Racial and Ethnic Disparities in Medicaid Disenrollment After the End of the COVID-19 Public Health Emergency.

This survey study reports the proportions of and reasons for Medicaid coverage loss among racially and ethnically minoritized individuals.

Racial and Ethnic Disparities in Geographic Availability of Buprenorphine.

OBJECTIVES: Overdose mortality has risen most rapidly among racial and ethnic minority groups while buprenorphine prescribing has increased disproportionately in predominantly non-Hispanic White urban areas. To identify whether buprenorphine availability equitably meets the needs of diverse populations, we examined the differential geographic availability of buprenorphine in areas with greater concentrations of racial and ethnic minority groups. METHODS: Using IQVIA longitudinal prescription data, IQVIA OneKey data, and Microsoft Bing Maps, we calculated 2 outcome measures across the continental United States: the number of buprenorphine prescribers per 1000 residents within a 30-minute drive of a ZIP code, and the number of buprenorphine prescriptions dispensed per capita at retail pharmacies among nearby buprenorphine prescribers. We then estimated differences in these outcomes by ZIP codes' racial and ethnic minority composition and rurality with t tests. RESULTS: Buprenorphine prescribers per 1000 residents within a 30-minute drive decreased by 3.8 prescribers per 1000 residents in urban ZIP codes (95% confidence interval = -4.9 to -2.7) and 2.6 in rural ZIP codes (95% confidence interval = -3.0 to -2.2) whose populations consisted of ≥5% racial and ethnic minority groups. There were 45% to 55% fewer prescribers in urban areas and 62% to 79% fewer prescribers in rural areas as minority composition increased. Differences in dispensed buprenorphine per capita were similar but larger in magnitude. CONCLUSIONS: Achieving more equitable buprenorphine access requires not only increasing the number of buprenorphine-prescribing clinicians; in urban areas with higher racial and ethnic minority group populations, it also requires efforts to promote greater buprenorphine prescribing among already prescribing clinicians.

Inaccuracies in provider directories persist for long periods of time.

A growing literature has identified substantial inaccuracies in consumer-facing provider directories, but it is unclear how long these inaccuracies persist. We re-surveyed inaccurately listed Pennsylvania providers (n = 5170) between 117 to 280 days after a previous secret-shopper survey. Overall, 19.0% (n = 983) of provider directory listings that had been identified as inaccurate were subsequently removed, 44.8% (n = 2316) of provider listings continued to show at least 1 inaccuracy, and 11.6% (n = 600) were accurate at follow-up. We were unable to reach 24.6% (n = 1271) of providers. Longer passage of time was associated with reductions in directory inaccuracies, particularly related to contact information, and to a lesser degree, with removal of inaccurate listings. We found substantial differences in corrective action by carrier. Together, these findings suggest persistent barriers to maintaining and updating provider directories, with implications for how well these tools can help consumers select health plans and access care.

Geographic Penetration of Private Equity Ownership in Outpatient and Residential Behavioral Health.

This cross-sectional study estimates the geographic penetration of private equity­owned outpatient mental health and substance use disorder practices across the US.

Life cycle of private equity investments in physician practices: an overview of private equity exits.

Private equity (PE) firms acquire and grow physician practices through add-on consolidation, generating outsized returns on the sale of the acquisition in 3-8 years ("exit"). Private equity's abbreviated investment timeline and exit incentives may deter long-term investments in care delivery and workforce needed for high-quality care. To our knowledge, there has been no published analyses of the nature or duration of PE exits from physician practices. We address this knowledge gap by using novel data to characterize PE exits from dermatology, ophthalmology, and gastroenterology, physician specialties with the largest number of acquisitions between 2016 and 2020. Of 807 acquisitions, over half (51.6%) of PE-acquired practices underwent an exit within 3 years of initial investment. In nearly all instances (97.8%), PE firms exited investments through secondary buyouts, where physician practices were resold to other PE firms with larger investment funds. Between investment and exit, PE firms increased the number of physician practices affiliated with the PE firm by an average of 595% in 3 years. Findings highlight the rapid scale of ownership change and consolidation under PE ownership and motivate evaluations by policymakers on the effects of PE ownership over the life cycle of PE investments.

Composition of buprenorphine prescribing networks in Medicaid and association with quality of care.

INTRODUCTION: Despite Medicaid's outsized role in delivering and financing medications for opioid use disorder (MOUD), little is known about the extent to which buprenorphine prescriber networks vary across Medicaid health plans, and whether network characteristics affect quality of treatment received. In this observational cross-sectional study, we used 2018-2019 Medicaid claims in Oregon to assess network variation in the numbers and types of buprenorphine prescribers, as well as the association of prescriber and network characteristics with quality of care. METHODS: We describe prescribers (MD/DOs and advanced practice providers) of OUD-approved buprenorphine formulations to patients with an OUD diagnosis, across networks. For each patient who initiated buprenorphine treatment during 2018, we assigned a "usual prescriber" and assessed four measures of quality in the 180d following initiation: 1) continuous receipt of buprenorphine; 2) receipt of any behavioral health counseling services; 3) receipt of any urine drug screen; and 4) receipt of any prescription for a benzodiazepine. We used multivariable linear regressions to examine the association of prescriber and network characteristics with quality of buprenorphine care following initiation. RESULTS: We identified 645 providers who prescribed buprenorphine to 20,739 eligible Medicaid enrollees with an OUD diagnosis. The composition of buprenorphine prescriber networks varied in terms of licensing type, specialty, and panel size, with the majority of prescribers providing buprenorphine to small panels of patients. In the 180 days following initiation, a third of patients were maintained on buprenorphine; 69.9 % received behavioral health counseling; 88.4 % had a urine drug screen; and 11.3 % received a benzodiazepine prescription. In regression analyses, while no single network characteristic was associated with higher quality across all examined measures, each one unit increase in prescriber-to-enrollee ratio was associated with a 1.18 p.p. increase in the probability of continuous buprenorphine maintenance during the 180 days following initiation (95 % confidence interval = [0.21, 2.15], p = 0.017). CONCLUSIONS: Medicaid plans may be able to leverage their networks to provide higher quality care. Our findings, which should be interpreted as descriptive only, suggest that higher prescriber-to-enrollee ratio is associated with increased buprenorphine maintenance. Future research should focus on isolating the causal relationships between MOUD prescribing network design and patient outcomes.

Administrative Frictions and the Mental Health Workforce.

This Viewpoint describes the administrative barriers experienced by mental health professionals and recommends strategies to address these barriers.

Physician Perspectives on Private Equity Investment in Health Care.

This survey study examines physician views toward private equity investment in health care.

Factors Influencing Turnover and Attrition in the Public Behavioral Health System Workforce: Qualitative Study.

Many states are experiencing a behavioral health workforce crisis, particularly in the public behavioral health system. An understanding of the factors influencing the workforce shortage is critical for informing public policies to improve workforce retention and access to care. The aim of this study was to assess factors contributing to behavioral health workforce turnover and attrition in Oregon. Semistructured qualitative interviews were conducted with 24 behavioral health providers, administrators, and policy experts with knowledge of Oregon's public behavioral health system. Interviews were transcribed and iteratively coded to reach consensus on emerging themes. Five key themes emerged that negatively affected the interviewees' workplace experience and longevity: low wages, documentation burden, poor physical and administrative infrastructure, lack of career development opportunities, and a chronically traumatic work environment. Large caseloads and patients' high symptom acuity contributed to worker stress. At the organizational and system levels, chronic underfunding and poor administrative infrastructure made frontline providers feel undervalued and unfulfilled, pushing them to leave the public behavioral health setting or behavioral health altogether. Behavioral health providers are negatively affected by systemic underinvestment. Policies to improve workforce shortages should target the effects of inadequate financial and workplace support on the daily work environment.

Increases in Medicare Spending and Use after Private Equity Acquisition of Retina Practices.

PURPOSE: Private equity (PE) firms increasingly are acquiring physician practices in the United States, particularly within procedural-based specialties such as ophthalmology including retina. To date, the potential impact of ophthalmology practice acquisitions remains unknown. We evaluated the association between PE acquisition and Medicare spending and use for common retina services. DESIGN: Retrospective difference-in-differences analysis using the 20% Medicare fee-for-service claims dataset from January 1, 2015, through December 31, 2019. PARTICIPANTS: Eighty-two practices acquired by PE during the study period and matched control practices. METHODS: We used novel data on PE acquisitions of retina practices linked to the 20% sample Medicare claims data. Retina practices acquired by PE between 2016 and 2019 were matched to up to 3 non-PE (control) practices based on characteristics before acquisition. Private equity-acquired practices were compared with matched control practices through 6 quarters after acquisition using a difference-in-differences event study design. Data analyses were performed between August 2022 and April 2023. MAIN OUTCOME MEASURES: Medicare spending and use of common retina services. RESULTS: Relative to control practices, PE-acquired retina practices increased the use of higher-priced anti-vascular endothelial growth factor (VEGF) agents including aflibercept, which differentially increased by 6.5 injections (95% confidence interval, 0.4-12.5; P = 0.03) per practice-quarter, or 22% from baseline. As a result, Medicare spending on aflibercept differentially increased by $13 028 per practice-quarter, or 21%. No statistically significant differences were found in use or spending for evaluation and management visits or diagnostic imaging. CONCLUSIONS: Private equity acquisition of retina practices are associated with modest increases in the use of higher-priced anti-VEGF drugs like aflibercept, leading to higher Medicare spending. This finding highlights the need to monitor the influence of PE firms' financial incentives over clinician decision-making and the appropriateness of care, which could be swayed by strong economic incentives. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Burn data management and usage across Canada.

INTRODUCTION: While some countries collect burn clinical data as part of nonspecific trauma datasets, others have developed burn registries allowing for benchmarking of outcome and quality-of-care data. The objectives of this project are to characterize the current state of burn clinical data collection and analysis in Canada, and to explore the interest of Canadian burn centers in contributing to a nation-wide burn registry. METHODS: A 23-item mixed methods survey was created and delivered via REDCap® to burn directors of 22 burn centers across Canada. Quantitative items were analyzed by means of descriptive statistics, and thematic analysis was used to explore qualitative data. RESULTS: Sixteen (72 %) complete survey responses were received. All respondent units collect burn clinical data. Data are largely collected for quality improvement (69 %) and clinical research (50 %) purposes. Half of the institutions did not analyze their data, and a majority (67 %) did not benchmark their data against other datasets. The majority of respondents (93 %) demonstrated interest in contributing to a Canada-wide burn registry. CONCLUSION: Although all respondent units are currently collecting burn clinical data, there is an opportunity to improve data analysis, benchmarking, and knowledge translation. Most centers demonstrated interest in contributing to a novel Canadian burn registry.

Rural and frontier access to mental health prescribers and nonprescribers: A geospatial analysis in Oregon Medicaid.

OBJECTIVE: Medicaid enrollees in rural and frontier areas face inadequate access to mental health services, but the extent to which access varies for different provider types is unknown. We assessed access to Medicaid-participating prescribing and nonprescribing mental health clinicians, focusing on Oregon, which has a substantial rural population. METHODS: Using 2018 Medicaid claims data, we identified enrollees aged 18-64 with psychiatric diagnoses and specialty mental health providers who billed Medicaid at least once during the study period. We measured both 30- and 60-minute drive time to a mental health provider, and a spatial access score derived from the enhanced 2-step floating catchment area (E2SFCA) approach at the level of Zip Code Tabulation Areas (ZCTAs). Results were stratified for prescribers and nonprescribers, across urban, rural, and frontier areas. RESULTS: Overall, a majority of ZCTAs (68.6%) had at least 1 mental health prescriber and nonprescriber within a 30-minute drive. E2SFCA measures demonstrated that while frontier ZCTAs had the lowest access to prescribers (84.3% in the lowest quintile of access) compared to other regions, some frontier ZCTAs had relatively high access to nonprescribers (34.3% in the third and fourth quartiles of access). CONCLUSIONS: Some frontier areas with relatively poor access to Medicaid-participating mental health prescribers demonstrated relatively high access to nonprescribers, suggesting reliance on nonprescribing clinicians for mental health care delivery amid rural workforce constraints. Efforts to monitor network adequacy should consider differential access to different provider types, and incorporate methods, such as E2SFCA, to better account for service demand and supply.

Population-based birth cohort study on diabetes in pregnancy and infant hospitalisations in Cree, other First Nations and non-Indigenous communities in Quebec.

OBJECTIVES: Diabetes in pregnancy, whether pre-gestational (chronic) or gestational (de novo hyperglycaemia), increases the risk of adverse birth outcomes. It is unclear whether gestational diabetes increases the risk of postnatal morbidity in infants. Cree First Nations in Quebec are at high risk for diabetes in pregnancy. We assessed whether pre-gestational or gestational diabetes may increase infant hospitalisation (an infant morbidity indicator) incidence, and whether this may be related to more frequent infant hospitalisations in Cree and other First Nations in Quebec. DESIGN: Population-based birth cohort study through administrative health data linkage. SETTING AND PARTICIPANTS: Singleton infants (≤1 year) born to mothers in Cree (n=5070), other First Nations (9910) and non-Indigenous (48 200) communities in rural Quebec. RESULTS: Both diabetes in pregnancy and infant hospitalisation rates were much higher comparing Cree (23.7% and 29.0%) and other First Nations (12.4% and 34.1%) to non-Indigenous (5.9% and 15.5%) communities. Compared with non-diabetes, pre-gestational diabetes was associated with an increased risk of any infant hospitalisation to a greater extent in Cree and other First Nations (relative risk (RR) 1.56 (95% CI 1.28 to 1.91)) than non-Indigenous (RR 1.26 (1.15 to 1.39)) communities. Pre-gestational diabetes was associated with increased risks of infant hospitalisation due to diseases of multiple systems in all communities. There were no significant associations between gestational diabetes and risks of infant hospitalisation in all communities. The population attributable risk fraction of infant hospitalisations (overall) for pre-gestational diabetes was 6.2% in Cree, 1.6% in other First Nations and 0.3% in non-Indigenous communities. CONCLUSIONS: The study is the first to demonstrate that pre-gestational diabetes increases the risk of infant hospitalisation overall and due to diseases of multiple systems, but gestational diabetes does not. High prevalence of pre-gestational diabetes may partly account for the excess infant hospitalisations in Cree and other First Nations communities in Quebec.

Access, Utilization, and Quality of Behavioral Health Integration in Medicaid Managed Care.

Importance: Many states have moved from models that carve out to those that carve in or integrate behavioral health in their Medicaid managed care organizations (MCOs), but little evidence exists about the effect of this change. Objective: To assess the association of the transition to integrated managed care (IMC) in Washington Medicaid with health services use, quality, health-related outcomes, and measures associated with social determinants of health. Design, Setting, and Participants: This cohort study used difference-in-differences analyses of Washington State's 2014 to 2019 staggered rollout of IMC on claims-based measures for enrollees in Washington's Medicaid MCO. It was supplemented with interviews of 24 behavioral health agency leaders, managed care administrators, and individuals who were participating in the IMC transition. The data were analyzed between February 1, 2023, and September 30, 2023. Main Outcomes and Measures: Claims-based measures of utilization (including specialty mental health visits and primary care visits); health-related outcomes (including self-harm events); rates of arrests, employment, and homelessness; and additional quality measures. Results: This cohort study included 1 454 185 individuals ages 13 to 64 years (743 668 female [51.1%]; 14 306 American Indian and Alaska Native [1.0%], 132 804 Asian American and Pacific Islander [9.1%], 112 442 Black [7.7%], 258 389 Hispanic [17.8%], and 810 304 White [55.7%] individuals). Financial integration was not associated with changes in claims-based measures of utilization and quality. Most claims-based measures of outcomes were also unchanged, although enrollees with mild or moderate mental illness experienced a slight decrease in cardiac events (-0.8%; 95% CI, -1.4 to -0.2), while enrollees with serious mental illness experienced small decreases in employment (-1.2%; 95% CI -1.9 to -0.5) and small increases in arrests (0.5%; 95% CI, 0.1 to 1.0). Interviews with key informants suggested that financial integration was perceived as an administrative change and did not have substantial implications for how practices delivered care; behavioral health agencies lacked guidance on how to integrate care in behavioral health settings and struggled with new contracts and regulatory policies that may have inhibited the ability to provide integrated care. Conclusions and Relevance: The results of this cohort study suggest that financial integration at the MCO level was not associated with significant changes in most measures of utilization, quality, outcomes, and social determinants of health. Additional support, including monitoring, training, and funding, may be necessary to drive delivery system changes to improve access, quality, and outcomes.

New Opportunities to Strengthen Medicaid Managed Care Network Adequacy Standards.

This Viewpoint discusses new standards proposed by the Centers for Medicare & Medicaid Services for ensuring that Medicare managed care networks meet enrollees' needs.

Postburn breast reconstruction: a scoping review.

Introduction: Postburn breast deformities pose functional and aesthetic concerns for burn patients, particularly when injury occurs before puberty, as normal breast development may be hindered. Postburn breast reconstruction aims at restoration of native anatomic features, as well as re-establishment of symmetry. The objectives of this scoping review are to map the literature on scar management and breast reconstruction, highlighting strategies that are particular to postburn deformities, as well as to establish optimal timing principles. Methods: A comprehensive search of the English literature across MEDLINE and EMBASE databases, including the grey literature, was conducted. Literature of all study designs were eligible, provided it discussed the treatment of postburn breast deformities. Results: A total of 64 studies were included. The most common study design was case series (58%) followed by retrospective cohorts (28%). Scar contracture release with split thickness skin grafts (26%) and various techniques for nipple-areola reconstruction (22%) were the most common reconstructive procedures. Discussion: Scar contracture releases predominate when there is normal breast development under a contracted skin envelope, and should be performed as soon as breast mound development is restricted. Surgical techniques widely used for postmastectomy reconstruction are required for patients with amastia or hypoplastic breasts. Conclusion: Given the heterogeneity of defects, availability of donor sites, and patient preference, no standardized guideline is available. Surgeons should combine basic scar management principles with postmastectomy techniques, adapting the surgical approach to features that are particular to thermally injured patients, as well as taking into account ideal timing considerations. Lay Summary: Breast deformities secondary to burn scars pose functional and aesthetic concerns for burn patients, particularly when injury occurs before puberty, as normal breast development may be hindered. Postburn breast reconstruction aims at restoration of native anatomic features, as well as re-establishment of symmetry. This literature review aimed at summarizing the available techniques to treat postburn breast deformities, as well as establishing optimal timing guidelines, given these issues may occur at any phase of breast development. When there is breast development under a scarred skin envelope, treatment entails scar contracture release and should be recommended as soon as the diagnosis is established, in order to allow the breast to further develop in an unrestricted manner. When there is absence of breast tissue, surgical techniques widely utilized for breast cancer reconstruction are warranted, and should be delayed until no further breast development is expected. Given the heterogeneity of deformities, availability of donor sites, and patience preference, no standardized guideline is available. Treatment options include several surgical techniques, in addition to non-surgical scar management, and timing considerations must take into account the patient's developmental phase and psychosocial wellness.

Psychiatrist Networks In Medicare Advantage Plans Are Substantially Narrower Than In Medicaid And ACA Markets.

Medicare Advantage now covers twenty-eight million older adults, many of whom have mental health needs. Enrollees are often restricted to providers who participate in a health plan's network, which may present a barrier to care. We used a novel data set linking network service areas, plans, and providers to compare psychiatrist network breadth-the percentage of providers in a given area that are considered "in network" for a plan-across Medicare Advantage, Medicaid managed care, and Affordable Care Act plan markets. We found that nearly two-thirds of psychiatrist networks in Medicare Advantage were narrow (that is, they contained fewer than 25 percent of providers in a network's service area) compared with approximately 40 percent in Medicaid managed care and Affordable Care Act plan markets. We did not observe similar differences in network breadth for primary care physicians or other physician specialists across markets. Amid efforts to strengthen network adequacy, our findings suggest that psychiatrist networks in Medicare Advantage are particularly narrow, which may disadvantage enrollees as they attempt to obtain mental health services.

Private equity in ophthalmology: taking the long view.

PURPOSE OF REVIEW: Private equity's momentum in eye care remains controversial, even as investment continues to hasten the consolidation of ophthalmology and optometry practices. In this review, we discuss the growing implications of private equity activity in ophthalmology, drawing on updated empirical findings from the literature. We also examine recent legal and policy efforts to address private equity investment in healthcare, with implications for ophthalmologists considering sales to private equity. RECENT FINDINGS: Concerns about private equity centres around evidence that some investment entities are not just valuable sources of capital or business expertise, but that they take outright ownership and control of acquired practices in order to drive high returns on investment. Although practices may receive considerable benefits from private equity investment, empirical evidence suggests that private equity's most consistent effect on acquired practices is to increase spending and utilization without commensurate benefits on patient health. Although data on workforce effects are limited, an early study on workforce composition changes in private equity-acquired practices demonstrates that physicians were more likely to enter and exit a given practice than their counterparts in nonacquired practices, suggesting some degree of workforce flux. State and federal oversight of private equity's impact on healthcare may be ramping up in response to these demonstrated changes. SUMMARY: Private equity will continue to broaden their footprint in eye care, necessitating ophthalmologists to take the long view of private equity's net effects. For practices considering a private equity sale, recent policy developments highlight the importance of identifying and vetting a well aligned investment partner, with safeguards to preserve clinical decision-making and physician autonomy.

Consent Practices for Assisted Vaginal Births (AVB) at Two Tertiary Care Hospitals: A Retrospective Review of Physician Documentation.

OBJECTIVE: To determine whether assisted vaginal birth (AVB) consent documentation, a surrogate for in vivo consent, aligns with Canadian practice guidelines at 2 Canadian tertiary-level obstetric centres. METHODS: This was a retrospective review of AVBs (vacuum and forceps) from July 2019 to December 2019 at 2 tertiary-level hospitals with template-based (Site 1) or dictation-based (Site 2) documentation. We extracted, from obstetric and neonatal charts, AVB type, physician and documenter types (resident/fellow/family doctor/generalist obstetrics and gynecology [OBGYN]/maternal-fetal medicine), and consent elements (present/absent) based on a predetermined checklist. Data were summarized and comparisons were made using chi-square test, Fisher exact test, and logistic regression, where appropriate. RESULTS: We identified 551 AVBs (156 forceps, 395 vacuum) with most documentation completed by generalist OBGYNs or residents (333/551, 60.5%). Most vacuum-assisted deliveries documented no specific maternal (366/395, 92.7%) or neonatal (364/395, 92.2%) risks, and 107/156 (68.6%) and 106/156 (67.9%) forceps-assisted deliveries lacked specific documentation of maternal and neonatal risk, respectively. At Site 2, postpartum hemorrhage risk at vacuum-assisted deliveries was more commonly documented (6/90 [6.7%] vs. 2/395 [0.7%], P = 0.002) as was at least 1 neonatal risk and risk of obstetrical anal sphincter injury at forceps-assisted deliveries (50/133 [37.6%] vs. 0/23 [0%], P < 0.001) and (43/133 [32.3%] vs. 0/23 [0%], P = 0.001), respectively. CONCLUSIONS: Opportunity to improve AVB consent documentation exists, warranting quality improvement initiatives.