Beneficiary Experience of Care by Level of Integration in Dual Eligible Special Needs Plans.

Importance: Dual Eligible Special Needs Plans (D-SNPs) are private managed care plans designed to promote Medicare and Medicaid integration for full-benefit, dually eligible beneficiaries. Currently, the highest level of D-SNP integration occurs in plans with exclusively aligned enrollment (EAE). Objective: To compare patient experience of care, out-of-pocket spending, and satisfaction among dually enrolled Medicaid beneficiaries in D-SNPs with EAE, those in D-SNPs without EAE, and those with traditional Medicare. Design, Setting, and Participants: This cross-sectional study included respondents to a mail survey fielded to a stratified random sample of full-benefit, community-dwelling, dual-eligible Medicaid beneficiaries who qualified for receipt of home and community-based services in the Virginia Medicaid Commonwealth Coordinated Care Plus program between March and October 2022. Exposure: Enrollment in a D-SNP with EAE or a D-SNP without EAE vs traditional Medicare. Main Outcomes and Measures: The main outcomes were self-reported measures of access and delays in receiving plan approvals, out-of-pocket spending, and satisfaction with health plans' customer service and choice of primary care and specialist physicians. Results: Of 7200 surveys sent, 2226 were completed (response rate, 30.9%). The analytic sample consisted of 1913 Medicaid beneficiaries with nonmissing data on covariates (mean [SD] age, 70.8 [15.6] years; 1367 [71.5%] female). Of these, 583 (30.5%) were enrolled in D-SNPs with EAE, 757 (39.6%) in D-SNPs without EAE, and 573 (30.0%) in traditional Medicare. Compared with respondents enrolled in D-SNPs without EAE, those in D-SNPs with the highest level of integration (EAE) were 6.77 percentage points (95% CI, 8.81-12.66 percentage points) more likely to report being treated with courtesy and respect and 5.83 percentage points (95% CI, 0.21-11.46 percentage points) more likely to know who to call when they had a health problem. No statistically significant differences were found between members in either type of D-SNP and between those in D-SNPs and traditional Medicare in terms of their difficulty accessing care, delays in care, and satisfaction with care coordination and physician choice. Conclusions and Relevance: This cross-sectional study found some benefits of integrating administrative processes under Medicare and Medicaid but suggests that care coordination and access improvements under full integration require additional time and/or efforts to achieve.

Is primary care ready for a potential new public health emergency in the wake of the COVID-19 pandemic, now subsided?

INTRODUCTION: The lingering burden of the COVID-19 pandemic on primary care clinicians and practices poses a public health emergency for the United States. This study uses clinician-reported data to examine changes in primary care demand and capacity. METHODS: From March 2020 to March 2022, 36 electronic surveys were fielded among primary care clinicians responding to survey invitations as posted on listservs and identified through social media and crowd sourcing. Quantitative and qualitative analyses were performed on both closed- and open-ended survey questions. RESULTS: An average of 937 respondents per survey represented family medicine, pediatrics, internal medicine, geriatrics, and other specialties. Responses reported increases in patient health burden, including worsening chronic care management and increasing volume and complexity. A higher frequency of dental- and eyesight-related issues was noted by respondents, as was a substantial increase in mental or emotional health needs. Respondents also noted increased demand, "record high" wait times, and struggles to keep up with patient needs and the higher volume of patient questions. Frequent qualitative statements highlighted the mismatch of patient needs with practice capacity. Staffing shortages and the inability to fill open clinical positions impaired clinicians' ability to meet patient needs and a substantial proportion of respondents indicated an intention to leave the profession or knew someone who had. CONCLUSION: These data signal an urgent need to take action to support the ability of primary care to meet ongoing patient and population health care needs.

Changes in buprenorphine waivered provider supply after Virginia Medicaid implements the addiction and recovery treatment services program and Medicaid expansion.

BACKGROUND: Shortages of providers authorized to prescribe buprenorphine may limit access to buprenorphine, which studies have shown to be effective in the treatment of opioid use disorder (OUD). OBJECTIVE: To examine whether two state Medicaid policies in Virginia-the Addiction and Recovery Treatment Services (ARTS) program in 2017, and Medicaid expansion in 2019-increased the number of buprenorphine waivered providers (BWP) in Virginia, compared to other southern states in the United States that did not expand Medicaid. METHODS: The study population includes providers authorized to prescribe buprenorphine. We compute the number of BWP per 100,000 people for the study states, overall and for different waiver limits (30, 100 or 275). Using difference-in-difference regression models, we examine changes in BWP rates for Virginia relative to nonexpansion states in the US South between 2015 and 2020. RESULTS: The rate of increase in BWP was higher in Virginia after implementation of ARTS and Medicaid expansion (148 %), compared to southern nonexpansion states over the same time period (115 %). Relative to nonexpansion states in the South, BWP with patient limits of 100 or 275 increased by 7 % in Virginia after ARTS implementation in 2017, and by an additional 22 % after Medicaid expansion in 2019 (p < 0.05 each). CONCLUSIONS: The findings suggest that public policies that expand access to OUD treatment services-including buprenorphine treatment-may also increase the supply of providers authorized to prescribe buprenorphine, helping to alleviate shortages of BWP providers and further increasing access to care.

Postpartum medication for opioid use disorder outcomes associated with prenatal treatment and neighborhood-level social determinants.

BACKGROUND: Opioid use disorder is a leading cause of death through the year postpartum. OBJECTIVE: This study aimed to identify the association of neighborhood-level social determinants of health and prenatal opioid use disorder treatment receipt with the outcomes of medication treatment for opioid use disorder through the year postpartum among a cohort of birthing people. STUDY DESIGN: This was a population-based retrospective cohort study that used state Medicaid claims and enrollment data for the 1690 individuals who delivered a live infant between July 1, 2016 and December 31, 2020 and received medication for opioid use disorder at delivery. The primary exposure was the state Health Opportunity Index, a composite measure of social determinants of health linked at the census-tract level. Secondary exposures included comprehensiveness of opioid use disorder treatment and duration of medication treatment for opioid use disorder received prenatally. Outcomes included the duration and continuity of postpartum medication treatment for opioid use disorder, operationalized as the time from delivery to the discontinuation of medication treatment for opioid use disorder, and percentage of days covered by medication treatment for opioid use disorder within the 12 months after delivery, respectively. RESULTS: Within the study sample, 711 deliveries were to birthing people in the lowest state Health Opportunity Index tercile (indicating high burden of negative social determinants of health), 647 in the middle state Health Opportunity Index tercile, and 332 in the highest state Health Opportunity Index tercile. Using stepwise multivariable regression (Cox proportional hazards and negative binomial models) guided by a socioecological framework, prenatal receipt of more comprehensive opioid use disorder treatment and/or longer duration of prenatal medication treatment for opioid use disorder was associated with improved 1-year postpartum opioid use disorder treatment outcomes (duration and continuity of medication treatment for opioid use disorder). When the state Health Opportunity Index was added to the models, these significant associations remained stable, with the state Health Opportunity Index not demonstrating an association with the outcomes (duration hazard ratio, 1.39; 95% confidence interval, 0.551-3.512; continuity relative risk, 1.024; 95% confidence interval, 0.323-3.247). CONCLUSION: Targeted efforts at expanding access to and quality of evidence-based opioid use disorder treatments for reproductive-age people across the life course should be prioritized within the spectrum of work aimed at eradicating disparities in pregnancy-related mortality.

Associations between blood pressure control and clinical events suggestive of nutrition care documented in electronic health records of patients with hypertension.

BACKGROUND: Clinical events suggestive of nutrition care found in electronic health records (EHRs) are rarely explored for their associations with hypertension outcomes. METHODS: Longitudinal analysis using structured EHR data from primary care visits at a health system in the US from December 2017-December 2020 of adult patients with hypertension (n = 4,237) tested for associations between last visit blood pressure (BP) control (≤ 140 Systolic BP and ≤ 90 Diastolic BP) and ≥ 1 nutrition care clinical event operationalized as (overweight or obesity (BMI > 25 or 30, respectively) diagnoses, preventive care visits, or provision of patient education materials (PEM)). Descriptive statistics and longitudinal targeted maximum likelihood estimation (LTMLE) models were conducted to explore average treatment effects (ATE) of timing and dose response from these clinical events on blood pressure control overall and by race. RESULTS: The median age was 62 years, 29% were male, 52% were Black, 25% were from rural areas and 50% had controlled BP at baseline. Annual documentation of overweight/obesity diagnoses ranged 3.0-7.8%, preventive care visits ranged 6.2-15.7%, and PEM with dietary and hypertension content were distributed to 8.5-28.8% patients. LTMLE models stratified by race showed differences in timing, dose, and type of nutrition care. Black patients who had nutrition care in Year 3 only compared to none had lower odds for BP control (ATE -0.23, 95% CI: -0.38,-0.08, p = 0.003), preventive visits in the last 2 years high higher odds for BP control (ATE 0.31, 95% CI: 0.07,0.54, p = 0.01), and early or late PEMs had lower odds for BP control (ATE -0.08, 95% CI: -0.15,-0.01, p = 0.03 and ATE -0.23, 95% CI: -0.41,-0.05, p = 0.01, respectively). CONCLUSIONS: In this study, clinical events suggestive of nutrition care are significantly associated with BP control, but are infrequent and effects differ by type, timing, and patient race. Preventive visits appear to have the most effect; additional research should include examining clinical notes for evidence of nutrition care among different populations, which may uncover areas for improving nutrition care for patients with chronic disease.

Telemedicine in Primary Care: Lessons Learned About Implementing Health Care Innovations During the COVID-19 Pandemic.

PURPOSE: During the COVID-19 pandemic, telemedicine emerged as an important tool in primary care. Technology and policy-related challenges, however, revealed barriers to adoption and implementation. This report describes the findings from weekly and monthly surveys of primary care clinicians regarding telemedicine during the first 2 years of the pandemic. METHODS: From March 2020 to March 2022, we conducted electronic surveys using convenience samples obtained through social networking and crowdsourcing. Unique tokens were used to confidentially track respondents over time. A multidisciplinary team conducted quantitative and qualitative analyses to identify key concepts and trends. RESULTS: A total of 36 surveys resulted in an average of 937 respondents per survey, representing clinicians from all 50 states and multiple specialties. Initial responses indicated general difficulties in implementing telemedicine due to poor infrastructure and reimbursement mechanisms. Over time, attitudes toward telemedicine improved and respondents considered video and telephone-based care important tools for their practice, though not a replacement for in-person care. CONCLUSIONS: The implementation of telemedicine during COVID-19 identified barriers and opportunities for technology adoption and highlighted steps that could support primary care clinics' ability to learn, adapt, and implement technology.

Associations between Blood Pressure Control and Documented Nutrition Care Using Structured Data from Electronic Health Records of Patients with Hypertension.

Background: Documentation in Electronic Health Records (EHRs) of nutrition care events (overweight or obesity (BMI > 25 or 30, respectively) diagnoses, preventive care visits, or provision of patient education materials (PEM)) for chronic diseases is unclear. Methods: Cross-sectional analysis using structured EHR data from primary care visits at a health system in the US from January 2018 - December 2020 of adult patients with hypertension (n = 6,419) tested for associations between last visit blood pressure (BP) control (≤ 140 Systolic BP and ≤ 90 Diastolic BP) and aggregate nutrition care events. Descriptive statistics and multiple logistic regression models were constructed to examine the predictive power of nutrition care events for blood pressure control. Results: The median age was 62 years, 32% were male, 48% were Black, 26% were from rural areas and 35.9% had controlled BP at last visit. For the 62% of patients with documented nutrition care, 14.6% had an overweight/obesity diagnosis, 26.2% had a preventive care visit, and 42% received PEM with dietary and hypertension content. The models showed patients who had more preventive care visits (aOR 1.12; CL 1.06, 1.18) had higher odds for BP control. Whereas Black patients compared with white patients (aOR 0.84; CL 0.74, 0.95), those with more hypertension medications (aOR 0.97; CL 0.96, 0.99) and more primary care visits over the study period (aOR 0.98; CL 0.97, 0.99) had lower odds for BP control. Conclusions: In this study, documented nutrition care in preventive care visits is significantly associated with BP control, but documentation is infrequent. Additional research should include examining clinical notes for evidence of nutrition care, which may uncover areas that show promise for improving nutrition care for patients with chronic disease.

Use of Home and Community-Based Services After Implementation of Medicaid Managed Long Term Services and Supports in Virginia.

Many state Medicaid programs contract with managed care organizations to deliver long-term services and supports (LTSS) to seniors and persons with disabilities. Managed LTSS (MLTSS) programs are often intended to increase access to and utilization of home- and community-based services (HCBS), yet there are few empirical studies of their effects. In this retrospective observational study, we used administrative data from Virginia Medicaid to compare HCBS waiver enrollment and service utilization pre- and post-implementation of MLTSS. Compared to the prior fee-for-service system, Medicaid beneficiaries with long-term care needs who were enrolled in Virginia's MLTSS program were more likely to be enrolled in Virginia's 1915(c) waivers for home and community-based services. Further, the likelihood of using personal care increased by nearly 5%, and the likelihood of using respite care increased by about 10%. These findings are pertinent to ongoing policy changes that use private managed care organizations to deliver long-term services and supports to seniors and persons with disabilities. Policymakers in states and the federal government should note these initial increases in service use under Medicaid MLTSS, while supporting evaluations of the long-term impacts of MLTSS on HCBS use and beneficiary health and satisfaction.

Disparities in opioid use disorder-related hospital use among postpartum Virginia Medicaid members.

INTRODUCTION: The overdose crisis is increasingly revealing disparities in opioid use disorder (OUD) outcomes by race and ethnicity. Virginia, like other states, has witnessed drastic increases in overdose deaths. However, research has not described how the overdose crisis has impacted pregnant and postpartum Virginians. We report the prevalence of OUD-related hospital use during the first year postpartum among Virginia Medicaid members in the years preceding the COVID-19 pandemic. We secondarily assess how prenatal OUD treatment is associated with postpartum OUD-related hospital use. METHODS: This population-level retrospective cohort study used Virginia Medicaid claims data for live infant deliveries between July 2016 and June 2019. The primary outcome of OUD-related hospital use included overdose events, emergency department visits, and acute inpatient stays. Independent variables of interest were prenatal receipt of medication for OUD (MOUD) and receipt of non-MOUD treatment components in line with a comprehensive care approach (e.g., case management, behavioral health). Both descriptive and multivariate analyses were performed for all deliveries and stratified by White and Black non-Hispanic individuals to bring attention to the devastating impacts of the overdose crisis within communities of color. RESULTS: The study sample included 96,649 deliveries. Over a third were by Black birthing individuals (n = 34,283). Prenatally, 2.5 % had evidence of OUD, which occurred more often among White (4 %) than Black (0.8 %) non-Hispanic birthing individuals. Postpartum OUD-related hospital use occurred in 10.7 % of deliveries with OUD, more commonly after deliveries by Black, non-Hispanic birthing individuals with OUD (16.5 %) than their White, non-Hispanic counterparts (9.7 %), and this disparity persisted in the multivariable analysis (Black AOR 1.64, 95 % CI 1.14-2.36). Postpartum OUD-related hospital events were less frequent for individuals receiving versus not receiving postpartum MOUD within 30 days prior to the event. Prenatal OUD treatment, including MOUD, was not associated with decreased odds of postpartum OUD-related hospital use in the race-stratified models. CONCLUSION: Postpartum individuals with OUD are at high risk for mortality and morbidity, especially Black individuals not receiving MOUD after delivery. An urgent need remains to effectively address the systemic and structural drivers of racial disparities in transitions of OUD care through the one-year postpartum period.

Primary Care: A Critical Stopgap of Mental Health Services During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic resulted in a worsening mental health crisis, while also dramatically reducing access to in-person primary care services. Primary care, an essential provider of mental health services, rapidly adopted telemedicine to address behavioral health needs. Here we examine the provision of mental health services by primary care during the pandemic, including the essential use of telemedicine. METHODS: Data were collected via a series of national, cross-sectional surveys of primary care clinicians in November 2020 by the Larry A. Green Center. The survey was distributed through a network of partner organizations and subscribers. Descriptive and chi squared analysis were utilized. RESULTS: Among 1,472 respondents, 88% reported increased mental health needs and 37% reported higher rates of substance use among patients. Most (65%) clinicians became more involved in providing mental health support, and 64% reported using telemedicine to provide behavioral health services. Phone-based care was more common for care delivery among patients who were uninsured (60% vs 42%, P < .01), Medicare beneficiaries (45% vs 36%, P < .05), non-English speaking (67% vs 40%, P < .001), and racial and ethnic minorities (58% vs 34%, P < .001). CONCLUSIONS: Primary care is a leading provider of mental health services and has played a critical role during the pandemic. Primary care clinicians have strong relationships with their patients as well as outreach within communities that may otherwise struggle to access mental health services. The use of telemedicine in primary care, and specifically phone-based services, has been an essential tool to providing equitable access to mental health services.

Medicaid participation among practitioners authorized to prescribe buprenorphine.

INTRODUCTION: This study examines Medicaid participation among buprenorphine waivered providers in Virginia in 2019, with a particular focus on the prescribing differences between different physician specialties, nurse practitioners and physicians assistants (NP and PA). METHODS: Secondary data sources include the 2019 DEA list of buprenorphine waivered prescribers, Virginia Medicaid claims for buprenorphine, physician characteristics from the Virginia Department of Health Professions, SAMHSA Behavioral Treatment Services Locator, and area level characteristics. This cross-sectional study is based on a linkage of Medicaid claims data to a list of Virginia practitioners authorized to prescribe buprenorphine in 2019. Using a two-part logistic regression, we assess prescriber license type and local area factors that are associated with: (1) the probability of prescribing buprenorphine to any Medicaid patients in 2019; (2) the number of Medicaid patients treated by each prescriber in 2019. RESULTS: Adjusted odds ratios show that nurse practitioners with buprenorphine waivers are more likely to treat any Medicaid patients compared to physicians (odds ratio (OR), 2.016; p = 0.000). Among prescribers who treated any Medicaid patients, the probability of treating a large number of Medicaid patients was higher among nurse practitioners relative to physicians (OR, 2.869, p = 0.002). Medicaid participation was much higher among prescribers with patient limits of 100 and 275 compared to prescribers with patient limits of 30 (OR, 6.66, p = 0.000 and 29.40, p = 0.000, respectively). CONCLUSIONS: State Medicaid programs have been at the forefront of addressing their state's opioid epidemic, including expanding access to buprenorphine treatment. This study provides evidence that targeted outreach efforts should include NP license types as well as physicians, and is consistent with prior studies showing that NP are especially important in filling treatment gaps for underserved areas and populations.

COVID-19 and Telehealth Operations in Texas Primary Care Clinics: Disparities in Medically Underserved Area Clinics.

The COVID-19 pandemic has dramatically altered the landscape of health care delivery, prompting a rapid, widespread adoption of telehealth in primary care practices. Using a pooled sample of 1,344 primary care clinics in Texas, we examined the adoption of telehealth in Texas during the initial months of the COVID-19 pandemic, by comparing medically underserved area (MUA) clinics and non-medically underserved area (non-MUA) clinics. Our analysis suggests that compared with MUA clinics, clinics in non-MUAs were more likely to conduct a majority of their visits via telehealth before May 1st, 2020. However, later surveys indicated that differences in telehealth use between MUA and non-MUA clinics lessened, suggesting that some of the barriers that MUA clinics initially faced might have resolved over time. This research provides an additional perspective in discussions about telehealth adoption on a widespread, permanent basis in Texas and the U.S.

Hospital Use Declines After Implementation Of Virginia Medicaid's Addiction And Recovery Treatment Services.

Medicaid programs responded to the opioid crisis by expanding treatment coverage and reforming delivery systems. We assessed whether Virginia's Addiction and Recovery Treatment Services (ARTS) program, implemented in April 2017, influenced emergency department and inpatient use. Using claims for January 2016-June 2018 and difference-in-differences models, we compared beneficiaries with opioid use disorder before and after ARTS implementation to beneficiaries with no substance use disorder. After program implementation, the likelihood of having an emergency department visit in a quarter declined by 9.4 percentage points (a 21.1 percent relative decrease) among beneficiaries with opioid use disorder, compared to 0.9 percentage points among beneficiaries with no substance use disorder. Similarly, the likelihood of having an inpatient hospitalization declined among beneficiaries with opioid use disorder. In contrast to other states, Virginia has a new Medicaid expansion population whose beneficiaries enter a delivery system in which reforms of the addiction treatment system are well under way.

Identifying Future High Cost Individuals within an Intermediate Cost Population.

BACKGROUND: Improving health and controlling healthcare costs requires better tools for predicting future health needs across populations. We sought to identify factors associated with transitioning of enrollees in an indigent care program from an intermediate cost segment to a high cost segment of this population. METHODS: We analyzed data from 9,624 enrollees of the Virginia Coordinated Care program between 2010 and 2013. Each fiscal year included all enrollees who were classified in intermediate cost segment in the preceding year and also enrolled in the program in the following year. Using information from the preceding year, we built logistic regression models to identify the individuals in the top 10% of expenditures in the following year. The effect of demographics, count of chronic conditions, presence of the prevalent chronic conditions, and utilization indicators were evaluated and compared. Models were compared via the Bayesian information criterion and c-statistic. RESULTS: The count of chronic conditions, diagnosis of congestive heart failure, and numbers of total hospital visits and prescriptions were significantly and independently associated with being in the future high cost segment. Overall, the model that included demographics and utilization indicators had a reasonable discrimination (c=0.67). CONCLUSIONS: A simple model including demographics and health utilization indicators predicted high future costs. The count of chronic conditions and certain medical diagnoses added additional predictive value. With further validation, the approach could be used to identify high-risk individuals and target interventions that decrease utilization and improve health.