Identifying virtual care modality in electronic health record data.

Background: Virtual care increased dramatically during the COVID-19 pandemic. The specific modality of virtual care (video, audio, eVisits, eConsults, and remote patient monitoring) has important implications for the accessibility and quality of care, but rates of use are relatively unknown. Methods for identifying virtual care modalities, especially in electronic health records (EHR) are inconsistent. This study (a) developed a method to identify virtual care modalities using EHR data and (b) described the distribution of these modalities over a 3-year study period. Methods: EHR data from 316 primary care safety net clinics throughout the study period (4/1/2020-3/31/2023) were included. Visit type (in-person vs virtual) by adults >18 years old were classified. Expert consultation informed the development of two algorithms to classify virtual care visit modalities; these algorithms prioritized different EHR data elements. We conducted descriptive analyses comparing algorithms and the frequency of virtual care modalities. Results: Agreement between the algorithms was 96.5% for all visits and 89.3% for virtual care visits. The majority of disagreement between the algorithms was among encounters scheduled as audio-only but billed as a video visit. Restricting to visits where the algorithms agreed on visit modality, there were 2-fold more audio-only than video visits. Conclusion: Visit modality classification varies depending upon which data in the EHR are prioritized. Regardless of which algorithm is utilized, safety net clinics rely on audio-only and video visits to provide care in virtual visits. Elimination of reimbursement for audio visits may exacerbate existing inequities in care for low-income patients.

Prenatal opioid use as a predictor of postpartum suicide attempts among reproductive-age women enrolled in Oregon Medicaid.

BACKGROUND: The rates of suicide and opioid use disorder (OUD) among pregnant and postpartum women continue to increase. This research characterized OUD and suicide attempts among Medicaid-enrolled perinatal women and examined prenatal OUD diagnosis as a marker for postpartum suicide attempts. METHODS: Data from Oregon birth certificates, Medicaid eligibility and claims files, and hospital discharge records were linked and analyzed. The sample included Oregon Medicaid women aged 15-44 who became pregnant and gave live births between January 2008 and January 2016 (N = 61,481). Key measures included indicators of suicide attempts (separately for any means and opioid poisoning) and OUD diagnosis, separately assessed during pregnancy and the one-year postpartum period. Probit regression was used to examine the overall relationship between prenatal OUD diagnosis and postpartum suicide attempts. A simultaneous equations model was employed to explore the link between prenatal OUD diagnosis and postpartum suicide attempts, mediated by postpartum OUD diagnosis. RESULTS: Thirty-three prenatal suicide attempts by any means were identified. Postpartum suicide attempts were more frequent with 58 attempts, corresponding to a rate of 94.3 attempts per 100,000. Of these attempts, 79% (46 attempts) involved opioid poisoning. A total of 1,799 unique women (4.6% of the sample) were diagnosed with OUD either during pregnancy or one-year postpartum with 53% receiving the diagnosis postpartum. Postpartum suicide attempts by opioid poisoning increased from 55.5 per 100,000 in 2009 to 105.1 per 100,000 in 2016. The rate of prenatal OUD also almost doubled over the same period. Prenatal OUD diagnosis was associated with a 0.15%-point increase in the probability of suicide attempts by opioid poisoning within the first year postpartum. This increase reflects a three-fold increase compared to the rate for women without a prenatal OUD diagnosis. A prenatal OUD diagnosis was significantly associated with an elevated risk of postpartum suicide attempts by opioid poisoning via a postpartum OUD diagnosis. CONCLUSIONS: The risk of suicide attempt by opioid poisoning is elevated for Medicaid-enrolled reproductive-age women during pregnancy and postpartum. Women diagnosed with prenatal OUD may face an increased risk of postpartum suicides attempts involving opioid poisoning.

Postpartum Medicaid coverage and outpatient care utilization among low-income birthing individuals in Oregon: impact of Medicaid expansion.

Objective: This study examined the effect of Medicaid expansion in Oregon on duration of Medicaid enrollment and outpatient care utilization for low-income individuals during the postpartum period. Methods: We linked Oregon birth certificates, Medicaid enrollment files, and claims to identify postpartum individuals (N = 73,669) who gave birth between 2011 and 2015. We created one pre-Medicaid expansion (2011-2012) and two post-expansion (2014-2015) cohorts (i.e., previously covered and newly covered by Medicaid). We used ordinary least squares and negative binomial regression models to examine changes in postpartum coverage duration and number of outpatient visits within a year of delivery for the post-expansion cohorts compared to the pre-expansion cohort. We examined monthly and overall changes in outpatient utilization during 0-2 months, 3-6 months, and 7-12 months after delivery. Results: Postpartum coverage duration increased by 3.14 months and 2.78 months for the post-Medicaid expansion previously enrolled and newly enrolled cohorts (p < 0.001), respectively. Overall outpatient care utilization increased by 0.06, 0.19, and 0.34 visits per person for the previously covered cohort and 0.12, 0.13, and 0.26 visits per person for newly covered cohort during 0-2 months, 3-6 months, and 7-12 months, respectively. Monthly change in utilization increased by 0.006 (0-2 months) and 0.004 (3-6 months) visits per person for post-Medicaid previously enrolled cohort and decreased by 0.003 (0-2 months) and 0.02 (7-12 months) visits per person among newly enrolled cohort. Conclusion: Medicaid expansion increased insurance coverage duration and outpatient care utilization during postpartum period in Oregon, potentially contributing to reductions in pregnancy-related mortality and morbidities among birthing individuals.

Use of Sexual and Reproductive Health Services Among Women Living in Rural and Urban Oregon: Impact of the Affordable Care Act Medicaid Expansion.

Objectives: We compared the use of sexual and reproductive health (SRH) services for Medicaid-enrolled women of reproductive age (WRA) living in Oregon by urban/rural status and examined the effect of the Affordable Care Act (ACA) Medicaid expansion on the use of SRH services for these women. Methods: We linked Oregon Medicaid enrollment files and claims for the years 2008-2016 to identify 392,111 WRA. Outcome measures included receipt of five key SRH services. The main independent variables were urban/rural status (urban, large rural cities, and small rural towns) and an indicator for the post-Medicaid expansion time period (2014-2016). We performed (conditional) fixed-effects logistic regression and multiple-group interrupted time-series analyses. Results: Women living in small rural towns were less likely than women living in urban areas to receive well-woman visits (odds ratio [OR] = 0.87; 95% confidence interval [95% CI] [0.80-0.94]), sexually transmitted infection (STI) screening (OR = 0.81; 95% CI [0.72-0.90]), and pap tests (OR = 0.91; 95% CI [0.84-0.99]). Women living in large rural cities were less likely than women living in urban areas to receive STI screening (OR = 0.91; 95% CI [0.84-0.98]). Following the implementation of ACA Medicaid expansion, the average number of all five SRH services increased for all women. With the exception of contraceptive services, the average number of SRH services examined increased more for urban women than for women living in small rural towns. Conclusions: Although Medicaid expansion contributed to increased use of SRH services for all WRA, the policy was unsuccessful in reducing disparities in access to SRH services for WRA living in rural areas compared with urban areas.

Before and During Pandemic Telemedicine Use: An Analysis of Rural and Urban Safety-Net Clinics.

INTRODUCTION: Differences in face-to-face and telemedicine visits before and during the COVID-19 pandemic among rural and urban safety-net clinic patients were evaluated. In addition, this study investigated whether rural patients were as likely to utilize telemedicine for primary care during the pandemic as urban patients. METHODS: Using electronic health record data from safety-net clinics, patients aged ≥18 years with ≥1 visit before or during the COVID-19 pandemic, March 1, 2019-March 31, 2021, were identified, and trends in face-to-face and telemedicine (phone and video) visits for patients by rurality using Rural‒Urban Commuting Area codes were characterized. Multilevel mixed-effects regression models compared service delivery method during the pandemic by rurality. RESULTS: Included patients (N=1,015,722) were seen in 446 safety-net clinics: 83% urban, 10.3% large rural, 4.1% small rural, and 2.6% isolated rural. Before COVID-19, little difference in the percentage of encounters conducted face-to-face versus through telemedicine by rurality was found. Telemedicine visits significantly increased during the pandemic by 27.2 percentage points among patients in isolated rural areas to 52.3 percentage points among patients in urban areas. Rural patients overall had significantly lower odds of using telemedicine for a visit during the pandemic than urban patients. CONCLUSIONS: Despite the increased use of telemedicine in response to the pandemic, rural patients had significantly fewer telemedicine visits than those in more urban areas. Equitable access to telemedicine will depend on continued reimbursement for telemedicine services, but additional efforts are warranted to improve access to and use of health care among rural patients.

Opening the Conversation: study protocol for a Phase III trial to evaluate a couple-based intervention to reduce reproductive and sexual distress among young adult breast and gynecologic cancer survivor couples.

BACKGROUND: Reproductive and sexual health (RSH) concerns are common and distressing for young adults diagnosed with breast and gynecologic cancer and their partners. This study evaluates the efficacy of a virtual couple-based intervention called Opening the Conversation (OC). The OC intervention is grounded in theory and evidence-based practice and was adapted to improve coping and communication specifically in relation to RSH concerns after cancer. METHODS: This Phase III trial is conducted in a fully remote setting and enrolls young adult couples (current age 18-44 years) with a history of breast or gynecologic cancer (stage 1-4, diagnosed under age 40) within the past 6 months to 5 years. Eligible dyads are recruited from across the USA. The target sample size is 100 couples. Dyads are randomly assigned to receive either the 5-session OC intervention or a 4-session active control intervention (Side by Side). The primary outcomes are change in reproductive distress and sexual distress. Secondary outcomes include communication about reproductive concerns, communication about sexual concerns, depressive symptoms, sexual function, relationship quality, relationship intimacy, sexual satisfaction, self-efficacy to communicate about sex and intimacy, and quality of life. An exploratory aim examines whether dyadic coping and communication quality mediate intervention effects on survivors' and partners' reproductive distress or sexual distress. Self-report outcome measures are assessed for both groups at baseline (T1), 2 weeks post-treatment (T2), and 3 months post-treatment (T3). DISCUSSION: Despite the importance of RSH for quality of life for young adult cancer survivors and their partners, evidence-based interventions that help couples navigate RSH concerns are lacking. This randomized controlled trial will determine the efficacy of a novel couple-based intervention to reduce distress related to RSH concerns for younger couples after breast or gynecologic cancer, in comparison to an active control intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT04806724. Registered on Mar 19, 2021.

Adapting a Theory-Informed Intervention to Help Young Adult Couples Cope With Reproductive and Sexual Concerns After Cancer.

OBJECTIVE: Most young adults diagnosed with breast or gynecologic cancers experience adverse reproductive or sexual health (RSH) outcomes due to cancer and its treatment. However, evidence-based interventions that specifically address the RSH concerns of young adult and/or LGBTQ+ survivor couples are lacking. Our goal is to develop a feasible and acceptable couple-based intervention to reduce reproductive and sexual distress experience by young adult breast and gynecologic cancer survivor couples with diverse backgrounds. METHODS: We systematically adapted an empirically supported, theoretically grounded couple-based intervention to address the RSH concerns of young couples coping with breast or gynecologic cancer through integration of stakeholder perspectives. We interviewed 11 couples (22 individuals) with a history of breast or gynecologic cancer to review and pretest intervention materials. Three of these couples were invited to review and comment on intervention modifications. Content experts in RSH and dyadic coping, clinicians, and community advisors (one heterosexual couple and one LGBTQ+ couple, both with cancer history) participated throughout the adaptation process. RESULTS: Findings confirmed the need for an online, couple-based intervention to support young couples experiencing RSH concerns after breast or gynecologic cancer. Qualitative themes suggested intervention preferences for: (1) A highly flexible intervention that can be tailored to couples' specific RSH concerns; (2) Active steps to help members of a dyad "get on the same page" in their relationship and family building plans; (3) A specific focus on raising partners' awareness about how cancer can affect body image and physical intimacy; and (4) Accessible, evidence-based information about RSH for both partners. These results, along with feedback from stakeholders, informed adaptation and finalization of the intervention content and format. The resulting virtual intervention, Opening the Conversation, includes five weekly sessions offering training to couples in communication and dyadic coping skills for addressing RSH concerns. CONCLUSION: The systematic adaptation process yielded a theory-informed intervention for young adult couples facing breast and gynecological cancers, which will be evaluated in a randomized controlled trial. The long-term goal is to implement and disseminate Opening the Conversation broadly to reach young adult couples with diverse backgrounds who are experiencing RSH concerns in cancer survivorship.

Dyadic support across contraceptive decision-making among young adult breast cancer survivors and their partners.

OBJECTIVE: The purpose of this study is to explore the role of dyadic support across the contraceptive decision-making process between young adult breast cancer (YABC) survivors and their partners. RESEARCH APPROACH: Semi-structured interviews with YABC survivors and their partners. PARTICIPANTS: Twenty-five young adult breast cancer survivors and their partners (n = 50). Survivors reported an average age of 36.9 years (SD = 4.30) and the majority self-identified as white (86.2%). METHODOLOGICAL APPROACH: Thematic analysis approach with dyads as the primary unit of analysis, guided by the dyadic decision-making framework and the Theory of Gender and Power. RESULTS: Perceived lack of contraceptive options due to a history of hormone-sensitive cancer, perceived infertility, and contraception as a result of cancer treatment (e.g., hysterectomy) contributed to the contraceptive decision context for survivors and their partners. Contraceptive support varied across couples depending on the cancer-specific context, where communication, sharing responsibility, and respecting bodily autonomy revealed as supportive behaviors. Other social influences including survivors' desire to conceive biologically and family planning desires also related to partner supportive behaviors. INTERPRETATIONS: YABC survivors face specific challenges to contraceptive decision-making where partners can offer supportive behaviors. Health care providers can also support couples by engaging in triadic communication about contraception and family planning. IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS OR POLICY: Psychosocial providers can support couples by encouraging them to talk together about contraception and highlighting the importance of triadic communication with a healthcare provider to support shared decision-making and alignment of contraceptive decisions with family planning desires.

Improved depression screening and treatment among low-income pregnant and postpartum women following Medicaid expansion in the U.S.

Objective: This study examined the effect of Medicaid expansion in Oregon under the Affordable Care Act on depression screening and treatment among pregnant and postpartum women who gave Medicaid-financed births. Methods: Oregon birth certificates were linked to Medicaid enrollment and claims records for 2011-2016. The sample included a policy group of 1,368 women (n = 2,831) who gave births covered by pregnancy-only Medicaid in the pre-expansion period (before 2014) and full-scope Medicaid in the post-expansion period, and the comparison group of 2,229 women (n = 4,580) who gave births covered by full-scope Medicaid in both pre- and post-expansion periods. Outcomes included indicators for depression screening, psychotherapy, pharmacotherapy, and combined psychotherapy-pharmacotherapy, separately for the first, second, and third trimesters, and 2 and 6 months postpartum. This study utilized a difference-in-differences approach that compared pre-post change in an outcome for the policy group to a counterfactual pre-post change from the comparison group. Results: Medicaid expansion led to a 3.64%-point increase in the rate of depression screening 6 months postpartum, 3.28%-point increase in the rate of psychotherapy 6 months postpartum, and 2.3 and 1%-point increases in the rates of pharmacotherapy and combined treatment in the first trimester, respectively. The relationships were driven by disproportionate gains among non-Hispanic whites and urban residents. Conclusions: Expanding Medicaid eligibility may improve depression screening and treatment among low-income women early in pregnancy and/or beyond the usual two-month postpartum period. However, it does not necessarily reduce racial/ethnic and regional gaps in depression screening and treatment.

Postabortion Medicaid Enrollment and the Affordable Care Act Medicaid Expansion in Oregon.

Background: The Affordable Care Act Medicaid expansion had the potential to increase continuity of insurance coverage and remove barriers to accessing health services following an abortion in states where Medicaid pays for abortion. We examined the association of Medicaid expansion with postabortion Medicaid enrollment and described postabortion preventive reproductive services among Medicaid-enrolled women in Oregon. Methods: We used Medicaid claims and enrollment data to identify abortions to women ages 20-44 in 2009-2017 (N = 30,786), classified into a treatment group-those likely to be affected by Medicaid expansion-and a comparison group. Outcomes included Medicaid enrollment (number of months enrolled and any lapse in enrollment) in the 6 and 12 months postabortion. Difference-in-differences analyses were used to compare outcomes preexpansion (2009-2012) and postexpansion (2014-2017) for treatment and comparison groups. Linear regression models were adjusted for age, race/ethnicity, rurality, and month. We described receipt of preventive reproductive services in 0-2 months and in 3-12 months postabortion. Results: Medicaid expansion was associated with enrollment increases of 2.0 and 4.7 months and with declines in any enrollment lapse of 54 and 48 percentage-points over 6 and 12 months postabortion, respectively (p < 0.001). Many who remained enrolled through postabortion received preventive care including contraceptive services (41%) and screening for sexually transmitted infections (23%). Conclusions: Medicaid expansion may increase continuity of insurance coverage for those receiving abortions, and in turn promote access to preventive services that can improve subsequent reproductive health outcomes.

Experiences of discrimination and endorsement of HIV/AIDS conspiracy beliefs: exploring difference among a sample of Latino, Black, and White young adults.

Racial/ethnic discrimination and HIV/AIDS conspiracy beliefs may contribute to disparities in use and satisfaction with healthcare services. Previous studies that examined racial/ethnic experiences of everyday discrimination (EOD), health care discrimination (HCD), and HIV/AIDS conspiracy beliefs (HCB) focused primarily on African Americans with few studies focusing on Latinos. This study used data from in-person structured interviews with 450 Latino, Black, and White young adults from East Los Angeles, California. Multivariable models, adjusting for all demographic covariates, investigated if race/ethnicity and gender were associated with EOD and HCD and endorsing HCB, and if the associations between race/ethnicity and discriminations and HCB varied by gender. Blacks and Latinos reported more experiences of EOD and HCD in almost all forms and endorsed more HIV/AIDS conspiracy beliefs compared to Whites. Additionally, Black and Latino men reported stronger feelings of EOD than their female counterparts. More reports of experiences of HCD and endorsement of HCB beliefs were found for Blacks, Latinos, and participants with children compared to their counterparts. This study contributes to a growing understanding of how different racial/ethnic groups experience discrimination across various settings and everyday activities and their endorsement of HIV/AIDS conspiracy beliefs. The field of Public Health must address the problems of racism and discrimination similar to any other toxic pathogen. In so doing, Public Health becomes proactive in its efforts to mitigate the effects of racial discriminations on population health.

Postpartum Care Utilization Among Women with Medicaid-Funded Live Births in Oregon.

INTRODUCTION: Postpartum care is an important strategy for preventing and managing chronic disease in women with pregnancy complications (i.e., gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP)). METHODS: Using a population-based, cohort study among Oregon women with Medicaid-financed deliveries (2009-2012), we examined Medicaid-financed postpartum care (postpartum visits, contraceptive services, and routine preventive health services) among women who retained Medicaid coverage for at least 90 days after delivery (n = 74,933). We estimated postpartum care overall and among women with and without GDM and/or HDP using two different definitions: 1) excluding care provided on the day of delivery, and 2) including care on the day of delivery. Pearson chi-square tests were used to assess differential distributions in postpartum care by pregnancy complications (p < .05), and generalized estimating equations were used to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). RESULTS: Of Oregon women who retained coverage through 90 days after delivery, 56.6-78.1% (based on the two definitions) received any postpartum care, including postpartum visits (26.5%-71.8%), contraceptive services (30.7-35.6%), or other routine preventive health services (38.5-39.1%). Excluding day of delivery services, the odds of receiving any postpartum care (aOR 1.26, 95% CI 1.08-1.47) or routine preventive services (aOR 1.32, 95% CI 1.14-1.53) were meaningfully higher among women with GDM and HDP (reference = neither). DISCUSSION: Medicaid-financed postpartum care in Oregon was underutilized, it varied by pregnancy complications, and needs improvement. Postpartum care is important for all women and especially those with GDM or HDP, who may require chronic disease risk assessment, management, and referrals.

Medicaid expansion and neonatal outcomes in Oregon.

RATIONALE, AIMS AND OBJECTIVES: Low-income women disproportionately experience preventable, adverse neonatal outcomes. Prior to the Affordable Care Act (ACA) Medicaid expansion, many low-income women became eligible for coverage only after becoming pregnant, reducing their access to healthcare before pregnancy and creating discontinuities in care that may delay Medicaid enrollment. The objective of this study was to examine the impact of the ACA Medicaid expansion on neonatal outcomes among low-income populations in Oregon. METHOD: We used linked Oregon birth certificate and Medicaid data from 2008-2016 to identify control and policy groups of women who gave birth both before and after implementation of the ACA Medicaid expansion (n = 21 204 births to N = 10 602 women). We conducted a difference-in-differences analysis of the effect of Medicaid expansion on preterm birth, low birthweight (LBW), neonatal intensive care unit (NICU) admissions, and neonatal mortality. RESULTS: We found policy effects on reducing LBW (interaction aOR = 0.71, 95% CI: 0.57-0.90) and preterm birth (interaction aOR 0.77, 95% CI: 0.62 = 0.96) but not on NICU admissions or neonatal mortality. CONCLUSIONS: This study provides evidence that expanding Medicaid coverage may have positive effects on LBW and preterm birth, which could lead to important long-term impacts on childhood and later-life health outcomes. States that have not expanded their Medicaid programs might improve neonatal outcomes among low-income populations by extending insurance coverage to low-income adults.

Impact of Medicaid expansion in Oregon on access to prenatal care.

Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) has the potential to improve reproductive health by allowing low-income women access to healthcare before and early in pregnancy. The aim of this study was to examine the effects of Oregon's Medicaid expansion on timely and adequate prenatal care. We included live births in Oregon from 2012 to 2015 and used individually-linked birth certificate and Medicaid eligibility data. Outcomes were receipt of first trimester prenatal care and receipt of adequate prenatal care. We also assessed Medicaid enrollment one month prior to pregnancy. We estimated the overall effect of Medicaid expansion on prenatal care utilization using probit regression models. Additionally, we assessed the impact of Medicaid expansion on prenatal care utilization via pre-pregnancy Medicaid enrollment using bivariate probit models. Overall, receipt of first trimester prenatal care increased post-expansion by 1.5 percentage points (p < 0.01) after expansion. Receipt of adequate prenatal care also increased significantly post-expansion with an incremental increase of 2.8 percentage points (p < 0.001). Pre-pregnancy Medicaid enrollment increased following Medicaid expansion (ß = 0.55, p < 0.001) and was associated with both timely (ß = 0.48, p < 0.001) and adequate receipt of prenatal care (ß = 0.14, p < 0.001). Using two years of post-ACA data we found that Medicaid expansion had significant positive associations with Medicaid enrollment prior to pregnancy, which subsequently increased receipt of timely and adequate prenatal care. Our study provides evidence that expanding Medicaid has positive effects on women's use of healthcare.

Association of Medicaid Expansion With Access to Abortion Services for Women With Low Incomes in Oregon.

BACKGROUND: The Affordable Care Act allowed states to expand Medicaid eligibility for women with low incomes before pregnancy. Women who experience an unintended pregnancy may encounter fewer delays in accessing abortion services if they are already enrolled in Medicaid. In states where the Medicaid program includes coverage for abortion services, Medicaid expansion may increase timely access to abortion services. Oregon has expanded Medicaid and is 1 of 16 states in which the Medicaid program covers abortion services. We explored how Medicaid expansion in Oregon was associated with Medicaid-financed abortion rates and receipt of medication abortion relative to surgical abortion. METHODS: Using Medicaid claims and eligibility data we identified women ages 19 to 43 (n = 30,367) who had abortions before the expansion period (2008-2013) and after the expansion period (2014-2016). We used American Community Survey data to estimate the annual number of Oregon women aged 19 to 43 with incomes below 185% of the federal poverty level who would be eligible for a Medicaid-financed abortion. We conducted interrupted time series analyses using negative binomial and logistic regression models. RESULTS: Incidence of Medicaid-financed abortion increased from 13.4 in 1,000 women in 2008 to 16.3 in 2016. Medication abortion receipt increased from 11.5% of abortions in 2008 to 31.7% in 2016. For both outcomes, we identified an increasing time trend after Medicaid expansion, followed by a subsequent leveling off of the trend. By the end of 2016, incidence of Medicaid-financed abortion was 4.5 abortions per 1,000 women-years (95% confidence interval, 3.3-5.7) higher than it would have been without expansion and medication abortions comprised a 7.4 percentage point (95% confidence interval, 4.4-10.4) greater share of all abortions. CONCLUSIONS: Medicaid expansion was associated with increased receipt of Medicaid-financed abortions and may have reduced out-of-pocket payment among women with low incomes. Increased receipt of medication abortion may indicate that expansion enhanced earlier access to services, possibly as a result of increased prepregnancy Medicaid enrollment, and this earlier access may increase reproductive autonomy and safety.

Contraceptive Services After Medicaid Expansion in a State with a Medicaid Family Planning Waiver Program.

Background: Medicaid family planning programs provide coverage for contraceptive services to low-income women who otherwise do not meet eligibility criteria for Medicaid. In some states that expanded Medicaid eligibility following the Affordable Care Act (ACA), women who were previously eligible only for family planning services became eligible for full-scope Medicaid. The objective of this study was to provide context for the impact of the ACA Medicaid expansion on contraceptive service provision to women in Oregon who were newly enrolled in Medicaid following the expansion. Materials and Methods: We used Medicaid eligibility data to identify women ages 15-44 years who were newly enrolled in Oregon's Medicaid program following the ACA expansion (n = 305,042). Using Medicaid claims data, we described contraceptive services and other preventive reproductive care received in 2014-2017. Results: Overall, 20% of women newly enrolled in Medicaid received contraceptive counseling and 31% received at least one method. The most frequently received methods were the pill (38% of women who received any method), intrauterine device (28%), implant (15%), and injectable (12%). Community health centers played a significant role in contraceptive service provision, particularly for the implant and injectable. Nine of 10 women (89%) who received contraceptive services also received other preventive reproductive services. Conclusions: This study provides insight regarding receipt of contraceptive services and preventive reproductive care following Medicaid expansion in a state with a Medicaid family planning program. These findings underscore the importance of Medicaid expansion for reproductive health even in states with preexisting Medicaid family planning.

Patient-Centered Communication to Address Young Adult Breast Cancer Survivors' Reproductive and Sexual Health Concerns.

Women faced with a diagnosis of breast cancer as young adults commonly experience negative effects of cancer and cancer treatment on their reproductive and sexual health (RSH) that are inadequately addressed by their healthcare providers (HCPs). The objectives of this study were to 1) identify approaches to improving RSH communication from YA breast cancer survivors' perspectives, 2) identify facilitators and barriers to the approaches identified, and 3) identify specific strategies to improve patient-centered RSH communication. We conducted individual telephone interviews with 29 women who were diagnosed with breast cancer under age 40 years. We used a grounded theory approach to identify themes, and explored how the themes related to the PCC framework to elucidate specific strategies for improving communication. Three main themes emerged: 1) Normalizing and integrating assessment of RSH concerns; 2) HCP conveying genuine caring and investment; and 3) Improving accessibility of comprehensive RSH services after cancer. Results revealed concrete strategies for improving patient-centered RSH communication at the patient-provider and health system levels. These included reminding patients that RSH concerns are common, routinely asking about RSH, using active listening, and connecting patients to HCP who can address their RSH concerns.

Pharmacist prescription and access to hormonal contraception for Medicaid-insured women in Oregon.

OBJECTIVE: To assess the impact of Oregon's policy that allows pharmacist prescription of the pill and patch on contraceptive receipt for Medicaid-insured women. STUDY DESIGN: We conducted a difference-in-differences analysis using Oregon Medicaid claims data to compare changes in receipt of all contraceptive services and receipt of the pill or patch for Medicaid-enrolled women (n = 436,258) before and after policy implementation in areas with and without participating pharmacists. We then described filled prescriptions for the contraceptive pill and patch by type of prescribing provider before and after implementation of the policy. We also compared past contraceptive use for women receiving prescriptions from pharmacists and non-pharmacists. RESULTS: We found no significant policy effects on receipt of all contraceptive services or on receipt of the pill or patch. More than 98% of prescriptions filled for the pill and patch in the first two years of policy implementation were prescribed by a non-pharmacist provider. Women receiving contraceptive pill and patch prescriptions from pharmacists and non-pharmacists were equally likely to be continuing contraceptive users. CONCLUSION: We identified no increase in receipt of contraceptive services among Medicaid-insured women in the two years following the implementation of a pharmacy access policy. Additional research is needed to investigate other possible benefits of the policy, such as satisfaction, convenience, cost and equity. IMPLICATIONS: We identified no effect of allowing pharmacist prescription of the contraceptive pill and patch on increasing utilization of contraceptive services for Medicaid-insured women in Oregon. Impacts on access to contraceptive services and unintended pregnancy may emerge in subsequent years as availability of and demand for pharmacist-prescribed hormonal contraception increases.