What Explains Inequalities in Telehealth Utilization Among North Carolina Medicaid Beneficiaries?

Background: Increased availability of telehealth can improve access to health care. However, there is evidence of persistent disparities in telehealth usage, as well as among people from minoritized racial and ethnic groups and rural residents. The objective of our work was to explore the degree to which disparities in telehealth use for behavioral health (BH) and musculoskeletal (MSK) related services during the COVID-19 pandemic are explained by observed beneficiary- and area-level characteristics. Methods: Using North Carolina Medicaid claims data of Medicaid beneficiaries with BH or MSK conditions, we apply nonlinear regression-based decomposition analysis-based models developed by Kitagawa, Oaxaca, and Blinder to determine which observed variables are associated with racial, ethnic, and rural inequalities in telehealth usage. Results: In the BH cohort, we found statistically significant differences in telehealth usage by race in the adult population, and by race, Hispanic ethnicity, and rurality in the pediatric population. In the MSK cohort, we found significant inequities by Hispanic ethnicity and rurality among adults, and by race and rurality among children. Inequalities in telehealth use between groups were small, ranging from 0.7 percentage points between urban and rural adults with MSK conditions to 3.8 percentage points between white adults and people of color among those with BH conditions. Overall, we found that racial and ethnic inequalities in telehealth use are not well explained by the observed variables in our data. Rural disparities in telehealth use are better explained by observed variables, particularly area-level broadband internet use. Conclusions: For inequalities between rural and urban residents, our analysis provides observational evidence that infrastructure such as broadband internet access is an important driver of differences in telehealth use. For racial and ethnic inequalities, the pathways may be more complex and difficult to measure, particularly when relying on administrative data sources in place of more detailed data on individual-level socioeconomic factors.

Did Medicaid Reimbursements Shape the Effects of Medicaid Expansion on Access to Health Care Among the Low-Income Population?

BACKGROUND: Whether variation in Medicaid reimbursement fees influenced the impacts of the Medicaid expansions is not well understood. OBJECTIVE: We examine whether changes in health care access associated with Medicaid expansion are different in states with comparatively high Medicaid reimbursement rates compared against expanding in states with lower Medicaid reimbursement rates. DESIGN: Using a difference-in-difference-in-difference (DDD or triple-difference) regression approach, we compare relative differences in Medicaid expansion effects between lower and higher reimbursement states. PARTICIPANTS: 512,744 low-income adults aged 20-64 in the 2011-2019 Behavioral Risk Factor Surveillance System. MAIN MEASURES: Health insurance coverage status, unmet medical needs due to cost, regular source for health care, and a regular/scheduled checkup within the past year. KEY RESULTS: Medicaid expansion has significant and positive impacts on health coverage and access in both high- and low-fee states. In states with fee levels above the median Medicare-to-Medicaid ratios, expanding Medicaid eligibility reduced uninsurance rate by 15.2 percentage point (ppt, p < 0.01), shrank the cost-associated unmet medical need by 10.3 ppt (p < 0.01), improved access to usual source of care by 1.9 ppt (p < 0.1), and increased regular checkup by 14.4 ppt (p < 0.01), while such effects in low-fee states were 11.7 ppt (p < 0.01), 8.3 ppt (p < 0.01), 3.1 ppt (p < 0.1), and 12.3 ppt (p < 0.01), respectively. Our results suggest that Medicaid expansion effect on unmet medical need due to cost in higher-reimbursing states was 2.98 ppt (p < 0.05) larger than in lower-reimbursing states. Evidence suggests modest increases in health care access were more strongly associated with expansions in higher-fee states. CONCLUSIONS: Medicaid's fee structure should be considered as a factor influencing large-scale coverage expansions.

Evaluating Telehealth Uptake Among North Carolina Medicaid Beneficiaries With Musculoskeletal Conditions: Insights From the COVID-19 Pandemic.

BACKGROUND: The shift from in-person to virtual visits, known as telehealth (TH), during the COVID-19 pandemic was a significant change for North Carolina (NC) Medicaid beneficiaries seeking treatment for musculoskeletal (MSK) conditions, as remote care for these conditions was previously unavailable. We used this policy change to investigate factors associated with TH uptake and whether TH availability mitigated disparities in access to care or affected emergency department (ED) visits among these beneficiaries. RESEARCH DESIGN: Using 2019-2021 NC Medicaid claims, we identified beneficiaries receiving treatment for MSK conditions before COVID-19 (March 2019-February 2020) and analyzed uptake of newly available TH during COVID-19 (April 2020-March 2021). We used descriptive analysis and Poisson generalized estimating equations to quantify TH uptake, factors associated with TH uptake, and the association with ED visits during COVID-19. RESULTS: Black and Hispanic beneficiaries were less likely to use TH compared with White and non-Hispanic counterparts (10%, P <0.001 and 20%, P =0.03, respectively). Adults eligible for Tailored Plans, specialized NC Medicaid plans for those with significant behavioral health needs or intellectual/developmental disabilities, were less likely to use TH [adjusted risk ratio (ARR):0.83, 95% CI (0.78, 0.87)]; youth eligible for Tailored Plans were more likely to use TH [ARR:1.28, 95% CI (1.16, 1.42)]. Lower county-level internet access was associated with lower TH use [ARR: 0.85, 95% CI (0.82, 0.99)]. No statistical difference in ED utilization was observed between TH users and non-users. CONCLUSIONS: TH has the potential to deliver convenient care to beneficiaries with MSK conditions who can access it. Further research and policy changes should explore and address underlying factors driving disparities and improve equitable access to care for this population.

Telehealth Utilization Among Adult Medicaid Beneficiaries in North Carolina with Behavioral Health Conditions During the COVID-19 Pandemic.

OBJECTIVE: We examined factors associated with telehealth utilization during COVID-19 among adult Medicaid beneficiaries with behavioral health conditions. DATA SOURCES AND STUDY SETTING: NC Medicaid 2019-2021 beneficiary and claims data. STUDY DESIGN: This retrospective cohort study examined and compared behavioral health service use pre-COVID-19 (03/01/2019 to 02/28/2020) and during COVID-19 (04/01/2020 to 03/31/2021). Telehealth users included those with at least one behavioral health visit via telehealth during COVID-19. Descriptive statistics were calculated for overall sample and by telehealth status. Multilevel modified Poisson generalized estimating equation examined associations between telehealth use and patient- and area-level characteristics. DATA COLLECTION/EXTRACTION METHODS: We identified individuals ages ≥ 21-64, diagnosed with a behavioral health condition, and had at least one behavioral-health specific visit before COVID-19. PRINCIPAL FINDINGS: Almost two-thirds of the cohort received behavioral health services during COVID-19, with half of these beneficiaries using telehealth. Non-telehealth users had steeper declines in service use from pre- to during COVID-19 compared to telehealth users. Beneficiaries identifying as Black, multiracial or other were significantly less likely to use telehealth (ARR = 0.86; 95% CI: (0.83, 0.89)); (ARR = 0.92; 95% CI: (0.87, 0.96)) compared to White beneficiaries. Those eligible for Medicaid through the blind/disabled programs and who qualified for a state-specific specialized behavioral health plan were more likely to use telehealth (17% and 20%, respectively). CONCLUSIONS: During the pandemic, telehealth facilitated continuity of care for beneficiaries with behavioral health conditions. Future research should aim to investigate how to reduce the digital divide and ensure equitable access to telehealth.

Trends in and Factors Contributing to the Slowdown in Medicare Spending Growth, 2007-2018.

Importance: After decades of rapid increase, Medicare per-beneficiary spending growth was historically low in the period leading up to the passage of the Affordable Care Act. In the years immediately following the legislation, Medicare expenditure growth slowed even further. Objective: To evaluate factors contributing to the slowdown in Medicare per-beneficiary spending growth. Design, Setting, and Participants: In this cross-sectional study, expected spending growth for 2012 to 2015 and 2016 to 2018 was predicted holding payment rates and population characteristics constant. By contrasting predicted and actual spending growth during these periods, the contribution of population vs payment factors to the Medicare spending slowdown was determined. Analyses included all Medicare fee-for-service beneficiaries aged 65 years and older, ranging from 30 to 35 million beneficiaries annually between 2007 and 2018. Data analyses were conducted from January 2018 to August 2018 and updated with new data in June 2021. Main Outcomes and Measures: The main outcome included annual growth in total per-beneficiary spending. The roles of payment rate changes and differences in the Medicare population over time were considered, including demographic characteristics and numbers of chronic conditions. Results: Between 2008 to 2011 and 2012 to 2015, the adjusted annual Medicare Parts A and B per-beneficiary spending growth rate declined from 3.3% to -0.1%. From 2016 to 2018, the mean annual Medicare spending growth rate rose relative to the previous period but remained lower than in the baseline period at 1.7% per year. This slowdown extended across all sectors within Parts A and B, except for physician-administered drugs offered under Part B. Changes in payment rates (including sequestration measures) and beneficiary characteristics explained 44% of the difference in overall per-beneficiary spending growth between 2007 to 2011 and 2012 to 2015, and 63% between 2007 to 2011 and 2016 to 2018. Conclusions and Relevance: In this cross-sectional study of trends in spending growth per Medicare beneficiary aged 65 years or older, results suggested that Medicare payment policy, including sector-specific payment rate changes and sequestration, will be a critical determinant of whether the Medicare spending growth slowdown persists.

Using a home time measure to differentiate ACO performance for seriously ill populations.

BACKGROUND: Alternative Payment Models (APMs) piloted by the Centers for Medicare and Medicaid Services (CMS) such as ACO Realizing Equity, Access and Community Health (REACH) seek to improve care and quality of life among seriously ill populations (SIP). Days at Home (DAH) was proposed for use in this model to evaluate organizational performance. It is important to assess the utility and feasibility of person-centered outcomes measures, such as DAH, as CMS seeks to advance care models for seriously ill beneficiaries. We leverage existing Accountable Care Organization (ACO) contracts to evaluate the feasibility of ACO-level DAH measure and examine characteristics associated with ACOs with more DAH. METHODS: We calculated DAH for Medicare fee-for-service beneficiaries aged 68 and over who were retrospectively attributed to a Medicare ACO between 2014 and 2018 and met the seriously ill criteria. We then aggregated to the ACO level DAH for each ACO's seriously ill beneficiaries and risk-adjusted this aggregated measure. Finally, we evaluated associations between risk-adjusted DAH per person-year and ACO, beneficiary, and market characteristics. RESULTS: ACOs' seriously ill beneficiaries spent an average of 349.3 risk-adjusted DAH per person-year. Risk-adjusted ACO variation, defined as the interquartile range, was 4.21 days (IQR = 347.32-351.53). Beneficiaries of ACOs are composed of a less racially diverse beneficiary cohort, opting for two-sided risk models, and operating in markets with fewer hospital and Skilled Nursing Facility beds had more DAH. CONCLUSIONS: Substantial variation across ACOs in the DAH measure for seriously ill beneficiaries suggests the measure can differentiate between high and low performing provider groups. Key to the success of the metric is accurate risk adjustment to ensure providers have adequate resources to care for seriously ill beneficiaries. Organizational factors, such as the ACO size and level of risk, are strongly associated with more days at home.

Younger Individuals Increase Their Use of Nursing Homes Following ACA Medicaid Expansion.

OBJECTIVES: This study examines the effect of Medicaid eligibility expansion under the Affordable Care Act (ACA) on the utilization of nursing home services by younger individuals and those covered by Medicaid. DESIGN: Compared the age of nursing home residents, proportion of individuals covered by Medicaid, annual nursing home admissions in those younger than 65, and nursing home length of stay in states that expanded Medicaid eligibility through the ACA to states that did not. We used data from LTCFocus (nursing home level), the Minimum Data Set (individual level), and Medicaid expansion status from the Kaiser Family Foundation. SETTING AND PARTICIPANTS: The study included 15,005,888 nursing home admissions, 2,446,950 of which were residents younger than 65, across 14,132 nursing homes between 2009 and 2016. METHODS: A time-varying difference-in-difference model including state and year fixed effects with effect modification by pre-2014 nursing home occupancy. RESULTS: Facilities in expansion states with a pre-ACA occupancy rate of more than 70% increased the fraction of residents younger than 65 by 2.74% to 6.32%, compared with similar facilities in nonexpansion states. Medicaid admissions varied, with an increase in year 2 after expansion compared with nonexpansion states. Among residents entering from an acute care hospital, the proportion younger than 65 increased in facilities with pre-2014 occupancy rates of more than 70%, compared with similar facilities in nonexpansion states, an increase of up to 6.51%. Median nursing home length of stay for individuals younger than 65 decreased relative to nonexpansion states across all occupancy categories, ranging from 1.68 to 6.06 days after Medicaid expansion. CONCLUSIONS AND IMPLICATIONS: Medicaid expansion increased access to nursing home post-acute care for individuals younger than 65. It remains unclear if the benefit of post-acute care is the same among this group, or if the needs of younger individuals can be adequately met in this setting.

Risk adjusting for Medicaid participation in Medicare Advantage.

OBJECTIVES: Determining appropriate capitated payments has important access implications for dual-eligible Medicare Advantage (MA) members. In 2017, MA plans began receiving higher capitated payments for beneficiaries with full vs partial Medicaid when payments started being risk adjusted for level of Medicaid benefits instead of any Medicaid participation. This approach could favor MA plans in states with more generous Medicaid programs where more beneficiaries qualify for full Medicaid and thus a higher capitated payment. To understand this issue, we examined adjusted Medicare spending for dual-eligible beneficiaries across states with differing Medicaid eligibility criteria. STUDY DESIGN: Retrospective analysis of 2007-2015 traditional Medicare data for dual-eligible beneficiaries 65 years and older. METHODS: We compared predicted per-beneficiary spending levels after adjusting for any Medicaid participation and for level of Medicaid benefits across states with varying Medicaid eligibility requirements. RESULTS: States with the most generous Medicaid requirements had more dual-eligible beneficiaries with full Medicaid compared with the most restrictive states (median, 82% vs 55%). Nationally, Medicare spending levels were 1.3 times greater for full vs partial Medicaid participants (range across states, 0.8-1.7). When per-beneficiary spending was adjusted for level of Medicaid benefits, rather than any Medicaid participation, states with more generous Medicaid eligibility had larger gains in predicted spending per dual-eligible beneficiary than states with less generous Medicaid coverage (1.7% vs 1.3% increase). CONCLUSIONS: Distinguishing between partial and full Medicaid in MA payments may disproportionately increase MA payments in states that have more full Medicaid beneficiaries due to more generous Medicaid eligibility.

Trends in Postacute Care Spending Growth During the Medicare Spending Slowdown.

Issue: Over the past decade, traditional Medicare's per-beneficiary spending grew at historically low levels. To understand this phenomenon, it is important to examine trends in postacute care, which experienced exceptionally high spending growth in prior decades. Goal: Describe per-beneficiary spending trends between 2007 and 2015 for postacute care services among traditional Medicare beneficiaries age 65 and older. Methods: Trend analysis of individual-level Medicare administrative data to generate per-beneficiary spending and utilization estimates for postacute care, including skilled nursing facilities, home health, and inpatient rehabilitation facilities. Key Findings and Conclusions: Per-beneficiary postacute care spending increased from $1,248 to $1,424 from 2007 to 2015. This modest increase reflects dramatic changes in annual spending and utilization growth rates, including a reversal from positive to negative spending growth rates for the skilled nursing facility and home health sectors. For example, the average annual spending growth rate for skilled nursing facility services declined from 7.4 percent over the 2008­11 period to ­2.8 percent over the 2012­15 period. Among beneficiaries with inpatient use, growth rates for postacute care spending and utilization slowed, but more moderately than observed among all beneficiaries. Reductions in hospital use, as well as reduced payment rates, contributed to declines in postacute spending.

Trends In Medicare Fee-For-Service Spending Growth For Dual-Eligible Beneficiaries, 2007-15.

Cost containment for dual-eligible beneficiaries (those enrolled in Medicare and Medicaid) is a key policy goal, but few studies have examined spending trends for this population. We contrasted growth in Medicare fee-for-service per beneficiary spending for those with and without Medicaid in the period 2007-15. Relative to Medicare-only enrollees, dual-eligible beneficiaries consistently had higher overall Medicare spending levels; however, they experienced steeper declines in spending growth over the study period. These trends varied across populations of interest. For instance, dual-eligible beneficiaries ages sixty-five and older went from having annual spending growth rates that were 1.8 percentage points higher than Medicare-only beneficiaries in 2008 to rates that were 1.1 percentage points lower in 2015. Across population groups, long-term users of nursing home care had some of the highest spending growth rates, averaging 1.7-4.1 percent annually depending on age group and Medicaid participation. These findings have implications for value-based payment and other Medicare policies aimed at controlling spending for dual-eligible beneficiaries.

Understanding Trends in Medicare Spending, 2007-2014.

OBJECTIVES: To analyze the sources of per-beneficiary Medicare spending growth between 2007 and 2014, including the role of demographic characteristics, attributes of Medicare coverage, and chronic conditions. DATA SOURCES: Individual-level Medicare spending and enrollment data. STUDY DESIGN: Using an Oaxaca-Blinder decomposition model, we analyzed whether changes in price-standardized, per-beneficiary Medicare Part A and B spending reflected changes in the composition of the Medicare population or changes in relative spending levels per person. DATA EXTRACTION METHODS: We identified a 5 percent sample of fee-for-service Medicare beneficiaries age 65 and above from years 2007 to 2014. RESULTS: Mean payment-adjusted Medicare per-beneficiary spending decreased by $180 between the 2007-2010 and 2011-2014 time periods. This decline was almost entirely attributable to lower spending levels for beneficiaries. Notably, declines in marginal spending levels for beneficiaries with chronic conditions were associated with a $175 reduction in per-beneficiary spending. The decline was partially offset by the increasing prevalence of certain chronic diseases. Still, we are unable to attribute a large share of the decline in spending levels to observable beneficiary characteristics or chronic conditions. CONCLUSIONS: Declines in spending levels for Medicare beneficiaries with chronic conditions suggest that changing patterns of care use may be moderating spending growth.