Social determinants of health and emergency department utilization in Alabama Children's Health Insurance Program.

OBJECTIVES: Injuries are the leading cause of death among children and youth in the United States, representing a major concern to society and to the public and private health plans covering pediatric patients. Data from ALL Kids, Alabama's Children's Health Insurance Program, were used to evaluate the relationship between community-level social determinants of health (SDOH) and pediatric emergency department (ED) use and differences in these associations by age and race. STUDY DESIGN: This was a retrospective, pooled cross-sectional analysis. METHODS: We used ALL Kids data to identify ED visits (injury and all-cause) among children who were enrolled at any time from 2015 to 2017. Exploratory factor analysis was used to categorize SDOH from 18 selected Census tract-level variables. Multilevel Poisson regression models were used to evaluate the effects of community and individual factors and their interactions. RESULTS: Census tract-level SDOH were grouped as low socioeconomic status (SES), urbanicity, and immigrant-density factors. Low SES and urbanicity factors were associated with ED visits (injury and all-cause). The low SES and urbanicity factors also moderated the association between race and ED visits (injury and all-cause). CONCLUSIONS: The environment in which children live influences their ED use; however, the impact varies by age, race, and Census tract factors. Further studies should focus on specific community factors to better understand the relationship among SDOH, individual characteristics, and ED utilization.

Dental hygienists' scope of practice regulations and preventable non-traumatic dental emergency department visits: A cross-sectional study of 10 U.S. states.

OBJECTIVES: As emergency department (ED) visits for non-traumatic dental complaints continue to rise in the United States (U.S.), some states are implementing initiatives to expand access to the oral health workforce. This study examines the associations between the 2014 Dental Hygiene Professional Practice Index (DHPPI) and preventable dental ED visits. METHODS: In 2020, we used ED data from 10 U.S. states and ordinary least squares models to examine the relationship between the states' DHPPI scores and preventable dental ED use. We stratified regressions by age to examine this relationship across different age cohorts and introduced interaction terms to assess the same relationship among rural and urban residents. RESULTS: On average, 23.8% of all non-traumatic dental ED visits were identified as preventable. Controlling for other factors, a one-point increase in DHPPI scores was associated with a decrease of 0.01 (95% CI -0.03, -0.02) preventable dental ED visits per 1000 county population in each year-quarter. In the age-stratified models, the strength of the association between DHPPI scores and preventable dental ED visits was higher in the 20 to 34 (-0.03, 95% CI -0.04, -0.02), and the 35 to 50 age cohorts (-0.17, 95% CI -0.00, -0.00). U.S. states with DHPPI scores below 60 saw significantly higher preventable dental ED visits among rural residents. CONCLUSIONS: This study demonstrates that stringent state policies regarding the dental hygienist workforce are associated with higher preventable dental ED visits in the U.S. Policy makers and stake holders must address the scope of practice policies to alleviate the burden of access to oral healthcare.

Correction: Adherence to Telemonitoring Therapy for Medicaid Patients With Hypertension: Case Study.

[This corrects the article DOI: 10.2196/29018.].

Disparities in Telehealth Utilization in a Population of Publicly Insured Children During the COVID-19 Pandemic.

Telehealth became a crucial vehicle for health care delivery in the United States during the COVID-19 pandemic. However, little research exists on inequities in telehealth utilization among the pediatric population. This study examines disparities in telehealth utilization in a population of publicly insured children. This observational, retrospective study used administrative data from Alabama's stand-alone Children's Health Insurance Program, ALL Kids. Rates of any telehealth use for March to December 2020 were examined. In addition-to capture lack of health care utilization-rates of having no medical claims were examined and compared with March to December 2019 and 2018. Multinomial logit models were estimated to investigate how telehealth use and having no medical claims (reference category: having medical claims but no telehealth) were associated with race/ethnicity, rural-urban residence, and family income. Of the 106,478 enrollees over March to December 2020, 13.4% had any telehealth use and 24.7% had no medical claims. The latter was greater than no medical claims in 2019 (19.5%) and 2018 (20.7%). Black and Hispanic children had lower odds of any telehealth use (odds ratio [OR]: 0.81, P < 0.01; OR: 0.68, P < 0.01) and higher odds of no medical claims (OR: 1.11, P < 0.05; OR: 1.73, P < 0.05) than non-Hispanic White children. Rural residents had lower odds of telehealth use than urban residents. Those in the highest family income-based fee group had higher odds of telehealth use than the lowest family income-based fee group. As telehealth will likely continue to play an important role in health care delivery, additional efforts/investments are required to ensure telehealth does not further exacerbate inequities in pediatric health care access.

Characteristics and outcomes associated with two asthma quality of care measures.

OBJECTIVE: We investigated asthma quality measures to understand patient characteristics associated with non-attainment of quality care and measure the association with asthma-related emergency department (ED) visits or inpatient hospitalizations (IPs). METHODS: Using administrative data from ALL Kids, Alabama's Children's Health Insurance Program, from 2013 to 2019 we calculated non-attainment of the Medication Management for Asthma (MMA) and Asthma Medication Ratio (AMR) quality measures. Patient characteristics and asthma-related ED visits and IPs associated with non-attainment of the MMA and AMR measures were assessed using logit regression models and Marginal effects at the mean. RESULTS: Among 2528 children with asthma, 53.2% failed to attain the MMA measure and 8.5% the AMR measure. Prior asthma-related ED visits or IP stays increased likelihood of non-attainment by 14.8 percentage points (95% CI 8.6-20.9) for MMA and 7.3 percentage points (95% CI 2.8-11.8) for AMR. Among 868 children (34.3%) with three years of continuous enrollment, AMR non-attainment was associated with a 6.1 percentage point increase in ED or IP utilization (95% CI 1.3-10.9), however MMA non-attainment was not associated with either outcome. Prior ED visit/IP stay was associated with a 17.2 percentage point (95% CI 8.3-26.1) increase in the likelihood of a subsequent ED visit/IP stay among those with non-attainment MMA and a 15.5 percentage point increase (95% CI 6.9-24.2) for non-attainment AMR. CONCLUSIONS: Patient characteristics associated with non-attainment of asthma quality measures presents actionable evidence to guide improvement efforts as non-attainment AMR increases the risk of subsequent ED visits and IP stays.

Mining Fiskeby III and Mandarin (Ottawa) Expression Profiles to Understand Iron Stress Tolerant Responses in Soybean.

The soybean (Glycine max L. merr) genotype Fiskeby III is highly resistant to a multitude of abiotic stresses, including iron deficiency, incurring only mild yield loss during stress conditions. Conversely, Mandarin (Ottawa) is highly susceptible to disease and suffers severe phenotypic damage and yield loss when exposed to abiotic stresses such as iron deficiency, a major challenge to soybean production in the northern Midwestern United States. Using RNA-seq, we characterize the transcriptional response to iron deficiency in both Fiskeby III and Mandarin (Ottawa) to better understand abiotic stress tolerance. Previous work by our group identified a quantitative trait locus (QTL) on chromosome 5 associated with Fiskeby III iron efficiency, indicating Fiskeby III utilizes iron deficiency stress mechanisms not previously characterized in soybean. We targeted 10 of the potential candidate genes in the Williams 82 genome sequence associated with the QTL using virus-induced gene silencing. Coupling virus-induced gene silencing with RNA-seq, we identified a single high priority candidate gene with a significant impact on iron deficiency response pathways. Characterization of the Fiskeby III responses to iron stress and the genes underlying the chromosome 5 QTL provides novel targets for improved abiotic stress tolerance in soybean.

Adherence to Telemonitoring Therapy for Medicaid Patients With Hypertension: Case Study.

BACKGROUND: Almost 50% of the adults in the United States have hypertension. Although clinical trials indicate that home blood pressure monitoring can be effective in managing hypertension, the reported results might not materialize in practice because of patient adherence problems. OBJECTIVE: The aims of this study are to characterize the adherence of Medicaid patients with hypertension to daily telemonitoring, identify the impacts of adherence reminder calls, and investigate associations with blood pressure control. METHODS: This study targeted Medicaid patients with hypertension from the state of Texas. A total of 180 days of blood pressure and pulse data in 2016-2018 from a telemonitoring company were analyzed for mean transmission rate and mean blood pressure change. The first 30 days of data were excluded because of startup effects. The protocols required the patients to transmit readings by a specified time daily. Patients not transmitting their readings received an adherence reminder call to troubleshoot problems and encourage transmission. The patients were classified into adherent and nonadherent cohorts; adherent patients were those who transmitted data on at least 80% of the days. RESULTS: The mean patient age was 73.2 (SD 11.7) years. Of the 823 patients, 536 (65.1%) were women, and 660 (80.2%) were urban residents. The adherent cohort (475/823, 57.7%) had mean transmission rates of 74.9% before the adherence reminder call and 91.3% after the call, whereas the nonadherent cohort (348/823, 42.3%) had mean transmission rates of 39% and 58% before and after the call, respectively. From month 1 to month 5, the transmission rates dropped by 1.9% and 10.2% for the adherent and nonadherent cohorts, respectively. The systolic and diastolic blood pressure values improved by an average of 2.2 and 0.7 mm Hg (P<.001 and P=.004), respectively, for the adherent cohort during the study period, whereas only the systolic blood pressure value improved by an average of 1.6 mm Hg (P=.02) for the nonadherent cohort. CONCLUSIONS: Although we found that patients can achieve high levels of adherence, many experience adherence problems. Although adherence reminder calls help, they may not be sufficient. Telemonitoring lowered blood pressure, as has been observed in clinical trials. Furthermore, blood pressure control was positively associated with adherence.

The Effect of the Medicaid Expansion on Frequent Emergency Department Use in New York.

BACKGROUND: There is limited evidence on the effect of the Affordable Care Act (ACA) on frequent emergency department (ED) use. OBJECTIVES: To estimate the effect of the ACA Medicaid expansion on frequent ED use in New York. METHODS: We used data from the Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases from 2011 to 2016. A consistent and unique patient identifier enabled us to identify ED visits by the same patient across different facilities within the state for each calendar year. Multivariate logistic regressions were used to quantify the policy's effect on frequent ED use (≥ 4 ED visits/year). We included in-state residents 18 to 64 years of age who were covered by Medicaid, private insurance, or were uninsured. Sensitivity analyses were conducted using alternative definitions of frequent use. To validate the findings, a falsification analysis was also conducted using only the 3 pre-expansion years. RESULTS: Our study included 14.3 million ED patients with 23.8 million ED visits from 2011 to 2016. Frequent users (7.2%) accounted for 26.6% of all ED visits. The likelihood of frequent ED use declined by 4% among Medicaid beneficiaries (adjusted odds ratio [AOR] 0.96, 95% confidence intervals (CI) 0.95-0.97) and by 12% for the uninsured (AOR 0.88, 95% CI 0.86-0.89) in the post-expansion period, compared with the pre-expansion period. Private insurance enrollees were 9% more likely to exhibit frequent use in the post-expansion period (AOR 1.09, 95% CI 1.08-1.11). The sensitivity analyses yielded results similar to those of the main model. The falsification analyses revealed small and insignificant year-to-year changes in the 3 pre-expansion years. CONCLUSION: The likelihood of frequent ED use decreased 3 years after New York implemented the ACA Medicaid expansion, particularly for Medicaid beneficiaries and the uninsured, highlighting the importance of expanding health insurance and provisions tailored at high-need populations.

Health services utilization, out-of-pocket expenditure, and underinsurance among insured non-elderly cancer survivors in the United States, 2011-2015.

BACKGROUND: High out-of-pocket (OOP) expenditure and inadequate insurance coverage may adversely affect cancer survivors. We aimed to characterize the extent and correlates of healthcare utilization, OOP expenditures, and underinsurance among insured cancer survivors. METHODS: We used 2011-2015 Medical Expenditure Panel Survey data to identify a nationally representative sample of insured non-elderly adult (age 18-64 years) cancer survivors. We used negative binomial, two-part (logistic and Generalized Linear Model with log link and gamma distribution), and logistic regression models to quantify healthcare utilization, OOP expenditures, and underinsurance, respectively, and identified sociodemographic correlates for each outcome. RESULTS: We identified 2738 insured non-elderly cancer survivors. Adjusted average utilization of ambulatory, non-ambulatory, prescription medication, and dental services was 14.4, 0.51, 24.9, and 1.4 events per person per year, respectively. Higher ambulatory and dental services utilization were observed in older adults, females, non-Hispanic Whites, survivors with a college degree and high income, compared to their counterparts. Nearly all (97.7%) survivors had some OOP expenditures, with a mean adjusted OOP expenditure of $1552 per person per year. Adjusted mean OOP expenditures for ambulatory, non-ambulatory, prescription medication, dental, and other health services were $653, $161, $428, $194, and $83, respectively. Sociodemographic variations in service-specific OOP expenditures were generally consistent with respective utilization patterns. Overall, 8.8% of the survivors were underinsured. CONCLUSION: Many insured non-elderly cancer survivors allocate a substantial portion of their OOP expenditure for healthcare-related services and experience financial vulnerability, resulting in nearly 8.8% of the survivors being underinsured. Utilization of healthcare services varies across sociodemographic groups.

The effect of expanded insurance coverage under the Affordable Care Act on emergency department utilization in New York.

BACKGROUND: One of the proposed benefits of expanding insurance coverage under the Affordable Care Act (ACA) was a reduction in emergency department (ED) utilization for non-urgent visits related to lack of health insurance coverage and access to primary care providers. The objective of this study was to estimate the effect of the 2014 ACA implementation on ED use in New York. METHODS: We used the Healthcare Cost and Utilization Project State Emergency Department and State Inpatient Databases for all outpatient and all inpatient visits for patients admitted through an ED from 2011 to 2016. We focused on in-state residents aged 18 to 64, who were covered under Medicaid, private insurance, or were uninsured prior to the 2014 expansion. We estimated the effect of the expanded insurance coverage on average monthly ED visits volumes and visits per 1000 residents (rates) using interrupted time-series regression analyses. RESULTS: After ACA implementation, overall average monthly ED visits increased by around 3.0%, both in volume (9362; 95% Confidence Intervals [CI]: 1681-17,522) and in rates (0.80, 95% CI:0.12-1.49). Medicaid covered ED visits volume increased by 23,972 visits (95% CI: 16,240 -31,704) while ED visits by the uninsured declined by 13,297 (95% CI:-15,856 - -10,737), and by 1453 (95% CI:-4027-1121) for the privately insured. Medicaid ED visits rates per 1000 residents increased by 0.77 (95% CI:-1.96-3.51) and by 2.18 (95% CI:-0.55-4.92) for those remaining uninsured, while private insurance visits rates decreased by 0.48 (95% CI:-0.79 - -0.18). We observed increases in primary-care treatable ED visits and in visits related to mental health and alcohol disorders, substance use, diabetes, and hypertension. All estimated changes in monthly ED visits after the expansion were statistically significant, except for ED visit rates among Medicaid beneficiaries. CONCLUSION: Net ED visits by adults 18 to 64 years of age increased in New York after the implementation of the ACA. Large increases in ED use by Medicaid beneficiaries were partially offset by reductions among the uninsured and those with private coverage. Our results suggest that efforts to expand health insurance coverage only will be unlikely to reverse the increase in ED use.

US Privacy Laws Go Against Public Preferences and Impede Public Health and Research: Survey Study.

BACKGROUND: Reaping the benefits from massive volumes of data collected in all sectors to improve population health, inform personalized medicine, and transform biomedical research requires the delicate balance between the benefits and risks of using individual-level data. There is a patchwork of US data protection laws that vary depending on the type of data, who is using it, and their intended purpose. Differences in these laws challenge big data projects using data from different sources. The decisions to permit or restrict data uses are determined by elected officials; therefore, constituent input is critical to finding the right balance between individual privacy and public benefits. OBJECTIVE: This study explores the US public's preferences for using identifiable data for different purposes without their consent. METHODS: We measured data use preferences of a nationally representative sample of 504 US adults by conducting a web-based survey in February 2020. The survey used a choice-based conjoint analysis. We selected choice-based conjoint attributes and levels based on 5 US data protection laws (Health Insurance Portability and Accountability Act, Family Educational Rights and Privacy Act, Privacy Act of 1974, Federal Trade Commission Act, and the Common Rule). There were 72 different combinations of attribute levels, representing different data use scenarios. Participants were given 12 pairs of data use scenarios and were asked to choose the scenario they were the most comfortable with. We then simulated the population preferences by using the hierarchical Bayes regression model using the ChoiceModelR package in R. RESULTS: Participants strongly preferred data reuse for public health and research than for profit-driven, marketing, or crime-detection activities. Participants also strongly preferred data use by universities or nonprofit organizations over data use by businesses and governments. Participants were fairly indifferent about the different types of data used (health, education, government, or economic data). CONCLUSIONS: Our results show a notable incongruence between public preferences and current US data protection laws. Our findings appear to show that the US public favors data uses promoting social benefits over those promoting individual or organizational interests. This study provides strong support for continued efforts to provide safe access to useful data sets for research and public health. Policy makers should consider more robust public health and research data use exceptions to align laws with public preferences. In addition, policy makers who revise laws to enable data use for research and public health should consider more comprehensive protection mechanisms, including transparent use of data and accountability.

The Rise in Pediatric Obesity-Related Conditions and Costs in Public Insurance Programs: Evidence from Alabama.

Background: The increase in pediatric obesity rates is well documented. The extent of corresponding increases in diagnoses of obesity-related conditions (Ob-Cs) and associated medical costs for children in public insurance programs is unknown. Methods: Retrospective claims data linked to enrollees' demographic data for Alabama's Children's Health Insurance Program (ALL Kids) 1999-2015 were used. Multivariate linear probability models were used to estimate the likelihood of having any Ob-C diagnoses. Two-part models for inpatient, outpatient, emergency department (ED), and overall costs were estimated. Results: The proportion of enrollees with Ob-C diagnoses almost doubled from 1.3% to 2.5%. The likelihood of diagnoses increased over time (0.0994 percentage points per year, p < 0.001). Statistically higher rates of increase were seen for minority and lowest-income enrollees and for those getting preventive well visits. Costs for those with Ob-Cs increased relative to those without over time, particularly inpatient and outpatient costs. Conclusions: Prevalence of Ob-C diagnoses and costs have increased substantially. This may partly be because of underdiagnoses/underreporting in the past. However, evidence suggests that underdiagnoses are still a major issue.

Assessing the Quality Measure for Follow-up Care After Children's Psychiatric Hospitalizations.

OBJECTIVES: Medicaid and Children's Health Insurance Program plans publicly report quality measures, including follow-up care after psychiatric hospitalization. We aimed to understand failure to meet this measure, including measurement definitions and enrollee characteristics, while investigating how follow-up affects subsequent psychiatric hospitalizations and emergency department (ED) visits. METHODS: Administrative data representing Alabama's Children's Health Insurance Program from 2013 to 2016 were used to identify qualifying psychiatric hospitalizations and follow-up care with a mental health provider within 7 to 30 days of discharge. Using relaxed measure definitions, follow-up care was extended to include visits at 45 to 60 days and visits to a primary care provider. Logit regressions estimated enrollee characteristics associated with follow-up care and, separately, the likelihood of subsequent psychiatric hospitalizations and/or ED visits within 30, 60, and 120 days. RESULTS: We observed 1072 psychiatric hospitalizations during the study period. Of these, 356 (33.2%) received follow-up within 7 days and 566 (52.8%) received it within 30 days. Relaxed measure definitions captured minimal additional follow-up visits. The likelihood of follow-up was lower for both 7 days (-18 percentage points; 95% confidence interval [CI] -26 to -10 percentage points) and 30 days (-26 percentage points; 95% CI -35 to -17 percentage points) regarding hospitalization stays of ≥8 days. Meeting the measure reduced the likelihood of subsequent psychiatric hospitalizations within 60 days by 3 percentage points (95% CI -6 to -1 percentage point). CONCLUSIONS: Among children, receipt of timely follow-up care after a psychiatric hospitalization is low and not sensitive to measurement definitions. Follow-up care may reduce the need for future psychiatric hospitalizations and/or ED visits.

Impact of Mental Health Parity and Addiction Equity Act on Costs and Utilization in Alabama's Children's Health Insurance Program.

OBJECTIVE: The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 mandates equivalent insurance coverage for mental health (MH) and substance use disorders (SUD) to other medical and surgical services covered by group insurance plans, Medicaid, and Children's Health Insurance Programs (CHIP). We explored the impact of MHPAEA on enrollees in ALL Kids, the Alabama CHIP. METHODS: We use ALL Kids claims data for October 2008 to December 2014. October 2008 through September 2009 marks the period before MHPAEA implementation. We evaluated changes in MH/SUD-related utilization and program costs and changes in racial/ethnic disparities in the use of MH/SUD services for ALL Kids enrollees using 2-part models. This allowed analyses of changes from no use to any use, as well as in intensity of use. RESULTS: No significant effect was found on overall MH service-use. There were statistically significant increases in inpatient visits and length of stay and some increase in overall MH costs. These increases may not be clinically important and were concentrated in 2009 to 2011. Disparities in utilization between African-American and non-Hispanic white enrollees were somewhat exacerbated, whereas disparities between other minorities and non-Hispanic whites were reduced. CONCLUSIONS: Findings indicate that MHPAEA led to a 14.3% increase in inpatient visits, a 12.5% increase in length of inpatient stay, and a 7.8% increase in MH costs. The increases appear limited to 2009 to 2011, suggesting existing pent-up "needs" among enrollees for added MH/SUD services that resulted in a temporary spike in service use and cost immediately after MHPAEA, which subsequently subsided.

Assessing the Impact of Case Management on Medicaid Clients with Chronic Diseases.

State Medicaid programs increasingly use case management to manage enrollees with chronic conditions who may become cost intensive for the program. The authors examined the impact of Alabama Department of Public Health (ADPH)'s case management on care expenditures for Medicaid enrollees with various chronic diseases, over 2011 to 2014. The authors matched case-managed enrollees with three controls per case using health conditions and sociodemographics. Thereafter, the authors used a quasi-experimental approach to estimate how per-member-per-month costs changed following case management. Case -management appeared to result in program savings, driven largely by inpatient and emergency department cost-savings. There was noticeable variation in savings for members with different chronic conditions.

Outcomes Associated With Early Preventive Dental Care Among Medicaid-Enrolled Children in Alabama.

Importance: There is a recommendation for children to have a dental home by 6 months of age, but there is limited evidence supporting the effectiveness of early preventive dental care or whether primary care providers (PCPs) can deliver it. Objective: To investigate the effectiveness of preventive dental care in reducing caries-related treatment visits among Medicaid enrollees. Design, Setting, and Participants: High-dimensional propensity scores were used to address selection bias for a retrospective cohort study of children continuously enrolled in coverage from the Alabama Medicaid Agency from birth between 2008 and 2012, adjusting for demographics, access to care, and general health service use. Exposures: Children receiving preventive dental care prior to age 2 years from PCPs or dentists vs no preventive dental care. Main Outcome and Measures: Two-part models estimated caries-related treatment and expenditures. Results: Among 19 658 eligible children, 25.8% (n = 3658) received early preventive dental care, of whom 44% were black, 37.6% were white, and 16.3% were Hispanic. Compared with matched children without early preventive dental care, children with dentist-delivered preventive dental care more frequently had a subsequent caries-related treatment (20.6% vs 11.3%, P < .001), higher rate of visits (0.29 vs 0.15 per child-year, P < .001), and greater dental expenditures ($168 vs $87 per year, P < .001). Dentist-delivered preventive dental care was associated with an increase in the expected number of caries-related treatment visits by 0.14 per child per year (95% CI, 0.11-0.16) and caries-related treatment expenditures by $40.77 per child per year (95% CI, $30.48-$51.07). Primary care provider-delivered preventive dental care did not significantly affect caries-related treatment use or expenditures. Conclusions and Relevance: Children with early preventive care visits from dentists were more likely to have subsequent dental care, including caries-related treatment, and greater expenditures than children without preventive dental care. There was no association with subsequent caries-related treatment and preventive dental care from PCPs. We observed no evidence of a benefit of early preventive dental care, regardless of the provider. Additional research beyond administrative data may be necessary to elucidate any benefits of early preventive dental care.

An assessment of the CHIP/Medicaid quality measure for ADHD.

OBJECTIVES: We analyzed a standard children's quality measure for attention-deficit/hyperactivity disorder (ADHD) using data from a single state to understand the characteristics of those meeting the measure, potential barriers to meeting the measure, and how meeting the measure affected outcomes. STUDY DESIGN: Retrospective study using claims from Alabama's Children's Health Insurance Program from 1999 to 2012. METHODS: We calculated the quality measure for ADHD care, as specified within CMS' Child Core Set and with an expanded denominator. We described the eligible population meeting the measure, assessed potential barriers, and measured the association with health expenditures using logit regressions and log-Poisson models. RESULTS: Among those receiving ADHD medication, 11% of enrollees were eligible for annual measure calculation during our study period. Calculated as specified by CMS, 38% of enrollees met the measure. Using an expanded denominator of 7615 eligible medication episodes, 14% met all aspects of the measure. Primary reasons for failing to meet the measure were lacking medication coverage (64%) and lacking a follow-up visit within 30 days (62%). The rate of meeting the measure decreased with age and was lower for black enrollees. Health service utilization and costs were greater among children meeting the measure. CONCLUSIONS: Too few children are eligible for inclusion, and systematic differences exist among those who meet the measure. The measure may be sensitive to arbitrary criteria while missing potentially relevant clinical care. Refinements to the measure should be considered to improve generalizability to all children with ADHD and improve clinical relevance. States must consider additional analyses to direct quality improvement.

The effects of direct-to-consumer advertising on medication use among Medicaid children with asthma.

Asthma medication adherence is low, particularly among Medicaid enrollees. There has been much debate on the impact of direct-to-consumer advertising (DTCA) on health care use, but the impact on medication use among children with asthma has been unexamined. The study sample included 180,584 children between the ages of 5 and 18 with an asthma diagnosis from a combined dataset of Medicaid Analytic eXtract and national advertising data. We found that DTCA expenditure during the study period was significantly associated with an increase in asthma medication use. However, the effectiveness declined after a certain level.

Health Expenditure Concentration and Characteristics of High-Cost Enrollees in CHIP.

Devising effective cost-containment strategies in public insurance programs requires understanding the distribution of health care spending and characteristics of high-cost enrollees. The aim was to characterize high-cost enrollees in a state's public insurance program and determine whether expenditure inequality changes over time, or with changes in cost-sharing policies or program eligibility. We use 1999-2011 claims and enrollment data from the Alabama Children's Health Insurance Program, ALL Kids. All children enrolled in ALL Kids were included in our study, including multiple years of enrollment (N = 1,031,600 enrollee-months). We examine the distribution of costs over time, whether this distribution changes after increases in cost sharing and expanded eligibility, patient characteristics that predict high-cost status, and examine health services used by high-cost children to identify what is preventable. The top 10% (1%) of enrollees account for about 65.5% (24.7%) of total program costs. Inpatient and outpatient costs are the largest components of costs incurred by high-cost utilizers. Non-urgent emergency department costs are a relatively small portion. Average expenditure increases over time, particularly after expanded eligibility, and the share of costs incurred by the top 10% and 1% increases slightly. Multivariable logistic regression results indicate that infants and older teens, Caucasian children, and those with chronic conditions are more likely to be high-cost utilizers. Increased cost sharing does not reduce cost concentration or average expenditure among high-cost utilizers. These findings suggest that identifying and targeting potentially preventable costs among high-cost utilizers are called for to help reduce costs in public insurance programs.