Medicare home health payment reform may jeopardize access for clinically complex and socially vulnerable patients.

The Affordable Care Act directed Medicare to update its home health prospective payment system to reflect more recent data on costs and use of services-an exercise known as rebasing. As a result, the Centers for Medicare and Medicaid Services will reduce home health payments 3.5 percent per year in the period 2014-17. To determine the impact that these reductions could have on beneficiaries using home health care, we examined the Medicare reimbursement margins and the use of services in a national sample of 96,621 episodes of care provided by twenty-six not-for-profit home health agencies in 2011. We found that patients with clinically complex conditions and social vulnerability factors, such as living alone, had substantially higher service delivery costs than other home health patients. Thus, the socially vulnerable patients with complex conditions represent less profit-lower-to-negative Medicare margins-for home health agencies. This financial disincentive could reduce such patients' access to care as Medicare payments decline. Policy makers should consider the unique characteristics of these patients and ensure their continued access to Medicare's home health services when planning rebasing and future adjustments to the prospective payment system.

Care coordination and unmet specialty care among children with special health care needs.

OBJECTIVES: Care coordination and the medical home may ensure access to specialty care. Children with special health care needs (CSHCN) have higher rates of specialty care use and unmet need compared with the general pediatric population. We hypothesized that care coordination, regardless of whether it was provided in a medical home, would decrease unmet specialty care needs among CSHCN and that the effect of care coordination would be greater among low-income families. METHODS: Secondary data analysis of participants in the 2009­2010 National Survey of CSHCN who reported unmet specialty care needs and for whom care coordination and medical home status could be determined (n = 18 905). Logistic regression models explored the association of unmet need with care coordination and medical home status adjusting for household income. RESULTS: Approximately 9% of CSHCN reported having unmet specialty care needs. Care coordination was associated with reduced odds of unmet specialty care need (without a medical home, odds ratio: 0.63, 95% confidence interval: 0.47­0.86; within a medical home, odds ratio: 0.22, 95% confidence interval: 0.16­0.29) with a greater reduction among those receiving care coordination within a medical home versus those receiving care coordination without a medical home. We did not find differences in the impact of care coordination by percentage of the federal poverty level. CONCLUSIONS: Care coordination is associated with family report of decreased unmet specialty care needs among CSHCN independent of household income. The effect of care coordination is greater when care is received in a medical home.

Racial and ethnic differences in subspecialty service use by children with autism.

OBJECTIVE: To describe racial differences in use of specialty care among children with autism spectrum disorder. METHODS: We identified patients ages 2 to 21 years with an International Classification of Diseases, Ninth Revision code of autism (299.0) seen from 2000 to 2011 at a major academic health center by using a research patient data repository and determined rates of specialty provider visits and procedures by race. We then used logistic regression to determine the associations of rates of subspecialty visits and procedures with race and ethnicity, controlling for gender, age, and payer type. RESULTS: We identified 3615 patients (2935 white, 243 Hispanic, 188 African American, and 249 other). The most striking differences were in use of gastroenterology (GI)/nutrition services. Nonwhite children were less likely to use GI/nutrition specialty providers (African American, odds ratio = 0.32 [95th percentile confidence interval: 0.18-0.55]; Hispanic, 0.32 [0.20-0.51]; other, 0.56 [0.34-0.92]) as well as neurology (African American, 0.52 [0.33-0.83]; Hispanic, 0.40 [0.27-0.59]) and psychiatry/psychology (African American, 0.44 [0.27-0.72]; Hispanic, 0.60 [0.41-0.88]; other, 0.62 [0.38-0.99]). Nonwhite children were less likely to have had GI studies: colonoscopy (African American, 0.23 [0.10-0.53]; Hispanic, 0.26 [0.14-0.50]), endoscopy (African American, 0.31 [0.16-0.58]; Hispanic, 0.27 [0.16-0.46]; other, 0.53 [0.31-0.90]), and stool studies (African American, 0.49 [0.30-0.91]). Hispanic children had lower rates of neurologic and other testing: EEG (Hispanic, 0.53 [0.35-0.78]), brain MRI (African American, 0.37 [0.22-0.63]; Hispanic, 0.62 [0.42-0.90]), sleep study (Hispanic, 0.18 [0.04-0.76]), and neuropsychiatric testing (Hispanic, 0.55 [0.32-0.96]). CONCLUSIONS: We found racial and ethnic differences among children diagnosed with autism in use of care and procedures. Possible explanations for these findings include differences in presentation, referral rates, or referral follow through.

Latino families, primary care, and childhood obesity: a randomized controlled trial.

BACKGROUND: Few successful treatment modalities exist to address childhood obesity. Given Latinos' strong identity with family, a family-focused intervention may be able to control Latino childhood obesity. PURPOSE: To assess the feasibility and effectiveness of a family-centered, primary care-based approach to control childhood obesity through lifestyle choices. DESIGN: Randomized waitlist controlled trial in which control participants received the intervention 6 months after the intervention group. SETTING/PARTICIPANTS: Forty-one Latino children with BMI >85%, aged 9-12 years, and their caregivers were recruited from an urban community health center located in a predominantly low-income community. INTERVENTION: Children and their caregivers received 6 weeks of interactive group classes followed by 6 months of culturally sensitive monthly in-person or phone coaching to empower families to incorporate learned lifestyles and to address both family and social barriers to making changes. MAIN OUTCOMES MEASURES: Caregiver report on child and child self-reported health-related quality of life (HRQoL); metabolic markers of obesity; BMI; and accelerometer-based physical activity were measured July 2010-November 2011 and compared with post-intervention assessments conducted at 6 months and as a function of condition assignment. Data were analyzed in 2012. RESULTS: Average attendance rate to each group class was 79%. Socio-environmental and family factors, along with knowledge, were cited as barriers to changing lifestyles to control obesity. Caregiver proxy and child self-reported HRQoL improved for both groups with a larger but not nonsignificant difference among intervention vs control group children (p=0.33). No differences were found between intervention and control children for metabolic markers of obesity, BMI, or physical activity. CONCLUSIONS: Latino families are willing to participate in group classes and health coaching to control childhood obesity. It may be necessary for primary care to partner with community initiatives to address childhood obesity in a more intense manner. TRIAL REGISTRATION: This study is registered at Clinicaltrials.partners.org 2009P001721.

The medical home: relationships with family functioning for children with and without special health care needs.

OBJECTIVE: In this study we tested the association of the medical home with family functioning for children without and with special health care needs (CSHCN). METHODS: We used data from the 2007 National Survey of Children's Health to run multivariate logistic regressions to test the association between having a medical home and family functioning (difficulty with parental coping, parental aggravation, childcare/work issues, and missed school days). We further assessed interactions of CSHCN status with having a medical home. RESULTS: In adjusted analysis, parents of children with a medical home were less likely to report difficulty with parental coping (odds ratio [OR] 0.26 [0.19-0.36]), parental aggravation (OR 0.54 [0.45-0.65]), childcare/work issues (OR 0.72 [0.61-0.84]), and missed school days (OR 0.87[0.78-0.97]) for their children than those without a medical home. Using interaction terms, we found that for most outcomes, the medical home had a greater association for CSHCN compared with healthy peers, with odds ratios ranging 0.40 (CI 0.22-0.56) for parental aggravation to 0.67 (CI0.52-0.86) for missed school days. CONCLUSIONS: We show that the medical home is associated with better family functioning. All children may benefit from receiving care in a medical home, but CSHCN, who have greater needs, may particularly benefit from this enhanced model of care.

Extending the time: solvothermal syntheses, crystal structures, and properties of two non-isostructural thioantimonates with the composition [Mn(tren)]Sb2S4.

The two novel compounds, [Mn(tren)]Sb2S4 (1 and 2), were obtained by the reaction of elemental Mn, Sb, and S in aqueous solutions of tren (tren = tris(2-aminoethyl)amine, C6H18N4) after different reaction times. Compound 1 is formed up to a reaction time of 13 d, and an extension of the reaction time leads to the formation of 2. Both compounds crystallize in monoclinic space groups (1, P2(1)/c; 2, C2/c). In 1, the two unique SbS3 trigonal pyramids share a common S atom to form a Sb2S5 unit. Two S atoms of this group have a bond to Mn2+ yielding a MnSb2S3 heteroring in the boat conformation. The Sb2S5 moieties are joined via common corners into the final undulated [Sb2S4]2- anion which is directed along [001]. The structure of 2 contains the [Mn(tren)]2+ ion, one SbS3 pyramid, and a SbS4 unit. Two symmetry-related SbS4 groups share an edge, forming a Sb2S6 group containing a Sb2S2 ring. This group is joined via corners to two SbS3 pyramids on both sides producing a Sb4S4 ring. The Sb2S2 and Sb4S4 rings are condensed into the final [Sb2S4]2- anion which runs along [010]. The [Mn(tren)] groups are bound to the thioantimonate(III) backbone on opposite sides of the Sb4S4 ring, and a small MnSbS2 ring is formed. In both structures, weak S...H bonds are found which may contribute to the stability of the materials. The two compounds decompose in one step upon heating, and only MnS and Sb2S3 could be identified as the crystalline part of the decomposition products. Both compounds can also be prepared under solvothermal conditions using MnSb2S4 as starting material. Compounds 1 and 2 are obtained from this ternary material in a high yield.