Financing Care for CYSHCN in the Next Decade: Reducing Burden, Advancing Equity, and Transforming Systems.

Blueprint for Change: Guiding Principles for a System of Services for CYSHCN and Their Families (Blueprint for Change), presented by the Maternal and Child Health Bureau at the Health Resources and Services Administration, outlines principles and strategies that can be implemented at the federal and state levels and by health systems, health care providers, payors, and advocacy organizations to achieve a strong system of care for children and youth with special health care needs (CYSHCN). The vision for the financing of services outlined in the Blueprint for Change: Guiding Principles for a System of Services for CYSHCN and their Families is one in which health care and other related services are accessible, affordable, comprehensive, continuous, and prioritize the wellbeing of CYSHCN and their families. There are several barriers caused or exacerbated by health care financing policies and structures that pose significant challenges for families of CYSHCN, including finding appropriate and knowledgeable provider care teams, ensuring adequate and continuous coverage for services, and ensuring benefit adequacy. Racial disparities and societal risks all exacerbate these challenges. This article outlines recommendations for improving financing for CYSHCN, including potential innovations to address barriers, such as state Medicaid expansion for CYSHCN, greater transparency in medical necessity processes and determinations, and adequate reimbursement and funding. Financing innovations must use both current and new measures to assess value and provide evidence for iterative improvements. These recommendations will require a coordinated approach among federal and state agencies, the public sector, the provider community, and the families of CYSHCN.

Supplemental Nutrition Assistance Program Participation is Associated with Lower Health Care Spending among Working Age Adults without Dependents.

Prior evidence suggests an association among food insecurity, poor health, and increased health care spending. In this study, we are using a natural experiment to confirm if longer participation in the Supplemental Nutrition Assistance Program (SNAP) is associated with reduced Medicaid spending among a highly impoverished group of adults. In 2013, the mandatory work requirements associated with SNAP benefits were lifted for able-bodied adults without dependents (ABAWDs). Using 2013 to 2015 Medicaid and SNAP data of 24,181 Minnesotans aged 18-49, we examined if changes in SNAP enrollment duration affect health care expenditures. In fully adjusted within-participant regression models, for each additional month of SNAP, average annual health care spending was $98.8 lower (95% CI: -131.7, -66.0; p<.001) per person. Our data suggests that allowing ABAWDs to receive SNAP even in months they are not working may be critical to their health as well as cost-effective.

The effects of financial incentives on diabetes prevention program attendance and weight loss among low-income patients: the We Can Prevent Diabetes cluster-randomized controlled trial.

BACKGROUND: Penetration and participation of real life implementation of lifestyle change programs to prevent type 2 diabetes has been challenging. This is particularly so among low income individuals in the United States. The purpose of this study is to examine the effectiveness of financial incentives on attendance and weight loss among Medicaid beneficiaries participating in the 12-month Diabetes Prevention Program (DPP). METHODS: This is a cluster-randomized controlled trial with two financial incentive study arms and an attention control study arm. Medicaid beneficiaries with prediabetes from 13 primary care clinics were randomly assigned to individually earned incentives (IND; 33 groups; n = 309), a hybrid of individual- and group-earned incentives (GRP; 30 groups; n = 259), and an attention control (AC; 30 groups; n = 279). Up to $520 in incentives could be earned for attaining attendance and weight loss goals over 12 months. Outcomes are percent weight loss from baseline, achieving 5% weight loss from baseline, and attending 75% of core and 75% of maintenance DPP sessions. Linear mixed models were used to examine weight change and attendance rates over the 16 weeks and 12 months. RESULTS: The percent weight change at 16 weeks for the IND, GRP, and AC participants were similar, at - 2.6, - 3.1%, and - 3.4%, respectively. However, participants achieving 5% weight loss in the IND, GRP, and AC groups was 21.5, 24.0% (GRP vs AC, P < 0.05), and 15.2%. Attendance at 75% of the DPP core sessions was significantly higher among IND (60.8%, P < 0.001) and GRP (64.0%, P < 0.001) participants than among AC (38.6%) participants. Despite substantial attrition over time, attendance at 75% of the DPP maintenance sessions was also significantly higher among IND (23.0%, P < 0.001) and GRP (26.1%, P < 0.001) participants than among AC (11.0%) participants. CONCLUSIONS: Financial incentives can improve the proportion of Medicaid beneficiaries attending the 12-month DPP and achieving at least 5% weight loss. TRIAL REGISTRATION: ClinicalTrials.gov NCT02422420 ; retrospectively registered April 21, 2015.

Financial incentives for diabetes prevention in a Medicaid population: Study design and baseline characteristics.

BACKGROUND: Medicaid beneficiaries at high risk for diabetes can benefit from the Diabetes Prevention Program (DPP) lifestyle intervention. The We Can Prevent Diabetes (WCPD) trial examined whether financial incentives are more effective than no financial incentives in sustaining participation in the DPP and increasing weight loss. Here we describe the study design and baseline characteristics. METHODS: The WCPD was a 3-arm group-randomized controlled trial. Medicaid beneficiaries were aged 18 to 74years, had prediabetes or gestational diabetes, and were overweight or obese. Subjects enrolled from 13 primary care clinics into groups of 8 to 15 participants. Participants received the 12-month DPP delivered by the YMCA or trained clinic staff, free of costs. Participants from groups randomized into the intervention conditions were eligible to receive incentives up to $520 by attending sessions and meeting weight loss goals. RESULTS: The WCPD enrolled 1154 participants into 98 groups. Among the 847 attending at least one DPP session, 71.2% were women; the mean age was 48.3years; 79.3% were obese; and 87.6% entered the study with an elevated HbA1c or fasting plasma glucose. Participants' primary languages were Somali (21.0%), Hmong (3.1%), Spanish (2.2%), or English (72.4%). CONCLUSIONS: The WCPD trial demonstrated that a collaborative approach with primary care clinics and the YMCA can efficiently identify, enroll, and deliver the 12-month DPP to Medicaid beneficiaries. If the WCPD incentive arms increase attendance and weight loss, the use of financial incentives may be an avenue for engaging low-income, high-risk patients in lifestyle change.

Early elective deliveries accounted for nearly 9 percent of births paid for by Medicaid.

Reducing early elective deliveries has become a priority for Medicaid medical directors and their state partners. Such deliveries lead to poor health outcomes for newborns and their mothers and generate additional costs for patients, providers, and Medicaid, which pays for up to 48 percent of all births in the United States each year. Early elective deliveries are non-medically indicated labor inductions or cesarean deliveries of infants with a confirmed gestational age of less than thirty-nine weeks. This retrospective descriptive study reports the results of a perinatal project, led by the state Medicaid medical directors, that sought to coordinate quality improvement efforts related to early elective deliveries for the Medicaid population. Twenty-two states participated in the project and provided data on elective deliveries in the period 2010-12. We found that 75,131 (8.9 percent) of 839,688 Medicaid singleton births were early elective deliveries. Thus, we estimate that there are 160,000 early elective Medicaid deliveries nationwide each year. In twelve states, early-term elective deliveries declined 32 percent between 2007 and 2011. Our study offers additional evidence and new tools for policy makers pursuing strategies to further reduce the number of such deliveries.

Perceived barriers to guidelines in peritoneal dialysis.

BACKGROUND: Little is known regarding barriers to guideline adherence in the nephrology community. We set out to identify perceived barriers to evidence-based medicine (EBM) and measurement of continuous quality indicators (CQI) in an international cohort of peritoneal dialysis (PD) practitioners. METHODS: Subscribers to an online nephrology education site (Nephrology Now) were invited to participate in an online survey. Nephrology Now is a non-profit, monthly mailing list that highlights clinically relevant articles in nephrology. Four hundred and seventy-five physicians supplying PD care participated in an online survey assessing their use of EBM and CQI in their PD practice. Ordinal logistic regression was utilized to determine relationships between baseline characteristics and EBM and CQI practices. RESULTS: The majority of physicians were nephrologists (89.7%), and 50.4% worked in an academic centre. Respondents were from the following geographic regions: 13.5% Canadian, 24% American, 23.8% European, 4.4% Australian, 5.3% South American, 10.7% African and 12.2% Asian. Adherence to PD clinical practice guidelines were generally strong; however, lower adherence was associated with countries with lower healthcare expenditure, not using personal digital assistant (PDA), the longer the physician had been practising and smaller (< 20 patients per centre) PD practice. CONCLUSIONS: International variation in guideline adherence may be influenced by a country's healthcare expenditure, physician's PDA use and experience, and size of PD practice which may impact future guideline development and implementation.

Preventing elective induction before 39 weeks.

Induction of labor has become a common practice in Minnesota and elsewhere in the United States during the last three decades. Yet a review of the research shows that elective induction has no medical benefit and, in fact, is associated with risks to both the mother and infant, particularly if labor is induced before 39 weeks gestation. This article reports the recommendations of a Minnesota Department of Human Services advisory group on perinatal practices and labor induction. The recommendations include having hospitals establish new policies on elective induction and encouraging medical providers to educate patients about the risks of early-term induction.