Phantom Networks: Discrepancies Between Reported And Realized Mental Health Care Access In Oregon Medicaid.
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ABSTRACT:
SUBMITTER: Zhu JM
PROVIDER: S-EPMC9876384 | biostudies-literature | 2022 Jul
REPOSITORIES: biostudies-literature
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Phantom Networks: Discrepancies Between Reported And Realized Mental Health Care Access In Oregon Medicaid.
Zhu Jane M JM Charlesworth Christina J CJ Polsky Daniel D McConnell K John KJ
Health affairs (Project Hope) 20220701 7
Understanding the extent to which beneficiaries can "realize" access to reported provider networks is imperative in mental health care, where there are significant unmet needs. We compared listings of providers in network directories against provider networks empirically constructed from administrative claims among members who were ages sixty-four and younger and enrolled in Oregon's Medicaid managed care organizations between January 1 and December 31, 2018. "In-network" providers were those wi ...[more]
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Project description:ObjectiveProvider networks for mental health are narrower than for other medical specialties. Providers' influence on access to care is potentially greater in Medicaid because enrollees are generally limited to contracted providers, without out-of-network options for nonemergency mental health care. The authors used claims-based metrics to examine variation in specialty mental health provider networks.MethodsIn a cross-sectional analysis of 2018 Oregon Medicaid claims data, claims from adults ages 18-64 years (N=100,515) with a psychiatric diagnosis were identified. In-network providers were identified as those associated with any medical claims filed for at least five unique Medicaid beneficiaries enrolled in a health plan (coordinated care organization [CCO]) during the study period. Specialty mental health providers were categorized as prescribers (psychiatrists and mental health nurse practitioners) and nonprescribers (therapists, counselors, clinical nurse specialists, psychologists, and social workers). Measures of network composition, provider-to-population ratio, continuity, and concentration of care were calculated at the CCO level; the correlation between these measures was estimated to describe the degree to which they capture unique dimensions of provider networks.ResultsAcross 15 CCOs, the number of prescribing providers per 1,000 patients was relatively stable. CCOs that expanded their networks did so by increasing the number of nonprescribing providers. Moderately negative correlations were found between the nonprescriber provider-to-population ratio and proportions of visits with prescribers as well as with usual provider continuity.ConclusionsThis analysis advances future research and policy applications by offering a more nuanced view of provider network measurement and describing empirical variation across networks.
| S-EPMC9800638 | biostudies-literature
Project description:ObjectiveTo describe how access to primary and specialty care differs for Medicaid patients relative to commercially insured patients, and how these differences vary across rural and urban counties, using comprehensive claims data from Oregon.DesignCross-sectional study of risk-adjusted access rates for two types of primary care providers (physicians; nurse practitioners (NPs) and physician assistants (PAs)); four types of mental health providers (psychiatrists, psychologists, advanced practice NPs or PAs specializing in mental health care, behavioral specialists); and four physician specialties (obstetrics and gynecology, general surgery, gastroenterology, dermatology).Participants420,947 Medicaid and 638,980 commercially insured adults in Oregon, October 2014-September 2015.OutcomePresence of any visit with each provider type, risk-adjusted for sex, age, and health conditions.ResultsRelative to commercially insured individuals, Medicaid enrollees had lower rates of access to primary care physicians (- 11.82%; CI - 12.01 to - 11.63%) and to some specialists (e.g., obstetrics and gynecology, dermatology), but had equivalent or higher rates of access to NPs and PAs providing primary care (4.33%; CI 4.15 to 4.52%) and a variety of mental health providers (including psychiatrists, NPs and PAs, and other behavioral specialists). Across all providers, the largest gaps in Medicaid-commercial access rates were observed in rural counties. The Medicaid-commercial patient mix was evenly distributed across primary care physicians, suggesting that access for Medicaid patients was not limited to a small subset of primary care providers.ConclusionsThis cross-sectional study found lower rates of access to primary care physicians for Medicaid enrollees, but Medicaid-commercial differences in access rates were not present across all provider types and displayed substantial variability across counties. Policies that address rural-urban differences as well as Medicaid-commercial differences-such as expansions of telemedicine or changes in the workforce mix-may have the largest impact on improving access to care across a wide range of populations.
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Project description:Access to general dental care is essential for preventing and treating oral diseases. To ensure adequate spatial accessibility for the most vulnerable populations, New York State mandates a ratio of one general dentist to 2000 Medicaid recipients within 30 min of public transportation. This study employed geospatial methods to determine whether the requirement is met in Manhattan by verifying the online directories of ten New York managed care organizations (MCOs), which collectively presented 868 available dentists from 259 facilities. Our survey of 118 dental facilities representing 509 dentists revealed that significantly fewer dentists are available to treat Medicaid recipients compared to MCO directories. The average dentist-to-patient ratio derived from the MCO listings by the Two-Step Floating Catchment Area (2SFCA) method was 1:315, while the average verified ratio was only 1:1927. "Phantom networks", or inaccurate provider listings, substantially overstated Medicaid dental accessibility. Surprisingly, our study also discovered additional Medicaid providers unlisted in any MCO directory, which we coined "hidden networks". However, their inclusion was inconsequential to the overall dental supply. We further scrutinized dental care access by uniquely applying six "patient-centered characteristics", and these criteria vastly reduced accessibility to an average ratio of merely 1:4587. Our novel evaluation of the spatial association between poverty, dental care access, and phantom networks suggests that Medicaid dental providers wish to be located in wealthier census tracts that are in proximity to impoverished areas for maximum profitability. Additionally, we discovered that poverty and phantom networks were positively correlated, and phantom providers masked a lack of dental care access for Medicaid recipients.
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Project description:ObjectiveThis study examined the effect of Medicaid expansion in Oregon on duration of Medicaid enrollment and outpatient care utilization for low-income individuals during the postpartum period.MethodsWe linked Oregon birth certificates, Medicaid enrollment files, and claims to identify postpartum individuals (N = 73,669) who gave birth between 2011 and 2015. We created one pre-Medicaid expansion (2011-2012) and two post-expansion (2014-2015) cohorts (i.e., previously covered and newly covered by Medicaid). We used ordinary least squares and negative binomial regression models to examine changes in postpartum coverage duration and number of outpatient visits within a year of delivery for the post-expansion cohorts compared to the pre-expansion cohort. We examined monthly and overall changes in outpatient utilization during 0-2 months, 3-6 months, and 7-12 months after delivery.ResultsPostpartum coverage duration increased by 3.14 months and 2.78 months for the post-Medicaid expansion previously enrolled and newly enrolled cohorts (p < 0.001), respectively. Overall outpatient care utilization increased by 0.06, 0.19, and 0.34 visits per person for the previously covered cohort and 0.12, 0.13, and 0.26 visits per person for newly covered cohort during 0-2 months, 3-6 months, and 7-12 months, respectively. Monthly change in utilization increased by 0.006 (0-2 months) and 0.004 (3-6 months) visits per person for post-Medicaid previously enrolled cohort and decreased by 0.003 (0-2 months) and 0.02 (7-12 months) visits per person among newly enrolled cohort.ConclusionMedicaid expansion increased insurance coverage duration and outpatient care utilization during postpartum period in Oregon, potentially contributing to reductions in pregnancy-related mortality and morbidities among birthing individuals.
| S-EPMC10352675 | biostudies-literature
Project description:BACKGROUND:While the Affordable Care Act's (ACA) Medicaid expansion has increased insurance coverage, its effects on health outcomes have been mixed. This may be because previous research did not disaggregate mental and physical health or target populations most likely to benefit. OBJECTIVE:To examine the association between Medicaid expansion and changes in mental health, physical health, and access to care among low-income childless adults with and without chronic conditions. DESIGN:We used a difference-in-differences analytical framework to assess differential changes in self-reported health outcomes and access to care. We stratified our analyses by chronic condition status. PARTICIPANTS:Childless adults, aged 18-64, with incomes below 138% of the federal poverty level in expansion (n = 69,620) and non-expansion states (n = 57,628). INTERVENTION:Active Medicaid expansion in state of residence. MAIN MEASURES:Self-reported general health; total days in past month with poor health, poor mental health, poor physical health, or health-related activity restrictions; disability; depression; insurance coverage; cost-related barriers; annual check-up; and personal doctor. KEY RESULTS:Medicaid expansion was associated with reductions in poor health days (-1.2 days [95% CI, -1.6,-0.7]) and days limited by poor health (-0.94 days [95% CI, -1.4,-0.43]), but only among adults with chronic conditions. Trends in general health measures appear to be driven by fewer poor mental health days (-1.1 days [95% CI, -1.6,-0.6]). Expansion was also associated with a reduction in depression diagnoses (-3.4 percentage points [95% CI, -6.1,-0.01]) among adults with chronic conditions. Expansion was associated with improvements in access to care for all adults. CONCLUSIONS:Medicaid expansion was associated with substantial improvements in mental health and access to care among low-income adults with chronic conditions. These positive trends are likely to be reversed if Medicaid expansion is repealed.
| S-EPMC5834959 | biostudies-literature
Project description:Importance:Several state Medicaid reforms are under way, but the relative performance of different approaches is unclear. Objective:To compare the performance of Oregon's and Colorado's Medicaid Accountable Care Organization (ACO) models. Design, Setting, and Participants:Oregon initiated its Medicaid transformation in 2012, supported by a $1.9 billion investment from the federal government, moving most Medicaid enrollees into 16 Coordinated Care Organizations, which managed care within a global budget. Colorado initiated its Medicaid Accountable Care Collaborative in 2011, creating 7 Regional Care Collaborative Organizations that received funding to coordinate care with providers and connect Medicaid enrollees with community services. Data spanning July 1, 2010, through December 31, 2014 (18 months before intervention and 24 months after intervention, treating 2012 as a transition year) were analyzed for 452?371 Oregon and 330?511 Colorado Medicaid enrollees, assessing changes in outcomes using difference-in-differences analyses of regional focus, primary care homes, and care coordination. Oregon's Coordinated Care Organization model was more comprehensive in its reform goals and in the imposition of downside financial risk. Exposures:Regional focus, primary care homes, and care coordination in Medicaid ACOs. Main Outcomes and Measures:Performance on claims-based measures of standardized expenditures and utilization for selected services, access, preventable hospitalizations, and appropriateness of care. Results:In a total of 782?882 Medicaid enrollees, 45.0% were male, with mean (SD) age 16.74 (14.41) years. Standardized expenditures for selected services declined in both states during the 2010-2014 period, but these decreases were not significantly different between the 2 states. Oregon's model was associated with reductions in emergency department visits (-6.28 per 1000 beneficiary-months; 95% CI, -10.51 to -2.05) and primary care visits (-15.09 visits per 1000 beneficiary-months; 95% CI, -26.57 to -3.61), improvements in acute preventable hospital admissions (-1.01 admissions per 1000 beneficiary-months; 95% CI, -1.61 to -0.42), 3 of 4 measures of access (well-child visits, ages 3-6 years, 2.69%; 95% CI, 1.20% to 4.19%; adolescent well-care visits, 6.77%; 95% CI, 5.22% to 8.32%; and adult access to preventive ambulatory care, 1.26%; 95% CI, 0.28% to 2.25%), and 1 of 4 measures of appropriateness of care (avoidance of head imaging for uncomplicated headache, 2.59%; 95% CI, 1.35% to 3.83%). Conclusions and Relevance:Two years into implementation, Oregon's and Colorado's Medicaid ACO models exhibited similar performance on standardized expenditures for selected services. Oregon's model, marked by a large federal investment and movement to global budgets, was associated with improvements in some measures of utilization, access, and quality, but Colorado's model paralleled Oregon's on several other metrics.
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Project description:ObjectiveTo examine how three measures of realized access to care vary by definitions and categorizations of "rural".Data sourcesHealth Information National Trends Survey (HINTS) data, a nationally representative survey assessing knowledge of health-related information, were used. Participants were categorized by county-based Urban Influence Codes (UICs), Rural-Urban Continuum Codes (RUCCs), and census tract-based Rural-Urban Commuting Area (RUCAs).Study designThree approaches were used across categories of UICs, RUCCs, and RUCAs: (1) non-metropolitan/metropolitan, (2) three-group categorization based upon population size, and (3) three-group categorization based on adjacency to metropolitan areas. Wald Chi-square tests evaluated differences in sociodemographic variables and three measures of realized access across three of Penchansky's "A's of access" and approaches. The three outcome measures included: having a regular provider (realized availability), self-reported "excellent" quality of care (realized acceptability), and self-report of the provider "always" spending enough time with you (provider attentiveness-realized accommodation). The average marginal effects corresponding to each outcome were calculated.Data collection/extraction methodsN/A PRINCIPAL FINDINGS: All approaches indicated comparable variation in sociodemographics. In all approaches, RUCA-based categorizations showed differences in having a regular provider (e.g., 68.9% of non-metropolitan and 64.4% of metropolitan participants had a regular provider). This association was attenuated in multivariable analyses. No rural-urban differences in quality of care were seen in unadjusted or adjusted analyses regardless of approach. After adjustment for covariates, rural respondents reported greater provider attentiveness in some categorizations of rural compared with urban (e.g., non-metropolitan respondents reported 6.03 percentage point increase in probability of having an attentive provider [CI = 0.76-11.31%] compared with metropolitan).ConclusionsOur findings underscore the importance of considering multiple definitions of rural to understand access disparities and suggest that continued research is needed to examine the interplay between potential and realized access. These findings have implications for federal funding, resource allocation, and identifying health disparities.
| S-EPMC9108055 | biostudies-literature
Project description:ImportanceFirearms are the most common method of suicide, one of the "diseases of despair" driving increased mortality in the US over the past decade. However, routine standardized questions about firearm access are uncommon, particularly among adult populations, who are more often asked at the discretion of health care clinicians. Because standard questions are rare, patterns of patient-reported access are unknown.ObjectiveTo evaluate whether and how patients self-report firearm access information on a routine mental health monitoring questionnaire and additionally to examine sociodemographic and clinical associations of reported access.Design setting and participantsCross-sectional study of patients receiving care for mental health and/or substance use in primary care or outpatient mental health specialty clinics of Kaiser Permanente Washington, an integrated health insurance provider and care delivery system.Main outcomes and measuresElectronic health records were used to identify patients who completed a standardized self-reported mental health monitoring questionnaire after a single question about firearm access was added from January 1, 2016, through December 31, 2019. Primary analyses evaluated response (answered vs not answered) and reported access (yes vs no) among those who answered, separately for patients seen in primary care and mental health. These analyses also evaluated associations between patient characteristics and reported firearm access. Data analysis took place from February 2020 through May 2021.ResultsAmong patients (n = 128 802) who completed a mental health monitoring questionnaire during the study period, 74.4% (n = 95 875) saw a primary care clinician and 39.3% (n = 50 631) saw a mental health specialty clinician. The primary care and mental health samples were predominantly female (63.1% and 64.9%, respectively) and White (75.7% and 77.0%), with a mean age of 42.8 and 51.1 years. In primary care, 83.4% of patients answered the question about firearm access, and 20.9% of patients who responded to the firearm question reported having access. In mental health, 91.8% of patients answered the question, and 15.3% reported having access.Conclusions and relevanceIn this cross-sectional study of adult patients receiving care for mental health and substance use, most patients answered a question about firearm access on a standardized mental health questionnaire. These findings provide a critical foundation to help advance understanding of the utility of standardized firearm access assessment and to inform development of practice guidelines and recommendations. Responses to standard firearm access questions used in combination with dialogue and decision-making resources about firearm access and storage may improve suicide prevention practices and outcomes.
| S-EPMC8796974 | biostudies-literature
Project description:OBJECTIVE: To examine the effect of capitated transportation brokerage services on Medicaid beneficiaries' access to care and expenditures. DATA SOURCES/STUDY SETTING: The study period from 1996 to 1999 corresponds to the period of a natural experiment during which Georgia and Kentucky implemented transportation brokerage services. Effects were estimated for asthmatic children and diabetic adults. STUDY DESIGN: We used difference-in-differences models to assess the effects of transportation brokerage services on access to care, measured by Medicaid expenditures and health services use. The study design is strengthened by the staggered implementation dates between states and within each state. PRINCIPAL FINDINGS: For asthmatic children, transportation brokerage services increased nonemergency transportation expenditures and the likelihood of using any services; reductions in monthly expenditures more than offsetting the increased transportation costs. For diabetic adults, nonemergency transportation costs decreased despite increased monthly use of health services; average monthly medical expenditures and the likelihood of hospital admission for an ambulatory care-sensitive condition (ACSC) also decreased. CONCLUSIONS: The shift to transportation brokerage services improved access to care among Medicaid beneficiaries and decreased the expenditures. The increase in access combined with reduced hospitalizations for asthmatic children and ACSC admissions for diabetic adults are suggestive of improvements in health outcomes.
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Project description:The proportion of low-income nonelderly adults covered by Medicaid varies widely by state. We sought to determine whether broader state Medicaid coverage, defined as the proportion of each state's low-income nonelderly adult population covered by Medicaid, associates with lower state-level incidence of ESRD and greater access to care. The main outcomes were incidence of ESRD and five indicators of access to care. We identified 408,535 adults aged 20-64 years, who developed ESRD between January 1, 2001, and December 31, 2008. Medicaid coverage among low-income nonelderly adults ranged from 12.2% to 66.0% (median 32.5%). For each additional 10% of the low-income nonelderly population covered by Medicaid, there was a 1.8% (95% confidence interval, 1.0% to 2.6%) decrease in ESRD incidence. Among nonelderly adults with ESRD, gaps in access to care between those with private insurance and those with Medicaid were narrower in states with broader coverage. For a 50-year-old white woman, the access gap to the kidney transplant waiting list between Medicaid and private insurance decreased by 7.7 percentage points in high (>45%) versus low (<25%) Medicaid coverage states. Similarly, the access gap to transplantation decreased by 4.0 percentage points and the access gap to peritoneal dialysis decreased by 3.8 percentage points in high Medicaid coverage states. In conclusion, states with broader Medicaid coverage had a lower incidence of ESRD and smaller insurance-related access gaps.
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