Effects of Maryland's global budget revenue model on emergency department utilization and revisits.

BACKGROUND: In 2014, Maryland (MD) implemented a "global budget revenue" (GBR) program that prospectively sets hospital budgets. This program introduced incentives for hospitals to tightly control volume and meet budget targets. We examine GBR's effects on emergency department (ED) visits, admissions, and returns. METHODS: We performed an interrupted time-series analysis with difference-in-differences comparisons using 2012 to 2015 Healthcare Cost Utilization and Project data from MD, New York (NY), and New Jersey (NJ). We examined GBR's effects on ED visits/1,000 population, admissions from the ED, and ED returns at 72 h and 9 days. We also examined rates of admission, intensive care unit (ICU) stay, and in-hospital mortality among returns. To evaluate racial/ethnic and payer outcome disparities among ED returns, we performed a triple differences analysis. RESULTS: ED visits decreased with GBR adoption in MD relative to NY and NJ, by five and six visits/1,000 population, respectively. ED admissions declined relative to NY and NJ, by 0.6% and 1.8%, respectively. There was also a post-GBR decline in ED returns by 0.7%. Admissions among returns declined by 2%, while ICU and in-hospital mortality among returns remained relatively stable. ED return outcomes varied by racial/ethnic and payer group. Non-Hispanic Whites and non-Hispanic Blacks experienced a similar decline in returns, while returns remained unchanged among Hispanics/Latinos, widening the disparity gap. Payer group disparities between privately insured and Medicare, Medicaid, and uninsured individuals improved, with the disparity reduction most pronounced among the uninsured. CONCLUSIONS: GBR adoption was associated with lower ED utilization and admissions. ED returns and admissions among returns also decreased, while mortality and ICU stays among returns remained stable, suggesting that GBR has not led to adverse patient outcomes from fewer admissions. However, changes in ED return disparities varied by subgroup, indicating that improvements in care transitions may be uneven across patient populations.

Emergency department care coordination strategies and perceived impact under Maryland's hospital payment reforms.

BACKGROUND: Emergency department (ED) care coordination plays an important role in facilitating care transitions across settings. We studied ED care coordination processes and their perceived effectiveness in Maryland (MD) hospitals, which face strong incentives to reduce hospital-based care through global budgets. METHODS: We conducted a qualitative study using semi-structured interviews to examine ED care coordination processes and perceptions of effectiveness. Interviews were conducted from January through October 2019 across MD hospital-based EDs. Results were reviewed to assign analytic domains and identify emerging themes. Descriptive statistics of ED care coordination staffing and processes were also calculated. RESULTS: A total of 25 in-depth interviews across 18 different EDs were conducted with ED physician leadership (n = 14) and care coordination staff (CCS) (n = 11). Across all EDs, there was significant variation in the hours and types of CCS coverage and the number of initiatives implemented to improve care coordination. Participants perceived ED care coordination as effective in facilitating safer discharges and addressing social determinants of health; however, adequate access to outpatient providers was a significant barrier. The majority of ED physician leaders perceived MD's policy reform as having a mixed impact, with improved care transitions and overall patient care as benefits, but increased physician workloads and worsened ED throughput as negative effects. CONCLUSIONS: EDs have responded to the value-based care incentives of MD's global budgeting program with investments to enhance care coordination staffing and a variety of initiatives targeting specific patient populations. Although the observed care coordination initiatives were broadly perceived to produce positive results, MD's global budgeting policies were also perceived to produce barriers to optimizing ED care. Further research is needed to determine the association of the various strategies to improve ED care coordination with patient outcomes to inform practice leaders and policymakers on the efficacy of the various approaches.

Expanding Medicaid Coverage for Community-Based Long-Term Services and Supports: Lessons From Maryland's Community First Choice Program.

Community First Choice (CFC) is a Medicaid state plan option authorized through the Affordable Care Act (ACA) that supports the delivery of long-term services and supports in home and community settings. We interviewed stakeholders in Maryland, one of the first states to adopt CFC, to assess challenges, benefits, and potential implications of this Medicaid option for state and federal policy makers. Study findings suggest that expanding coverage for home- and community-based services through CFC in Maryland has been financially feasible, expanded the personal care workforce, and supported a more equitable approach to personal care services. We conclude that greater coverage for home- and community-based long-term services is a promising avenue to improve access to care for high-need Medicaid beneficiaries.

Innovative Solutions for State Medicaid Programs to Leverage Their Data, Build Their Analytic Capacity, and Create Evidence-Based Policy.

As states have embraced additional flexibility to change coverage of and payment for Medicaid services, they have also faced heightened expectations for delivering high-value care. Efforts to meet these new expectations have increased the need for rigorous, evidence-based policy, but states may face challenges finding the resources, capacity, and expertise to meet this need. By describing state-university partnerships in more than 20 states, this commentary describes innovative solutions for states that want to leverage their own data, build their analytic capacity, and create evidence-based policy. From an integrated web-based system to improve long-term care to evaluating the impact of permanent supportive housing placements on Medicaid utilization and spending, these state partnerships provide significant support to their state Medicaid programs. In 2017, these partnerships came together to create a distributed research network that supports multi-state analyses. The Medicaid Outcomes Distributed Research Network (MODRN) uses a common data model to examine Medicaid data across states, thereby increasing the analytic rigor of policy evaluations in Medicaid, and contributing to the development of a fully functioning Medicaid innovation laboratory.

Racial and ethnic minority participants in chronic disease self-management programs: findings from the Communities Putting Prevention to Work initiative.

BACKGROUND: The Communities Putting Prevention to Work: Chronic Disease Self-Management Program (CDSMP) Initiative funded grantees in 45 states, the District of Columbia and Puerto Rico to implement and expand delivery of CDSMP to older adults. We examine whether there are differences in the enrollment and completion rates of members of racial and ethnic minority groups and what sites have done to enhance their delivery of the CDSMP to such groups. METHOD: This study used a multi-method approach including: site visits to 6 states, telephone interviews with the 47 program grantees and delivery sites, review of program reports, and analysis of administrative data on participants, completers, workshops and leaders. RESULTS: Grantees served 89,861 participants, including 56.3% who self-identified as White, 17.3% as Black, 5.0% as other/multi-racial, 3.2% as Asian/Asian Americans, 1.4% as American Indian/Alaskans, .8% as Native Hawaiian/Pacific Islanders, and 16.0% individuals of unknown race. Overall, completion rates averaged 74.5%, with Native Hawaiian/Pacific Islanders completing workshops at a higher rate (90.6%) than other groups. Completion rates for participants aged > or = 75 were higher than for younger participants. Senior centers, health care organizations, and residential facilities served 63.1% of the participants. CONCLUSIONS: Grantees have successfully delivered CDSMP to racially and ethnically diverse participants in a range of settings. As the Administration for Community Living/Administration on Aging (ACL/AoA) grantees have demonstrated, CDSMP can be brought to scale by community organizations, partnerships and networks to reach diverse populations in diverse settings. The program can be a significant tool for addressing health disparities and empowering racial/ethnic minorities to take charge, promote better health and self-management of chronic conditions.

Medicare Advantage Special Needs Plans for dual eligibles: a primer.

The Special Needs Plan (SNP), a new type of Medicare Advantage plan created by the Medicare Modernization Act of 2003 (MMA), targets one of three special-needs populations--including beneficiaries who qualify both for Medicare and Medicaid benefits ("dual eligibles"), the focus of this issue brief. It identifies the key issues that underlie one of the MMA's central goals for dual eligible SNPs--"the potential to offer the full array of Medicare and Medicaid benefits, and supplemental benefits, through a single plan"--and it outlines their progress thus far. The brief observes that true coordination between SNPs and Medicaid programs, despite some state and federal initiatives, has largely failed to occur, and it discusses some of the reasons why. Consequently, the brief offers recommendations for improving dual-eligible SNPs' prospects and extending their lives (legal authorization for SNPs is scheduled to expire at year-end 2008).

Coordinating care for dual eligibles: options for linking state Medicaid programs with Medicare Advantage Special Needs Plans.

Medicare Advantage Special Needs Plans (SNPs) for dual eligibles--individuals who qualify both for Medicare and Medicaid benefits--have the potential to coordinate Medicare benefits with state-administered Medicaid benefits. States that aim to develop such programs may choose from among three potential models: 1) a Medicaid program in which the beneficiary voluntarily enrolls in a single managed care organization (MCO) that delivers both Medicaid and Medicare services; 2) a program in which the beneficiary is required to enroll in a Medicaid MCO but retains freedom of choice regarding whether to enroll in a capitated Medicare plan; and 3) an administrative services organization approach,in which Medicaid retains a vendor to coordinate Medicaid services with the SNPsoperating in the state. The authors also provide guidance on contractual issues important to state Medicaid agencies, and they discuss environmental factors that influence the choice of models and the program's prospects for success.