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Publications of Note: April–June 2019

Behavioral Health and Other Chronic Conditions Common Among Adult Medicaid Enrollees Subject to Work Requirements

An analysis of data from the National Survey on Drug Use and Health found people with behavioral health and other chronic conditions were more likely to be enrolled in Medicaid and subject to work requirements than those without any identified health conditions. Among Medicaid enrollees, these groups were also less likely to have worked 20 hours or more in the past week, and thus would be less likely to meet work requirements. The authors say that if work requirements are to be a continued element of Medicaid programs, policy changes are needed to ensure the program covers a full continuum of behavioral health services and that enrollees with work-limiting conditions are given reasonable accommodations and exemptions. Hefei Wen, Brendan Saloner, and Janet R. Cummings, “Behavioral and Other Chronic Conditions Among Medicaid Enrollees: Implications for Work Requirements,” Health Affairs 38, no. 4 (Apr. 2019): 660–67.


Vulnerable Subpopulations Not Adversely Impacted by Bundled Payments Initiative

The Bundled Payments for Care Improvement (BPCI) initiative, which bundles reimbursement for certain medical and surgical procedures into a single payment for an episode of care, has on average lowered Medicare spending without adversely impacting quality of care. To see if beneficiaries with one or more of three vulnerable characteristics — dementia, dual eligibility for Medicare and Medicaid, and recent institutional care — were negatively impacted relative to other groups, researchers looked at changes in emergency department (ED) visits, unplanned hospital readmissions, and all-cause mortality within 90 days of hospital discharges. The results for 12 types of medical and surgical episodes suggest that bundled payment did not adversely affect care quality for beneficiaries with such vulnerabilities. Nonetheless, the authors recommend policymakers support ongoing research to ensure that vulnerable populations are not adversely affected. The study examined BPCI model two, the largest of four BPCI models. Brandon C. Maughan et al., “Medicare’s Bundled Payments for Care Improvement Initiative Maintained Quality of Care for Vulnerable Patients,” Health Affairs 38, no. 4 (Apr. 2019): 561–68.


Adjusting for Social Risk Factors Would Reduce Readmission Penalties for Safety-Net Hospitals

Researchers found poverty, disability, housing instability, residence in a disadvantaged neighborhood, and share of hospital population from a disadvantaged neighborhood were associated with higher readmission rates among hospitals. Using the current specifications for Medicare’s Hospital Readmissions Reduction Program, they found safety-net hospitals had higher readmission rates than the most affluent hospitals for three conditions (acute myocardial infarction, pneumonia, and congestive heart failure). Adding social factors to risk adjustment cut these differences in half. More than half of the safety-net hospitals saw the penalty decline with this risk adjustment, and 47.5 percent went from having a penalty to no penalty, resulting in a $17 million reduction in penalties. Karen E. Joynt Maddox et al., “Adjusting for Social Risk Factors Impacts Performance and Penalties in the Hospital Readmissions Reduction Program,” Health Services Research 54, no. 2 (Apr. 2019): 327–36.


Developing a Lexicon for Social Risk

The authors of this commentary advocate for defining and distinguishing key terms and concepts related to the social determinants of health to ensure they are not misunderstood, conflated, or confused. They propose a set of definitions for key terms, including social determinants of health, population health, social needs, social risk factors, and behavioral risk factors as these terms describe different approaches and causes of action. Some characterize structural factors that govern the distribution of resources such as income and education, which may not in and of themselves impair health, while others point to individual-level social or behavioral risk factors that do. Hugh Alderwick and Laura M. Gottlieb, “Meanings and Misunderstandings: A Social Determinants of Health Lexicon for Health Care Systems,” Milbank Quarterly 97, no. 2 (June 2019): 407–19.


Review of Evidence Suggests ACOs Reduce Institutional Care, Improve Chronic Disease Management

A review of publications describing the association between public and private accountable care organizations (ACOs) and health care service use, processes, and outcomes found the most consistent associations across payer types were reduced inpatient use, reduced emergency department visits, and improved measures of preventive care and chronic disease management. Seven studies evaluating patient experience or clinical outcomes found no evidence that ACOs worsen outcomes of care. The authors say the impact on patient care and outcomes should continue to be monitored. The 42 articles covered a mix of ACO contracts: Medicare (24), Medicaid (5), commercial (11), and all payers (2). Brystana G. Kaufman et al., “Impact of Accountable Care Organizations on Utilization, Care, and Outcomes: A Systematic Review,” Medical Care Research and Review 76, no. 3 (June 2019): 255–90.


Loss of SNAP Associated with Food Insecurity and Poor Health in Working Families with Young Children

Researchers examined how benefit reductions or cutoffs in the Supplemental Nutrition Assistance Program (SNAP) were related to economic hardships (food and energy insecurity, unstable housing, forgone health and/or dental care, and health cost sacrifices) and to caregiver and child health. Families with children younger than age 4 whose benefits were altered after their incomes increased had significantly higher odds of household and child food insecurity compared with a group with consistent participation in SNAP, a program that helps working families meet their nutritional needs. Reduced benefits were also associated with 1.43 and 1.22 times greater odds of fair or poor caregiver and child health, respectively. The authors recommend policy modifications to smooth changes in benefit levels as families’ income increases. Stephanie Ettinger de Cuba et al., “Loss of SNAP Is Associated with Food Insecurity and Poor Health in Working Families with Young Children,” Health Affairs 38, no. 5 (May 2019): 765–73.


Medicaid Expansions Reduce Disparities in Birth Outcomes Between Black and White Women

Using data from 2011–16, researchers found expansion of Medicaid eligibility was not significantly associated with differences in rates of low birth weight or preterm birth outcomes overall, but there were significant improvements in relative disparities for black infants compared with white infants in states that expanded Medicaid compared with those that did not. In these states, disparities between white and black infants declined for preterm birth, very preterm birth, low birthweight, and very low birthweight. Clare C. Brown et al., “Association of State Medicaid Expansion Status with Low Birth Weight and Preterm Birth,” Journal of the American Medical Association 321, no. 16 (April 23/30, 2019): 1598–1609.


Collaborations Between Health and Social Service Sectors Benefit Health System Engagement

A study that sought to identify the features of effective collaboration between the health and social services sectors measured six types of ties (any collaboration, referrals, sharing information, cosponsoring projects, financial contracts, and joint needs assessment), examining their impact on avoidable health care use and spending for older adults. The researchers found high-performing networks were distinguished from low-performing networks by two features: having health care organizations occupy a central position and having subnetworks that were more cohesive. Across all networks, Area Agencies on Aging were more centrally positioned than any other type of organization. The authors conclude that cross-sector engagement by health care organizations may reduce preventable health care use and spending. These efforts could leverage Area Agencies on Aging, which are already positioned as network brokers, they say. Amanda L. Brewster et al., “Collaboration in Health Care and Social Service Networks for Older Adults,” Medical Care 57, no. 5 (May 2019): 327–33.


Women in High-Deductible Health Plans Experienced Delayed Breast Cancer Care

A study of time to first breast cancer diagnostic testing, diagnosis, and chemotherapy among a group of women whose employers switched their insurance coverage from health plans with low deductibles ($500 or less) to plans with high deductibles ($1,000 or more) found low-income women in high-deductible plans experienced relative delays of 1.6 months to first breast imaging, 2.7 months to first biopsy, 6.6 months to incident early-stage breast cancer diagnosis, and 8.7 months to first chemotherapy. High-income women in high-deductible plans experienced delays; however, these were shorter than those experienced by their low-income counterparts. The authors found members living in metropolitan, nonmetropolitan, predominantly white, and predominantly nonwhite areas also experienced delayed breast cancer care. Policies that reduce out-of-pocket spending obligations for breast cancer care may be needed, they say. J. Frank Wharam et al., “Vulnerable and Less Vulnerable Women in High-Deductible Health Plans Experienced Delayed Breast Cancer Care,” Health Affairs 38, no. 3 (Mar. 2019): 408–15.


Mental Health Visits to the ED Rising Among Youth and Young Adults

Researchers found visits to the emergency department (ED) for psychiatric purposes among youth are rising across the U.S. Between 2011 and 2015, there was a 28 percent overall increase in psychiatric ED visits per 1,000 youth. The largest increases were observed among adolescents (54%) and African American (53%) and Hispanic patients (91%). A 2.5-fold increase in suicide-related visits was observed among adolescents. Although psychiatric ED visits were long (more than half were three or more hours in length), only 16 percent of patients were seen by a mental health professional during their visit. The authors say psychiatric expertise as well as effective mental health treatment options, particularly those directed at combatting the rising suicide epidemic among adolescents, are needed in the ED. Luther G. Kalb et al., “Trends in Psychiatric Emergency Department Visits Among Youth and Young Adults in the U.S.,” Pediatrics 143, no. 4 (Apr. 2019): e20182192.


Homeless Infants Face Long-Standing Health Challenges

By linking Massachusetts emergency shelter enrollment records with Medicaid claims, researchers found infants born during a period of unstable housing resulting in homelessness had higher rates of low birthweight, respiratory problems, fever, and other common conditions as well as higher annual spending. The differences in most health conditions persisted for two to three years. Asthma diagnoses, emergency department visits, and spending were significantly higher through age 6. They say while screening and access to health care can be improved for homeless infants, long-term solutions require a broader focus on housing and income. Robin E. Clark et al., “Infants Exposed to Homelessness: Health, Health Care Use, and Health Spending from Birth to Age Six,” Health Affairs 38, no. 5 (May 2019): 721–28.


Practicing Physicians’ Knowledge About Their Legal Obligations When Caring for Patients with Disability

Researchers interviewed practicing physicians to explore their knowledge of their obligations to accommodate patients with disability under federal civil rights law. Interviewees reported having had little formal training about, and demonstrated superficial or incorrect understanding of, their obligations in three potentially problematic areas: deciding which accommodations their practices should implement, refusing patients with disability, and holding patients accountable for costs of accommodations. To achieve equitable treatment of the approximately 61 million Americans with disability, further education in the Americans with Disabilities Act and other disability civil rights laws may be warranted, the authors say. Nicole D. Agaronnik et al., “Knowledge of Practicing Physicians About Their Legal Obligations When Caring for Patients with Disability,” Health Affairs 38, no. 4 (Apr. 2019): 545–53.


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Publication Date: June 27, 2019