marketing database., Principal Findings: We found that in many cases, racial/ethnic minorities had lower specialty BH expenditures/utilization, relative to whites, primarily driven by differences in service penetration. Among women, relative to whites, Asian non-English speakers, Asian English speakers, Hispanic non-English speakers, Hispanic English speakers, and blacks had $106, $95, $90, $48, and $61 less in total expenditures. SES explained racial/ethnic differences in treatment intensity but not service penetration., Conclusions: In this population, SES was not a major driver of racial/ethnic differences in specialty BH utilization. Future studies should explore the role of other factors not studied here, such as stigma, cultural competence, and geography., (© Health Research and Educational Trust.)

Background: Dipeptidyl peptidase-4 (DPP-4) inhibitors have repeatedly shown no reduction in the clinical outcomes of cardiovascular death, myocardial infarction, stroke, or all-cause mortality. Because the treatment of diabetes is generally one of the top drug categories by cost to health plans and self-funded employers, it is necessary to evaluate coverage of DPP-4 inhibitors, considering their lack of cardiovascular benefit relative to other treatment options., Objective: To describe the cost and utilization outcomes of drugs used to treat diabetes after exclusion of DPP-4 inhibitors in a self-funded managed care plan., Methods: This study was a retrospective, descriptive analysis of the cost and utilization outcomes after exclusion of DPP-4 inhibitors. Pharmacy claims data and plan membership were analyzed 6 months before DPP-4 inhibitor exclusion (preperiod: December 1, 2016-May 31, 2017) and 6 months after DPP-4 inhibitor coverage ended for all users (postperiod: September 1, 2017-February 28, 2018). The allowed amount, which is not influenced by overlapping plan copay changes, and utilization per member per month (PMPM) were used to estimate the effect of the DPP-4 inhibitor benefit exclusion on plan costs for the antidiabetic class., Results: From preperiod to postperiod, all DPP-4 inhibitor products decreased in utilization by 3.02 claims per 1,000 members per month (PTMPM). Glucagon-like peptide-1 receptor agonists, insulins, sodium-glucose cotransporter-2 inhibitors, and thiazolidinedione claims increased by 0.72, 0.43, 0.30, and 0.48 claims PTMPM, respectively, but there was an absolute decrease of 1.35 claims for antidiabetic medications per 1,000 plan members. However, the days supplied PMPM increased from 2.55 to 2.61 (2.3%) days. Allowed amount PMPM increased by $0.27 from $12.19 in the preperiod to $12.31 in the postperiod (2.2%). However, it is estimated that drug cost inflation accounted for over half of the PMPM increase in allowed costs., Conclusions: The observed increase in the allowed amount PMPM was attributable in similar amounts by an increase in utilization of medications with higher cost per day supplied and higher drug prices. Future research will evaluate patient-level effects of this benefit change in terms of antidiabetic medication utilization and outcomes., Disclosures: No outside funding supported this study. Davis, Bemberg, and Johnson currently work for or previously worked for the UAMS Evidence-Based Prescription Drug Program, which advises the Employee Benefits Division (EBD) on pharmacy benefit management. The EBD did not provide any additional funding for this study. McAdam-Marx reports grants from AstraZeneca and Sanofi Aventis outside the submitted work. The other authors have no other relevant information to disclose.

Type 2 diabetes mellitus (T2DM) is a chronic disease that requires long-term therapy and regular check-ups to prevent complications. In this study, insurance claim data from the National Health Insurance Service (NHIS) of Korea were used to investigate insulin use in T2DM patients according to the economic status of patients and their access to primary physicians, operationally defined as the frequently used medical care providers at the time of T2DM diagnosis. A total of 91,810 participants were included from the NHIS claims database for the period between 2002 and 2013. The utilization pattern of insulin was set as the dependent variable and classified as one of the following: non-use of antidiabetic drugs, use of oral antidiabetic drugs only, or use of insulin with or without oral antidiabetic drugs. The main independent variables of interest were level of income and access to a frequently-visited physician. Multivariate Cox proportional hazards analysis was performed. Insulin was used by 9,281 patients during the study period, while use was 2.874 times more frequent in the Medical-aid group than in the highest premium group [hazard ratio (HR): 2.874, 95% confidence interval (CI): 2.588-3.192]. Insulin was also used ~50% more often in the patients managed by a frequently-visited physician than in those managed by other healthcare professionals (HR: 1.549, 95% CI: 1.434-1.624). The lag time to starting insulin was shorter when the patients had a low income and no frequently-visited physicians. Patients with a low level of income were more likely to use insulin and to have a shorter lag time from diagnosis to starting insulin. The likelihood of insulin being used was higher when the patients had a frequently-visited physician, particularly if they also had a low level of income. Therefore, the economic statuses of patients should be considered to ensure effective management of T2DM. Utilizing frequently-visited physicians might improve the management of T2DM, particularly for patients with a low income., Competing Interests: The authors have declared that no competing interests exist.

Background: In July 2018, the Centers for Medicare and Medicaid Services (CMS) updated its Medicaid Managed Care (MMC) regulations that govern network and access standards for enrollees. There have been few published studies of whether there is accurate geographic information on primary care providers to monitor network adequacy., Methods: We analyzed a sample of nurse practitioner (NP) and physician address data registered in the state labor, licensing, and regulation (LLR) boards and the National Provider Index (NPI) using employment location data contained in the patient-centered medical home (PCMH) data file. Our main outcome measures were address discordance (%) at the clinic-level, city, ZIP code, and county spatial extent and the distance, in miles, between employment location and the LLR/NPI address on file., Results: Based on LLR records, address information provided by NPs corresponded to their place of employment in 5% of all cases. NP address information registered in the NPI corresponded to their place of employment in 64% of all cases. Among physicians, the address information provided in the LLR and NPI corresponded to the place of employment in 64 and 72% of all instances. For NPs, the average distance between the PCMH and the LLR address was 21.5 miles. Using the NPI, the distance decreased to 7.4 miles. For physicians, the average distance between the PCMH and the LLR and NPI addresses was 7.2 and 4.3 miles., Conclusions: Publicly available data to forecast state-wide distributions of the NP workforce for MMC members may not be reliable if done using state licensure board data. Meaningful improvements to correspond with MMC policy changes require collecting and releasing information on place of employment.

Objective: The ability to identify children with special health care needs (CSHCN) is crucial to evaluate disparities in the quality of health care for children in Medicaid Managed Care. We developed and assessed the accuracy of a new method to classify CSHCN., Data Sources: Secondary data analysis was conducted using NYS Medicaid administrative data and the Children with Chronic Conditions Screener (CCC Screener)., Study Design: This study included 5,907 NYS Medicaid beneficiaries (17 years old or younger) whose parents completed the CCC Screener in 2014. Medicaid administrative data were used to create a risk score to assess the risk of special needs, and a cut point was identified to differentiate between children with versus without special needs. Diagnostic accuracy of the method was assessed using sensitivity and specificity analyses., Principal Findings: Applying the CCC Screener as the "gold standard," the risk score correctly classified the majority of CSHCN as positive (sensitivity = 75 percent) and the majority of the children without special needs as negative (specificity = 79 percent). This method demonstrated decent diagnostic ability (AUC = 0.77)., Conclusions: Our method can identify CSHCN in the NYS Medicaid Managed Care population and will help the State monitor the quality of care for this vulnerable population., (Published 2018. This article is a U.S. Government work and is in the public domain in the USA.)

Rationale: The risk of all-cause mortality of nontuberculous mycobacterial lung disease (NTMLD) in the United States (US) population is not well established., Objectives: This study aims to assess the public health burden of NTMLD in the US by comparing the relative risk of all-cause mortality in the NTMLD population with an age- and sex-matched cohort from the general population., Methods: Patients with physician claims for NTMLD (ICD-9 0.031; ICD-10 A31.0) were identified between 2007 and 2016 from a large US national managed care insurance plan covering approximately 15-18 million members annually. A control group with no NTMLD ICD-9 or 10 codes was randomly selected from the general population and matched 3:1 to the NTMLD sample according to birth year, gender, and insurance benefit coverage. The date of first NTMLD diagnosis of each patient was assigned to the matched controls as the index date. The Cox proportional hazard method compared survival between cohorts, adjusting for demographic factors and baseline comorbidities., Results: A total of 2005 patients with NTMLD and 6014 controls were identified, with a mean follow-up duration of 3.4 years and 3.7 years, respectively. The NTMLD group had substantially higher proportions of patients with asthma (23.3% versus 3.5%), bronchiectasis (36.5% versus 0.1%), COPD (52.0% versus 5.9%), arrhythmia (22.6% versus 6.5%), coronary artery disease (18.5% versus 6.6%), heart failure (11.9% versus 4.1%), and cancer (18.5% versus 5.0%). The unadjusted rate of all-cause mortality from the index date was 20.7 per 1000 person-years in the NTMLD group vs 5.6 per 1000 person-years in the control group (rate ratio = 3.73; 95% CI: 2.93-4.75). Multivariable Cox regression, adjusted for the above variables as well as all other important baseline covariates, showed a doubling risk of all-cause mortality (hazard ratio [HR] = 2.06; CI: 1.52-2.79; P < 0.001) in the NTMLD vs control group., Conclusions: All-cause mortality, adjusted for other factors, more than doubled with NTMLD compared with an age-sex-matched control group in a large US national managed care insurance plan., (Copyright © 2018. Published by Elsevier Ltd.)

Purpose: To evaluate health care utilization, treatment patterns and costs among patients with mycosis fungoides-cutaneous T-cell lymphoma (MF-CTCL)., Methods: This retrospective cohort study queried the HealthCore Integrated Research Database to identify patients ≥18 years with ≥2 diagnoses of MF-CTCL (ICD-9-CM code 202.1x, 202.2x) between 07 January 2006 and 07 January 2013. Index date was defined as first MF-CTCL diagnosis. Patients were continuously enrolled ≥6 months before and ≥12 months after index date. Severe MF-CTCL was identified via systemic therapy use postindex. Generalized linear model (GLM) was used to estimate the relationship between MF-CTCL severity and healthcare costs controlling for selected factors., Results: A total of 1981 MF-CTCL patients were evaluated: 493 (24.9%) severe and 1488 (75.1%) with mild to moderate disease. GLM analysis indicated severe MF-CTCL patients incurred higher all-cause healthcare total costs compared to patients with mild-to-moderate MF-CTCL (coefficient estimate: 4.19, p < .0001). About 51% of patients did not receive any MF-CTCL-specific treatment within 60 days after MF-CTCL diagnosis., Conclusions: MF-CTCL severity was associated with greater healthcare resource utilization and costs. These findings suggest that about half of MF-CTCL patients do not receive MF-CTCL-specific treatment within 60 days following initial diagnosis. Future studies are needed to understand reasons for delayed treatment initiation.

Objective: This study measured the presence, extent, and type of behavioral health factors in a high-cost Medicare population and their association with the probability and intensity of emergency department (ED) use., Methods: Retrospective claims analysis and a comprehensive electronic medical record-based review were conducted for patients enrolled in a 65-month prospective care management program at an academic tertiary medical center (N=3,620). A two-part model used multivariable logistic regression to evaluate the effect of behavioral health factors on the probability of ED use, complemented by a Poisson model to measure the number of ED visits. Control variables included demographic characteristics, poststudy survival, and hierarchical condition category risk score., Results: After analyses controlled for comorbidities and other relevant variables, patients with two or more behavioral health diagnosis categories or two or more behavioral health medications were about twice as likely as those without such categories or medications to use the ED. Patients with a diagnosis category of psychosis, neuropsychiatric disorders, sleep disorders, or adjustment disorders were significantly more likely than those without these disorders to use the ED. Most primary ED diagnoses were not of behavioral health conditions., Conclusions: Behavioral health factors had a substantial and significant effect on the likelihood and number of ED visits in a population of high-cost Medicare patients. Attention to behavioral health factors as independent predictors of ED use may be useful in influencing ED use in high-cost populations.

Objective: Guidelines recommend non-invasive ischaemia testing (NIIT) for the majority of patients with suspected ischaemic heart disease in a non-emergency setting. A substantial number of these patients undergo diagnostic coronary angiography (CA) without therapeutic intervention inappropriately due to lacking preceding NIIT. The aim of this study was to evaluate the effect of voluntary healthcare models with limited access on the proportion of patients without NIIT prior to elective purely diagnostic CA., Design: Retrospective cross-sectional analysis of insurance claims data from 2012 to 2015. Data included claims of basic and voluntary healthcare models from approximately 1.2 million patients enrolled with the Helsana Insurance Group. Voluntary healthcare models with limited health access are divided into gate keeping (GK) and managed care (MC) capitation models., Inclusion Criteria: patients undergoing CA., Exclusion Criteria: Patients<18 years, incomplete health insurance data coverage, acute cardiac ischaemia and emergency procedures, therapeutic CA (coronary angioplasty/stenting or coronary artery bypass grafting). The effect of voluntary healthcare models on the proportion of NIIT undertaken within 2 months before diagnostic CA was assessed by means of multiple logistic regression analysis, controlled for influencing factors., Results: 9173 patients matched inclusion criteria. 33.2% (3044) did not receive NIIT before CA. Compared with basic healthcare models, MC was independently associated with a higher proportion of NIIT (p<0.001, OR 1.17, CI 1.045 to 1.312), when additionally controlled for demographics, insurance coverage, inpatient treatment, cardiovascular medication, chronic comorbidities, high-risk status (patients with therapeutic cardiac intervention 1 month after or 18 months prior to diagnostic CA). GK models showed no significant association with the rate of NIIT (p=0.07, OR 1.11, CI 0.991 to 1.253)., Conclusions: In a non-GK healthcare system, voluntary MC healthcare models with capitation were associated with a reduced inappropriate use of diagnostic CA compared with GK or basic models., Competing Interests: Competing interests: OR and AS are employed by the Helsana Group., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The objective of this study was to evaluate an ongoing initiative to improve colorectal cancer (CRC) screening uptake in the New York State (NYS) Medicaid managed care population., Methods: Patients aged 50 to 75 years who were not up to date with CRC screening and resided in 2 NYS regions were randomly assigned to 1 of 3 cohorts: no mailed reminder, mailed reminder, and mailed reminder + incentive (in the form of a $25 cash card). Screening prevalence and the costs of the intervention were summarized., Results: In total, 7123 individuals in the Adirondack Region and 10,943 in the Central Region (including the Syracuse metropolitan area) were included. Screening prevalence in the Adirondack Region was 7.2% in the mailed reminder + incentive cohort, 7.0% in the mailed reminder cohort, and 5.8% in the no mailed reminder cohort. In the Central Region, screening prevalence was 7.2% in the mailed reminder cohort, 6.9% in the mailed reminder + incentive cohort, and 6.5% in the no mailed reminder cohort. The cost of implementing interventions in the Central Region was approximately 53% lower than in the Adirondack Region., Conclusions: Screening uptake was low and did not differ significantly across the 2 regions or within the 3 cohorts. The incentive payment and mailed reminder did not appear to be effective in increasing CRC screening. The total cost of implementation was lower in the Central Region because of efficiencies generated from lessons learned during the first round of implementation in the Adirondack Region. More varied multicomponent interventions may be required to facilitate the completion of CRC screening among Medicaid beneficiaries., (© 2018 American Cancer Society.)