Mitigating Risk in a State Health Insurance Exchange

Describes how the Massachusetts HealthConnector designed a risk-mitigation program to stabilize insurance premiums. Offers lessons for federal reform efforts in implementing risk corridors, reinsurance, and risk adjustment

Coordinating Care Between Behavioral Health and Primary Care Providers: Examining Agency Challenges, Capacity, and Patient Service Utilization

abstract: Health care in the United States has been undergoing significant changes since the 2010 passage of the Patient Protection and Affordable Care Act. One of the outcomes of this policy was an attempt to bring physical health care and behavioral health care together in an effort to provide more coordinated care for patients. This change created an opportunity to improve the quality of care for patients, and as a result reduce high cost emergency service that could be prevented through better maintenance of chronic conditions. Three studies were conducted to examine challenges behavioral health agencies face in implementing two models of coordinated care (co-located and fully integrated), staff and organization capacity and needs, and patient service utilization by model of care coordination. The first study used site visits and interviews to capture the challenges faced by agencies. Results from this study indicated that behavioral health agencies faced a number of challenges in providing coordinated care including financial barriers, regulations, information sharing, inadequate technology, and provider training needs. The second study used a staff survey to assess agency and staff capacity and needs in providing coordinated care. The results from this study found differences in capacity based on model of coordination in multiple dimensions related to inter-agency coordination and communication, role clarity, and team cohesion. The third study examined patient service utilization for outpatient visits, inpatient visits, and emergency visits. The results indicated that patients receiving care from co-located agencies were more likely to have at least one encounter in each of the three service utilization categories compared to patients at fully integrated agencies. Overall, the three studies suggest that agencies that have or will implement models of coordinated care face significant barriers that may impact the sustainability or feasibility of such care. Given the findings on patient service utilization, it seems that coordinated care has great potential for patient level outcomes which makes addressing agency barriers even more critical.Dissertation/ThesisDoctoral Dissertation Social Work 201

NEIGHBORHOOD MATTERS: EXPLORING THE RELATIONSHIPS BETWEEN NEIGHBORHOOD SOCIAL RISK AND MEDICAL SPENDING IN A MEDICAID POPULATION

Background: It is well established that attributes of neighborhoods are associated with individual-level health outcomes, however, little is known about the association between neighborhood social and economic resources and medical spending in low income populations. Objective: This dissertation aims to: 1) describe a process for maximizing use of local neighborhood measures to construct multidimensional indices that may be used in community health planning and research; 2) Evaluate the associations between medical spending and neighborhood social and environmental resources across the distribution of medical spending; and, 3) Examine how different domains of neighborhood social and economic resources are associated with medical spending. Methods: The first study demonstrates a methodology for reducing a large number of local community measures into 7 domains of neighborhood risk as well as a single multidimensional index that reflects social and environmental resources within neighborhoods. The second study examines the association between high, medium, and low values of the neighborhood social and environmental index across the distribution of medical spending among individuals enrolled in a single Medicaid Managed Care plan in Baltimore, Maryland using quantile regression methods. The third study capitalizes on the neighborhood domain-specific indices created in paper 1 to examine the association between each domain and medical spending. Results: In paper one we successfully created indices of crime, housing, employment and workforce, education, living environment, and income and wealth at the level of the neighborhood, as well as an overall neighborhood social and environmental resource index. In paper two we find that neighborhoods with low versus high values of the neighborhood resource index were associated with higher individual-level medical spending across all quantiles of spending, even after adjusting for age, gender, morbidity and race. In paper 3 we find the domains of crime, housing, and employment and workforce were also associated with variation in medical spending. Conclusions: Study findings indicate that neighborhood-level measures could be informative to value based contracts, for risk adjustment purposes, and to guide interventions that address neighborhood factors that are associated with disparities in health outcomes

Identifying Barrett's Esophagus Risk in a Primary Care Setting

Barrett’s esophagus incidence has been on the rise for the past four decades. Early identification of Barrett’s esophagus is essential to preventing the morbidity and mortality associated with esophageal adenocarcinoma, a malignancy with an 18% five-year survival rate. With no national standard for screening, primary care providers must identify and refer patients who are at high risk of Barrett’s esophagus for endoscopic evaluation. This quality improvement project aimed to develop a protocol to identify patients at high risk for Barrett’s esophagus. Risk assessment was accomplished with a patient-completed over-the-counter medication survey and GerdQ questionnaire to identify patients with gastroesophageal reflux disease. When gastroesophageal reflux disease (GERD) was identified, providers assessed for the presence of additional Barrett’s esophagus risk factors. During the 14-week implementation period, 79 patients were evaluated. Over-the-counter medications were used by 64% of patients, and 37% reported using over-the-counter reflux medication at least monthly. A diagnosis of GERD was identified in 29% of the patients. Of the 79 patients completing the tools, 62 were evaluated for Barrett’s esophagus risk, with 15% identified as high risk and 6% meeting the criteria for endoscopic screening. The use of the over-the-counter survey and GerdQ questionnaire were effective for identification of Barrett’s esophagus high risk in this primary care practice. Recommendations were made for the use of these tools at the time of colorectal cancer screening referral to facilitate risk assessment and concurrent referral for Barrett’s esophagus screening if needed.D.N.P

ACVIM consensus statement on the treatment of immune thrombocytopenia in dogs and cats

Management of immune thrombocytopenia (ITP) in dogs and cats is evolving, but there are no evidence-based guidelines to assist clinicians with treatment decisions. Likewise, the overall goals for treatment of ITP have not been established. Immunosuppressive doses of glucocorticoids are the first line treatment, but optimal treatment regimens beyond glucocorticoids remain uncertain. Additional options include secondary immunosuppressive drugs such as azathioprine, modified cyclosporine, and mycophenolate mofetil, usually selected based on clinician preference. Vincristine, human IV immunoglobulin (hIVIg), and transfusion of platelet or red blood cell–containing products are often used in more severe cases. Splenectomy and thrombopoietin receptor agonists are usually reserved for refractory cases, but when and in which patient these modalities should be employed is under debate. To develop evidence-based guidelines for individualized treatment of ITP patients, we asked 20 Population Intervention Comparison Outcome (PICO) format questions. These were addressed by 17 evidence evaluators using a literature pool of 288 articles identified by a structured search strategy. Evidence evaluators, using panel-designed templates and data extraction tools, summarized evidence and created guideline recommendations. These were integrated by treatment domain chairs and then refined by iterative Delphi survey review to reach consensus on the final guidelines. In addition, 19 non-PICO questions covering scenarios in which evidence was lacking or of low quality were answered by expert opinion using iterative Delphi surveys with panelist integration and refinement. Commentary was solicited from multiple relevant professional organizations before finalizing the consensus. The rigorous consensus process identified few comparative treatment studies, highlighting many areas of ITP treatment requiring additional studies. This statement is a companion manuscript to the ACVIM Consensus Statement on the Diagnosis of Immune Thrombocytopenia in Dogs and Cats

The Prevalence of Multimorbidity among People with Non-Affective Psychotic Disorders 10-Years After First Diagnosis

Prior research suggests that people with psychotic disorders have an excess risk of individual chronic conditions, however less is known about their risk of co-occurring multiple chronic health conditions; that is, multimorbidity. The overall objective of this thesis was to examine the association between psychotic disorders and multimorbidity using two complementary studies. First, our systematic review and meta-analysis of fourteen studies found that people with psychotic disorders had an increased risk of 2+ chronic conditions relative to those without psychosis (RR=1.69, 95%CI=1.37,2.08). Second, our retrospective matched cohort study found that people with psychotic disorders treated by an early psychosis intervention program (n=439) may have a 26% higher prevalence of multimorbidity relative to people without psychosis (n=1,759), although our findings include the possibility of a null effect (PR=1.26, 95%CI=0.96,1.66). We suggest future research using larger sample sizes and longer follow-up periods to better understand the association between psychotic disorders and multimorbidity