Adverse selection and network design under regulated plan prices: Evidence from Medicaid.

Health plans for the poor increasingly limit access to specialty hospitals. We investigate the role of adverse selection in generating this equilibrium among private plans in Medicaid. Studying a network change, we find that covering a top cancer hospital causes severe adverse selection, increasing demand for a plan by 50% among enrollees with cancer versus no impact for others. Medicaid's fixed insurer payments make offsetting this selection, and the contract distortions it induces, challenging, requiring either infeasibly high payment rates or near-perfect risk adjustment. By contrast, a small explicit bonus for covering the hospital is sufficient to make coverage profitable.

The Home Care Workforce Has Not Kept Pace With Growth In Home And Community-Based Services.

Home and community-based services (HCBS) are the predominant approach to delivering long-term services and supports in the US, but there are growing numbers of reports of worker shortages in this industry. Medicaid, the primary payer for long-term services and supports, has expanded HCBS coverage, resulting in a shift in the services' provision out of institutions and into homes. Yet it is unknown whether home care workforce growth has kept up with the increased use of these services. Using data from the American Community Survey and the Henry J. Kaiser Family Foundation, we compared trends in the size of the home care workforce with data on Medicaid HCBS participation between 2008 and 2020. The home care workforce grew from approximately 840,000 to 1.22 million workers between 2008 and 2013. After 2013, growth slowed, ultimately reaching 1.42 million workers in 2019. In contrast, the number of Medicaid HCBS participants grew continuously from 2008 to 2020, with accelerated growth between 2013 and 2020. As a consequence, the number of home care workers per 100 HCBS participants declined by 11.6 percent between 2013 and 2019, with preliminary estimates suggesting that further declines occurred in 2020. Improving access to HCBS will require not just expanded insurance coverage but also new workforce investments.

Medicare Accountable Care Organizations and Antidepressant Use by Patients With Depression.

OBJECTIVE: This study examined whether Medicare accountable care organization (ACO) programs were associated with early changes in antidepressant use or adherence among beneficiaries with depression. METHODS: A difference-in-difference design was used to compare claims from Medicare fee-for-service beneficiaries (2009-2013) and ACO patients with those from local control groups. Outcome measures were total antidepressant days supplied, filling one or more antidepressant prescriptions, and proportion of days covered (PDC) by supply among antidepressant users (adherence). RESULTS: Among antidepressant users, ACO contracts were associated with slight differential increases in PDC (.4-.8 percentage point, p≤.03), depending on ACO program and entry year. The proportion of patients with one or more prescriptions was unchanged or decreased slightly for ACO patients with depression, such that total supply did not consistently increase. CONCLUSIONS: Medicare ACO programs were associated with early modest increases in antidepressant adherence but not with increases in the proportion of patients with depression who received antidepressants.

Quality of Health Insurance Coverage and Access to Care for Children in Low-Income Families.

IMPORTANCE: An increasing diversity of children's health coverage options under the US Patient Protection and Affordable Care Act, together with uncertainty regarding reauthorization of the Children's Health Insurance Program (CHIP) beyond 2017, merits renewed attention on the quality of these options for children. OBJECTIVE: To compare health care access, quality, and cost outcomes by insurance type (Medicaid, CHIP, private, and uninsured) for children in households with low to moderate incomes. DESIGN, SETTING, AND PARTICIPANTS: A repeated cross-sectional analysis was conducted using data from the 2003, 2007, and 2011-2012 US National Surveys of Children's Health, comprising 80,655 children 17 years or younger, weighted to 67 million children nationally, with household incomes between 100% and 300% of the federal poverty level. Multivariable logistic regression models compared caregiver-reported outcomes across insurance types. Analysis was conducted between July 14, 2014, and May 6, 2015. EXPOSURES: Insurance type was ascertained using a caregiver-reported measure of insurance status and each household's poverty status (percentage of the federal poverty level). MAIN OUTCOMES AND MEASURES: Caregiver-reported outcomes related to access to primary and specialty care, unmet needs, out-of-pocket costs, care coordination, and satisfaction with care. RESULTS: Among the 80,655 children, 51,123 (57.3%) had private insurance, 11,853 (13.6%) had Medicaid, 9554 (18.4%) had CHIP, and 8125 (10.8%) were uninsured. In a multivariable logistic regression model (with results reported as adjusted probabilities [95% CIs]), children insured by Medicaid and CHIP were significantly more likely to receive a preventive medical (Medicaid, 88% [86%-89%]; P < .01; CHIP, 88% [87%-89%]; P < .01) and dental (Medicaid, 80% [78%-81%]; P < .01; CHIP, 77% [76%-79%]; P < .01) visits than were privately insured children (medical, 83% [82%-84%]; dental, 73% [72%-74%]). Children with all insurance types experienced challenges in access to specialty care, with caregivers of children insured by CHIP reporting the highest rates of difficulty accessing specialty care (28% [24%-32%]), problems obtaining a referral (23% [18%-29%]), and frustration obtaining health care services (26% [23%-28%]). These challenges were also magnified for privately insured children with special health care needs, whose caregivers reported significantly greater problems accessing specialty care (29% [26%-33%]) and frustration obtaining health care services (36% [32%-41%]) than did caregivers of children insured by Medicaid, and a lower likelihood of insurance always meeting the child's needs (63% [60%-67%]) than children insured by Medicaid or CHIP. Caregivers of privately insured children were also significantly more likely to experience out-of-pocket costs (77% [75%-78%]) than were caregivers of children insured by Medicaid (26% [23%-28%]; P < .01) or CHIP (38% [35%-40%]; P < .01). CONCLUSIONS AND RELEVANCE: This examination of caregiver experiences across insurance types revealed important differences that can help guide future policymaking regarding coverage for families with low to moderate incomes.

Mental Health, Behavioral and Developmental Issues for Youth in Foster Care.

Youth in foster care represent a unique population with complex mental and behavioral health, social-emotional, and developmental needs. For this population with special healthcare needs, the risk for adverse long-term outcomes great if needs go unaddressed or inadequately addressed while in placement. Although outcomes are malleable and effective interventions exist, there are barriers to optimal healthcare delivery. The general pediatrician as advocate is paramount to improve long-term outcomes.

Propensity Score Methods for Analyzing Observational Data Like Randomized Experiments: Challenges and Solutions for Rare Outcomes and Exposures.

Randomized controlled trials are the "gold standard" for estimating the causal effects of treatments. However, it is often not feasible to conduct such a trial because of ethical concerns or budgetary constraints. We expand upon an approach to the analysis of observational data sets that mimics a sequence of randomized studies by implementing propensity score models within each trial to achieve covariate balance, using weighting and matching. The methods are illustrated using data from a safety study of the relationship between second-generation antipsychotics and type 2 diabetes (outcome) in Medicaid-insured children aged 10-18 years across the United States from 2003 to 2007. Challenges in this data set include a rare outcome, a rare exposure, substantial and important differences between exposure groups, and a very large sample size.

Risk for incident diabetes mellitus following initiation of second-generation antipsychotics among Medicaid-enrolled youths.

IMPORTANCE: Second-generation antipsychotics (SGAs) have increasingly been prescribed to Medicaid-enrolled children, either singly or in a medication combination. Although metabolic adverse effects have been linked to SGA use in youths, estimating the risk for type 2 diabetes mellitus, a rarer outcome, has been challenging. OBJECTIVE: To determine whether SGA initiation was associated with an increased risk for incident type 2 diabetes mellitus. Secondary analyses examined the risk associated with multiple-drug regimens, including stimulants and antidepressants, as well as individual SGAs. DESIGN, SETTING, AND PARTICIPANTS: Retrospective national cohort study of Medicaid-enrolled youths between January 2003 and December 2007. In this observational study using national Medicaid Analytic eXtract data files, initiators and noninitiators of SGAs were identified in each month. Included in this study were US youths aged 10 to 18 years with a mental health diagnosis and enrolled in a Medicaid fee-for-service arrangement during the study. Those with chronic steroid exposure, a diagnosis of diabetes mellitus, or SGA use during a 1-year look-back period were ineligible. The mean follow-up time for all participants was 17.2 months. Youths were followed up until diagnosis of diabetes mellitus or end of follow-up owing to censoring caused by the transition into a Medicaid managed care arrangement or Medicaid ineligibility (the end of available data). Propensity weights were developed to balance observed demographic and clinical characteristics between exposure groups. Discrete failure time models were fitted using weighted logistic regression to estimate the risk for incident diabetes mellitus between initiators and noninitiators. EXPOSURE: A filled SGA prescription. MAIN OUTCOMES AND MEASURES: Incident type 2 diabetes mellitus identified through visit and pharmacy claims during the observation period. RESULTS: Among 107,551 SGA initiators and 1,221,434 noninitiators, the risk for incident diabetes mellitus was increased among initiators (odds ratio [OR], 1.51; 95% CI, 1.35-1.69; P < .001). Compared with youths initiating only SGAs, the risk was higher among SGA initiators who used antidepressants concomitantly at the time of SGA initiation (OR, 1.54; 95% CI, 1.17-2.03; P = .002) but was not significantly different for SGA initiators who were concomitantly using stimulants. As compared with a reference group of risperidone initiators, the risk was higher among those initiating ziprasidone (OR, 1.61; 95% CI, 0.99-2.64; P = .06) and aripiprazole (OR, 1.58; 95% CI, 1.21-2.07; P = .001) but not quetiapine fumarate or olanzapine. CONCLUSIONS AND RELEVANCE: The risk for incident type 2 diabetes mellitus was increased among youths initiating SGAs and was highest in those concomitantly using antidepressants. Compared with risperidone, newer antipsychotics were not associated with decreased risk.

Second-generation antipsychotic use among stimulant-using children, by organization of medicaid mental health.

OBJECTIVE: Reducing overuse of second-generation antipsychotics among Medicaid-enrolled children is a national priority, yet little is known about how service organization affects use. This study compared differences in second-generation antipsychotic utilization among Medicaid-enrolled children across fee-for-service, integrated managed care, and managed behavioral health carve-out organizational structures. METHODS: Organizational structures of Medicaid programs in 82 diverse counties in 34 states were categorized and linked to child-level cross-sectional claims data from the Medicaid Analytic Extract covering fiscal years 2004, 2006, and 2008. To approximate the population at risk of antipsychotic treatment, the sample was restricted to stimulant-using children ages three to 18 (N=419,226). The sample was stratified by Medicaid eligibility group, and logistic regression models were estimated for probability of second-generation antipsychotic use. Models included indicators of county-level organizational structure as main predictors, with sequential adjustment for personal and county-level covariates. RESULTS: With adjustment for person-level covariates, second-generation antipsychotic use was 31% higher among youths in foster care in fee-for-service counties than for youths in counties with carve-outs (odds ratio [OR]=1.69, 95% confidence interval [CI]=1.26-2.27). Foster care youths in integrated counties had the second highest adjusted odds (OR=1.31, CI=1.08-1.58). Similar patterns of use also were found for youths eligible for Supplemental Security Income but not for those eligible for Temporary Assistance for Needy Families. Differences persisted after adjustment for county-level characteristics. CONCLUSIONS: Carve-outs, versus other arrangements, were associated with lower second-generation antipsychotic use. Future research should explore carve-out features (for example, tighter management of inpatient or restricted access, as well as care coordination) contributing to lower second-generation antipsychotic use.

Growth in the concurrent use of antipsychotics with other psychotropic medications in Medicaid-enrolled children.

OBJECTIVE: Second-generation antipsychotics (SGAs) have increasingly been prescribed to Medicaid-enrolled children; however, there is limited understanding of the frequency of concurrent SGA prescribing with other psychotropic medications. This study describes the epidemiology of concurrent SGA use with 4 psychotropic classes (stimulants, antidepressants, mood stabilizers, and α-agonists) among a national sample of Medicaid-enrolled children and adolescents 6 to 18 years old between 2004 and 2008. METHOD: Repeated cross-sectional design was used, with national Medicaid Analytic eXtract data (10.6 million children annually). Logit and Poisson regression, standardized for year, demographics, and Medicaid eligibility group, estimated the probability and duration of concurrent SGA use with each medication class over time and examined concurrent SGAs in relation to clinical and demographic characteristics. RESULTS: While SGA use overall increased by 22%, 85% of such use occurred concurrently. By 2008, the probability of concurrent SGA use ranged from 0.22 for stimulant users to 0.52 for mood stabilizer users. Concurrent SGA use occurred for long durations (69%-89% of annual medication days). Although the highest users of concurrent SGA were participants in foster care and disability Medicaid programs or those with behavioral hospitalizations, the most significant increases over time occurred among participants who were income-eligible for Medicaid (+13%), without comorbid ADHD (+15%), were not hospitalized (+13%), and did not have comorbid intellectual disability (+45%). CONCLUSION: Concurrent SGA use with other psychotropic classes increased over time, and the duration of concurrent therapy was consistently long term. Concurrent SGA regimens will require further research to determine efficacy and potential drug-drug interactions, given a practice trend toward more complex regimens in less-impaired children/adolescents.