Telehealth Use in a Rural State: A Mixed-Methods Study Using Maine's All-Payer Claims Database.

PURPOSE: This study assesses trends in telehealth use in Maine-a rural state with comprehensive telehealth policies-across payers, services, and rurality, and identifies barriers and facilitators to the adoption and use of telehealth services. METHODS: Using a mixed-methods approach, researchers analyzed data from Maine's All Payer Claims Database (2008-2016) and key informant interviews with health care organization leaders to examine telehealth use and explore factors impacting telehealth adoption and implementation. FINDINGS: Despite a 14-fold increase in the use of telehealth over the 9-year study period, use remains low-0.28% of individuals used telehealth services in 2016 compared with 0.02% in 2008. Services provided via telehealth varied by rurality; speech language pathology (SLP) was the most common type of service among rural residents, while psychiatric services were most common among urban residents. Medicaid was the primary payer for over 70% of telehealth claims in both rural and urban areas of the state, driving the increase of telehealth claims over time. Issues challenging organizations seeking to deploy telehealth included provider resistance, staff turnover, provider shortages, and lack of broadband. Key informants identified inadequate and inconsistent reimbursement as barriers to comprehensive, systematic billing for telehealth services, resulting in underrepresentation of telehealth services in claims data. CONCLUSIONS: Claims covered by Medicaid account for much of the observed expansion of telehealth use in Maine. Telehealth appears to be improving access to behavioral health and SLP services. Provider shortages, broadband, and Medicare and commercial coverage policies limit the use of telehealth services in rural areas.

Acuity Differences Among Newly Admitted Older Residents in Rural and Urban Nursing Homes.

BACKGROUND AND OBJECTIVES: Our primary objective was to assess rural-urban acuity differences among newly admitted older nursing home residents. RESEARCH DESIGN AND METHODS: Data included the 2015 Minimum Data Set v3.0, the Area Health Resources File, the Provider of Services File, and Rural-Urban Commuting Area codes. Activities of daily living, the Cognitive Function Scale, and aggression/wandering indicators were used to assess functional, cognitive, and behavioral status, respectively. Excluding assessments for short stays (less than 90 days), assessments for 209,719 newly admitted long-stay residents aged 65 and older across 14,834 facilities in 47 states were evaluated. Difference in differences (DID) generalized linear models with state-fixed effects and clustering by facilities were used to assess the interaction effect of older age (75 plus) on rural-urban acuity differences, controlling for socioeconomic factors, admission source, and market characteristics. RESULTS: Residents admitted to rural facilities were less functionally impaired (incidence rate ratio: 0.973-0.898) but had more cognitive (odds ratio [OR]: 1.03-1.22) and problem behaviors (OR: 1.19-1.48) than urban. Although older age was predictive of higher acuity, in DID models, the expected decline in functional status was comparable in rural and urban facilities, while the cognitive and behavioral status for older admissions was 8.0% and 8.5% lower in rural versus urban facilities, respectively. DISCUSSION AND IMPLICATIONS: Although the higher prevalence of cognitive impairment and problem behaviors among rural admissions was attributable in part to older age, rural facilities admitted less complex individuals among older age residents than urban facilities. Findings may reflect less capacity to manage older, complex individuals in rural facilities.

Long-Term Services and Supports Use Among Older Medicare Beneficiaries in Rural and Urban Areas.

State and federal policies have shifted long-term services and support (LTSS) priorities from nursing home care to home and community-based services (HCBS). It is not clear whether the rural LTSS system reflects this system transformation. Using the Medicare Current Beneficiary Survey, we examined nursing home use among rural and urban Medicare beneficiaries aged 65 and older. Study findings indicate that even after controlling for known predictors of nursing home use, rural Medicare beneficiaries exhibited greater odds of nursing home residence and that the higher odds of rural nursing home residence are, in part, associated with higher rural nursing home bed supplies. A complex interplay of policy, LTSS infrastructure, and social, cultural, and other factors may be influencing the observed differences. Federal and state efforts to build rural HCBS capacity may be necessary to mitigate stubbornly persistent rural-urban differences in the patterns of institutional and community-based LTSS use.

Patterns of Telehealth Use Among Rural Medicaid Beneficiaries.

PURPOSE: Few studies have examined telehealth use among rural Medicaid beneficiaries. This study produced a descriptive overview of telehealth use in 2011, including the prevalence of telehealth use among rural and urban Medicaid beneficiaries, characteristics of telehealth users, types of telehealth services provided, and diagnoses associated with telehealth use. METHODS: Using data from the 2011 Medicaid Analytic eXtract (MAX), we conducted bivariate analyses to test the associations between rurality and prevalence and patterns of telehealth use among Medicaid beneficiaries. FINDINGS: Rural Medicaid beneficiaries were more likely to use telehealth services than their urban counterparts, but absolute rates of telehealth use were low-0.26% of rural nondual Medicaid beneficiaries used telehealth in 2011. Psychotropic medication management was the most prevalent use of telehealth for both rural and urban Medicaid beneficiaries, but the proportion of users who accessed nonbehavioral health services through telehealth was significantly greater as rurality increased. Regardless of telehealth users' residence, mood disorders were the most common reason for obtaining telehealth services. As rurality increased, significantly higher proportions of telehealth users received services to address attention-deficit/hyperactivity disorder (ADHD) and other behavioral health problems usually diagnosed in childhood. CONCLUSIONS: These findings provide a baseline for further policy-relevant investigations including examinations of changes in telehealth use rates in Medicaid since 2011. Reimbursement policies and unique rural service needs may account for the observed differences in rural-urban Medicaid telehealth use rates.

Feasibility of a Web-Based Self-management Intervention for Intermittent Urinary Catheter Users With Spinal Cord Injury.

PURPOSE: The purpose of this study was to evaluate the feasibility of a new Web-based intermittent catheter self-management intervention. DESIGN: We tested the acceptability and usability of intervention components, which included multiple Web-based materials (an online urinary diary adapted for mobile phone use and an educational booklet), 3 phone calls with a nurse, and a peer-led discussion forum. SUBJECTS AND SETTING: Thirty adults with spinal cord injury using intermittent catheterization for bladder drainage were enrolled; 26 participants received the nurses' phone-based consultations. METHODS: Preliminary effectiveness of new self-efficacy and self-management scales were evaluated using baseline and 3-month online surveys. Participants' perceived value of the intervention components, self-management changes, and suggestions were assessed with data from the 3-month surveys, followed by brief tape-recorded interviews. RESULTS: Several catheter practices improved somewhat over 3 months. The frequency of catheterizations every 4 to 6 hours increased from 71% to 77%. Self-management of neurogenic bladder dysfunction increased significantly (P = .032); participant comments indicated that fluid intake was the biggest change. Catheter-related self-efficacy and quality-of-life scores increased but not significantly. The frequency of urinary tract infection and pain did not change significantly. For feasibility, intervention components, with the exception of the forum, were rated highly by the majority of participants for usefulness, satisfaction (desired information), and Web-based usability. CONCLUSION: Further testing of this intervention is recommended in a multisite randomized clinical trial.

Development of a Web-Based Self-management Intervention for Intermittent Urinary Catheter Users With Spinal Cord Injury.

While Web-based interventions have proliferated recently, information in the literature is often lacking about how the intervention was developed. In response to that gap, this is a report of the development of a Web-based self-management intervention for intermittent urinary catheter users and pretesting with four adults with spinal cord injury living in the community. Two Web sites were created, one for recruitment and the other for the intervention itself. The intervention involved developing new Web-based technology, including an interactive urinary diary (with fluid intake/urine output and a journal), extensive catheter products information, three intervention nurse phone call consultations, and user-community discussion forums. Study participants completed an online survey and were interviewed twice about the enrollment process and their perceptions of their involvement in the intervention. Suggestions from the pretesting participants were used to revise the Web site applications prior to the next stage of research (a feasibility study). Numerous recommendations and comments were received related to content, interactivity of components, and usability. This article provides a description of how the Web sites were developed (including the technology and software programs used), issues encountered and what was done to address them, and how the Web-based intervention was modified for improvements.

A Web-Based Self-Management Intervention for Intermittent Catheter Users.

A new Web-based self-management intervention was developed for persons with spinal cord injury who use intermittent urinary catheters. Included are a description of the components, examples from the educational book, and multiple screen shots of the online urinary diary.

Factors affecting costs in Medicaid populations with behavioral health disorders.

BACKGROUND: Persons with behavioral disorders incur higher healthcare costs. Although they utilize behavioral health (BH) services others do not, they also have higher utilization of medical services OBJECTIVES: : To determine the degree to which higher costs for persons with BH disorders are attributable to utilization of BH services, multiple chronic medical conditions (CMCs) or other issues specific to populations with BH disorders. RESEARCH DESIGN: Data base consisted of claims for 63,141 Medicaid beneficiaries, 49% of whom had one of 5 categories of BH disorder. Generalized linear models were used to identify relative impact of demographics, BH status, multiple CMCs and primary care access on total, behavioral, nonbehavioral, and medical/surgical costs. RESULTS: Number of CMCs was associated with significant increases in all cost categories, including behavioral costs. Presence of any BH disorder significantly influenced these same costs, including those not associated with BH care. Effect size in each cost category varied by BH group. CONCLUSIONS: BH status has a large impact on all healthcare costs, including costs of medical and other non-BH services. The number of CMCs affects BH costs independent of BH disorder. Results suggest that costs might be reduced through better integration of behavioral and medical health services.

Low costs of defensive medicine, small savings from tort reform.

In this paper we present the costs of defensive medicine in thirty-five clinical specialties to determine whether malpractice liability reforms would greatly reduce health care costs. Defensive medicine includes tests and procedures ordered by physicians principally to reduce perceived threats of medical malpractice liability. The practice is commonly assumed to increase health care costs. The results of studies of the costs of defensive medicine have been inconsistent. We found that estimated savings resulting from a 10 percent decline in medical malpractice premiums would be less than 1 percent of total medical care costs in every specialty. These savings are lower than most previous estimates, and they suggest that the presumed impact of tort reform on health care costs may be overstated.