Effects of Medicaid managed care on early detection of cancer: Evidence from mandatory Medicaid managed care program in Pennsylvania.

OBJECTIVE: To examine changes in late- versus early-stage diagnosis of cancer associated with the introduction of mandatory Medicaid managed care (MMC) in Pennsylvania. DATA SOURCES AND STUDY SETTING: We analyzed data from the Pennsylvania cancer registry (2010-2018) for adult Medicaid beneficiaries aged 21-64 newly diagnosed with a solid tumor. To ascertain Medicaid and managed care status around diagnosis, we linked the cancer registry to statewide hospital-based facility records collected by an independent state agency (Pennsylvania Health Care Cost Containment Council). STUDY DESIGN: We leveraged a natural experiment arising from county-level variation in mandatory MMC in Pennsylvania. Using a stacked difference-in-differences design, we compared changes in the probability of late-stage cancer diagnosis among those residing in counties that newly transitioned to mandatory managed care to contemporaneous changes among those in counties with mature MMC programs. DATA COLLECTION/EXTRACTION METHODS: N/A. PRINCIPAL FINDINGS: Mandatory MMC was associated with a reduced probability of late-stage cancer diagnosis (-3.9 percentage points; 95% CI: -7.2, -0.5; p = 0.02), particularly for screening-amenable cancers (-5.5 percentage points; 95% CI: -10.4, -0.6; p = 0.03). We found no significant changes in late-stage diagnosis among non-screening amenable cancers. CONCLUSIONS: In Pennsylvania, the implementation of mandatory MMC for adult Medicaid beneficiaries was associated with earlier stage of diagnosis among newly diagnosed cancer patients with Medicaid, especially those diagnosed with screening-amenable cancers. Considering that over half of the sample was diagnosed with late-stage cancer even after the transition to mandatory MMC, Medicaid programs and managed care organizations should continue to carefully monitor receipt of cancer screening and design strategies to reduce barriers to guideline-concordant screening or diagnostic procedures.

Risk of Hospitalization Associated with Use of Consumer-Directed Attendant Care.

Older people with disabilities living independently often use attendant care, also known as Personal Assistive Services (PAS). The aides providing care can come from a home health agency contracted by the state Medicaid authority, known as agency-directed PAS, or the Medicaid recipient can receive a monthly budget and arrange their own care, known as consumer-directed care. Consumer-directed care is hypothesized to have some possible benefits but could also potentially lead to health hazards. This study examined whether people receiving consumer-directed PAS versus people receiving agency-directed PAS faced a higher risk of hospitalization. The data for this study came from Pennsylvania Medicaid claims, enrollment files, standardized assessments, and hospitalization claims from Medicare and Medicaid. The analysis used two-stage least square regression, with the percentage of people in a county using consumer-directed care as an instrument for the type of PAS. People using consumer-directed care did not have a statistically significant difference in risk for hospitalization compared to people using agency-directed PAS (p = .976). Risk of hospitalization was not different for people using consumer-directed care compared to people using agency-directed care.

Association of Medicare eligibility with access to and affordability of care among older cancer survivors.

PURPOSE: Older cancer survivors have substantial needs for ongoing care, but they may encounter difficulties accessing care due to cost concerns. We examined whether near-universal insurance coverage through Medicare-a key source of health insurance coverage in this population-is associated with improvements in care access and affordability among older cancer survivors around age 65. METHODS: In a nationally representative sample of cancer survivors (aged 50-80) from 2006-2018 National Health Interview Survey, we employed a quasi-experimental, regression discontinuity design to estimate changes in insurance coverage, delayed/skipped care due to cost, and worries about or problems paying medical bills at age 65. RESULTS: Medicare coverage sharply increased from 8.3% at age 64 to 98.2% at age 65, ensuring near-universal insurance coverage (99.5%). Medicare eligibility at age 65 was associated with reductions in delayed/skipped care due to cost (discontinuity, - 5.7 percentage points or pp; 95% CI, - 8.1, - 3.3; P < .001), worries about paying for medical bills (- 7.7 pp; 95% CI, - 12.0, - 3.2; P = .001), and problems paying medical bills (- 3.2 pp; 95% CI, - 6.1, - 0.2; P = .036). However, a sizable proportion reported any access or affordability problems (29.7%) between ages 66 and 80. CONCLUSIONS: Near-universal Medicare coverage at age 65 was associated with a reduction-but not elimination-of access and affordability problems among cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS: These findings reaffirm the role of Medicare in improving access and affordability for older cancer survivor and highlight opportunities for reforms to further alleviate financial burden of care in this population.

Supplemental Oxygen Therapy in Interstitial Lung Disease: A Narrative Review.

Patients with interstitial lung diseases (ILD) often have hypoxemia at rest and/or with exertion, for which supplemental oxygen is commonly prescribed. The number of patients with ILD who require supplemental oxygen is unknown, although estimates suggest it could be as much as 40%; many of these patients may require high-flow support (>4 L/min). Despite its frequent use, there is limited evidence for the impact of supplemental oxygen on clinical outcomes in ILD, with recommendations for its use primarily based on older studies in patients with chronic obstructive pulmonary disease. Oxygen use in ILD is rarely included as an outcome in clinical trials. Available evidence suggests that supplemental oxygen in ILD may improve quality of life and some exercise parameters in patients whose hypoxemia is a limiting factor; however, oxygen therapy also places new burdens and barriers on some patients that may counter its beneficial effects. The cost of supplemental oxygen in ILD is also unknown but likely represents a significant portion of overall healthcare costs in these patients. Current Centers for Medicare and Medicaid reimbursement policies provide only a modest increase in payment for high oxygen flows, which may negatively impact access to oxygen services and equipment for some patients with ILD. Future studies should examine clinical and quality-of-life outcomes for oxygen use in ILD. In the meantime, given the current limited evidence for supplemental oxygen and considering cost factors and other barriers, providers should take a patient-focused approach when considering supplemental oxygen prescriptions in patients with ILD.

Risk of hospitalization associated with different constellations of home & community based services.

BACKGROUND: Identify the association between specific combinations of home and community-based services (HCBS) and risk of acute hospitalization. METHODS: Data for this study came from Pennsylvania Medicaid claims and Medicare records. This was a retrospective, observational cohort study that examined hospitalization, HCBS service use and patient characteristics between July, 2014 and December, 2016. This analysis compared risk of inpatient hospitalization risk for community dwelling disabled older adults using a range of Medicaid financed HCBS. Twelve constellations of HCBS were identified representing different combinations of common services (personal assistive services [PAS], delivered meals, and adult day care). Since HCBS users are not randomly assigned to different combinations of services, we used logistic regression to estimate the predicted probability of experiencing hospitalization conditional on the constellation of services, and adjusting for demographics, health and level of disability. RESULTS: The most common constellation was people who used under four hours of PAS per person per day. This group experienced a hospitalization rate of 13.7%. however, those individuals receiving more than 4 h per person per day experienced only a 10.2% hospitalization rate. Similar trends were seen for people who used PAS in combination with home delivered meals. However, those who used adult day care experienced higher hospitalization rates as the number of hours of personal assistive service increased: increasing from 6.8% among those with under 4 h, to 8.6% among those with 8 or more hours per person per day. CONCLUSION: Using medium and high levels of PAS was associated with lower hospitalization risk for people who PAS alone or in combination with delivered meals. By contrast, higher levels of PAS was associated with increased hospitalization for adult day users (both alone or in combination). Policy makers should consider offering higher levels of PAS to offset potential risk of hospitalization. Future research is needed to explain the association between adult day care and risk.

Virtual crossmatch for deceased donor kidney transplantation in the United States: A survey of histocompatibility lab directors and transplant surgeons.

Virtual crossmatch (VXM) is used as an alternative to or in conjunction with a cell-based physical crossmatch (PXM) for assessing HLA (human leukocyte antigen) compatibility prior to deceased donor kidney transplantation (DDKT). Data on practice patterns and perceptions regarding VXM use in the US are limited. We performed a survey of US HLA directors and transplant surgeons regarding HLA testing and crossmatch strategies. 53 (56 %) HLA directors and 68 surgeons (representing âˆ¼ 23 % of US transplant centers) completed the survey. Both groups agreed that VXM could reduce cold ischemia time (CIT), costs and improve allocation efficiency. VXM use increased following the 2021 kidney allocation change. Reducing CIT was the primary reason for favoring VXM over PXM. Preference for VXM reduced as candidates' panel reactive antibodies increased. Regulations, program policies and limitations of HLA technology were cited as important reasons for preferring PXM over VXM. Surgeons reported similar perceptions, but findings are limited by the low response rate. Finally, half the labs reported lacking specific protocols for VXM use. In conclusion, improved HLA technology and protocols along with changes to institutional procedures and policy regulations are needed for safer expansion of VXM in DDKT.

Patterns of Home and Community Based Service Use by Beneficiaries Enrolled in the Pennsylvania Medicaid Aging Waiver.

BACKGROUND: This study examines multiple services are used across a population and the association between type and amount of services use with level of disability and living arrangement. METHODS: This is a descriptive cross-sectional analysis examining HCBS use among older Pennsylvanians from 2014 to 2016 enrolled in Pennsylvania's 1915(c) waiver program. Data were derived from Medicaid claims. Logistic regression and OLS regression were used to examine the association between service use and level of disability, controlling for age, gender, race, and other covariates. RESULTS: People with Alzheimer's or a related dementia were more likely to use adult day care. People with higher ADL and IADL limitations were more likely to use higher amounts of PAS and less likely to have delivered meals. CONCLUSIONS: These findings demonstrate HCBS is a complex package of services that are allocated regarding the level of need and resources available to individual program participants.

Home- and Community-Based Provider Preparation for Pennsylvania's Managed Long-term Services and Supports.

As Pennsylvania implements its managed long-term services and supports program, we explore how home- and community-based providers are preparing for and perceiving the transition through an online survey. We summarize responses and conduct chi-square analysis to measure differences between select provider groups. Despite high levels of uncertainty about program impact, over 84% of respondents plan to participate. We found that providers in the first implementation phase had more strategic and operational discussions with MCOs than the other two phases (p < .03). As program rollout continues, we anticipate changes in MCO-provider conversation frequency and topics based upon implementation zone.

The Importance of Ascertaining Participant Preferences: The Importance of What Is Important.

Rosalie Kane made major contributions to research on ascertaining personal preferences. Her work influenced others and was part of a growing movement to place high priority on the voice and subjective experience of people who live with Long-Term Services and Supports (LTSS). This essay summarizes some highlights of Rosalie's research, and traces the idea of incorporating participant preferences through different programs, policies and measurement tools over the past three decades. The current policy environment takes as paramount the notion that participants in LTSS programs should have an active role in planning their own care. While language supporting preferences is not new, the technology to effectively and efficiently elicit preferences is relatively recent. Key milestones in the development of these policies are reviewed. Rosalie's influence on generations of researchers and policy makers cannot be understated. She challenged colleagues, state program agencies and program directors to consider "the art of the possible," pushing them to explore how LTSS could fully support the dignity, independence and autonomy of every participant. A remaining challenge for researchers, policy makers and program managers is to move beyond incorporating preferences and choices as outcomes, and develop methods to accountably and reliably measure and incorporate individual goals of care into LTSS care plans. As LTSS continues to shift more and more into home and community-based settings, the quality of care and the quality of life for people who rely on those services will demand more subtle and individualized measures of processes and outcomes.

The Patients Save Lives Program to Facilitate Organ Donor Designation in Primary Care Offices.

BACKGROUND: There are about 120 000 people on the US waiting list for a solid organ transplant; nearly 22 people die every day who could be helped through organ donation. Joining a donor registry and informing one's family of one's preferences increases recovery rates and can avoid misunderstandings during an emotionally difficult time. Although the vast majority of people support organ donation, only about half of adults have joined a state donor registry. Methods. A 3-group design was used. Primary care physician offices were randomly assigned to either web-based training, in-person training, or a control condition. The control condition consisted of a poster and traditional brochure and donor form placed in the waiting room. In the 2 intervention groups, the Patients Save Lives form was distributed during the check-in process in addition to the poster. RESULTS: A total of 1521 physicians and office staff at 81 clinic sites (48 in-person and 33 web-based) received the training; there were 33 control locations. A total of 21 189 patients were exposed to the intervention over a 6-month period; 761 (8.1%) of 9428 people who were not already registered completed the designation form to be organ donors. There were no donor designations in the control group locations. CONCLUSION: Organ donor designation can be incorporated into the office check-in procedure without disrupting the workflow or burdening clinicians. The program is available online and can be sustained inexpensively with cooperation between primary care offices and regional Organ Procurement Organizations.

Change in Functional Status After Prostate Cancer Treatment Among Medicare Advantage Beneficiaries.

OBJECTIVE: To examine the relationship between treatment and subsequent functional status among prostate cancer patients. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey data, we identified men 65 years or older diagnosed with prostate cancer between 1998 and 2009 (follow-up through 2010) who were treated with conservative management, surgery, or radiation. Our primary outcome was functional status as measured by activities of daily living. Secondary outcomes included physical component summary and mental component summary scores, which are both calculated from the Short Form 36 (SF-36) and the Veterans RAND 12-item health survey (VR-12) questionnaires. We included patients who completed 2 surveys and performed propensity score analyses to match patients 1:5 with noncancer controls. We used generalized linear mixed effects models, accounting for clustering due to insurance plan. RESULTS: We identified 408 patients of whom 143 (35%) underwent conservative management, 59 (14%) underwent surgery, and 206 (51%) underwent radiation. Among conservative management and radiation patients, changes in functional status mirrored that of their noncancer controls (all P > .05). Among surgery patients, changes in activities of daily living scores were not significant, but physical component summary (mean difference = 4.5, P < .001) and mental component summary (mean difference = 3.3, P = .01) scores declined slightly more than for their noncancer peers. CONCLUSION: Surgery patients had a slight decline in their general functional status whereas conservative management and radiation patients had no differences in functional status compared with their noncancer peers. Although the functional status of surgery patients declined more than that of their noncancer peers, this difference may not be clinically significant.

Broad Consent for Research on Biospecimens: The Views of Actual Donors at Four U.S. Medical Centers.

Commentators are concerned that broad consent may not provide biospecimen donors with sufficient information regarding possible future research uses of their tissue. We surveyed with interviews 302 cancer patients who had recently provided broad consent at four diverse academic medical centers. The majority of donors believed that the consent form provided them with sufficient information regarding future possible uses of their biospecimens. Donors expressed very positive views regarding tissue donation in general and endorsed the use of their biospecimens in future research across a wide range of contexts. Concerns regarding future uses were limited to for-profit research and research by investigators in other countries. These results support the use of broad consent to store and use biological samples in future research.

Association of functional status and treatment choice among older men with prostate cancer in the Medicare Advantage population.

BACKGROUND: There are several effective treatments for prostate cancer. To what extent a patient's functional status influences the treatment decision is unknown. This study examined the association between functional status and treatment among older men with prostate cancer. METHODS: Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey data were used to identify men who were 65 years old or older and were diagnosed with prostate cancer between 1998 and 2009. The primary outcome was treatment choice: conservative management, surgery, or radiation within 1 year of the diagnosis. The exposure was the functional status assessed as 4 measures within 3 domains: 1) physical function (activities of daily living [ADLs] and physical component summary score), 2) cognitive function (survey completer: self vs proxy), and 3) emotional well-being (mental component summary score). A multivariate, multinomial logistic regression was fitted with adjustments for several patient, tumor, and regional characteristics. RESULTS: This study identified 508 conservative management patients, 195 surgery patients, and 603 radiation patients. Compared with men with no ADL dependency, those with any ADL dependency had lower odds of receiving surgery (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.38-0.99) or radiation (OR, 0.58; 95% CI, 0.43-0.78) versus conservative management. ADL dependency did not differ when surgery and radiation were compared. Patients with a proxy survey response were less likely to receive surgery or radiation versus conservative management. CONCLUSIONS: Functional status is associated with treatment choice for men with prostate cancer. Future research should examine whether this is due to physician recommendations, patient preferences, or a combination. Cancer 2016;122:3199-206. © 2016 American Cancer Society.

Development of an Applied Framework for Understanding Health Information Technology in Nursing Homes.

There is growing evidence that Health Information Technology (HIT) can play a role in improving quality of care and increasing efficiency in the nursing home setting. Most research in this area, however, has examined whether nursing homes have or use any of a list of available technologies. We sought to develop an empirical framework for understanding the intersection between specific uses of HIT and clinical care processes. Using the nominal group technique, we conducted a series of focus groups with different types of personnel who work in nursing homes (administrators, directors of nursing, physicians, mid-level practitioners, consultant pharmacists, and aides). The resulting framework identified key domain areas that can benefit from HIT: transfer of data, regulatory compliance, quality improvement, structured clinical documentation, medication use process, and communication. The framework can be used to guide both descriptive and normative research.