Background: Federally Qualified Health Centers (FQHCs) are essential safety-net providers, but traditional payment mechanisms may focus on volume over quality-of-care. Alternative payment models (APMs) have been introduced to enhance value-based purchasing. It is hypothesized that APMs would improve flexibility and incentivize quality of care, but evidence remains limited, especially for maternal and child health and cardiovascular conditions. Objectives: We aim to evaluate the impact of APMs on quality-of-care in FQHCs in the United States. Methods: We used a 2-stage difference-in-differences design to compare FQHCs in states adopting APMs with those that did not, using data from 2014 to 2024 in 695 FQHCs. Quality-of-care was measured using 6 indicators, including 2 associated with maternal and child services (early prenatal care and dental sealants), 2 with preventive care (depression screening and tobacco use screening), and 2 with cardiovascular disease management (cardiovascular and ischemic vascular disease treatment). To examine heterogeneity of the effects, the analysis stratified FQHCs into 3 groups based on patient volume. Results: APM adoption was significantly associated with improvements in 4 quality measures: a 3.82-percentage-point increase in early prenatal care, a 9.12 percentage point increase in dental sealants, a 5.08 percentage point increase in depression screening, and a 3.50 percentage point increase in ischemic vascular disease treatment. Stratified analyses showed that large FQHCs in APM-adopting states experienced statistically significant improvements in 3 indicators. Conclusions: Overall, APMs were associated with positive but modest improvements in quality-of-care at FQHCs.
Background: Medicaid prescription cap policies persist in 12 states; however, it is unclear how they affect the quality of opioid use disorder (OUD) treatment. Objectives: To examine the association between cap policies and the continuity in receipt of medication for OUD (MOUD) treatment in Medicaid. Methods: Using 2016–2021 T-MSIS Analytical Files data from 37 states, we identified nondual adult (18–64 y) Medicaid enrollees diagnosed with OUD who received MOUD. The exposure was the state’s Medicaid prescription cap policy status. The main outcome was a binary variable for MOUD continuity, overall and by type, defined as no treatment gap exceeding 7 consecutive days during a 180-day observation period. We estimated risk ratios for MOUD continuity using modified Poisson regression models, adjusting for individual and state-level covariates to test associations. Results: Nearly half the sample was female, and the mean age was 37 years. MOUD continuity ranged from 40.7% to 44.3% in states without cap policies and 37.5%–39.6% in cap states. Compared with enrollees in noncap states, those in cap states had a 12% higher likelihood of experiencing at least 1 MOUD treatment gap [risk ratio (RR)=1.12; 95% CI: 1.12–1.13]. These findings were consistent for buprenorphine and methadone. Factors associated with overall MOUD discontinuity included younger age, male sex, living in nonmetropolitan areas, and having 3 or more comorbidities. Conclusions: Prescription caps were associated with reduced continuity of MOUD, overall and for buprenorphine and methadone, suggesting that revising or removing these policies could improve OUD quality metrics in Medicaid.
Background: As the veteran population ages, the Veterans Health Administration (VHA) faces challenges in how to meet the care needs of patients with dementia. Providing high-quality, integrated care models in the home, such as home-based primary care (HBPC), can offer care aligned with veteran goals and present potential cost-savings to the VHA. Objective: Examine the effect of VHA HBPC on the probability of emergency department/urgent care (ED) use. Research Design: Cohort analysis using an instrumental variable approach. Subjects: Veterans aged 65+ with dementia (2021–2023) Measure(s): We define HBPC as beginning the first month veterans have 2+ HBPC claims within 91 days. ED use is the key outcome. Results: Among 133,846 veterans with dementia, 17.36% (n=23,240) received HPBC during the evaluation period. Compared with non-HBPC veterans, veterans in HBPC were older and more likely to be female, reside in a metropolitan area, be Hispanic, be Black/African American, have post-traumatic stress disorder, a traumatic brain injury, have more Elixhauser conditions, and have higher ED use (7.1% vs. 5.9%). When using the instrumental variable of lagged HBPC penetration to address selection into HBPC ( F -stat>100), we find that HBPC enrollees were 3.60 percentage points less likely to have ED use than non-HBPC enrollees ( P <0.001). Conclusions: Reducing ED visits among people with dementia may signal improved care and offer potential cost-savings to health care systems. Our findings can help inform VHA efforts to invest in the optimal allocation of resources to best support veterans with dementia while containing costs by avoiding potentially avoidable, high-cost care.
Background: Monitoring and antiviral treatment are essential to reduce chronic hepatitis B (CHB)-related morbidity and mortality. Methods: We analyzed Medicaid claims data from January 1, 2016, through December 31, 2019, to estimate claims-recorded CHB prevalence and to evaluate CHB-directed monitoring, antiviral use, and qualifying liver imaging. Results: Among 72.4 million adult Medicaid beneficiaries, 292,267 had claims-recorded CHB diagnosis (0.40%). After excluding beneficiaries with HIV or hepatitis C, HCC, or liver transplantation, 208,933 remained in the care-analysis cohort. Non-Hispanic Asians represented 6.2% of Medicaid beneficiaries but 42.8% of the care-analysis cohort. CHB-directed monitoring was received by 53.4% overall and 66.9% of patients with cirrhosis; antiviral use by 12.8% overall and 35.9% of those with cirrhosis. More than 90% of patients with cirrhosis had ≥1 qualifying liver imaging; among patients without cirrhosis, 73.5% of men aged 40 years or older and 74.9% of women aged 50 years or older had liver imaging. Non-Hispanic Asian and Native Hawaiian/Pacific Islander beneficiaries were significantly more likely to receive CHB-directed monitoring and antiviral therapy than non-Hispanic White beneficiaries, whereas Hispanic beneficiaries were significantly less likely. Substantial state-level variation was observed; among patients with cirrhosis, CHB-directed monitoring ranged from 51.4% to 89.8% and antiviral use from 21.1% to 51.5%. Conclusion: Substantial gaps and disparities in CHB monitoring and antiviral use persist among Medicaid beneficiaries highlighting the urgent need for targeted interventions and integration of CHB care into Medicaid quality measures. Standardizing CHB care and reducing demographic and geographic disparities are critical steps toward minimizing CHB-related complications and mortality.
Background: US maternal mortality and severe maternal morbidity (SMM) are marked by substantial disparities by race, payer, and geography. To the extent that such disparities are driven by differences across hospitals rather than within hospitals, understanding what shapes delivery hospital choice can inform policy responses. Objectives: To examine how distance, hospital attributes, and maternal characteristics jointly shape delivery hospital choice, and whether patterns differ between urban Atlanta and smaller Georgia markets. Research Design: Retrospective observational study using a conditional logit model to estimate delivery hospital choice. Hospital markets were defined through community detection on patient-flow data. We report marginal effects on selection probability. Subjects: Seven hundred ten thousand eight hundred seventy deliveries across 84 Georgia hospitals, 2016–2021. Measures: Deterministically linked hospital discharge, birth, and fetal death records, supplemented with American Hospital Association, CMS, and Area Resource Files data. Results: Distance (in miles) strongly deterred hospital selection in both markets, with greater sensitivity in Atlanta (−2.7 percentage points [pp] per additional mile) than outside Atlanta (−1.9 pp/mile). Individuals preferred hospitals with higher perinatal levels of care and teaching status. A hospital’s elective C-section rate was negatively associated with its selection outside Atlanta (−1.3 pp) but positively in Atlanta (+2.5 pp). Higher comorbidity was associated with higher-quality hospital selection, though the highest-risk Atlanta individuals showed lower preference for high-elective-C-section hospitals. Conclusions: Delivery hospital choice in Georgia reflects distance, practice environment, insurance, and clinical complexity, with urban/nonurban differences. Medicaid-insured individuals show delivery patterns consistent with provider supply-side constraints, which may raise concerns to the extent that they face an elevated risk of adverse maternal outcomes. Findings inform payment and referral policies improving access to risk-appropriate delivery settings and reducing maternal health disparities.
