Cost of start-up activities to implement a community-level opioid overdose reduction intervention in the HEALing Communities Study.

BACKGROUND: Communities That HEAL (CTH) is a novel, data-driven community-engaged intervention designed to reduce opioid overdose deaths by increasing community engagement, adoption of an integrated set of evidence-based practices, and delivering a communications campaign across healthcare, behavioral-health, criminal-legal, and other community-based settings. The implementation of such a complex initiative requires up-front investments of time and other expenditures (i.e., start-up costs). Despite the importance of these start-up costs in investment decisions to stakeholders, they are typically excluded from cost-effectiveness analyses. The objective of this study is to report a detailed analysis of CTH start-up costs pre-intervention implementation and to describe the relevance of these data for stakeholders to determine implementation feasibility. METHODS: This study is guided by the community perspective, reflecting the investments that a real-world community would need to incur to implement the CTH intervention. We adopted an activity-based costing approach, in which resources related to hiring, training, purchasing, and community dashboard creation were identified through macro- and micro-costing techniques from 34 communities with high rates of fatal opioid overdoses, across four states-Kentucky, Massachusetts, New York, and Ohio. Resources were identified and assigned a unit cost using administrative and semi-structured-interview data. All cost estimates were reported in 2019 dollars. RESULTS: State-level average and median start-up cost (representing 8-10 communities per state) were $268,657 and $175,683, respectively. Hiring and training represented 40%, equipment and infrastructure costs represented 24%, and dashboard creation represented 36% of the total average start-up cost. Comparatively, hiring and training represented 49%, purchasing costs represented 18%, and dashboard creation represented 34% of the total median start-up cost. CONCLUSION: We identified three distinct CTH hiring models that affected start-up costs: hospital-academic (Massachusetts), university-academic (Kentucky and Ohio), and community-leveraged (New York). Hiring, training, and purchasing start-up costs were lowest in New York due to existing local infrastructure. Community-based implementation similar to the New York model may have lower start-up costs due to leveraging of existing infrastructure, relationships, and support from local health departments.

Policy Complexities in Financing First Episode Psychosis Services: Implementation Realities from a Home Rule State.

Over the past decade, significant investments have been made in coordinated specialty care (CSC) models for first episode psychosis (FEP), with the goal of promoting recovery and preventing disability. CSC programs have proliferated as a result, but financing challenges imperil their growth and sustainability. In this commentary, the authors discuss (1) entrenched and emergent challenges in behavioral health policy of consequence for CSC financing; (2) implementation realities in the home rule context of Ohio, where significant variability exists across counties; and (3) recommendations to improve both care quality and access for individuals with FEP. The authors aim to provoke careful thought about policy interventions to bridge science-to-service gaps, and in this way, advance behavioral health equity.

Costs of Coordinated Specialty Care for First-Episode Psychosis: A Microcosting Analysis.

In this study, the authors measured and described the costs of coordinated specialty care (CSC) for first-episode psychosis in Ohio. A microcosting tool was used to estimate personnel and nonpersonnel costs of service delivery at seven CSC programs. Average annual cost per participant (N=511 participants) was estimated as $17,810 (95% CI=$9,141-$26,479). On average, 61% (95% CI=53%-69%) of annual program costs were nonbillable. Key cost drivers included facility costs, administrative tasks, and social services. Novel financing models may redress reimbursement gaps incurred by CSC programs.

ED Visits for Schizophrenia Spectrum Disorders During the COVID-19 Pandemic at 5 Campus Health Systems.

Importance: Although substantial research has reported grave population-level psychiatric sequelae of the COVID-19 pandemic, evidence pertaining to temporal changes in schizophrenia spectrum disorders in the US following the pandemic remains limited. Objective: To examine the monthly patterns of emergency department (ED) visits for schizophrenia spectrum disorders after the onset of the COVID-19 pandemic. Design, Setting, and Participants: This observational cohort study used time-series analyses to examine whether monthly counts of ED visits for schizophrenia spectrum disorders across 5 University of California (UC) campus health systems increased beyond expected levels during the COVID-19 pandemic. Data included ED visits reported by the 5 UC campuses from 2016 to 2021. Participants included persons who accessed UC Health System EDs had a diagnosis of a psychiatric condition. Data analysis was performed from March to June 2023. Exposures: The exposures were binary indicators of initial (March to May 2020) and extended (March to December 2020) phases of the COVID-19 pandemic. Main Outcomes and Measures: The primary outcome was monthly counts of ED visits for schizophrenia spectrum disorders. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes, categorized within Clinical Classification Software groups, were used to identify ED visits for schizophrenia spectrum disorders and all other psychiatric ED visits, from the University of California Health Data Warehouse database, from January 2016 to December 2021. Time-series analyses controlled for autocorrelation, seasonality, and concurrent trends in ED visits for all other psychiatric conditions. Results: The study data comprised a total of 377 872 psychiatric ED visits, with 37 815 visits for schizophrenia spectrum disorders. The prepandemic monthly mean (SD) number of ED visits for schizophrenia spectrum disorders was 519.9 (38.1), which increased to 558.4 (47.6) following the onset of the COVID-19 pandemic. Results from time series analyses, controlling for monthly counts of ED visits for all other psychiatric conditions, indicated 70.5 additional ED visits (95% CI, 11.7-129.3 additional visits; P = .02) for schizophrenia spectrum disorders at 1 month and 74.9 additional visits (95% CI, 24.0-126.0 visits; P = .005) at 3 months following the initial phase of the COVID-19 pandemic in California. Conclusions and Relevance: This study found a 15% increase in ED visits for schizophrenia spectrum disorders within 3 months after the initial phase of the pandemic in California across 5 UC campus health systems, underscoring the importance of social policies related to future emergency preparedness and the need to strengthen mental health care systems.

Service trends among non-obstetrics/gynecology providers in the U.S.: Long-acting reversible contraception insertions, removals, and re-insertions.

This study evaluates trends in long-acting reversible contraception (LARC) services among obstetrician/gynecologists (OB/GYNs) and non-OB/GYNs in the U.S. during 2012-2018. Using public and private insurance claims from the Symphony Health database, we calculated the percentage of LARC insertions, removals, and reinsertions performed by OB/GYNs and non-OB/GYNs. We then assessed time trends with linear regression. The proportion of LARC services that were performed by non-OBGYNs increased modestly between 2012 and 2018. Increases were similar for insertions, removals, and reinsertions. Further research is needed to understand trends in LARC service provision within primary care to better tailor medical training and policy interventions.

Comparative Effectiveness of 2 Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening Among Women in the Rural US: A Randomized Clinical Trial.

Importance: Women living in rural areas have lower rates of breast, cervical, and colorectal cancer screening compared with women living in urban settings. Objective: To assess the comparative effectiveness of (1) a mailed, tailored digital video disc (DVD) intervention; (2) a DVD intervention plus telephonic patient navigation (DVD/PN); and (3) usual care with simultaneously increased adherence to any breast, cervical, and colorectal cancer screening that was not up to date at baseline and to assess cost-effectiveness. Design, Setting, and Participants: This randomized clinical trial recruited and followed up women from rural Indiana and Ohio (community based) who were not up to date on any or all recommended cancer screenings. Participants were randomly assigned between November 28, 2016, and July 1, 2019, to 1 of 3 study groups (DVD, DVD/PN, or usual care). Statistical analyses were completed between August and December 2021 and between March and September 2022. Intervention: The DVD interactively assessed and provided messages for health beliefs, including risk of developing the targeted cancers and barriers, benefits, and self-efficacy for obtaining the needed screenings. Patient navigators counseled women on barriers to obtaining screenings. The intervention simultaneously supported obtaining screening for all or any tests outside of guidelines at baseline. Main Outcomes and Measures: Receipt of any or all needed cancer screenings from baseline through 12 months, including breast, cervical, and colorectal cancer, and cost-effectiveness of the intervention. Binary logistic regression was used to compare the randomized groups on being up to date for all and any screenings at 12 months. Results: The sample included 963 women aged 50 to 74 years (mean [SD] age, 58.6 [6.3] years). The DVD group had nearly twice the odds of those in the usual care group of obtaining all needed screenings (odds ratio [OR], 1.84; 95% CI, 1.02-3.43; P = .048), and the odds were nearly 6 times greater for DVD/PN vs usual care (OR, 5.69; 95% CI, 3.24-10.5; P < .001). The DVD/PN intervention (but not DVD alone) was significantly more effective than usual care (OR, 4.01; 95% CI, 2.60-6.28; P < .001) for promoting at least 1 (ie, any) of the needed screenings at 12 months. Cost-effectiveness per woman who was up to date was $14 462 in the DVD group and $10 638 in the DVD/PN group. Conclusions and Relevance: In this randomized clinical trial of rural women who were not up to date with at least 1 of the recommended cancer screenings (breast, cervical, or colorectal), an intervention designed to simultaneously increase adherence to any or all of the 3 cancer screening tests was more effective than usual care, available at relatively modest costs, and able to be remotely delivered, demonstrating great potential for implementing an evidence-based intervention in remote areas of the midwestern US. Trial Registration: ClinicalTrials.gov Identifier: NCT02795104.

Early Data on Predictors of COVID-19 Treatment Frequency at Community Health Centers.

INTRODUCTION: Federally-funded community health centers (CHCs) serve on the front lines of the COVID-19 pandemic, providing essential COVID-19 testing and care for vulnerable patient populations. Overlooked in the scholarly literature is a description of how different characteristics and vulnerabilities shaped COVID-19 care delivery at CHCs in the first year of the pandemic. Our research objective was to identify organization- and state-level factors associated with more or fewer COVID-19 care and testing visits at CHCs in 2020. METHODS: Multilevel random intercept regression models examined associations among organization and state-level predictor variables and the frequency of COVID-19 care and testing visits at CHCs in 2020. The study sample included 1267 CHCs across the 50 states and the District of Columbia. RESULTS: The average CHC provided 932 patient visits for COVID-19-related care in 2020. Yet, the CHC's role in delivering COVID-19 services proved as diverse as the populations and localities CHCs serve. For example, after adjusting for other factors, each percentage-point increase in a CHC's Hispanic patient population size was associated with a 1.3% increase in the frequency of patient visits for COVID-19 care in 2020 (P < .001). Serving a predominantly rural patient population was associated with providing significantly fewer COVID-19-related care visits (P = .002). Operating in a state that enacted a mask-wearing policy in 2020 was associated with a 26.2% lower frequency of COVID-19 testing visits at CHCs in 2020, compared to CHCs operating in states without mask-wearing policies (P = .055). CONCLUSIONS: In response to the pandemic, the federal government legislated funding to help CHCs address challenges associated with COVID-19 and provide services to medically-underserved patient populations. Policymakers will likely need to provide additional support to help CHCs address population-specific vulnerabilities affecting COVID-19 care and testing delivery, especially as highly contagious COVID-19 variants proliferate (eg, Delta and Omicron).

Impact of the Affordable Care Act Medicaid expansion on oral surgery delivery at community health centers: an observational study.

BACKGROUND: Unmet oral health needs routinely affect low-income communities. Lower-income adults suffer a disproportionate share of dental disease and often cannot access necessary oral surgery services. The Affordable Care Act (ACA) Medicaid expansion created new financial opportunities for community health centers (CHCs) to provide mission-relevant services in low-income areas. However, little is understood in the literature about how the ACA Medicaid expansion impacted oral surgery delivery at CHCs. Using a large sample of CHCs, we examined whether the ACA Medicaid expansion increased the likelihood of oral surgery delivery at expansion-state CHCs compared to non-expansion-state CHCs. METHODS: Exploiting a natural experiment, we estimated Poisson regression models examining the effects of the Medicaid expansion on the likelihood of oral surgery delivery at expansion-state CHCs relative to non-expansion-state CHCs. We merged data from multiple sources spanning 2012-2017. The analytic sample included 2054 CHC-year observations. RESULTS: Compared to the year prior to expansion, expansion-state CHCs were 13.5% less likely than non-expansion-state CHCs to provide additional oral surgery services in 2016 (IRR = 0.865; P = 0.06) and 14.7% less likely in 2017 (IRR = 0.853; P = 0.02). All else equal, and relative to non-expansion-state CHCs, expansion-state CHCs included in the analytic sample were 8.7% less likely to provide oral surgery services in all post-expansion years pooled together (IRR = 0.913; P = 0.01). CONCLUSIONS: Medicaid expansions can provide CHCs with opportunities to expand their patient revenue and services. However, whether because of known dental treatment capacity limitations, new competition, or coordination with other providers, expansion-state CHCs in our study sample were less likely to provide oral surgery services on the margin relative to non-expansion-state CHCs following Medicaid expansion.

The Relationship Between Unemployment and Health Insurance Coverage: Before and After the Affordable Care Act's Coverage Expansions.

OBJECTIVE: The objective of this study was to determine whether the Affordable Care Act's (ACA) major coverage expansions mitigated the impact of unemployment on health insurance coverage status. DATA SOURCE: A 2011-2019 versions of the American Community Survey developed by the University of Minnesota Integrated Public Use Microdata Series program. RESEARCH DESIGN: We use difference-in-difference-in-differences (ie, triple difference) regressions to compare changes in the short-run impacts of local unemployment rates before and after the ACA. PRINCIPAL FINDINGS: Before the ACA, rises in local unemployment were associated with uninsurance due to losses in private coverage (ie, both nongroup and employer sponsored).Following the ACA's full implementation, the link between employment and coverage was attenuated by access to publicly subsidized qualified health plans on the ACA's nongroup market, and enhanced access to Medicaid in states that expanded. Our findings suggest protections from unemployment-linked uninsured spells are largest in states that expanded Medicaid. CONCLUSIONS: Expanded access to coverage under the ACA could mitigate the adverse effects on insurance status and access to care historically linked to job loss. However, should the ACA be repealed, many households stand to lose their ability to turn to Medicaid or subsidized nongroup coverage as safety-net resources to offset the burdens of job loss.

Health economic design for cost, cost-effectiveness and simulation analyses in the HEALing Communities Study.

BACKGROUND: The HEALing Communities Study (HCS) is designed to implement and evaluate the Communities That HEAL (CTH) intervention, a conceptually driven framework to assist communities in selecting and adopting evidence-based practices to reduce opioid overdose deaths. The goal of the HCS is to produce generalizable information for policy makers and community stakeholders seeking to implement CTH or a similar community intervention. To support this objective, one aim of the HCS is a health economics study (HES), the results of which will inform decisions around fiscal feasibility and sustainability relevant to other community settings. METHODS: The HES is integrated into the HCS design: an unblinded, multisite, parallel arm, cluster randomized, wait list-controlled trial of the CTH intervention implemented in 67 communities in four U.S. states: Kentucky, Massachusetts, New York, and Ohio. The objectives of the HES are to estimate the economic costs to communities of implementing and sustaining CTH; estimate broader societal costs associated with CTH; estimate the cost-effectiveness of CTH for overdose deaths avoided; and use simulation modeling to evaluate the short- and long-term health and economic impact of CTH, including future overdose deaths avoided and quality-adjusted life years saved, and to develop a simulation policy tool for communities that seek to implement CTH or a similar community intervention. DISCUSSION: The HCS offers an unprecedented opportunity to conduct health economics research on solutions to the opioid crisis and to increase understanding of the impact and value of complex, community-level interventions.

Income-Based Disparities in Financial Burdens of Medical Spending Under the Affordable Care Act in Families With Individuals Having Chronic Conditions.

This study examined income-based disparities in financial burdens from out-of-pocket (OOP) medical spending among individuals with multiple chronic physical and behavioral conditions, before and after the Affordable Care Act's (ACA) implementation in 2014. Using the 2012-2015 Medical Expenditure Panel Survey data, we studied changes in financial burdens experienced by nonelderly U.S. populations. Financial burdens were measured by (1) high financial burden, defined as total OOP medical spending exceeding 10% of annual household income; (2) health care cost-sharing ratio, defined as self-paid payments as a percent of total health care payments, excluding individual contributions to premiums; and (3) the total OOP costs spent on health care utilization. The findings indicated reductions in the proportion of those who experienced a high financial burden, as well as reductions in the OOP costs for some individuals. However, individuals with incomes below 138% federal poverty level (FPL) and those with incomes between 251% and 400% FPL who had multiple physical and/or behavioral chronic conditions experienced large increases in high financial burden after the ACA, relative to those with incomes greater than 400% FPL. While the ACA was associated with relieved medical financial burdens for some individuals, the worsening high financial burden for moderate-income individuals with chronic physical and behavioral conditions is a concern. Policymakers should revisit the cost subsidies for these individuals, with a particular focus on those with chronic conditions.

A review of the cost-effectiveness of adult influenza vaccination and other preventive services.

The Centers for Disease Control and Prevention recommend annual influenza vaccination of persons ≥6 months old. However, in 2016-17, only 43.3% of U.S. adults reported receiving an influenza vaccination. Limited awareness about the cost-effectiveness (CE) or the economic value of influenza vaccination may contribute to low vaccination coverage. In 2017, we conducted a literature review to survey estimates of the CE of influenza vaccination of adults compared to no vaccination. We also summarized CE estimates of other common preventive interventions that are recommended for adults by the U.S. Preventive Services Task Force. Results are presented as costs in US$2015 per quality-adjusted life-year (QALY) saved. Among adults aged 18-64, the CE of influenza vaccination ranged from $8000 to $39,000 per QALY. Assessments for adults aged ≥65 yielded lower CE ratios, ranging from being cost-saving to $15,300 per QALY. Influenza vaccination was cost-saving to $85,000 per QALY for pregnant women in moderate or severe influenza seasons and $260,000 per QALY in low-incidence seasons. For other preventive interventions, CE estimates ranged from cost-saving to $170,000 per QALY saved for breast cancer screening among women aged 50-74, from cost-saving to $16,000 per QALY for colorectal cancer screening, and from $27,000 to $600,000 per QALY for hypertension screening and treatment. Influenza vaccination in adults appears to have a similar CE profile as other commonly utilized preventive services for adults. Efforts to improve adult vaccination should be considered by adult-patient providers, healthcare systems and payers given the health and economic benefits of influenza vaccination.

Disappearing Medicaid Enrollment Disparities for US Citizen Children in Immigrant Families: State-Level Trends from 2008 to 2015.

OBJECTIVE: Medicaid and the Children's Health Insurance Program (CHIP) provide health insurance to 38% of all children in the United States. Uninsured rates continued to fall over the past decade, and citizen children in immigrant families experienced the most dramatic gains. Our objective is to test whether states have managed to close Medicaid enrollment gaps between US citizen children in native and immigrant families. METHODS: We use the 2008 to 2015 American Community Surveys to compare uninsured rates for 2.4million Medicaid-eligible citizen children in immigrant and native families. State fixed-effects probit models estimate the probability of children remaining uninsured when eligible for public coverage, excluding children covered by private insurance. We compare the states with the largest enrollment gains across differences in policies relevant to CHIP/Medicaid participation for all children, including CHIP Reauthorization Act (CHIPRA) enrollment simplification, Immigrant Children's Health Improvement Act, and Affordable Care Act (ACA) Medicaid expansion. RESULTS: Most states reduced their enrollment disparities by one half or even completely eliminated their enrollment differentials. However, the states with the largest gains did not adopt ACA and CHIPRA policy options that would have improved CHIP/Medicaid participation for children in their states-or implemented the policies long before the observed gains. CONCLUSIONS: Rather than policy anchoring the gains, the improvements may be rooted in operational changes and outreach efforts during CHIPRA and ACA implementation. Absent a policy anchor, the large enrollment differentials of a decade ago may reappear for children in immigrant families, affect the wellbeing of children and their communities.

Did Health Care Reform Help Kentucky Address Disparities in Coverage and Access to Care among the Poor?

OBJECTIVE: To evaluate the impact of Kentucky's full rollout of the Affordable Care Act on disparities in access to care due to poverty. DATA SOURCE: Restricted version of the Behavioral Risk Factor Surveillance System (BRFSS) for Kentucky and years 2011-2015. STUDY DESIGN: We use a difference-in-differences framework to compare trends before and after implementation of the Affordable Care Act (ACA) in health insurance coverage, several access measures, and health care utilization for residents in higher versus lower poverty ZIP codes. PRINCIPAL FINDINGS: Much of the reduction in Kentucky's uninsured rate appears driven by large uptakes in coverage from areas with higher concentrations of poverty. Residents in high-poverty communities experienced larger reductions, 8 percentage points (pp) in uninsured status and 7.5 pp in reporting unmet needs due to costs, than residents of lower poverty areas. These effects helped remove pre-ACA disparities in uninsured rates across these areas. CONCLUSION: Because we observe positive effects on coverage and reductions in financial barriers to care among those from poorer communities, our findings suggest that expanding Medicaid helps address the health care needs of the impoverished.

US Health Care Reform and Rural America: Results From the ACA's Medicaid Expansions.

PURPOSE: Medicaid expansions, prompted by the Affordable Care Act, generated generally positive effects on coverage and alleviated much of the financial burden associated with seeking health care. We do not know if these shifts also extend to the nation's rural populations. METHODS: Using 2011-2015 Behavioral Risk Factor Surveillance System data, this study compares trend changes for coverage, access to care, and health care utilization in response to Medicaid expansion among urban and rural residents using a difference-in-differences regression approach. FINDINGS: Following Medicaid expansion, low-income rural and urban residents both experienced reductions in uninsurance; however, the coverage uptake in rural settings (8.5 percentage points [pp], P < .01) was much larger than the uptake in coverage in more urban settings (4.1 pp, P > .10). In spite of larger uptakes in coverage among rural residents, reductions in cost-related barriers to medical care were slightly larger among urban residents, and access to a regular source of medical care (5.2 pp, P < .05) and doctor visitation (4.5 pp, P < .01) were only statistically significant among urban residents. CONCLUSIONS: The ACA Medicaid expansions produced larger gains in coverage for rural residents than urban residents; however, it appears there remain opportunities to improve access to care among potentially vulnerable rural residents.

Medicaid Expansion and ACA Repeal: Evidence From Ohio.

OBJECTIVES: To examine the health insurance coverage options for Medicaid expansion enrollees if the Affordable Care Act (ACA) is repealed, using evidence from Ohio, where more than half a million adults have enrolled in the state's Medicaid program through the ACA expansion. METHODS: The Ohio Medicaid Assessment Survey interviewed 42 000 households in 2015. We report data from a unique battery of questions designed to identify insurance coverage immediately prior to Medicaid enrollment. RESULTS: Ninety-five percent of new Medicaid enrollees in Ohio did not have a private health insurance option immediately before enrollment. These new enrollees are predominantly older, low-income Whites with a high school education or less. Only 5% of new Medicaid enrollees were eligible for an employer-sponsored insurance plan to which they could potentially return in the case of repeal of the ACA. CONCLUSIONS: The vast majority of Medicaid expansion enrollees would have no plausible pathway to obtaining private-sector insurance if the ACA were repealed. Demographic similarities between the expansion population and 2016 exit polls suggest that coverage losses would fall disproportionately on members of the winning Republican coalition.

Patterns of Care for Metastatic Colorectal Cancer in Appalachia, and the Clinical, Sociodemographic, and Service Provider Determinants.

BACKGROUND: Appalachia has high colorectal cancer (CRC) incidence and mortality, at least in part due to screening disparities. This paper examines patterns and determinants of metastatic colorectal cancer care. METHODS: CRC patients diagnosed in 2006-2008 from 4 cancer registries (Kentucky, Ohio, Pennsylvania, and North Carolina) were linked to Medicare claims (2005-2009.) The final sample after exclusions included 855 stage IV and 590 stages I-III patients with metachronous or synchronous metastases. We estimate bivariate and multivariate analyses for several surgical and chemotherapeutic strategies of care using clinical, sociodemographic, and contextual determinants. RESULTS: Among 1,445 CRC patients, 84% had primary tumor resection and 44% received chemotherapy. Of the chemotherapy patients, 44% received newer systemic agents for at least 75% of the cycles. One year survivors with liver or lung metastases were more likely to have their primary tumor resected immediately (86.1% vs 69.5% for liver, and 78.2% vs 64.9% for lung) and have their metastases resected/ablated (15.7% vs 2.6% for liver and 15.0% vs 0.5% for lung). Patients with stages I-III primary tumors (versus IV) were much more likely to be resected, but they were less likely to receive chemotherapy. Patients with comorbidities (congestive heart failure, dementia, or respiratory disease) had lower odds of chemotherapy. Smaller hospital size and surgical volume had higher odds of immediate versus delayed surgery. The newer chemotherapeutic agents were more common with higher surgical volume. CONCLUSIONS: Metastatic colorectal cancer has clinical, sociodemographic, and service provider determinants.

A Comparison of Benefit Limits in Mental Health.

This study provides insight to policy makers and stakeholders on how three types of benefits limits on Medicaid-covered mental health services might affect access for consumers diagnosed with severe mental illness. The study used a retrospective cohort design with data for Medicaid-covered, community-based mental health services provided in Ohio during fiscal year 2010. Log-binomial regression was used for the analysis. Results indicate that limits compared have significant, varying consequences based on Medicaid coverage and diagnoses. When constraining Medicaid costs, policy makers should consider how limits will disrupt care and include clinicians in discussions prior to implementation.

Disparities in Colorectal Cancer Treatment Delay Within Appalachia--The Role of For-Profit Hospitals.

BACKGROUND: Appalachian residents have a higher overall cancer burden than the rest of the United States because of the unique features of the region. Treatment delays vary widely within Appalachia, with colorectal cancer patients undergoing median treatment delays of 5 days in Kentucky compared to 9 days for patients in Pennsylvania, Ohio, and North Carolina combined. OBJECTIVE: This study identified the source of this disparity in treatment delay using statistical decomposition techniques. METHODOLOGY: This study used linked 2006 to 2008 cancer registry and Medicare claims data for the Appalachian counties of Kentucky, Pennsylvania, Ohio, and North Carolina to estimate a 2-part model of treatment delay. An Oaxaca Decomposition of the 2-part model revealed the contribution of the individual determinants to the disparity in delay between Kentucky counties and the remaining 3 states. RESULTS: The Oaxaca Decomposition revealed that the higher percentage of patients treated at for-profit facilities in Kentucky proved the key contributor to the observed disparity. In Kentucky, 22.3% patients began their treatment at a for-profit facility compared to 1.4% in the remaining states. Patients initiating treatment at for-profit facilities explained 79% of the observed difference in immediate treatment (<2 days after diagnosis) and 72% of Kentucky's advantage in log days to treatment. CONCLUSIONS: The unique role of for-profit facilities led to reduced treatment delay for colorectal cancer patients in Kentucky. However, it remains unknown whether for-profit hospitals' more rapid treatment converts to better health outcomes for colorectal cancer patients.