Medicaid Managed Care and Pediatric Dental Emergency Department Visits.

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.

Private equity and healthcare firm behavior: Evidence from ambulatory surgery centers.

Healthcare firms regularly seek outside capital; yet, we have an incomplete understanding of external investor influence on provider behavior. We investigate the effects of private equity investment, divestment, and an initial public offering (IPO) on ambulatory surgery centers (ASCs). Throughput is unchanged while charges grow by up to 50% for the same service mix. Affected ASCs witness declines in privately insured cases and rely more on Medicare business. Private equity increases physician ASC ownership stakes, and both simultaneously divest when the ASC is sold. Our findings appear more consistent with private equity influencing the financing of ASCs, rather than treatment approaches.

Long-run growth of ambulatory surgery centers 1990-2015 and Medicare payment policy.

OBJECTIVE: To examine long-run growth in the ambulatory surgery center (ASC) industry and potential factors influencing its trajectory. DATA SOURCES: National data for all Medicare-certified ASCs (1990-2015) and outpatient discharge records from the state of Florida in 2007. STUDY DESIGN: We documented the number of ASCs in the United States over time and decomposed the trend into underlying ASC market entry and exit behavior. We then examined the plausibility of 2008 Medicare payment reforms to influence the trend changes. DATA EXTRACTION METHODS: Data on ASC openings and closures are obtained from the Centers for Medicare and Medicaid Services Provider of Service files. Secondary data on ASC volume in Florida are obtained from the Florida Agency for Health Care Administration. PRINCIPAL FINDINGS: The number of ASCs in the United States grew 5%-10% annually between 1990 and 2007 but by 1% or less beginning in 2008. This change coincided with substantive reductions in Medicare payments for key ASC services. The annual number of new ASCs was as much as 50% lower following the payment change. CONCLUSIONS: ASCs are an important competitor for outpatient services, but growth has slowed dramatically. Sharp changes in new ASC entry align with less generous Medicare fees.

Treatment flows after outsourcing public insurance provision: Evidence from Florida Medicaid.

While politics can determine what public goods are available, elected officials must decide on the method of allocation. Commonly, governments provide public health insurance directly or pay private parties to administer it on their behalf. Such contracting can leverage private sector expertise but also raises agency concerns. In particular, little is known about how private provision of public health insurance impacts medical decision-making and treatment flows for low-income populations. An example comes from the Medicaid program, which has increasingly relied on outside insurers to deliver health services to enrollees. We exploit a large legislative intervention in Florida to show that Medicaid managed care (MMC) organizations generally do not skimp on short-run treatment delivery in the inpatient setting. In fact, patients with severe and chronic illnesses receive more inpatient services under these contracts, especially in relation to managing care transitions. We also document increased competition in the MMC market following the state's policy intervention.

Effects of Educational Messaging on Urgent and Emergent Care-Seeking Behaviors Among Publicly Insured Populations.

BACKGROUND: The impact of messaging campaigns on influencing urgent care- and emergent care-seeking behaviors, including the use of in-network providers, is not well-understood. Although out-of-network healthcare utilization can have negative financial consequences for patients in narrow network Affordable Care Act plans, individuals with time-sensitive medical conditions, and especially patients visiting the emergency department, may not think about out-of-network issues. Inappropriate or avoidable emergency department visits can also create unnecessary costs for patients. OBJECTIVE: To evaluate the impact of 5 messaging strategies to educate individuals about the use of in-network providers and when care should be sought in the emergency department, urgent care center, or other sites of care. METHODS: Using a retrospective analysis, individuals aged ≥18 years who were enrolled in an individually purchased Affordable Care Act-compliant Humana plan as of July 1, 2015, were randomized to 1 of 5 messaging arms (e-mail, magnet mailer with or without e-mail, and key-tag mailer with or without e-mail) or to a control group. The outreach was implemented and evaluated in 2 distinct, geographically defined populations of Orlando, Palm Beach, and Tampa, Florida (Population 1); and Atlanta, Georgia, and San Antonio and Austin, Texas (Population 2). The relative number of each emergency department, urgent care, and out-of-network visits during follow-up was modeled using negative binomial regression. Cox proportional hazard models were used to calculate the risk for ≥1 of each visit type (assessed separately) and high emergency department utilization (defined as ≥3 visits during follow-up) relative to the control, while accounting for variable follow-up time. RESULTS: The relative numbers of each visit type assessed were not significantly different for any message group compared with the control in either population. The risk for an emergency department visit was 4% lower in the e-mail arm of Population 2 (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.94-0.99; P = .005) and 7% lower in the e-mail/key-tag arm of Population 1 (HR, 0.93; 95% CI, 0.89-0.97; P = .001). The risk for high emergency department utilization was significantly reduced by the key-tag, magnet, and e-mail/key-tag strategies in Population 1, but no impact was found in Population 2. CONCLUSION: Despite the mixed results, the study provides new insights into how different messaging strategies could be used to educate patients and influence healthcare utilization decisions by people with health insurance.

Returns to specialization: Evidence from the outpatient surgery market.

Technological changes in medicine have created new opportunities to provide surgical care in lower cost, specialized facilities. This paper examines patient outcomes in ambulatory surgery centers (ASCs), which were developed as a low-cost alternative to outpatient surgery in hospitals. Because we are concerned that selection into ASCs may bias estimates of facility quality, we use predicted changes in federally set Medicare facility payment rates as an instrument for ASC utilization to estimate the effect of location of treatment on patient outcomes. We find that patients treated in an ASC are less likely to be admitted to a hospital or visit an emergency room a short time after outpatient surgery. The findings in this paper indicate that factors other than patient and physician heterogeneity contribute to the observed returns to specialization in the ASC market.

Procedures take less time at ambulatory surgery centers, keeping costs down and ability to meet demand up.

During the past thirty years outpatient surgery has become an increasingly important part of medical care in the United States. The number of outpatient procedures has risen dramatically since 1981, and the majority of surgeries performed in the United States now take place in outpatient settings. Using data on procedure length, we show that ambulatory surgery centers (ASCs) provide a lower-cost alternative to hospitals as venues for outpatient surgeries. On average, procedures performed in ASCs take 31.8 fewer minutes than those performed in hospitals--a 25 percent difference relative to the mean procedure time. Given the rapid growth in the number of surgeries performed in ASCs in recent years, our findings suggest that ASCs provide an efficient way to meet future growth in demand for outpatient surgeries and can help fulfill the Affordable Care Act's goals of reducing costs while improving the quality of health care delivery.

The labor market effects of California's minimum nurse staffing law.

In 2004, California became the first state to implement statewide minimum nurse-to-patient ratios in general hospitals. In spite of years of work to establish statewide staffing regulations, there is little evidence that the law was effective in attracting more nurses to the hospital workforce or improving patient outcomes. This paper examines the effects of this legislation on employment and wages of registered nurses. By using annual financial data from California hospitals, I show that nurse-to-patient ratios in medical/surgical units increased substantially following the staffing mandate. However, survey data from two nationally representative datasets indicate that the law had no effect on the aggregate number of registered nurses or the hours they worked in California hospitals, and at most a modest effect on wages. My findings suggest that offsetting changes in labor demand due to hospital closures, combined with reclassification of workers within hospitals, and mitigated the employment effects of California's staffing regulation. This paper cautions that California's experience with minimum nurse staffing legislation may not be generalizable to states considering similar policies in very different hospital markets.