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

A retrospective observational study is one of the most widely used research methods in medicine. However, evidence postulated from a single data source likely contains biases such as selection bias, information bias, and confounding bias. Acquiring enough data from multiple institutions is one of the most effective methods to overcome the limitations. However, acquiring data from multiple institutions from many countries requires enormous effort because of financial, technical, ethical, and legal issues as well as standardization of data structure and semantics. The Observational Health Data Sciences and Informatics (OHDSI) research network standardized 928 million unique records or 12% of the world's population into a common structure and meaning and established a research network of 453 data partners from 41 countries around the world. OHDSI is a distributed research network wherein researchers do not own or directly share data but only analyzed results. However, sharing evidence without sharing data is difficult to understand. In this review, we will look at the basic principles of OHDSI, common data model, distributed research networks, and some representative studies in the cardiovascular field using the network. This paper also briefly introduces a Korean distributed research network named FeederNet.

Though unemployment and homelessness are closely intertwined, vocational services are rarely prioritized for homeless-experienced individuals engaging in housing services. Our goal was to examine associations between vocational service use and housing outcomes among homeless-experienced Veterans engaged in permanent supportive housing. We obtained data from Veterans Health Administration (VHA) medical record and homelessness registry data for homeless-experienced Veterans engaged in U.S. Department of Veterans Affairs (VA) Greater Los Angeles' permanent supportive housing program from October 2016 to September 2017 (n = 1,200). We used multivariate logistic regression to examine whether vocational service use was associated with housing attainment and/or premature permanent supportive housing exits. We found that Veterans in permanent supportive housing who used vocational services were more likely to attain housing (OR = 2.52, p < .001) than their peers who did not use these services. There were no between-group differences in the odds of premature exits from the permanent supportive housing program (OR = 1.92, p = .425). Our study suggests that, among homeless-experienced Veterans engaged in permanent supportive housing programs, those who use vocational services potentially may be more likely to attain housing. However, future research can better elucidate the pathways underlying vocational service use and housing outcomes for individuals in permanent supportive housing programs. Greater integration of vocational services and permanent supportive housing programs, and encouragement of vocational service use may enhance housing outcomes among permanent supportive housing participants. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Development and validation of a management system and dataset quality assessment tool for the Radiology Common Data Model (R_CDM): A case study in liver disease

Introduction Access to medications for opioid use disorder (MOUD) varies across racial and ethnic groups. As the largest payer for MOUD, Medicaid has potential to ensure access for all enrollees. We aimed to quantify recent trends and state variation in MOUD use by race and ethnicity in Medicaid. Methods Using a distributed research network, we conducted a cross-sectional study of 11 states' Medicaid data from 2016 to 2020. Among enrollees diagnosed with opioid use disorder (OUD), we measured the percent receiving MOUD (overall; and methadone, buprenorphine, naltrexone, separately), continuity of MOUD for &ge;180 days, and claims-based overdose event rates. We estimated logistic regression models in each state with fixed effects for year, race/ethnicity, and year and race/ethnicity interaction terms to examine changes in demographic differences in outcomes over time, adjusting for patient characteristics. We pooled estimates using random effects meta-analyses. Results Of the 542,414 enrollees with OUD in 2020, 430,891 (79.4%) were non-Hispanic white, 77,952 (14.4%) were non-Hispanic Black, 17,094 (3.2%) were Hispanic, and 16,477 (3.0%) had other race or ethnicity. MOUD use increased among enrollees in all racial and ethnic groups over time. The share of non-Hispanic white enrollees diagnosed with OUD receiving MOUD increased from 52.3% to 68.8% from 2016 to 2020 while the percent of non-Hispanic Black enrollees receiving MOUD from 37.2% to 49.7% during that period. Differences were widest for buprenorphine versus methadone or naltrexone. In adjusted analyses, Hispanic and Non-Hispanic Black enrollees were less likely to receive MOUD (adjusted odds ratios (AOR) = 0.67 [95 CI 0.49&ndash;0.91] and AOR = 0.41 [95 CI 0.33&ndash;0.52], respectively) compared to non-Hispanic white enrollees in 2016. Differences in receipt of MOUD did not change from 2016 to 2020. Non-Hispanic Black enrollees were less likely to have continuous MOUD relative to non-Hispanic white enrollees (AOR = 0.68 [95 CI 0.61&ndash;0.77)]. Overdose events peaked in 2017 for all racial and ethnic groups and were highest for Hispanic enrollees in 2020. Conclusion MOUD increased among all racial and ethnic groups in 11 state Medicaid programs from 2016 to 2020. Yet, racial and ethnic differences in MOUD persisted, especially for buprenorphine. Our findings can inform Medicaid efforts to improve access to MOUD for all enrollees affected by OUD.

This dissertation consists of three essays. The first essay provides an analysis of the interaction between special interest groups, public interest factors, median voters' tastes and preferences regarding the provision of medical services for the poor, and cost containment policies on one side, and drug reimbursement levels, the size of state Medicaid programs, and the size of states' drug budgets on the other. The relative strengths of special interest are shown to be one of the most important determinants of drug reimbursement levels and drug expenditures. The median voters' preferences significantly explain the size of states' Medicaid programs. The results verify the existence of substantial variation in state Medicaid programs, and point to potentially growing disparities as a result of current policies. The second essay examines alternatives to the traditional retrospective fee for service (FFS) payment mechanisms regarding Medicaid inpatient hospital services. These alternatives may be grouped into direct price or utilization controls, particularly, prospective payment and coverage limitations, and managed care, either in the form of fee for service primary care case management, or risk based enrollment in prepaid health plans or health maintenance organizations. Both special interest groups and median voter variables are shown to have significant explanatory power in the adoption of these alternative payment mechanisms. The third essay uses a system of six equations to examine the relative effects of direct and market driven cost containment policies, relating to the general inpatient hospital component of Medicaid. Direct cost containment policies, consisting of diagnosis related groups prospective payment systems and rate-of-increase control based prospective payment systems are found to be effective. To a lesser extent, Managed care principles also generate savings. Furthermore, significant substitute and complementary relationships between program components emphasize the importance of system-wide analysis.

LTC-Vital Medicaid Is on the Bargaining Table

Policies to improve the health and well-being of Roma people: The European experience

Newer antiretroviral treatments are adding years to the lives of people with HIV. At the same time, the face of the epidemic is changing to include increasing numbers of people with other diagnoses, especially chronic substance use and/or mental illness, that compromise their ability to secure and maintain permanent housing. Social service providers are increasingly attempting to meet the need for permanent supportive housing. However, many social service providers are new to developing specialized permanent housing, and little practical guidance exists. We use the experience of five agencies participating in the Department of Housing and Urban Development's Housing Opportunities for People with AIDS (HOPWA) Multiple Diagnoses Initiative to explore the potential pitfalls and solutions in developing these programs, from the point of view of providers from social service rather than housing backgrounds

The effects of homelessness and permanent supportive housing (PSH) on healthcare utilization have been well documented. Prior research on the association between PSH entry and Medicaid expenditures indicates that such housing support could result in savings to Medicaid programs; however, whether changes occur in healthcare use and expenditures after individuals exit PSH is unknown. If efficiency gains from PSH persist after the individual leaves, the savings to payers such as Medicaid may continue even after the costs to provide housing for a PSH recipient have ended. We used linked Medicaid and housing data from Pennsylvania to examine changes in the level and composition of Medicaid expenditures for 580 adult enrollees during the 12 months before and after exit from PSH, adjusting for relevant covariates. In adjusted analyses, we estimated that monthly spending declined by $255.96 (95% CI: $358.70, $154.40) in the first quarter post exit and by $271.50 (95% CI: $394.30, $146.50) in the fourth quarter. Our findings suggest that PSH may have sustained budgetary benefits to state Medicaid agencies even for beneficiaries exiting the program. However, more research is needed to understand whether these reductions in expenditures last beyond 12 months and do not reflect underuse of care that may be important for managing health over the long term.

Many are concerned that growth of state Medicaid and State Children's Health Insurance Program (SCHIP) spending, along with limited political clout among beneficiaries, make these programs extremely vulnerable in periods of serious state budget constraints. But observations based on Community Tracking Study site visits show that states have thus far largely avoided major cuts that would seriously harm beneficiaries' access, primarily because programs have more support among coalitions of public officials, health care providers, and local advocates than commonly assumed. However, the limits to this surprising level of support are exemplified by decisions in many states to shelve some planned future expansions indefinitely.

Despite their documented successes, permanent supportive housing programs have not received adequate funding at federal or state levels. Building public will to fund permanent supportive housing, therefore, becomes the order of the day. Drawing on the work of the Rhode Island Coalition for the Homeless (RICH), the authors describe how RICH, housing advocates, activists representing the homeless and formerly homeless, and other allies forged an inclusive, multiconstituency network. This coalition went on to reverse state cuts in the highly effective Neighborhood Opportunities Program, which had built more than 1,000 units of well-received affordable housing including permanent supportive housing units.

Despite established disparities in serious illness prevalence among formerly homeless people living in permanent supportive housing, there is a dearth of research aimed at promoting and enhancing palliative care service delivery in this setting. This paper describes current practices, perceived barriers, and recommendations in permanent supportive housing for residents living with serious illness through a thematic analysis of interviews with cross-sector stakeholders ( n = 30) from the Research and Supportive Care at Later-life for Unhoused People (RASCAL-UP) study. Themes identified across resident care, program collaboration, and policy and environment areas included: (1) unique resident care needs; (2) on-site relationships; (3) adaptation of aging, disability, and healthcare services for residents; (4) internal implementation barriers; (5) preparing the environment for serious illness; and (6) missing levels of care. From these results, we put forth recommendations for future collaborative care intervention development, supportive housing policy, and capacity-building efforts for healthcare and housing providers alike.

State Medicaid programs are the largest source of funding for long-term services and supports (LTSS). We characterized states across quartiles of mean LTSS spending for individuals ≥65 and used the Health and Retirement Study to examine the demographic, functional, and caregiving characteristics across these quartiles. Individuals in states with lower Medicaid spending on LTSS reported more family and friend caregiving hours and were more likely to be from racial and ethnic minority groups. Continued work is needed to improve Medicaid LTSS policy to better support vulnerable populations, particularly in lower quartile states.

Permanent supportive housing (PSH) is designed to house people who experience chronic homelessness with one or more of the following: serious mental illness (SMI), substance use disorders (SUD) or human immunodeficiency virus. The Department of Housing and Urban Development has required major metropolitan areas to develop a coordinated entry system (CES) to prioritize access to PSH to those who need it the most. The aim of this paper is to determine whether PSH residents with SMI, SUD, or dual diagnosis were more likely to be housed after implementation of CES and were more likely to be housed in housing models with more intensive services provided. A cross-sectional survey with 855 residents of different PSH models. Those with SMI, SUD, or dual diagnosis were not more likely to be housed using the CES but were more likely to be housed in higher intensity service programs. Those with SMI are more likely to be housed in PSH with high-intensity services.

Permanent supportive housing (PSH) is an evidence-based solution to chronic homelessness. There are two common PSH models: place-based (PB) programs where clients live in one building with services provided onsite and scattered-site (SS) programs, which use community apartments coupled with mobile case management and support. Understanding the relative strengths and weaknesses of PB and SS is important for PSH planning and service delivery. This paper explores homeless service provider perspectives on these two models after the onset of the COVID-19 pandemic. Service providers (N = 37) from across 5 PSH agencies in Los Angeles that provided either PB or SS services during the pandemic participated in focus groups. Discussions were recorded, transcribed, and analyzed using template analysis, grounded theory, and inductive techniques. Providers identified four major differences between PB and SS services: (1) challenges in finding placements; (2) managing relationships with landlords/property managers; (3) frequency of contact; and (4) community integration. Advantages of PB included ease of finding units, ease of managing relationships with landlords/property managers, greater ability to serve clients efficiently, more frequent client contact, and more community among residents. SS was seen to provide tenants with more opportunities to grow, live in healthier environments, and develop independence. During the pandemic, finding units for SS clients became more difficult, while differences between PB and SS related to frequency of contact and community integration became more attenuated. PB can be advantageous for clients with higher levels of acuity, whereas SS could be more appropriate for clients who are more stable and independent. PB programs are seen to have practical and logistical advantages, but some providers prefer SS services. Clients and providers should be matched to PSH configurations that best match their needs and preferences, and providers should be aware that public health emergencies may impact PB and SS settings differently.