Affordable Care Act Impact on Medicaid Coverage of Smoking-Cessation Treatments.

INTRODUCTION: Four sections of the Affordable Care Act address the expansion of Medicaid coverage for recommended smoking-cessation treatments for: (1) pregnant women (Section 4107), (2) all enrollees through a financial incentive (1% Federal Medical Assistance Percentage increase) to offer comprehensive coverage (Section 4106), (3) all enrollees through Medicaid formulary requirements (Section 2502), and (4) Medicaid expansion enrollees (Section 2001). The purpose of this study is to document changes in Medicaid coverage for smoking-cessation treatments since the passage of the Affordable Care Act and to assess how implementation has differentially affected Medicaid coverage policies for: pregnant women, enrollees in traditional Medicaid, and Medicaid expansion enrollees. METHODS: From January through June 2017, data were collected and analyzed from 51 Medicaid programs (50 states plus the District of Columbia) through a web-based survey and review of benefits documents to assess coverage policies for smoking-cessation treatments. RESULTS: Forty-seven Medicaid programs have increased coverage for smoking-cessation treatments post-implementation of the Affordable Care Act by adopting one or more of the four smoking-cessation treatment provisions. Coverage for pregnant women increased in 37 states, coverage for newly eligible expansion enrollees increased in 32 states, and 15 states added coverage and/or removed copayments in order to apply for a 1% increase in the Federal Medical Assistance Percentage. Coverage for all recommended pharmacotherapy and group and individual counseling increased from seven states in 2009 to 28 states in 2017. CONCLUSIONS: The Affordable Care Act was successful in improving and expanding state Medicaid coverage of effective smoking-cessation treatments. Many programs are not fully compliant with the law, and additional guidance and clarification from the Centers for Medicare and Medicaid Services may be needed.

Mandatory public reporting of hospital-acquired infection rates: a report from California.

One way to motivate hospitals to improve patient safety is to publicly report their rates of hospital-acquired infections, as California is starting to do this year. We conducted a baseline study of California's acute care hospitals just before mandatory reporting of hospital-acquired infection rates to the state began, in 2008. We found variability in many areas: For example, 70.1 percent of hospitals said that they were fully implementing evidence-based guidelines to fight infection by methicillin-resistant Staphylococcus aureus, but 22.8 percent of hospitals had not adopted any. Our analysis showed that rural hospitals, many of which lack resources to implement needed procedures, faced the greatest challenges in reporting and improving infection rates. Our findings should be of interest to Medicare policy makers who will implement the hospital-acquired infection performance measures in the Affordable Care Act, and to leaders in the thirty-eight states that have enacted legislation requiring reports of hospital-acquired infection rates. California's baseline data also present a unique opportunity to assess the impact of mandatory and public reporting laws.

Adoption of health promotion practices in a cohort of U.S. physician organizations.

BACKGROUND: Physician organizations such as medical groups and independent practice associations can play a vital role in health promotion through the adoption of effective health promotion practices such as health risk assessments, patient reminder systems, and health promotion education programs. PURPOSE: To examine organizational changes in a cohort of physician organizations and changing health promotion practices. METHODS: Data for a cohort of 369 physician organizations in the U.S. with 20 or more physicians were collected between September 2000 and September 2001 and subsequently from March 2006 to March 2007. Paired-sample t tests were used to identify changes in physician organization characteristics and the use of nine health promotion practices between 2000-2001 and 2006-2007. RESULTS: Compared to 2000-2001, the cohort of physician organizations in 2006-2007 was larger, more likely to be owned by physicians; less likely to be owned by a hospital, health system, or HMO; more profitable; and more likely to use electronic information technology. Between 2000-2001 and 2006-2007, physician organizations increased the use of health risk appraisals to contact high-risk patients and increased the use of reminders for eye exams for diabetic patients. During the same time period, physician organizations decreased the use of nutrition and weight-loss health promotion programs. CONCLUSIONS: The adding and dropping of programs among physician organizations is due to many factors, including changing regulatory environments, market conditions, populations, and new health promotion technologies. In the coming years, incentives and regulatory policy should encourage the adoption of effective health promotion practices by physician organizations.

Adoption of policies to treat tobacco dependence in U.S. medical groups.

BACKGROUND: There remains an ongoing need to reduce tobacco use in the U.S. Physician organizations, such as medical groups, can support healthcare providers to be more effective in their delivery of tobacco cessation by adopting practices recommended in the Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence (PHS Guideline). PURPOSE: To document the extent to which activities to reduce tobacco use, as recommended in the PHS Guideline as system-level interventions, are provided within large medical groups in the U.S. METHODS: During 2006-2007, data were collected on 339 medical groups operating in the U.S., with 20 or more physicians treating at least one of four chronic conditions. Organizations were surveyed regarding activities to reduce tobacco use as recommended in the PHS Guideline as system-level interventions (i.e., tobacco-use status documentation, policies to promote provider interventions, and staff dedicated to treating tobacco dependence). Between 2008 and 2009, bivariate associations and multivariate logistic regression models assessed the relationship of organizational characteristics and external incentives with adoption of systems strategies for treating tobacco dependence. RESULTS: Nearly 83% of medical groups with 20 or more physicians operating in the U.S. in 2006-2007 have adopted one or more strategies recommended as effective to support the treatment of tobacco dependence. However, only 5.6% of medical groups engage in all eight tobacco control activities examined in this study. The two factors that were associated most consistently with medical group policies to treat tobacco dependence were the patient-centeredness of the organization and participation in a quality demonstration program. CONCLUSIONS: There is much room for improvement in increasing medical group adoption of systems strategies to reduce tobacco use. The findings in this paper suggest recommendations to achieve these improvements.

The origins and demise of the public option.

The "public option" for health insurance, as defined by the 111th Congress, grew from roots planted in California in 2001. Progressives supported it as a voluntary transition toward single-payer insurance, while conservatives opposed it as a government "takeover" of health care. Although present in several interim bills and in legislation passed in November 2009 by the House of Representatives, the public option was omitted from the legislation passed by the Senate in December 2009 and from the final package adopted by both houses in March 2010. Lack of support among moderate Democrats, opposition from Republicans, and ambiguous messages from the White House are among the explanations for the public option's defeat. However, there is nothing in the recently enacted legislation that would prohibit states from creating a public option in their exchanges.

Trends in employer-sponsored health insurance coverage for tobacco-dependence treatments.

BACKGROUND: Nearly 1.8 million smokers in California receive their health insurance benefits through their employer. The extent to which these workers have coverage for tobacco-dependence treatments (TDTs) through their employer-sponsored health care is unknown. METHODS: This research used the 2000 and 2005 data from the California Employer Health Benefits Surveys to determine coverage for TDTs by private firms. The overall response rates of firms to the survey were 41% and 36%, respectively. The samples used in this analysis are limited to private firms in California that offered employee health benefits in 2000 (n=729) or in 2005 (n=745). RESULTS: This research found that among private firms offering health insurance coverage, there was a significant increase from 2000 to 2005 in the percentage of workers covered for any TDTs (44% to 57%). Rates of coverage for all three forms of TDTs (nicotine replacement therapy, Zyban, counseling) doubled from 11% to 22% over the 5-year time period. CONCLUSIONS: Although coverage levels have improved, they still fall short of the recommendations made in the U.S. Public Health Service guidelines as well as in the Healthy People 2010 objectives. Given the effectiveness, cost effectiveness, public demand for coverage, and relatively low cost of covering TDTs--estimated to be $3-$6 per member per year--it is difficult to understand why such coverage is not more widely available in California.

MDS-based state Medicaid reimbursement and the ADL-decline quality indicator.

PURPOSE: We examined the relationship between the quality indicator for decline in activities of daily living (ADL) and the use of the Minimum Data Set (MDS) for determining Medicaid skilled nursing facility reimbursement. DESIGN AND METHODS: We conducted a cross-sectional analysis using the 2004 National MDS Facility Quality Indicator reports as the dependent variable in a multilevel regression model. Our primary explanatory variable was a state-level binary variable distinguishing whether or not the state used an MDS-based Medicaid-reimbursement system in 2004. We obtained control variables through the Online Survey, Certification, and Reporting System. RESULTS: Skilled nursing facilities located in states that used the MDS for Medicaid reimbursement reported more ADL decline than did facilities in states that did not use the MDS for reimbursement. IMPLICATIONS: The finding suggests that the ADL-decline quality indicator captures more than just quality, including state-level policy differences. Therefore, the ADL-decline quality indicator should be investigated and refined prior to being relied on for pay-for-performance initiatives.

Impact of Medicaid reimbursement on mental health quality indicators.

OBJECTIVE: To examine the relationship between the use of the Minimum Data Set (MDS) for determining Medicaid reimbursement to nursing facilities and the MDS Quality Indicators examining nursing facility residents' mental health. DATA SOURCES: The 2004 National MDS facility Quality Indicator reports served as the dependent variables. Explanatory variables were based on the 2004 Online Survey Certification and Reporting system (OSCAR) and an examination of existing reports, a review of the State Medicaid Plans, and State Medicaid personnel. STUDY DESIGN: Multilevel regression models were used to account for the hierarchical structure of the data. DATA COLLECTION: MDS and OSCAR data were linked by facility identifiers and subsequently linked with state-level variables. PRINCIPAL FINDINGS: The use of the MDS for determining Medicaid reimbursement was associated with higher (poorer) quality indicator values for all four mental health quality indicators examined. This effect was not found in four comparison quality indicators. CONCLUSIONS: The findings indicate that documentation of mental health symptoms may be influenced by economic incentives. Policy makers should be cautioned from using these measures as the basis for decision making, such as with pay-for-performance initiatives.

Knowledge of Medicaid coverage and effectiveness of smoking treatments.

BACKGROUND: Tobacco dependence has enormous health and financial repercussions in the United States, particularly among Medicaid enrollees, where a disproportionate share of the population smokes (36% compared to 23% in the general population). This paper examines two factors associated with the use of tobacco-dependence treatments (TDTs) in the Medicaid population: knowledge of TDT coverage and perceived effectiveness of TDTs. METHODS: Medicaid-enrolled smokers and recent quitters in four areas in the United States with comprehensive coverage of TDTs were interviewed as part of a random-digit-dial telephone survey in September 2003. Information was collected on demographics, health status, smoking history, knowledge of Medicaid coverage of TDTs (nicotine replacement patch and gum, Zyban, and counseling), and perceived effectiveness of TDTs. Logistic regression models were estimated to explain variation in enrollee use of TDTs as a function of knowledge of covered benefits and perceived effectiveness of the treatments. RESULTS: Both knowledge of TDT coverage and the perceived effectiveness of TDTs are positively associated with the use of TDTs in the Medicaid population. However, a majority of Medicaid smokers do not know that Medicaid covers TDTs, and the perceived effectiveness of TDTs is often at odds with findings from the scientific literature. CONCLUSIONS: Knowledge of Medicaid coverage and the perceived effectiveness of TDTs are associated with increased use of TDTs in the Medicaid population. Additional research is needed to better inform Medicaid smokers of their coverage and the effectiveness of TDTs in ways that encourage them to use these treatments to assist quit attempts.

Assessing the public health impact of state health benefit mandates.

OBJECTIVE: To document the process used in assessing the public health impact of proposed health insurance benefit mandates in California as part of the California Health Benefits Review Program (CHBRP) to serve as a guide for other states interested in incorporating a public health impact analysis into their state mandated benefit review process. BACKGROUND: As of September 2004, of the 26 states that require reviews of mandated benefit legislation, 25 required an assessment of the cost impact, 12 required an assessment of the medical efficacy, and only 6 had language requiring an assessment of the public health impact. METHODOLOGY: This paper presents the methodology used to calculate the overall public health impact of each mandate. This includes a discussion of data sources, required data elements, and the methods used to quantify the impact of a mandated health insurance benefit on: overall public health, on gender and racial disparities in health outcomes, on premature death, and on the economic loss associated with disease. In addition we identify the limitations of this type of analysis. CONCLUSIONS: The approach that California has adopted to review proposed health benefit mandates represents a leap forward in its consideration of the impact of such mandates on the health of the population. the approach is unique in its specific requirements to address public health impacts as well as the attempt to quantify these impacts by the CHBRP team. The requirement to make available this information to the state government has the potential, ultimately, to increase the availability of health insurance products in California that will maximize public health.

Influence of primary care practice and provider attributes on preventive service delivery.

BACKGROUND: While visits to the doctor's office are appropriate times to advise patients on health behaviors, these opportunities are often missed. Lapses in care quality are no longer attributed solely to individuals, but are also increasingly understood to be the result of organizational factors. This research examines the influence that both practice and provider attributes have on the delivery of preventive services for health behaviors. METHODS: This study used data collected from the Prescription for Health initiative sponsored by the Robert Wood Johnson Foundation. Quantitative data on 52 primary care practices and 318 healthcare providers were gathered from September 2003 to September 2004, and were analyzed upon completion of data collection. Hierarchical linear modeling was used to examine associations between both practice and provider attributes and preventive service delivery. RESULTS: Practice staff participation in decisions regarding quality improvement, practice change, and clinical operations positively influenced the effect of work relationships and negatively influenced the effect of practice size on service delivery. Nurse practitioners and allied health professionals reported more frequent delivery of services compared to physicians. Last, use of reminder systems and patient registries were positively associated with preventive service delivery. CONCLUSIONS: This study offers preliminary support for staff participation in practice decisions as a positive aspect of teamwork and collaboration. Findings also suggest leveraging nonphysician clinical staff and organized clinical systems to improve the delivery of preventive services for health behaviors.

Medicaid coverage for tobacco-dependence treatments.

This paper presents an update on the availability of tobacco-dependence treatments in Medicaid benefit packages from 1998 to 2003 and discusses variation in states' approaches for addressing tobacco cessation. In 2003 thirty-seven states had coverage for at least one evidence-based treatment. Since 1998, thirteen Medicaid programs have added coverage for at least one, while five programs have expanded coverage of these treatments. Overall, the coverage increases indicate a growing awareness of the treatments' importance for the health of Medicaid recipients, although further expansions are still needed.

Health promotion in physician organizations: results from a national study.

BACKGROUND: Health promotion programs can be effective in improving the delivery of clinical preventive services and in improving population health; however, the availability of health promotion programs offered through physician organizations, such as medical groups and independent practice associations, are largely unknown. METHODS: This research uses data from the National Study of Physician Organizations and the Management of Chronic Illness, conducted by the University of California, Berkeley, to document the extent to which physician organizations offer health promotion programs. Of 1587 physician organizations nationally with 20 or more physicians, 1104 participated, for a response rate of 70%. RESULTS: Overall, 60% of physician organizations offer at least one health promotion program targeting one or more of eight areas: prenatal education (42%), smoking cessation (39%), nutrition (39%), weight loss (34%), health risk assessments (25%), stress management (25%), substance abuse (20%), and sexually transmitted disease prevention (16%). Factors positively associated with offering health promotion programs include the following: outside reporting of quality measures, public recognition for quality measures, clinical information technology systems, being a medical group, and ownership by a hospital or health plan. CONCLUSIONS: Physician organizations in the United States have a long way to go in offering these important programs to their patients. However, our findings also suggest that health plans, purchasers, and policymakers can play a positive role in increasing the use of these programs. By offering recognition and incentives for quality improvement, and by funding the expansion of information technology, the healthcare community can encourage and enable physician organizations to increase the availability of health promotion programs nationally.