BACKGROUND: Few studies have assessed acute care utilization and health care costs among rural Medicaid enrollees in a national sample; fewer still have examined the relationship of health care utilization with different...BACKGROUND: Few studies have assessed acute care utilization and health care costs among rural Medicaid enrollees in a national sample; fewer still have examined the relationship of health care utilization with different levels of rurality and enrollee race/ethnicity. OBJECTIVES: This study's objective is to compare Medicaid acute care utilization patterns by race/ethnicity and rurality interactions to identify rural populations with higher health care needs or receiving potentially insufficient care. RESEARCH DESIGNS: We used the 2019 Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF), which includes inpatient, outpatient, and prescription data on all Medicaid enrollees. We ran zero-inflated poisson, negative binomial, and generalized linear models to examine the association between enrollee rurality (defined using Rural Urban Commuting Area Codes) and race/ethnicity and 4 health care utilization outcomes. SUBJECTS: All Medicaid enrollees with 12 months of full-scope coverage in T-MSIS TAF (N=50,631,371). MEASURES: Our outcome measures included rate of emergency department (ED) visits and inpatient stays, inpatient length-of-stay (LOS), and spending per-member per-month. RESULTS: Rural Medicaid enrollees had lower rates (12.6%-18.2% lower) of inpatient stays compared with urban enrollees, only Medicaid enrollees in Isolated (the most remote) rural areas had lower rates (11.0% reduction) of ED compared with those in urban areas. Average inpatient LOS and spending were both lower for rural Medicaid enrollees. Utilization varied by enrollee race/ethnicity, with the lowest utilization among Hispanic enrollees. CONCLUSION: Rural Medicaid enrollees had generally lower acute care utilization and expenditures; however, heterogeneity by rurality and race/ethnicity suggests that some rural populations have higher health care needs.
BACKGROUND: Stakeholders have called for measures of how much time patients spend at home and in the community to incentivize coordinated, timely, and primary care-based services and reduce unnecessary acute care. OBJECT...BACKGROUND: Stakeholders have called for measures of how much time patients spend at home and in the community to incentivize coordinated, timely, and primary care-based services and reduce unnecessary acute care. OBJECTIVES: We developed a claims-based "Days at Home" Accountable Care Organization (ACO) measure for Medicare beneficiaries, intended to assess the number of days in a calendar year that adults with complex chronic disease spend at outside acute or postacute inpatient facilities. METHODS: Testing used 2017 and 2018 Medicare claims for fee-for-service patients enrolled in 610 Shared Savings Program ACOs. We used a split-half method for reliability testing, and a survey of technical experts and comparison to related measures for validity. The measure adjusts for 51 clinical and demographic variables and one social determinant of health (Medicaid dual-eligibility). To avoid unintended consequences of discouraging medically appropriate care and excessive reliance on nursing homes, the measure adjusts for mortality and new admissions to long-term nursing home care. RESULTS: The cohort (N=1,154,779) was predominantly White (84.9%) and aged 65 years or older (84.0%), and 22.8% were Medicaid dual-eligible. Mean ACO-level adjusted days at home was 330.4, ranging from 291.0 to 345.9 days (interquartile range: 329.1-332.1). Split-sample reliability was 0.833. External experts rated the measure as having face validity; in assessing external validity the measure generally correlated with related measures. CONCLUSIONS: The Days at Home ACO measure is a reliable and valid measure that can be used to promote coordinated and prevention-focused home-based and community-based care.
IMPORTANCE: Anesthesia care is delivered by Certified Registered Nurse Anesthetists (CRNAs) working independently, physician anesthesiologists working alone, and anesthesia care teams with CRNAs supervised by physician a...IMPORTANCE: Anesthesia care is delivered by Certified Registered Nurse Anesthetists (CRNAs) working independently, physician anesthesiologists working alone, and anesthesia care teams with CRNAs supervised by physician anesthesiologists. The impact of these models and CRNA supervision on patient satisfaction remains unclear. OBJECTIVE: To identify associations between anesthesia care team credentials, CRNA supervision, and patient satisfaction with care access, provider ratings, and overall satisfaction. DESIGN: We linked survey data on patient satisfaction with administrative data from the Veterans Health Administration (VHA) to gather veteran demographics, staffing, and clinical features of each surgical case. PARTICIPANTS: Our sample included 45,757 veterans who responded to the Survey of Healthcare Experiences of Patients following an invasive surgical procedure performed in a VHA operating room between 2016 and 2023. MAIN MEASURES: Satisfaction was assessed using 4 outpatient survey items: overall VHA satisfaction, provider ratings, whether the provider listened carefully, and whether the provider showed respect. Inpatient measures included hospital ratings, doctors' courtesy and respect, doctors' attentiveness, willingness to recommend the VHA, and preference for VHA over free care elsewhere. RESULTS: Anesthesia care models and supervision ratios were not significantly associated with veterans' overall satisfaction, provider or hospital ratings, or likelihood of recommending the VHA. Small positive effects of CRNA involvement were observed on provider attentiveness and respect. Satisfaction was high across all provider types, and findings were robust to exclusion of COVID-19 data and lower-complexity cases. CONCLUSIONS: Veterans' overall satisfaction with anesthesia care reflects a consistently high standard across models and credentials, with subtle benefits from CRNA involvement in patient-provider communication.
OBJECTIVES: This paper examines whether Medicaid payment rates are aligned with the cost of caring for Medicaid residents and how this relationship varies by facility characteristics. BACKGROUND: Medicaid is the primary...OBJECTIVES: This paper examines whether Medicaid payment rates are aligned with the cost of caring for Medicaid residents and how this relationship varies by facility characteristics. BACKGROUND: Medicaid is the primary payer for most nursing home residents, but limited information exists on the relationship between payment rates and costs of caring for Medicaid beneficiaries. METHODS: Per diem Medicaid payment rates were obtained directly from states. Estimated Medicaid per diem costs were calculated from Medicare Cost Reports, then combined with payment rates to calculate a payment-to-cost ratio. Medicaid payment rates and payment-to-cost ratios were examined by key facility characteristics: ownership, Medicaid payer-mix, and nursing staff levels. RESULTS: Nationally, the mean Medicaid payment rate was $198 per resident-day, while the mean Medicaid cost was $253. On average, Medicaid payment rates covered about 82 cents per dollar of estimated Medicaid costs in nursing homes in 2019. This figure declined to 76 cents in not-for-profit facilities. Most nursing homes (92%) had Medicaid per-diem costs that exceed Medicaid payments. Nursing homes with a greater share of Medicaid residents had Medicaid costs that better aligned with Medicaid payment rates. Furthermore, Medicaid payments covered a smaller share of Medicaid costs in nursing homes with the highest nursing staff levels compared with those with lower staffing levels. CONCLUSIONS: Policymakers should consider Medicaid payment as part of nursing home reform, as Medicaid payment levels that do not cover costs reduce available financial resources to increase nursing staff levels and improve quality of care absent cross-subsidization from other funding sources.
BACKGROUND: Patients with Alzheimer disease and related dementias (ADRD) face risks from medications labeled "potentially inappropriate in older adults" (risky); concurrent receipt of anti-dementia drugs may amplify risk...BACKGROUND: Patients with Alzheimer disease and related dementias (ADRD) face risks from medications labeled "potentially inappropriate in older adults" (risky); concurrent receipt of anti-dementia drugs may amplify risk. We studied adverse events among older adults concurrently receiving anti-dementia and risky medications. METHODS: Using 2016-2019 administrative data from a random 40% sample of fee-for-service Medicare beneficiaries receiving anti-dementia medications (acetylcholinesterase inhibitors (AChEI) and/or memantine), we identified days with concurrent receipt of select, risky medications (benzodiazepines, sedative hypnotics, opioids). We measured diagnosed falls, hip fractures, and deaths among person-days with anti-dementia drug receipt comparing person-days with versus without concurrent risky drug receipt. We stratified regression analyses on long-term care (LTC) residence. RESULTS: We studied 633,528 beneficiaries; 64.3% were women, 33.7% met LTC residence criteria. Mean (SD) age was 80.9 (7.6) years. Each beneficiary contributed a mean (SD) of 551.7 (449.2) anti-dementia drug receipt days. Overall, 4.5% of person-days involved receipt of AChEI plus benzodiazepines; 3.8% involved AChEI plus an opioid. Falls, the most common outcome, affected 22.5% of our beneficiaries. Concurrent receipt of AChEI and opioids was associated with the greatest fall risk increase. Among community-dwelling beneficiaries, AChEI and opioid receipt (vs. AChEI alone) was associated with a hazard ratio for falls of 2.25 (95% CI: 2.19, 2.32); among LTC residents the corresponding hazard ratio was 1.46 (95% CI: 1.42, 1.51). CONCLUSIONS: Assessment and treatment of symptoms among people with ADRD is complex; concurrent receipt of opioids and dementia medications is uncommon but seems risky. Efforts to eliminate avoidable opioids may decrease adverse events and associated suffering in this population.
OBJECTIVE: To assess the relationship between burnout scores for patient safety professionals and perceived support from the National Center for Patient Safety (NCPS) and direct communication with medical center director...OBJECTIVE: To assess the relationship between burnout scores for patient safety professionals and perceived support from the National Center for Patient Safety (NCPS) and direct communication with medical center directors in the Veterans Health Administration (VA). Our secondary objective was to analyze qualitative responses on communication barriers to identify areas for improvement. STUDY SETTING AND DESIGN: A system-wide cross-sectional quality improvement survey of VA patient safety professionals. DATA SOURCES AND ANALYTIC SAMPLE: Our final sample included 212 patient safety professionals who completed a questionnaire adapted from the Copenhagen Burnout Inventory. The survey measured personal, work-related, and facility-related burnout, with an additional item addressing the emotional impact of patient safety events. Nonparametric tests were used to examine relationships due to small sample sizes and non-normal distributions. PRINCIPAL FINDINGS: Feeling supported by the NCPS was associated with significantly lower burnout scores across all dimensions ( P <0.001). Facility staff-related burnout was higher among those reporting communication barriers with directors ( P =0.012), although one-on-one communication was not significantly associated with lower burnout scores. Qualitative responses from 12 participants identified logistical and bureaucratic challenges as key barriers to direct communication with directors. CONCLUSIONS: These findings indicate that organizational support may help mitigate burnout among patient safety professionals. Addressing logistical and bureaucratic barriers could enhance communication and improve the effectiveness of patient safety programs in the VA as well as other systems of care.
OBJECTIVE: We sought to examine changes in mild-to-moderate TBI-related symptoms among service members and veterans (SM/Vs) following participation in a 5-site inpatient rehabilitation program with the US Department of V...OBJECTIVE: We sought to examine changes in mild-to-moderate TBI-related symptoms among service members and veterans (SM/Vs) following participation in a 5-site inpatient rehabilitation program with the US Department of Veterans Affairs between 7/1/2022 and 5/30/2024. METHODS: Neurobehavioral outcomes, posttraumatic stress disorder (PTSD) symptoms, pain interference, and lifestyle behaviors related to brain injury were assessed at baseline, discharge, and a 6-month follow-up. Mixed effects linear regression models, adjusting for key patient characteristics, were estimated to determine changes in TBI-related outcomes across the 3 time points. RESULTS: Mean participant age, for those with complete data (n = 127), was 41.64 years (SD = 5.57), with a mean of 7.45 deployments (SD = 3.12) and 16.32 concussive events (SD = 7.21). Participants were predominantly White (73.23%) Special Operations personnel (82.68%). TBI-related outcomes, including neurobehavioral symptoms, pain interference, PTSD, and brain injury adaptability, decreased significantly from baseline to discharge (b = -14.36, SE = 1.03; b = -3.79, SE = 0.49; b = -11.14, SE = 1.27; b = -2.41, SE = 0.41), with Cohen's d effect sizes of 1.14, 0.71, 0.69, and 0.56, respectively. Six-month follow-up, TBI-related outcomes remained statistically and practically below baseline levels in all measures except adaptability. CONCLUSIONS AND RELEVANCE: Findings illustrate an interdisciplinary, inpatient rehabilitation program for mild-to-moderate TBI yields significant improvements in TBI-related symptoms that are common among SM/Vs and are sustained at 6 months postdischarge.
BACKGROUND: Older adults with Alzheimer's disease and related dementias can benefit from palliative care (PC). Whether specialty and nonspecialty PC have the same effect on outcomes is unclear. We examined the effects of...BACKGROUND: Older adults with Alzheimer's disease and related dementias can benefit from palliative care (PC). Whether specialty and nonspecialty PC have the same effect on outcomes is unclear. We examined the effects of these 2 interventions on comfort, symptom management, satisfaction with care, and potentially burdensome transitions, including hospital admission, emergency department visit, intensive care unit admission in the end-of-life, and in-hospital death. METHODS: This PRISMA-adherent systematic review involved a search of PubMed, Medline, EMBASE, Cochrane Library, ProQuest, and CINAHL for studies published from January 1, 2013, to November 4, 2024. Primary studies that reported at least one of the 7 patient-level outcomes were included: Comfort Assessment in Dying with Dementia (CAD-EOLD), Symptom Management at the End-of-Life (SM-EOLD), Satisfaction with Care at the End-of-Life in Dementia (SWC-EOLD), hospital admissions, emergency department visits, intensive care unit admissions, and in-hospital death. RESULTS: Nineteen articles involving 142,772 participants were included. The evidence, comprising studies of adequate to strong quality, revealed that both specialty and nonspecialty PC did not differ in terms of comfort, symptom management, or satisfaction with care. However, both approaches significantly reduced the likelihood of intensive care unit admissions and in-hospital deaths. Specialty PC was associated with decreased emergency department visits (OR 0.53, 95% CI 0.28-1.00; I2=86%). CONCLUSIONS: Future research is needed to understand factors influencing PC interventions that can improve comfort, symptom management, and care satisfaction for these individuals and their families.
BACKGROUND: A consistent approach to track Long COVID symptoms at the Veterans Health Administration (VHA) was lacking. OBJECTIVES: To reach consensus among clinical stakeholders on how long COVID symptoms should be asse...BACKGROUND: A consistent approach to track Long COVID symptoms at the Veterans Health Administration (VHA) was lacking. OBJECTIVES: To reach consensus among clinical stakeholders on how long COVID symptoms should be assessed at VHA outpatient visits and recommend an assessment battery. RESEARCH DESIGN: Hybrid Delphi-Nominal Group approach. SUBJECTS: Members of the VHA Long COVID Field Advisory Board (FAB) and the VHA Long COVID Community of Practice (CoP) participated. Veteran stakeholders provided input. MEASURES: A literature review and clinician questionnaires identified 68 instruments across 14 symptom domains. In the first consensus round, FAB members excluded instruments with limited clinical usability. The remaining 25 instruments were ranked by CoP members. Multiple rounds of asynchronous voting were conducted until one instrument remained per domain. The top instruments were grouped into 3 batteries. Final consensus on a preferred battery was reached through additional voting. Veterans from the Los Angeles Veteran Engagement Panel assessed clarity, burden, and feasibility. RESULTS: The final battery included the Modified Yorkshire COVID-19 Rehabilitation Survey, VHA Whole Health Well-Being Signs, the Exercise Vital Signs Questionnaire, and the 2-Minute Step Test. Whole Health questions were also included to support the VHA's Whole Health System mission. Symptom-specific instruments already used in VHA routine care were not included in the final battery, as clinics already had access to them. CONCLUSIONS: A structured, rapid consensus process was used to identify a battery of symptom instruments to standardize Long COVID symptom assessment across VHA clinics.
BACKGROUND: Prior literature has shown that favorable selection of enrollees in Medicare Advantage (MA) that is not accounted for under the Hierarchical Condition Category (HCC) risk adjustment model can result in signif...BACKGROUND: Prior literature has shown that favorable selection of enrollees in Medicare Advantage (MA) that is not accounted for under the Hierarchical Condition Category (HCC) risk adjustment model can result in significant overpayments to MA plans. Detailed data from the Veterans Health Administration's (VHA) Nosos risk score can measure previously undetected favorable selection in a unique cohort of patients. OBJECTIVE: To analyze characteristics associated with Veteran enrollment in MA versus Traditional Medicare (TM) and quantify previously undetected favorable selection. RESEARCH DESIGN: Pooled, cross-sectional study using nationally representative VHA survey data and VHA administrative data, 2016-2019. SUBJECTS: Dual VHA-Medicare enrollees. MEASURES: Enrollee characteristics, risk scores, and VHA inpatient and outpatient costs. RESULTS: Compared with VHA-TM enrollees, VHA-MA enrollees were older [73.8 (8.5) vs. 72.2 (8.2) y; SMD=0.19], more likely to have Medicaid coverage (13.7% vs. 4.7%; SMD=0.31), less likely to use VHA care (67.4% vs. 74.3%; SMD=0.26), and more likely to be in the lowest priority group (facing VHA copays) (21.4% vs. 17.6%; SMD=0.15). However, in 2019, MA enrollees had Nosos scores that were 25.6 percentage points lower (95% CI: -35.7, -15.5) than TM enrollees, signaling a healthier population. In adjusted comparisons, MA enrollees had $453.79 lower VHA costs (95% CI: $832.30, $75.27) than TM enrollees. CONCLUSIONS: MA plans enroll Veterans who are healthier and less costly than TM-enrolled Veterans. Our findings underscore plans' potential selection of enrollees based on characteristics unobservable in the HCC risk adjustment model. Policymakers may consider opportunities to adopt additional risk-adjustment factors specifically for dual VHA-MA enrollees.
BACKGROUND: Health care delivery organizations increasingly employ advanced practice professionals (APPs) and participate in alternative payment models such as accountable care organizations (ACOs). Given the former's in...BACKGROUND: Health care delivery organizations increasingly employ advanced practice professionals (APPs) and participate in alternative payment models such as accountable care organizations (ACOs). Given the former's incentive to constrain spending, APPs' practice patterns may vary in ACO-participating versus non-ACO practices. OBJECTIVES: To compare outpatient care provided by APPs and physicians through ACO participation. RESEARCH DESIGN: We used multivariate linear regression to compare measures of workload allocation and billing across ACO-participating and non-ACO practices in 2022, controlling for practice size and market. SUBJECTS: A total of 91,149 practices, 12,072 in a Medicare Shared Savings Program ACO in 2022. MEASURES: We used 100% fee-for-service Medicare claims to identify ACO-participating and non-ACO practices. For every practice, we calculated the share of outpatient encounters provided by APPs rather than physicians and the share of APP-provided encounters billed indirectly to Medicare. We also calculated the share of annual wellness visits, chronic condition care management services, transitional care management services, and postoperative visits provided by APPs. RESULTS: APPs provided a smaller share of outpatient encounters at ACO-participating versus non-ACO practices, but were more likely to bill indirectly. Among most categories of routine services (eg, annual wellness visits and chronic condition management), APPs provided a smaller share of services at ACO-participating versus non-ACO practices. In the largest quartile of practices, APP practice patterns were more similar across ACO-participation status, and indirect billing was less likely within ACOs. CONCLUSIONS: Findings provide little evidence that ACOs deploy their APP workforce in a more cost-conscious manner than non-ACOs.
BACKGROUND: Identification of transgender and gender diverse (TGD) people has been limited to diagnoses and text rather than self-identified gender identity (SIGI), representing a subset of TGD people. In 2017, the Veter...BACKGROUND: Identification of transgender and gender diverse (TGD) people has been limited to diagnoses and text rather than self-identified gender identity (SIGI), representing a subset of TGD people. In 2017, the Veterans Health Administration (VHA) implemented SIGI, allowing for precise identification of TGD veterans, including subgroups (transgender man, transgender woman, and nonbinary). OBJECTIVES: Health conditions, adverse social determinants of health (SDOH), and health care utilization were compared among veterans (1) identified by SIGI only, both SIGI and diagnosis/text, diagnosis/text only (ie, without SIGI), and (2) SIGI subgroups. RESEARCH DESIGN: Cross-sectional. SUBJECTS: Twenty thousand seventy-nine TGD VHA patients from 2019 to 2023; SIGI only (n=5523), both SIGI and diagnosis/text (n=4066), and without SIGI (n=10,490). MEASURES: Health conditions, adverse SODH and health care utilization. RESULTS: In adjusted models, SIGI only veterans were less likely to have documentation of depression (32.4% vs. 60.7% vs. 54.8%), post-traumatic stress disorder (PTSD; 23.5% vs. 41.4% vs. 37.5%), housing instability (8.8% vs. 21.5% vs. 16.1%), unemployment/financial problems (10.5% vs. 23.8% vs. 19.0%), and mental health visits (72.5% vs. 97.7% vs. 95.2%) compared with those with both SIGI and diagnosis/text and without SIGI. Health conditions were more similar across the diagnosis groups (i.e. both SIGI and diagnosis/text and without SIGI). Among veterans with SIGI data, we identified 49% transgender women, 38% transgender men, and 14% nonbinary veterans without many differences across subgroups. In adjusted models, more nonbinary veterans than transgender women and transgender men had documentation of alcohol use disorder (10.1% vs. 6.1% vs. 7.5%), depression (62.3% vs. 42.6% vs. 47.0%), PTSD (45.9% vs. 27.4% vs. 33.5%), mental health visits (96.7% vs. 89.1% vs. 91.9%), and experienced unemployment/financial problems (21.3% vs. 16.9% vs. 14.7%). CONCLUSIONS: Without diagnosis, SIGI enables the identification of healthier TGD veterans. Regardless of SIGI, diagnosis signals much higher rates of health concerns. SIGI data facilitates understanding veteran subgroups, informing TGD policy and practice.
INTRODUCTION: The Surveillance, Epidemiology, and End Results (SEER) Program collects data on the first course of cancer treatment, but no and unknown receipt of treatment cannot be distinguished for radiation therapy (R...INTRODUCTION: The Surveillance, Epidemiology, and End Results (SEER) Program collects data on the first course of cancer treatment, but no and unknown receipt of treatment cannot be distinguished for radiation therapy (RT) and chemotherapy. As part of the Data Use Agreement (DUA), users must acknowledge that they understand the data limitations and agree to include a description of the limitations in any analyses published using the data. The objective of this review was to evaluate users' compliance with the recommendations of the DUA. METHODS: Publications from a PubMed search were matched with the names of SEER treatment data users, and keywords were applied to identify relevant studies. Five reviewers (with 2 per publication) independently assessed if the authors (a) conducted analyses supported by these data, (b) correctly labelled no/unknown treatment as "no/unknown", and (c) described the limitations of their use. Publications were classified as "followed recommendations", "partially followed recommendations", or "did not follow recommendations" of the DUA. RESULTS: Among a total of 120 studies included in the review, 106 (88.3%) studies did not follow recommendations, 11 (9.2%) partially followed recommendations, and 3 studies (2.5%) followed recommendations. Only 11.7% of publications correctly labelled the "no/unknown" category as "no/unknown", and described the limitations associated with the no/unknown issue. CONCLUSIONS: In this review, we found substantial misuse of the SEER treatment data and limited acknowledgement of the limitations of the SEER treatment data in publications. Such findings highlight the need to think of effective ways of encouraging appropriate use of the treatment data.
BACKGROUND: Telehealth can improve health care access in underserved areas. Hub-and-spoke-models, wherein providers in regional hubs deliver care through telehealth to patients visiting local "spoke" clinics, can improve...BACKGROUND: Telehealth can improve health care access in underserved areas. Hub-and-spoke-models, wherein providers in regional hubs deliver care through telehealth to patients visiting local "spoke" clinics, can improve access. However, cost impacts of this model are unknown. OBJECTIVE: Evaluate the utilization and cost impacts of VA's Clinical Resource Hub program for primary care (CRH-PC), a hub-and-spoke-model. DESIGN: Adjusted difference-in-difference and event study analyses comparing patients at program-sites who used CRH-PC services with patients who never used CRH-PC services, prepost program adoption, fiscal years 2018-2021. We also compared all patients at CRH-PC sites versus at non-CRH-PC sites to assess site-wide impacts. PARTICIPANTS: CRH-PC sites: 164 sites and 1,546,892 patients; Non-CRH-PC sites: 704 sites and 4,062,797 patients. MEASURES: Costs and number of VA-provided and VA-purchased primary, emergency, and acute inpatient care visits. RESULTS: At CRH-PC sites, 64,973 patients (4%) used CRH-PC services. Rural patients, African-American patients, and patients with greater comorbidities had higher odds of receiving program services. Program exposure was associated with an 18% increase in primary care visits (+0.7) and $612 per program-user per year. Comparing all patients (users and nonusers) at program-sites versus nonprogram sites, we found no impact, except video-based care more often replaced in-person services at program-sites. CONCLUSIONS: Among program-users, VA's CRH-PC increased mean primary care visits and VA costs, but as only 4% of patients at program-clinics were program-users, there were no differences in overall cost or utilization between program and nonprogram clinics. Findings suggest clinics can offer primary care telehealth services to high-need populations without affecting clinic-level costs, but costs should be monitored upon wider adoption.
BACKGROUND: In 2022, Louisiana Medicaid began offering reimbursement for some community health worker (CHW) services ordered and billed by a supervising clinician. OBJECTIVES: We analyzed the extent to which CHW services...BACKGROUND: In 2022, Louisiana Medicaid began offering reimbursement for some community health worker (CHW) services ordered and billed by a supervising clinician. OBJECTIVES: We analyzed the extent to which CHW services were reimbursed by Louisiana Medicaid during 2022-2023, including number of encounters, demographics of Medicaid members served, number of encounters per member, geographic distribution of CHW encounters, primary diagnosis of members receiving CHW services, and provider type billing for CHW services. RESEARCH DESIGN: Retrospective cohort study of Louisiana Medicaid members receiving CHW services reimbursed by Medicaid. We included paid fee-for-service claims and managed care encounters for CPT codes 98960, 98961, or 98962 with dates of service from 1/1/2022 through 12/31/23. RESULTS: A total of 10,726 unique individuals received 17,373 reimbursed CHW services, with an estimated total reimbursement of $314,905.52. Medicaid members ranged from 0 to 88 years, were majority female (56.8%), and received between 1 and 13 services; mean: 1.6 (SD: 1.1), median: 1 (IQR 1-2 encounters). The highest rate of CHW services per Medicaid member occurred in urban areas. Nearly all (99.97%) were individual services. A total of 41.9% of services were for screening without a specified diagnosis, and health-related social needs were more common than medical conditions. Over half (60.6%) of CHW services were billed by family practice or internal medicine providers. DISCUSSION: Health care practices may be asking CHWs primarily to conduct screenings, rather than provide the longitudinal services CHWs traditionally offer. CONCLUSION: Uptake of billing for CHW services was limited. Providers may need education about CHW roles and technical assistance to support CHW integration and billing.