Background Understanding drivers of high healthcare utilisation costs among individuals experiencing first-episode psychosis (FEP) is essential for improving care in those with psychotic disorders.Objectives To characterise and compare patient-level factors and longitudinal healthcare utilisation costs across 3 years in FEP high-cost (HC) versus non-high-cost (NHC) patients.Methods Commercial US insurance claims data from 2013 to 2019 were used to identify HC and NHC patients with FEP. HC were patients accounting for ≥50% of total direct healthcare expenditures within the FEP cohort. Binomial logistic regression was used to identify patient-level factors associated with the HC group. Total healthcare costs and service modalities, including inpatient, outpatient, emergency and prescription drugs, were compared between HC and NHC across time.Results Of 27 587 patients with FEP, 12% were HC with higher rates of multiple psychotic disorder diagnoses (p<0.001), chronic medical conditions (p<0.001) and exposure to adverse social determinants of health (p<0.01), particularly for economic category (p<0.001), with vitamin deficiency listed as the highest frequency. Cost analysis revealed a positive relationship between psychosis- and non-psychosis-related conditions, with HC having increased inpatient use for both.Conclusions Factors associated with being HC in this nationally representative private-payer FEP population were behavioural diagnostic instability, comorbid mental and physical health conditions, and exposure to adverse social factors, including nutritional deficiency. Additionally, psychosis and non-psychosis-related costs stabilise within 2 years. These findings may be important in identifying individuals who may benefit from additional, more intensive services.

This brief’s objective was to examine variation in first-episode psychosis (FEP) incidence rates by applying previously published study criteria to U.S. MarketScan claims data. Estimated FEP incidence rates ranged from 20 to 163 per 100,000 individuals, highlighting the need for standardization. Factors contributing to this variation included ICD coding definitions, age range, duration of continuous enrollment prior to the index diagnosis, minimum number of psychosis-related claims, and antipsychotic prescription requirements.

Background:The opioid overdose crisis remains a public health emergency in the United States. Evidence-based practices-including medications for opioid use disorder (MOUD) and naloxone distribution-can reduce harms, but their community-level cost-effectiveness is uncertain and may vary locally. We aimed to evaluate the cost-effectiveness of enhanced community-level implementation of evidence-based practices for opioid use disorder (OUD). Methods:We used a validated microsimulation model of OUD, calibrated with data from the HEALing Communities Study across 26 highly impacted communities in Massachusetts, New York, and Ohio. Six intervention scenarios for 2025-2030: maintaining 2024 evidence-based practice levels (status quo); improved naloxone distribution; improved MOUD retention; improved MOUD initiation; combined initiation and retention; and combined initiation, retention, and naloxone distribution. Outcomes included opioid overdose deaths (OODs), non-overdose opioid-related deaths, quality-adjusted life years (QALYs), costs (healthcare and societal), and incremental cost-effectiveness ratios (ICERs). Findings:Maintaining 2024 evidence-based practice levels was projected to yield OODs of 39-468 per 100,000 and non-overdose deaths of 238-3018 per 100,000 across communities. Enhancing MOUD initiation, retention, and naloxone distribution reduced OODs by 15-40% and non-overdose deaths by 7-24%, producing the largest QALY gains (1006-38,292). From the healthcare perspective, improved initiation plus retention was cost-effective in all communities (ICER US$11,765-US$91,058 per QALY); from the societal perspective, all enhanced scenarios were cost-saving (US$121 million-US$4.74 billion net savings). Interpretation:Community-level enhancement of MOUD initiation and retention, and for some communities also enhancing naloxone distribution, can substantially reduce opioid-related-overdose and non-overdose-deaths. These strategies are cost-effective from a healthcare perspective and cost-saving from a societal perspective, supporting investment in comprehensive, community-tailored interventions. Funding:NIH HEAL Initiative.

BACKGROUND:The HEALing Communities Study (HCS) was conducted across four states with the goal of decreasing opioid-related overdose deaths by increasing community-level adoption of evidence-based practices (EBPs). Providing communities with training, technical assistance, and resources to aid them in addressing opioid overdoses was central to the Communities That HEAL (CTH) intervention. The intervention included 1) community engagement (CE) to facilitate data-driven EBP selection and implementation, 2) a menu of EBPs to implement, and 3) communication campaigns. METHODS:We performed an economic cost analysis for the 33 communities implementing CTH over a 30-month intervention period in Kentucky, Massachusetts, New York, and Ohio. Cost data were obtained from community members, consultants, and research faculty and staff. This study focuses on the communities' perspective and reports costs paid directly with HCS funds and the opportunity costs of community members' time and other unreimbursed resources. We report average costs across communities and for each component of the CTH. RESULTS:The average cost per community of CE was $1030,405, EBPs was $668,030, and communication campaigns was $235,915. The total community cost of CE was $34,003,373, of EBP implementation was $22,044,987, of communications campaign was $7785,182. CONCLUSIONS:Our study provides insight into the scope and value of resources incurred to implement community-based interventions to reduce opioid overdose deaths across four states.

Background: Sexual and gender minority young adult (SGM YA) populations use tobacco at higher rates than their non-SGM YA peers. Prior studies have identified significant correlations between interpersonal stigma and tobacco use, yet structural stigma may also influence tobacco use among SGM YA. This study aimed to assess the indirect effects of structural stigma on current tobacco use among SGM YA and non-SGM YA via depletion of economic resources, interpersonal discrimination, and perceived psychological stress. Methods: Structural Equation Modeling was used to conduct a secondary data analysis from a cross-sectional parent study. Eligible participants were 18-35 years old and currently residing in the U.S. (N = 2,857). Current use of combustible cigarettes and nicotine vapes was our dependent variable. Our independent variable of interest, structural stigma, was a latent variable comprised of three state-level indicator items: Attitudes toward SGM people, SGM protective policies (absence of), and SGM discriminatory policies (introduced or passed in 2022). We assessed three mediators of interest: Depletion of economic resources was a latent variable, which included two indicator items: food insecurity and financial strain. Interpersonal discrimination and perceptions of psychological stress were also assessed. Covariates included race/ethnicity, age, and educational attainment. Results: Structural stigma was indirectly associated with current tobacco use via depletion of economic resources for SGM YA, but not non-SGM YA. Interpersonal discrimination was also directly and indirectly associated with current tobacco use via depletion of economic resources for both groups. Conclusions: Future tobacco intervention research should consider the role of structural stigma when working with SGM YA; specifically, how interventions promoting economic stability may influence tobacco use and cessation in this population.

BACKGROUND Evidence-based practices for reducing opioid-related overdose deaths include overdose education and naloxone distribution, the use of medications for the treatment of opioid use disorder, and prescription opioid safety. Data are needed on the effectiveness of a community-engaged intervention to reduce opioid-related overdose deaths through enhanced uptake of these practices. METHODS In this community-level, cluster-randomized trial, we randomly assigned 67 communities in Kentucky, Massachusetts, New York, and Ohio to receive the intervention (34 communities) or a wait-list control (33 communities), stratified according to state. The trial was conducted within the context of both the coronavirus disease 2019 (Covid-19) pandemic and a national surge in the number of fentanyl-related overdose deaths. The trial groups were balanced within states according to urban or rural classification, previous overdose rate, and community population. The primary outcome was the number of opioid-related overdose deaths among community adults. RESULTS During the comparison period from July 2021 through June 2022, the population-averaged rates of opioid-related overdose deaths were similar in the intervention group and the control group (47.2 deaths per 100,000 population vs. 51.7 per 100,000 population), for an adjusted rate ratio of 0.91 (95% confidence interval, 0.76 to 1.09; P=0.30). The effect of the intervention on the rate of opioid-related overdose deaths did not differ appreciably according to state, urban or rural category, age, sex, or race or ethnic group. Intervention communities implemented 615 evidence-based practice strategies from the 806 strategies selected by communities (254 involving overdose education and naloxone distribution, 256 involving the use of medications for opioid use disorder, and 105 involving prescription opioid safety). Of these evidence-based practice strategies, only 235 (38%) had been initiated by the start of the comparison year. CONCLUSIONS In this 12-month multimodal intervention trial involving community coalitions in the deployment of evidence-based practices to reduce opioid overdose deaths, death rates were similar in the intervention group and the control group in the context of the Covid-19 pandemic and the fentanyl-related overdose epidemic.

Treatment of patients with end stage kidney disease (ESKD) in the United States (US) accounted for expenditures of approximately $50 billion in 2020.1 This spending was largely attributed to costs associated with dialysis care and inpatient hospitalizations.1 One means of reducing potentially avoidable inpatient hospitalizations is to ensure safe and effective use of medications. Patients with ESKD being treated with dialysis are especially vulnerable to toxicity from medications excreted by the kidneys and those that are non-dialyzable.

BACKGROUND:Communities That HEAL (CTH) is a novel, data-driven community-engaged intervention designed to reduce opioid overdose deaths by increasing community engagement, adoption of an integrated set of evidence-based practices, and delivering a communications campaign across healthcare, behavioral-health, criminal-legal, and other community-based settings. The implementation of such a complex initiative requires up-front investments of time and other expenditures (i.e., start-up costs). Despite the importance of these start-up costs in investment decisions to stakeholders, they are typically excluded from cost-effectiveness analyses. The objective of this study is to report a detailed analysis of CTH start-up costs pre-intervention implementation and to describe the relevance of these data for stakeholders to determine implementation feasibility. METHODS:This study is guided by the community perspective, reflecting the investments that a real-world community would need to incur to implement the CTH intervention. We adopted an activity-based costing approach, in which resources related to hiring, training, purchasing, and community dashboard creation were identified through macro- and micro-costing techniques from 34 communities with high rates of fatal opioid overdoses, across four states-Kentucky, Massachusetts, New York, and Ohio. Resources were identified and assigned a unit cost using administrative and semi-structured-interview data. All cost estimates were reported in 2019 dollars. RESULTS:State-level average and median start-up cost (representing 8-10 communities per state) were $268,657 and $175,683, respectively. Hiring and training represented 40%, equipment and infrastructure costs represented 24%, and dashboard creation represented 36% of the total average start-up cost. Comparatively, hiring and training represented 49%, purchasing costs represented 18%, and dashboard creation represented 34% of the total median start-up cost. CONCLUSION:We identified three distinct CTH hiring models that affected start-up costs: hospital-academic (Massachusetts), university-academic (Kentucky and Ohio), and community-leveraged (New York). Hiring, training, and purchasing start-up costs were lowest in New York due to existing local infrastructure. Community-based implementation similar to the New York model may have lower start-up costs due to leveraging of existing infrastructure, relationships, and support from local health departments.

There is growing attention among health systems to advancing health equity spurred, in part, by increased recognition of how social determinants of health at the community-level (e.g., cost and availability of housing) shape individual-level social needs inextricably linked to health outcomes (e.g., housing instability). Health system-based social needs screening programs have proliferated as a result, but interventions that address social needs have struggled in scale and sustainability, partly due to misalignment in financing mechanisms.1Fichtenberg CM Alley DE Mistry KB. Improving Social Needs Intervention Research: Key Questions for Advancing the Field.Am J Prev Med. 2019; 57: S47-S54https://doi.org/10.1016/J.AMEPRE.2019.07.018Abstract Full Text Full Text PDF PubMed Google Scholar As social needs resolution interventions are developed and implemented, careful attention is owed towards programmatic sustainability, with an orientation to long-term financing via public and private payors. Expanding evaluation efforts to include cost analysis can contribute to the sustainability of effective interventions by helping payers better understand the upfront, ongoing, and return on investment. This Current Issues manuscript aims to (1) review evidence of effectiveness for social needs resolution interventions, (2) discuss the need for enumerating cost alongside program effectiveness, and (3) survey the policy landscape, identifying areas of opportunity to sustain the momentum behind effective social needs resolution interventions. Recent evaluations have demonstrated effectiveness in modifying outcomes closely associated with cost savings, including reduced emergency department visits,2Joseph JJ Gray DM Williams A et al.Addressing non-medical health-related social needs through a community-based lifestyle intervention during the COVID-19 pandemic: The Black Impact program.PLoS One. 2023; 18e0282103https://doi.org/10.1371/journal.pone.0282103Crossref Scopus (5) Google Scholar cost-related medication underuse,3Koeman J Mehdipanah R. Prescribing Housing: A Scoping Review of Health System Efforts to Address Housing as a Social Determinant of Health.Popul Health Manag. 2021; 24: 316-321https://doi.org/10.1089/pop.2020.0154Crossref Scopus (9) Google Scholar transportation barriers,3Koeman J Mehdipanah R. Prescribing Housing: A Scoping Review of Health System Efforts to Address Housing as a Social Determinant of Health.Popul Health Manag. 2021; 24: 316-321https://doi.org/10.1089/pop.2020.0154Crossref Scopus (9) Google Scholar and social needs reported by patients.2Joseph JJ Gray DM Williams A et al.Addressing non-medical health-related social needs through a community-based lifestyle intervention during the COVID-19 pandemic: The Black Impact program.PLoS One. 2023; 18e0282103https://doi.org/10.1371/journal.pone.0282103Crossref Scopus (5) Google Scholar However, the majority of social needs intervention studies address discrete components within the complicated, multi-step sequence from screenings to referrals to resolution, resulting in scant evidence for effective interventions that address the full spectrum of social needs in an integrated manner. Instead, extant literature has focused on best practices for comprehensive social needs screening as opposed to interventions.4Vanjani R Reddy N Giron N et al.The Social Determinants of Health — Moving Beyond Screen-and-Refer to Intervention.New England Journal of Medicine. 2023; 389 (Malina D, ed.): 569-573https://doi.org/10.1056/NEJMms2211450Crossref Scopus (1) Google Scholar,5Yan AF Chen Z Wang Y et al.Effectiveness of Social Needs Screening and Interventions in Clinical Settings on Utilization, Cost, and Clinical Outcomes: A Systematic Review.Health Equity. 2022; 6: 454-475https://doi.org/10.1089/heq.2022.0010Crossref PubMed Scopus (27) Google Scholar Other research has focused on standalone interventions that address a single social need (e.g., food insecurity), producing evidence of effectiveness for these targeted approaches.6Oronce CIA Miake-Lye IM Begashaw MM Booth M Shrank WH Shekelle PG. Interventions to Address Food Insecurity Among Adults in Canada and the US: A Systematic Review and Meta-analysis.JAMA Health Forum. 2021; 2 (e212001-e212001)https://doi.org/10.1001/JAMAHEALTHFORUM.2021.2001Crossref Google Scholar Evaluation of comprehensive social needs screening and resolution interventions are limited and have yielded mixed results. One randomized controlled trial found that connecting eligible patients to community resources via navigation programs did not significantly improve social needs resolution, relative to a control group.7Renaud J McClellan SR DePriest K et al.Addressing Health-Related Social Needs Via Community Resources: Lessons From Accountable Health Communities.Health Aff. 2023; 42: 832-840https://doi.org/10.1377/hlthaff.2022.01507Crossref Scopus (5) Google Scholar Insufficient community resources were cited as prominent barriers in connecting patients to services, and the authors concluded that investments in community resources are required before implementing referral systems within health systems.7Renaud J McClellan SR DePriest K et al.Addressing Health-Related Social Needs Via Community Resources: Lessons From Accountable Health Communities.Health Aff. 2023; 42: 832-840https://doi.org/10.1377/hlthaff.2022.01507Crossref Scopus (5) Google Scholar Others have cited similar challenges with connecting patients to resources, including inadequate staff time and training.8Sandhu S Lian T Smeltz L Drake C Eisenson H Bettger JP. Patient Barriers to Accessing Referred Resources for Unmet Social Needs.The Journal of the American Board of Family Medicine. 2022; 35: 793-802https://doi.org/10.3122/JABFM.2022.04.210462Crossref Google Scholar Key facilitators to uptake of navigation services include collaborations with community organizations, supportive leadership, established relationships with the patient community, and comprehensiveness of social needs resolution interventions.9Steeves-Reece AL Totten AM Broadwell KDB Richardson DM Nicolaidis C Davis MM. Social Needs Resource Connections: A Systematic Review of Barriers, Facilitators, and Evaluation.Am J Prev Med. 2022; 62: e303https://doi.org/10.1016/J.AMEPRE.2021.12.002Abstract Full Text Full Text PDF Google Scholar The two approaches – targeted interventions that address a single social need versus comprehensive social need programs – require a different level of resource intensity and investment. As evidence of effectiveness emerges, healthcare administrators, insurance providers, and policymakers inevitably ask, ‘What does it cost?’ In order to assess cost, however, an outcome must be identified, requiring critical consideration of what constitutes “resolution,” particularly when social needs arise from structurally oppressive forces that operate at multiple levels: from policy to cultural norms to individual- and institutional-level practices.10Bailey ZD Feldman JM Bassett MT. How Structural Racism Works — Racist Policies as a Root Cause of U.S. Racial Health Inequities.New England Journal of Medicine. 2021; 384: 768-773https://doi.org/10.1056/NEJMms2025396Crossref PubMed Scopus (741) Google Scholar Policymakers, health system leaders, and researchers may debate appropriate outcomes, considering the role of health systems in achieving such outcomes and the risks of such involvement.11Kreuter MW Thompson T McQueen A Garg R. Addressing Social Needs in Health Care Settings: Evidence, Challenges, and Opportunities for Public Health.Annu Rev Public Health. 2021; 42: 329-344https://doi.org/10.1146/annurev-publhealth-090419-102204Crossref PubMed Scopus (69) Google Scholar,12Butler SM. How Health Care Organizations Should Support Social Services.JAMA Health Forum. 2023; 4e234569https://doi.org/10.1001/jamahealthforum.2023.4569Crossref Scopus (1) Google Scholar The appropriate resolution outcome measure should be defined from the patient's perspective and consider the social impact of the intervention, adding additional complexities to costing studies.13Perla R Stiefel M Francis D Shah NR. Defining Success In Resolving Health-Related Social Needs.Health Affairs Forefront. January 26, 2017; (Published online)https://doi.org/10.1377/forefront.20170126.058458Crossref Google Scholar Understanding the costs of these interventions will be instrumental in selecting programs for replication and securing funding for successful long-term interventions, yet there is a dearth of evidence on program costs–and the cost to scale program reach. It remains poorly understood which programs are most effective, how programs can be implemented in a pilot setting, and how programs can be effectively scaled. Evaluations of these programs remain challenging, and there is little relevant work to date.3Koeman J Mehdipanah R. Prescribing Housing: A Scoping Review of Health System Efforts to Address Housing as a Social Determinant of Health.Popul Health Manag. 2021; 24: 316-321https://doi.org/10.1089/pop.2020.0154Crossref Scopus (9) Google Scholar These challenges emerge from the complexity of programs whose sequences of action cross organizational and sectoral boundaries. Careful and innovative economic evaluation methodologies capable of measuring economic outcomes of compartmental interventions within the spectrum of tasks are needed to effect downstream change. Methods gaps and application of "wrong" methods may fail to capture potential economic effects of social needs interventions. To address this gap, experts have used innovative methodologies, such as cash benchmarking, an approach in which one study arm receives some intervention (e.g., referral to social needs resolution program), and the other receives the monetary value of the intervention in cash–to estimate the value of integrated care.14Berkowitz SA Edwards ST Polsky D. Cash Benchmarking For Integrated Health Care And Human Services Interventions: Finding The Value Added.Health Aff. 2020; 39: 582-586https://doi.org/10.1377/hlthaff.2019.01579Crossref Scopus (3) Google Scholar Others have used microsimulation methods to estimate the cost of providing evidence-based interventions to address social needs, which was estimated at $60 per-patient monthly ($720/patient annually).15Basu S Berkowitz SA Davis C Drake C Phillips RL Landon BE. Estimated Costs of Intervening in Health-Related Social Needs Detected in Primary Care.JAMA Intern Med. 2023; 183: 762https://doi.org/10.1001/jamainternmed.2023.1964Crossref Scopus (2) Google Scholar Such estimates are dependent on assumptions about patient and provider decision-making, and thus, must be validated with implementation research. Importantly, these estimates may not capture other sizable expenses incurred at implementation, including workforce development and electronic health record integration, both of which were cited as notable cost drivers in an implementation study across four federally-qualified health centers in North Carolina.16Drake C Reiter K Weinberger M et al.The Direct Clinic-Level Cost of the Implementation and Use of a Protocol to Assess and Address Social Needs in Diverse Community Health Center Primary Care Clinical Settings.J Health Care Poor Underserved. 2021; 32: 1872-1888https://doi.org/10.1353/hpu.2021.0171Crossref Scopus (4) Google Scholar Additionally, per-patient costs may vary significantly according to patient need, as annual estimates in the North Carolina study ranged from $9.76/patient to $47.98/patient.16Drake C Reiter K Weinberger M et al.The Direct Clinic-Level Cost of the Implementation and Use of a Protocol to Assess and Address Social Needs in Diverse Community Health Center Primary Care Clinical Settings.J Health Care Poor Underserved. 2021; 32: 1872-1888https://doi.org/10.1353/hpu.2021.0171Crossref Scopus (4) Google Scholar These estimates may have implications for managed care organizations’ monthly per-member payments should they consider social needs in patient risk stratification. The limited number and scope of studies underscores the need for further studies of not only cost, but also cost-effectiveness. Social needs resolution interventions often involve cross-sector partnerships, making it difficult to ascertain and attribute costs.17Walker DM Garner JA Hefner JL et al.Rationale and design of the linking education, produce provision, and community referrals to improve diabetes care (LINK) study.Contemp Clin Trials. 2023; 130107212https://doi.org/10.1016/j.cct.2023.107212Crossref Scopus (0) Google Scholar Considering the costs of social needs resolution interventions must include a variety of perspectives, including funders, health systems, community-based organizations, and patients themselves. Accounting for these diverse perspectives will help to develop funding models that properly align incentives and allow different stakeholders to share in costs–and savings. Cost-effectiveness evaluations of social needs resolution interventions may require longer study durations given the entrenched nature of the issues they aim to address. This timeline may be problematic for funders that operate on a shorter time horizon, creating a mismatch between the urgency of funding decisions and the intricate, time-intensive nature of comprehensively assessing the costs and cost-effectiveness of these complex interventions. The urgent question that must be asked after identifying cost-effective programs is how to sustain them so that they can be integrated reliably into workflows. Currently, there are discussions around how to pay for these programs,18Bleich SN Dupuis R Seligman HK. Food Is Medicine Movement—Key Actions Inside and Outside the Government.JAMA Health Forum. 2023; 4e233149https://doi.org/10.1001/jamahealthforum.2023.3149Crossref Scopus (1) Google Scholar but the lack of costing data makes it difficult to consider the long-term investment required. Fortunately, research funders, including the National Institutes of Health, have created new funding mechanisms to support implementation research (including cost analyses), which would inform how to administer these programs most effectively in healthcare settings. The Centers for Medicare and Medicaid Services (CMS) have released new reporting requirements that will be foundational to costing studies of health systems’ social needs programs. Beginning in 2024, hospitals are required to report (a) the number of individuals screened for housing instability, transportation needs, utility difficulties, and interpersonal safety, relative to the total number of patients admitted to the hospital (i.e., proportion of patients screened for social needs) and (b) the number of individuals that screened positive for social needs, relative to the total number of patients screened (i.e., proportion of patients with social needs identified through screening). State Medicaid programs will complement the efforts of CMS in exploring payment mechanisms for social needs resolution interventions through Section 1115 waivers, in which states can test different strategies to effectively address enrollees’ unmet social needs. CMS will consider state requests to cover evidence-based services for mitigating the negative health impacts of unmet social needs.19Philips AP Adashi EY Musumeci M. Medicaid Section 1115 Waivers: From Work Requirements To Social Determinants Of Health.Health Affairs Forefront. April 20, 2023; (Published online)https://doi.org/10.1377/forefront.20230418.28499Crossref Google Scholar As of 2023, 18 states have received CMS approval for waivers relating to broadly defined social needs, and four states (Arizona, Arkansas, Massachusetts, and Oregon) have received waivers focused on services for food and housing insecurity.19Philips AP Adashi EY Musumeci M. Medicaid Section 1115 Waivers: From Work Requirements To Social Determinants Of Health.Health Affairs Forefront. April 20, 2023; (Published online)https://doi.org/10.1377/forefront.20230418.28499Crossref Google Scholar Unlike basic healthcare services covered by Medicaid, CMS caps social needs waiver funding, making costing analyses critical to the selection and sustainability of social needs initiatives. In addition to Section 1115 waivers, in 2016, CMS revised its regulations relating to Medicaid Managed Care in ways that extend flexibility for plans covering nontraditional services that address social needs (e.g., home-delivered meals following a hospital discharge). Previously, plans were financially discouraged from providing nonclinical services that addressed social needs; these services were not covered by the plans’ contracts with state Medicaid agencies and counted as administrative services when calculating plans’ medical loss ratios (i.e., the percent of revenue not spent on medical expenditures). Revisions in 2016 rendered many non-clinical services as medical services, partially removing plans’ disincentives from pursuing population health-oriented initiatives. While plans now count non-traditional services in their favor when calculating required medical loss ratios, these services remain excluded from the rate setting process and cannot be included in their capitated rates charged to state Medicaid agencies.20Machledt D. Addressing the Social Determinants of Health Through Medicaid Managed Care.Issue Brief (Commonw Fund). 2017; 2017: 1-9http://www.ncbi.nlm.nih.gov/pubmed/29235781Google Scholar Future revisions to the Section 1115 waivers may seek to incorporate non-traditional services in the rate setting process, ultimately helping to ensure sustained financing for these programs. Private and non-profit payers, too, have established social needs resolution interventions. Kaiser Permanente, for example, began its “Food for Life” initiative to connect more eligible patients to existing food security resources (e.g., the Supplemental Nutrition Assistance Program) while also piloting a medically tailored meal program and collaborating with partners to create formal channels for social need referrals. In multiple states, Blue Cross Blue Shield partnered with community organizations to address food insecurity via food boxes, nutrition education, and community health worker programs. In some cases, these programs are funded by the foundational arm of the payer's operation (e.g., Cigna's grant-based investment in a suite of child-centric programs). To be truly sustainable, costs paid by a foundational arm need to be incorporated in the capitated rate, but existing restrictions prohibit including these expenditures in rate calculations. In other cases, the private investment is targeted specifically to align with public payer priorities (e.g., Humana's Healthy Horizons program for Medicaid recipients). As other scholars have aptly noted, addressing people's social needs effectively in a lasting way will require more resources. Investments should be informed by rigorous implementation research studies that build cross-sector partnerships to sustainably address patients’ social needs.11Kreuter MW Thompson T McQueen A Garg R. Addressing Social Needs in Health Care Settings: Evidence, Challenges, and Opportunities for Public Health.Annu Rev Public Health. 2021; 42: 329-344https://doi.org/10.1146/annurev-publhealth-090419-102204Crossref PubMed Scopus (69) Google Scholar One such example is the ongoing LINK study testing the effect of a combination of produce provision, diabetes and culinary skills training, and a social needs screening, navigation, and resolution intervention on hemoglobin A1c levels in individuals with type 2 diabetes. Importantly, this study has used an inclusive process to identify relevant costs for the intervention,17Walker DM Garner JA Hefner JL et al.Rationale and design of the linking education, produce provision, and community referrals to improve diabetes care (LINK) study.Contemp Clin Trials. 2023; 130107212https://doi.org/10.1016/j.cct.2023.107212Crossref Scopus (0) Google Scholar where representatives from each intervention convened through a workgroup to detail their organization's workflow and identify the direct and indirect costs associated with providing services to participants. Cost savings were not considered in this process. The end-product of the co-produced cost diagram is shown in Figure 1. The LINK study is an example of one social needs resolution intervention, but others are sorely needed. Research should carefully consider (a) costs of scaling programs, (b) sources of cost variability across programs, and (c) cost benefits associated with the intervention's health and social impact. The current landscape of funding models for social needs resolution interventions is incredibly varied. Public, private, and non-profit funders are actively experimenting with differing approaches to investing in social needs resolution while also balancing other core priorities. This creativity creates a ripe opportunity for the evaluation of these models with consideration not only of program reach and impact, but also of costs and efficiency (i.e., cost-effectiveness). Moving forward, considering costs when evaluating interventions is essential to developing scalable programs and sustainable financing solutions. The authors extend their appreciation to Kathryn Hasenstab-Kenney for her helpful feedback on this manuscript. This work was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award number R01DK132403. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. No financial disclosures or conflicts of interest have been reported by the authors of this paper.

This study evaluates trends in long-acting reversible contraception (LARC) services among obstetrician/gynecologists (OB/GYNs) and non-OB/GYNs in the U.S. during 2012-2018. Using public and private insurance claims from the Symphony Health database, we calculated the percentage of LARC insertions, removals, and reinsertions performed by OB/GYNs and non-OB/GYNs. We then assessed time trends with linear regression. The proportion of LARC services that were performed by non-OBGYNs increased modestly between 2012 and 2018. Increases were similar for insertions, removals, and reinsertions. Further research is needed to understand trends in LARC service provision within primary care to better tailor medical training and policy interventions.

Background: Individuals with type 2 diabetes (T2D) experiencing food insecurity may have other non-medical, health-related social needs (e.g., transportation, housing instability) that decrease their ability to attain T2D control and impact other health outcomes. Methods: A pragmatic randomized controlled trial (pRCT) to test the effect of produce provision, diabetes and culinary skills training and education, and social needs screening, navigation, and resolution, on hemoglobin A1c (A1c) levels in individuals with T2D (A1c >= 7.5%) experiencing food insecurity; a cost-effectiveness evaluation of the interventions that comprise the pRCT; and a process evaluation to understand the contextual factors that impact the uptake, effectiveness, and sustainability of the interventions. Setting: Ambulatory care clinics (e.g., family medicine, general internal medicine, endocrinology) affiliated with an academic medical center in an urban environment in the Midwest. Design: 2 x 2 factorial design. Interventions: Cooking Matters for Diabetes is a 6-week diabetes and culinary education intervention. The Health Impact Ohio Central Ohio Pathways Hub intervention is a community health worker model designed to evaluate and address participants' social needs. All participants will receive referral to the Mid-Ohio Farmacy to provide weekly access to fresh produce. Outcomes: Primary outcome of the pRCT is change in A1c at 3 months; secondary outcomes include A1c at 6 months, and diabetes self-efficacy, food insecurity, and diet quality at 3 and 6 months. Discussion: Food insecurity, unmet social needs, diabetes education and self-efficacy are critical issues that must be addressed to improve T2D treatment, care, and health equity. ClinicalTrials.gov: NCT05472441.

ImportanceWomen living in rural areas have lower rates of breast, cervical, and colorectal cancer screening compared with women living in urban settings. ObjectiveTo assess the comparative effectiveness of (1) a mailed, tailored digital video disc (DVD) intervention; (2) a DVD intervention plus telephonic patient navigation (DVD/PN); and (3) usual care with simultaneously increased adherence to any breast, cervical, and colorectal cancer screening that was not up to date at baseline and to assess cost-effectiveness. Design, Setting, and ParticipantsThis randomized clinical trial recruited and followed up women from rural Indiana and Ohio (community based) who were not up to date on any or all recommended cancer screenings. Participants were randomly assigned between November 28, 2016, and July 1, 2019, to 1 of 3 study groups (DVD, DVD/PN, or usual care). Statistical analyses were completed between August and December 2021 and between March and September 2022. InterventionThe DVD interactively assessed and provided messages for health beliefs, including risk of developing the targeted cancers and barriers, benefits, and self-efficacy for obtaining the needed screenings. Patient navigators counseled women on barriers to obtaining screenings. The intervention simultaneously supported obtaining screening for all or any tests outside of guidelines at baseline. Main Outcomes and MeasuresReceipt of any or all needed cancer screenings from baseline through 12 months, including breast, cervical, and colorectal cancer, and cost-effectiveness of the intervention. Binary logistic regression was used to compare the randomized groups on being up to date for all and any screenings at 12 months. ResultsThe sample included 963 women aged 50 to 74 years (mean [SD] age, 58.6 [6.3] years). The DVD group had nearly twice the odds of those in the usual care group of obtaining all needed screenings (odds ratio [OR], 1.84; 95% CI,1.02-3.43; P=.048), and the odds were nearly 6 times greater for DVD/PN vs usual care (OR, 5.69; 95% CI, 3.24-10.5; P<.001). The DVD/PN intervention (but not DVD alone) was significantly more effective than usual care (OR,4.01; 95% CI,2.60-6.28; P<.001) for promoting at least 1 (ie, any) of the needed screenings at 12 months. Cost-effectiveness per woman who was up to date was $14462 in the DVD group and $10638 in the DVD/PN group. Conclusions and RelevanceIn this randomized clinical trial of rural women who were not up to date with at least 1 of the recommended cancer screenings (breast, cervical, or colorectal), an intervention designed to simultaneously increase adherence to any or all of the 3 cancer screening tests was more effective than usual care, available at relatively modest costs, and able to be remotely delivered, demonstrating great potential for implementing an evidence-based intervention in remote areas of the midwestern US. Trial RegistrationClinicalTrials.gov Identifier: NCT02795104

Over the past decade, significant investments have been made in coordinated specialty care (CSC) models for first episode psychosis (FEP), with the goal of promoting recovery and preventing disability. CSC programs have proliferated as a result, but financing challenges imperil their growth and sustainability. In this commentary, the authors discuss (1) entrenched and emergent challenges in behavioral health policy of consequence for CSC financing; (2) implementation realities in the home rule context of Ohio, where significant variability exists across counties; and (3) recommendations to improve both care quality and access for individuals with FEP. The authors aim to provoke careful thought about policy interventions to bridge science-to-service gaps, and in this way, advance behavioral health equity.

Importance Although substantial research has reported grave population-level psychiatric sequelae of the COVID-19 pandemic, evidence pertaining to temporal changes in schizophrenia spectrum disorders in the US following the pandemic remains limited. Objective To examine the monthly patterns of emergency department (ED) visits for schizophrenia spectrum disorders after the onset of the COVID-19 pandemic. Design, Setting, and Participants This observational cohort study used time-series analyses to examine whether monthly counts of ED visits for schizophrenia spectrum disorders across 5 University of California (UC) campus health systems increased beyond expected levels during the COVID-19 pandemic. Data included ED visits reported by the 5 UC campuses from 2016 to 2021. Participants included persons who accessed UC Health System EDs had a diagnosis of a psychiatric condition. Data analysis was performed from March to June 2023. Exposures The exposures were binary indicators of initial (March to May 2020) and extended (March to December 2020) phases of the COVID-19 pandemic. Main Outcomes and Measures The primary outcome was monthly counts of ED visits for schizophrenia spectrum disorders. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes, categorized within Clinical Classification Software groups, were used to identify ED visits for schizophrenia spectrum disorders and all other psychiatric ED visits, from the University of California Health Data Warehouse database, from January 2016 to December 2021. Time-series analyses controlled for autocorrelation, seasonality, and concurrent trends in ED visits for all other psychiatric conditions. Results The study data comprised a total of 377 872 psychiatric ED visits, with 37 815 visits for schizophrenia spectrum disorders. The prepandemic monthly mean (SD) number of ED visits for schizophrenia spectrum disorders was 519.9 (38.1), which increased to 558.4 (47.6) following the onset of the COVID-19 pandemic. Results from time series analyses, controlling for monthly counts of ED visits for all other psychiatric conditions, indicated 70.5 additional ED visits (95% CI, 11.7-129.3 additional visits; P = .02) for schizophrenia spectrum disorders at 1 month and 74.9 additional visits (95% CI, 24.0-126.0 visits; P = .005) at 3 months following the initial phase of the COVID-19 pandemic in California. Conclusions and Relevance This study found a 15% increase in ED visits for schizophrenia spectrum disorders within 3 months after the initial phase of the pandemic in California across 5 UC campus health systems, underscoring the importance of social policies related to future emergency preparedness and the need to strengthen mental health care systems.

In this study, the authors measured and described the costs of coordinated specialty care (CSC) for first -episode psychosis in Ohio. A microcosting tool was used to estimate personnel and nonpersonnel costs of service delivery at seven CSC programs. Average annual cost per participant (N= 511 participants) was estimated as $17,810 (95% CI=$9,141-$26,479). On average, 61% (95% CI=53%-69%) of annual program costs were nonbillable. Key cost drivers included facility costs, administrative tasks, and social services. Novel financing models may redress reimbursement gaps incurred by CSC programs.

Recent COVID-19-related federal legislation has resulted in time-limited increases in Mental Health Block Grant (MHBG) set-aside dollars for coordinated specialty care (CSC) throughout the United States. The state of Ohio has opted to apply these funds to establish a learning health network of Ohio CSC teams, promote efforts to expand access to CSC, and quantify the operating costs and rates of reimbursement from private and public payers for these CSC teams. These efforts may provide other states with a model through which they can apply increased MHBG funds to support the success of their own CSC programs.

Background Unmet oral health needs routinely affect low-income communities. Lower-income adults suffer a disproportionate share of dental disease and often cannot access necessary oral surgery services. The Affordable Care Act (ACA) Medicaid expansion created new financial opportunities for community health centers (CHCs) to provide mission-relevant services in low-income areas. However, little is understood in the literature about how the ACA Medicaid expansion impacted oral surgery delivery at CHCs. Using a large sample of CHCs, we examined whether the ACA Medicaid expansion increased the likelihood of oral surgery delivery at expansion-state CHCs compared to non-expansion-state CHCs. Methods Exploiting a natural experiment, we estimated Poisson regression models examining the effects of the Medicaid expansion on the likelihood of oral surgery delivery at expansion-state CHCs relative to non-expansion-state CHCs. We merged data from multiple sources spanning 2012–2017. The analytic sample included 2054 CHC-year observations. Results Compared to the year prior to expansion, expansion-state CHCs were 13.5% less likely than non-expansion-state CHCs to provide additional oral surgery services in 2016 (IRR = 0.865; P = 0.06) and 14.7% less likely in 2017 (IRR = 0.853; P = 0.02). All else equal, and relative to non-expansion-state CHCs, expansion-state CHCs included in the analytic sample were 8.7% less likely to provide oral surgery services in all post-expansion years pooled together (IRR = 0.913; P = 0.01). Conclusions Medicaid expansions can provide CHCs with opportunities to expand their patient revenue and services. However, whether because of known dental treatment capacity limitations, new competition, or coordination with other providers, expansion-state CHCs in our study sample were less likely to provide oral surgery services on the margin relative to non-expansion-state CHCs following Medicaid expansion.

Introduction: Federally-funded community health centers (CHCs) serve on the front lines of the COVID-19 pandemic, providing essential COVID-19 testing and care for vulnerable patient populations. Overlooked in the scholarly literature is a description of how different characteristics and vulnerabilities shaped COVID-19 care delivery at CHCs in the first year of the pandemic. Our research objective was to identify organization- and state-level factors associated with more or fewer COVID-19 care and testing visits at CHCs in 2020. Methods: Multilevel random intercept regression models examined associations among organization and state-level predictor variables and the frequency of COVID-19 care and testing visits at CHCs in 2020. The study sample included 1267 CHCs across the 50 states and the District of Columbia. Results: The average CHC provided 932 patient visits for COVID-19-related care in 2020. Yet, the CHC's role in delivering COVID-19 services proved as diverse as the populations and localities CHCs serve. For example, after adjusting for other factors, each percentage-point increase in a CHC's Hispanic patient population size was associated with a 1.3% increase in the frequency of patient visits for COVID-19 care in 2020 (P < .001). Serving a predominantly rural patient population was associated with providing significantly fewer COVID-19-related care visits (P = .002). Operating in a state that enacted a mask-wearing policy in 2020 was associated with a 26.2% lower frequency of COVID-19 testing visits at CHCs in 2020, compared to CHCs operating in states without mask-wearing policies (P = .055). Conclusions: In response to the pandemic, the federal government legislated funding to help CHCs address challenges associated with COVID-19 and provide services to medically-underserved patient populations. Policymakers will likely need to provide additional support to help CHCs address population-specific vulnerabilities affecting COVID-19 care and testing delivery, especially as highly contagious COVID-19 variants proliferate (eg, Delta and Omicron).

Background: The coronavirus disease 2019 (COVID-19) pandemic has created exceptional health and economic uncertainty for Ohioans in 2020. In the spring of 2020, the state commissioned the Ohio COVID-19 Survey (OCS) to ask residential Ohio adults about how the pandemic was affecting them. The purpose of this research is to provide state leadership with real-time information about the effects of the pandemic and concurrent recession on Ohio households.Methods: The OCS is a special supplement to the Ohio Medicaid Assessment Survey (OMAS), a stratified random digit dial, cell phone and landline telephone survey. This study includes data collected weekly between April 20, 2020, and August 24, 2020. We conducted descriptive time-series analysis of the survey data and provided updates to the state's COVID-19 Response Team throughout the survey period.Results: Preliminary findings from the OCS reflect 3 themes among respondents: 1) elevated levels of concern over health and household economics; 2) disproportionate effects that exacerbate existing inequities; and 3) majority adjustment to "new normal" and acceptance of public health guidelines .Conclusion: Preliminary findings indicate that groups that were struggling before the pandemic have faced the biggest challenges with regard to health and household economics since it began. Data from the OCS enabled us to provide real-time analysis to state leadership regarding Ohioans' experience during the first 6 months of the COVID-19 pandemic. Further analysis and integration of additional data will allow us to provide deeper insights as Ohio seeks to move into recovery.

OBJECTIVE:The objective of this study was to determine whether the Affordable Care Act's (ACA) major coverage expansions mitigated the impact of unemployment on health insurance coverage status. DATA SOURCE:A 2011-2019 versions of the American Community Survey developed by the University of Minnesota Integrated Public Use Microdata Series program. RESEARCH DESIGN:We use difference-in-difference-in-differences (ie, triple difference) regressions to compare changes in the short-run impacts of local unemployment rates before and after the ACA. PRINCIPAL FINDINGS:Before the ACA, rises in local unemployment were associated with uninsurance due to losses in private coverage (ie, both nongroup and employer sponsored).Following the ACA's full implementation, the link between employment and coverage was attenuated by access to publicly subsidized qualified health plans on the ACA's nongroup market, and enhanced access to Medicaid in states that expanded. Our findings suggest protections from unemployment-linked uninsured spells are largest in states that expanded Medicaid. CONCLUSIONS:Expanded access to coverage under the ACA could mitigate the adverse effects on insurance status and access to care historically linked to job loss. However, should the ACA be repealed, many households stand to lose their ability to turn to Medicaid or subsidized nongroup coverage as safety-net resources to offset the burdens of job loss.