ForHealth Consulting at UMass Chan Medical School (formerly Commonwealth Medicine) partners with purposeful organizations to make healthcare and human services more equitable, effective, and accessible. This collection showcases journal articles and other publications and presentations produced by ForHealth Consulting researchers.


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Recently Published

  • Getting Started with the Scholarly Journal Publication Process

    Sefton, Laura A. (2022-08-25)
    Blog post to AEA365, a blog sponsored by the American Evaluation Association (AEA). Shares resources related to getting started in the publication process.
  • Pay-for-Performance in the Massachusetts Medicaid Delivery System Transformation Initiative

    Sefton, Laura; Tierney, Laxmi (2022-08-24)
    Pay-for-performance (P4P) is among the alternative payment models (APMs) that are designed to incentivize enhancements to healthcare efficiency and quality. Massachusetts' Office of Medicaid implemented a delivery system transformation initiative (DSTI) through an 1115(a) Demonstration Waiver to support and incentivize seven safety net hospitals to implement clinical care changes and transition to risk-based APMs. Comparative case study design was used to describe achievement of hospital-specific clinical and operational measures. Qualifying hospitals implemented 47 projects across three categories: (1) development of a fully integrated delivery system, (2) health outcomes and quality, and (3) ability to respond to statewide transformation to value-based purchasing and to accept alternatives to fee-for-service payments that promote system sustainability. Projects commonly focused on care transitions improvements, physical and behavioral healthcare integration, and chronic disease care management interventions. Collectively, the hospitals met all or most of 60 population-focused improvement measures and 10 common measures' targets, indicative of the progress. Some hospitals achieved substantial positive gains; however, missed targets suggest substantial organizational and workflow changes over a longer timeframe as well as consistent patient engagement may be necessary. Overall, the P4P structure of DSTI was effective in encouraging organizational change and supporting the transition of these hospitals towards APMs.
  • The Expanding Use of Continuous Glucose Monitoring in Type 2 Diabetes

    Dabbagh, Zakery; McKee, M Diane; Pirraglia, Paul A; Clements, Karen M; Liu, Feifan; Amante, Daniel J; Shukla, Prateek; Gerber, Ben S (2022-06-09)
    Over the last two decades, continuous glucose monitoring (CGM) has become a common self-monitoring strategy in type 1 diabetes (T1D). CGM, in which a minimally invasive, sensor-based device automatically measures and reports one's glucose levels up to every 5 min, improves hemoglobin A1c (HbA1c), reduces the frequency of dysglycemia, improves quality of life, and is cost-effective for people living with T1D compared to self-monitoring blood glucose (SMBG). CGM studies in type 2 diabetes (T2D) have been limited to date, especially those involving participants not requiring intensive insulin therapy.
  • Medicaid Policymaker Approaches to Prior Authorization Policies for Direct-Acting Antivirals for the Treatment of Hepatitis C Virus

    Greenwood, Bonnie C.; Pratt, Carter; Sefton, Laura; Goldman, Roberta; Gurewich, Deborah; Clements, Karen M.; Clark, Melissa (2022-06-05)
    Research Objective: In response to the high cost of direct‐acting antivirals (DAAs) for the treatment of hepatitis C virus (HCV), many Medicaid agencies implemented prior authorization (PA) policies designed to restrict access based on advanced liver disease, prescriber specialty, and/or substance use disorder history. Although PA policies have since been loosened, we have limited insight about the association between PA policies and DAA uptake, and factors impacting Medicaid agency policy decisions. In this mixed‐methods study evaluating the uptake of DAAs in four New England Medicaid programs, the objective of this analysis is to understand how and why the external context supports and impedes DAA uptake and the specific PA policies Medicaid agencies adopt. Study Design: Qualitative, recorded videoconference interviews were conducted between November 2020 and January 2021 using a semi‐structured interview guide. Key domains of inquiry included: 1) the PA policies adopted and why; 2) the systems and structures established to support these policies; and 3) factors that facilitate and impede policy implementation. Rapid qualitative analysis techniques were used to identify content and themes within the interviews. We compared results across states defined by relative uptake of DAAs (i.e., high versus low). DAA uptake was defined in the quantitative analysis as annually between 2014 and 2017. High uptake was defined as >10% uptake annually for all four years of the study. Population Studied: Interviews were conducted with the pharmacy director and other senior administrators responsible for setting medication PA policies from Medicaid agencies in four New England states. Two to three individuals were interviewed per state (N=11). Principal Findings: One state had high DAA uptake relative to the other three states. The interviews explored eight topic areas with only one emerging as varied between the high and low uptake states: the high uptake state did not have managed care organizations (MCOs); all low‐uptake states did. All states consulted with multiple internal stakeholders such as the Medicaid agency’s pharmacy team, drug utilization review board, medical director, and/or senior agency staff. All states consulted with multiple external stakeholders such as clinicians, academic institutions, departments of health, national and professional organizations, pharmacy benefit manager or fiscal agent, and/or MCOs. Supplemental rebates were leveraged by all states. Only one state implemented a specialized PA process for the DAAs. Conclusions: Overall, there were few differences in DAA PA policies and the development process between high and low‐uptake states but there were differences with respect to presence of MCOs. This suggests that variation in DAA uptake may be less driven by PA policies than by provider‐ and possibly patient‐level factors. Implications for Policy or Practice: To understand the variation in DAA uptake in Medicaid it is necessary to explore contextual factors beyond PA policy, such as provider‐ and possibly patient‐level factors. This research suggests there may be differences in how PA policies are mediated at the provider level. Understanding the broader context for medication uptake can allow Medicaid agencies to ensure they are achieving intended utilization patterns among their membership.
  • Direct Acting Antiviral Uptake for Hepatitis C Virus among Medicaid Members with Substance Use Disorder

    Clements, Karen M.; Kunte, Parag; Person, Sharina; Greenwood, Bonnie C.; Gurewich, Deborah; Sefton, Laura; Pratt, Carter; Clark, Melissa (2022-06-05)
    Research Objective: Substance use disorder (SUD) is a risk factor for contracting hepatitis C virus (HCV). Direct acting antivirals (DAA), introduced in late 2013, are highly effective in treating HCV regardless of SUD status. Many state Medicaid agencies initially imposed prior authorization (PA) requirements mandating a period of abstinence or SUD treatment prior to authorizing DAAs in this population. Over time some states relaxed requirements, although as of 2021 such requirements remain in 28 states. We evaluated DAA uptake from 2014‐2017 among Medicaid members to compare uptake among members with and without SUD and to assess the effect of SUD‐related PA requirements over time for predicting treatment among members with SUD. Study Design: This retrospective cohort study used enrollment, medical, and pharmacy claims from Medicaid enrollees in 13 Medicaid plans from three New England states. We used chi‐square tests to compare DAA uptake (1+ pharmacy claims for a DAA) among members with and without an ICD‐9/10 code for SUD and to compare uptake among members with SUD in plans with no SUD‐related PA requirements, plans that lifted requirements between 2014‐2017, and plans with requirements through 2017. Generalized estimating equations with binomial distribution and log link function identified the independent role of SUD‐related PA requirements and calendar time, adjusting for demographic and clinical variables, for predicting uptake. Adjusted risk ratios (aRR) are presented. Population Studied: The population included Medicaid members ages 18‐64 years with HCV (2+ claims with ICD‐9/10 code for HCV or 1+ claim for chronic HCV) from 12/2013–12/2017. Individuals remained in the sample until treatment initiation or Medicaid disenrollment. Uptake was identified through 12/2017. Principal Findings: Overall, 21,186 members (65% of those with HCV) had a SUD diagnosis during the study period. Cumulatively, 13.4% with SUD vs 34.1% without SUD (p<0.0001) were treated for HCV. Among members with SUD, 2,561 (15.2%) members in a plan with no SUD‐related PA requirements, compared with 1,772 (11.5%) in a plan that lifted SUD‐related PA requirements during the study period and 268 (12.8%) in a plan with SUD‐related PA requirements through 2017 (p<0.0001) were treated. In multivariable analyses, members with SUD were less than half as likely to be treated in a month during which SUD‐related PA requirements were in place in their plan relative to months with no SUD‐related PA requirement (aRR = 0.42, 95% CI 0.38‐0.47). Nevertheless, over time uptake increased more steeply, 8%/month, for members during months under SUD requirements (aRR=1.08, 95% CI 1.07‐1.09), and increased 1%/month during months not under requirements (aRR = 1.01, 95%CI 1.01‐1.01). Conclusions: Medicaid members with SUD were less likely to be treated for HCV than their peers without SUD. SUD‐related PA requirements exacerbated the discrepancy in treatment, although over time DAA uptake has increased among members in plans that imposed SUD‐related requirements. Policy implications: While SUD‐related PA requirements limited DAA treatment among Medicaid members with HCV, the increase in treatment over time among members subject to these requirements suggests a clinical, cultural and/or policy shift towards facilitating HCV treatment in this population. Future research ought to explore the merits of continued SUD‐related PA requirements.
  • Do Patient Outcomes Vary by Patient Age Following Primary Total Hip Arthroplasty?

    Ayers, David C; Yousef, Mohamed; Zheng, Hua; Yang, Wenyun; Franklin, Patricia D (2022-05-31)
    Background: Multiple authors have sought to determine what patient characteristics influence outcome after total hip arthroplasty (THA). Age has shown no effect on outcome in some evaluations, while others have reported higher functional improvement in younger patients. The aim of this study was to determine if outcome after THA varies based on patient age. Methods: A prospective, multicenter cohort of 7,934 unilateral primary THA patients from the FORCE-TJR comparative effectiveness consortium was evaluated. Demographic data, comorbid conditions, and Patient-Reported Outcome Measures, including (HOOS), HOOS-12, HOOS JR, and SF-36 (PCS) and (MCS), were collected preop and at 1-year postop. Descriptive statistics were generated, stratified by age (<55 years [younger adult], 55-64 years [older adult], 65-74 years [early elder], and ≥75 years [late elder]), and differences in pain, function, and quality of life among the 4 age groups were evaluated. A multivariate regression model with 95% confidence interval (CI) was used to assess the role of patient age as a predictive factor for HOOS pain and function scores reported 1 year after primary THA. Results: Prior to surgery, younger patients (<55 years) reported worse pain, function, and quality of life than the other 3 patient groups. At 1 year after THA, younger patients (<55 years) reported slightly worse pain and quality of life but better function scores than the 3 older patients' groups. Younger patients (<55 years) achieved higher baseline to 1-year pain, and function score changes when compared to the older patients' groups. The quality of life score changes was not different among the 4 age groups. The differences in 1-year postop scores (ranging from 2.74 to 8.46) and the magnitude of score changes from baseline to 1 year (ranging from 1.9 to 5.85), although statistically significant (P < .001), did not reach the minimal clinically important difference (MCID). The multivariate regression analysis shows that age is a significant predictor for pain at 1 year but not for function. Although HOOS pain score is predicted to be higher by 4.38 points (less pain) 1 year after THA in older patients (≥75), when compared to younger patients (<55 years), again the difference is well below the MCID and is clinically insignificant. Conclusion: Although there are statistically significant differences in pain relief, functional improvement, and quality of life between younger and older patients among different patients' age groups, there is no clinically significant difference. THA provides an improvement in quality of life by decreasing pain and increasing function in all 4 age groups, with large improvements in Patient-Reported Outcome Measures scores (>2 standard deviations) without clinically significant age-related differences in THA outcome at 1 year.
  • Uptake of hepatitis C virus treatment in a multi-state Medicaid population, 2013-2017

    Clements, Karen M; Kunte, Parag S; Clark, Melissa A; Gurewich, Deborah; Greenwood, Bonnie C; Sefton, Laura; Pratt, Carter; Person, Sharina D; Wessolossky, Miryea A (2022-05-04)
    Objective: To examine trends in the direct acting antiviral (DAA) uptake in a multi-state Medicaid population with hepatitis C virus (HCV) prior to and after ledipasvir/sofosbuvir (LDV/SOF) approval and changes in prior authorization (PA) requirements. Data sources: Analyses utilized enrollment, medical, and pharmacy claims in four states, December 2013-December 2017. Study design: An interrupted time series examined trends in uptake (1+ claim for a DAA) before and after two events: LDV/SOV approval (October 2014) and lifting of PA requirements for 40% of members (July 2016). Analyses were also performed in subgroups defined by the number and dates of change in PA requirements in members' Medicaid plans. Data collection/extraction methods: Members aged 18-64 years with an ICD code for HCV were included in the sample from diagnosis date until treatment initiation or Medicaid disenrollment. Principal findings: The annual sample size ranged from 38,302 to 45,005 with approximately 30% ages 18-34 years and 40% female. In December 2013, 0.08% was treated, rising to 0.74% in December 2017 (p < 0.001). Uptake increased from 0.34%/month in October 2014 to 0.70%/month after LDV/SOF approval, (p < 0.001), and increased relative to the pre-LDV/SOV trend through June 2016 (p = 0.04). Uptake increased to 1.18%/month after PA change, (p < 0.001) and remained flat through 2017 (p = 0.64). Cumulatively, 20.1% were treated by December 2017. In plans with few/no requirements through 2017, uptake increased to 1.19%/month after LDV/SOF approval (p < 0.001) and remained flat through 2017 (p = 0.11), with 22.2% cumulatively treated. Among plans that lifted PA requirements from three to zero in mid-2016, uptake did not increase after LDV/SOF approval (p = 0.36) but did increase to 1.41%/month (p < 0.001) after PA change, with 18.1% cumulatively treated. Conclusions: HCV Treatment increased through 2017. LDV/SOF approval and lifting PA requirements led to an increase in uptake followed by flat monthly utilization. Cumulative uptake was higher in plans with few/no PA requirements relative to those with three requirements through mid-2016.
  • Evaluating proactive outreach for prior authorization recertifications in Medicaid patients

    Vishwanath, Soumya; Tran, Stephanie N; Pomfret, Thomas C; Boss, Kaelyn C; Tesell, Mark; Price, Mylissa; Alper, Caroline J; Muchnik, Lorean; Clements, Karen M; Lenz, Kimberly (2021-11-01)
    Objectives: To assess the effectiveness of a proactive provider intervention in prompting prior authorization (PA) submissions or provider response prior to PA expiration for medically complex Medicaid patients. Study design: Pre-post outreach study with data from pharmacy claims and provider outreach. Methods: The intervention and historical comparison (control) groups included expired PAs from December 2019 to February 2020 and from December 2018 to February 2019, respectively. Provider outreach, including telephonic and fax attempts, was conducted over a 2-week period prior to PA expiration. Outcomes were classified as positive or negative based on provider conversation coupled with the result (eg, PA submission) for the intervention group and based solely on pharmacy claims for the control group. The primary end point was the percentage of positive outcomes between the groups, analyzed via χ2 test. The time from PA expiration to the new PA submission was evaluated via t test. Results: A total of 342 outreach attempts were conducted for 270 PAs representing 193 unique patients. Outreach was more likely to result in positive outcomes in the intervention group vs no outreach in the control group (87% vs 25%; P < .00001). On average, PAs were submitted 3.5 days prior to expiration in the intervention group vs 13.0 days after expiration in the control group (t = -7.50; P < .00001). Conclusions: Proactive outreach resulted in a greater percentage of PA submissions and a significantly reduced time to PA submission. These findings provide important information for payers in guiding clinical programs to enhance continuity of care among at-risk populations.
  • Perceived Barriers of Using Modern Family Planning Methods among Women in Jordan: A Qualitative Study

    Shattnawi, Khulood K; Khader, Yousef S; Al-Sheyab, Nihaya; Alyahya, Mohammad; Ready, Kelley; Halasa-Rappel, Yara A; Prince, Heath (2021-10-01)
    Background: Some cultural and social factors may discourage the use of modern family planning (MFP) methods. The purpose of this study was to better understand the barriers and social norms that might affect women's ability to take optimal advantage of the free family planning services offered by the Jordanian Ministry of Health (MOH). Methods: Using a qualitative descriptive design, 7 focus group discussions were conducted from January to February 2018, with a purposive sample of 52 married women. Each group consisted of 6-12 participants. Ethical approvals were obtained. Data were analysed using inductive thematic analysis. Results: Data analysis revealed three main themes and four subthemes. The first theme 'conforming to social and cultural norms' included the following subthemes: 'to conform to family and social pressure to bear children' and 'to prioritize having male children'. The second theme 'unmet needs in expected family planning counselling' included the following subthemes: 'need for consistency across providers in family planning counselling', and 'need for follow-up counselling'. The third theme was the 'undesirable side-effects' of the MFP methods, which included both the 'experienced' and the 'anticipated' side effects. Conclusion: This study identified a number of women's perceived barriers to using MFP methods. These included conforming to the social pressure, inconsistency of the counselling process, and undesirable side effects. Their perspectives should be carefully addressed in any family planning program.
  • Individual and Area-Level Predictors of Direct Acting Antiviral Uptake for Hepatitis C Virus in a New England Medicaid Population

    Clements, Karen M.; Kunte, Parag; Greenwood, Bonnie C.; Pratt, Carter; Sefton, Laura; Clark, Melissa; Leary, Amy; Person, Sharina; Gurewich, Deborah (2021-06-14)
    Research Objective: Direct acting antivirals (DAAs) offer significant improvement over previous options for hepatitis C virus (HCV) treatment. Although uptake has increased since their introduction in 2013, many with HCV remain untreated. While some individual- and area-level disparities in prescribing have been documented, including age, disease stage, substance use disorder, and rural residence, research focusing in the Medicaid population is sparse. We examined individual- and area-level predictors of DAA use in a multi-state Medicaid population. Study Design: This retrospective cohort study used enrollment, medical, and pharmacy claims from Medicaid enrollees in three New England states, linked to databases with area-level information about socioeconomic indicators and healthcare providers. Predictors of DAA uptake (1+ pharmacy claims for a DAA) were examined overall, by individual-level characteristics, including demographic (age, gender, homeless status) and clinical (disease stage, HIV, psychiatric diagnoses, substance use disorder, other comorbidity) characteristics, and area-level characteristics (rural-urban designation, education and unemployment levels in zip code, number of gastroenterologists and primary care providers (PCPs)/100,000 population in county). Generalized estimating equations with binomial distribution and log link identified independent predictors of uptake. Adjusted risk ratios (aRR) are presented. Population Studied: The population included Medicaid members ages 18-64 years with HCV (2+ claims with ICD-9/10 code for HCV diagnosis or 1+ claim for chronic HCV) from 12/2013–6/2018. Uptake was identified through 6/2018. Principal Findings: Overall, 55,207 members with HCV comprised the sample and 18.2% received a DAA. The strongest individual-level predictors of uptake included older age (aRR = 1.25, 95% CI 1.20-1.31 and 1.25, 95% CI 1.19-1.31 for ages 35-49 and 50-64 years, respectively, compared with ages 18-34 years), HIV diagnosis (aRR = 1.44, 95% CI 1.36-1.54), and advanced liver disease (aRR = 1.42, 95% CI 1.35-1.50). Individuals with alcohol use disorder (aRR = 0.74, 95% CI 0.70-0.78) and opioid use disorder (aRR = 0.78, 95% CI 0.74–0.72) were less likely to receive treatment. Female gender, other substance use disorders, some psychiatric diagnoses, tobacco use, and documented homelessness were also associated with lower uptake. The strongest area-level predictor of uptake was living in a county with few gastroenterologists (aRR = 1.31, 95% CI 1.11-1.53 for 0-1 gastroenterologists /100,000 vs. 6-20/100,000 population). Uptake was also higher among members living in a zip code with the lowest area-level education attainment and lower in counties both with the lowest and highest number of PCPs/1000 population relative to counties with an average density of PCPs. Conclusions: Among the high percentage of Medicaid members with HCV who remain untreated, women, younger adults, individuals at early disease stage, homeless, and with substance use disorders appear at higher risk of not being treated. Medicaid members living in areas with higher socioeconomic indicators and highest density of specialists and PCPs are also at higher risk. Implications for Policy or Practice: These findings identify groups in the Medicaid population that may benefit from targeted interventions designed to increase HCV treatment. The unexpected finding of lower uptake among individuals living in geographical areas with higher socioeconomic indicators and high density of healthcare providers merits further exploration into healthcare access of Medicaid members living in these areas.
  • Barriers and Facilitators to Implementation of Value-Based Care Models in New Medicaid Accountable Care Organizations in Massachusetts: A Study Protocol

    Goff, Sarah L.; Gurewich, Deborah; Alcusky, Matthew J.; Kachoria, Aparna; Nicholson, Joanne; Himmelstein, Jay S. (2021-04-06)
    Introduction: Massachusetts established 17 new Medicaid accountable care organizations (ACOs) and 24 affiliated Community Partners (CPs) in 2018 as part of a large-scale healthcare reform effort to improve care value. The new ACOs will receive $1.8 billion dollars in state and federal funding over 5 years through the Delivery System Reform Incentive Program (DSRIP). The multi-faceted study described in this protocol aims to address gaps in knowledge about Medicaid ACOs' impact on healthcare value by identifying barriers and facilitators to implementation and sustainment of the DSRIP-funded programs. Methods and analysis: The study's four components are: (1) Document Review to characterize the ACOs and CPs; (2) Semi-structured Key Informant Interviews (KII) with ACO and CP leadership, state-level Medicaid administrators, and patients; (3) Site visits with selected ACOs and CPs; and (4) Surveys of ACO clinical teams and CP staff. The Consolidated Framework for Implementation Research's (CFIR) serves as the study's conceptual framework; its versatile menu of constructs, arranged across five domains (Intervention Characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Processes) guides identification of barriers and facilitators across multiple organizational contexts. For example, KII interview guides focus on understanding how Inner and Outer Setting factors may impact implementation. Document Review analysis includes extraction and synthesis of ACO-specific DSRIP-funded programs (i.e., Intervention Characteristics); KIIs and site visit data will be qualitatively analyzed using thematic analytic techniques; surveys will be analyzed using descriptive statistics (e.g., counts, frequencies, means, and standard deviations). Discussion: Understanding barriers and facilitators to implementing and sustaining Medicaid ACOs with varied organizational structures will provide critical context for understanding the overall impact of the Medicaid ACO experiment in Massachusetts. It will also provide important insights for other states considering the ACO model for their Medicaid programs. Ethics and dissemination: IRB determinations were that the overall study did not constitute human subjects research and that each phase of primary data collection should be submitted for IRB review and approval. Study results will be disseminated through traditional channels such as peer reviewed journals, through publicly available reports on the mass.gov website; and directly to key stakeholders in ACO and CP leadership.
  • Comment on: COVID-19 in Nursing Homes: Calming the Perfect Storm

    Zorowitz, Robert A.; Bergman, Christian; Haimowitz, Daniel; Kalender-Rich, Jessica L.; Polakoff, David F.; Steinberg, Karl; Wright, James L. (2021-02-01)
    To the Editor: Ouslander's and Grabowski's recent article which included recommendations for “Calming the Perfect Storm” of COVID‐19 in nursing facilities was timely and thorough.Although excellent in scope, in our opinion it did not address one critical area, namely, the vital role of clinical leadership to navigate this crisis. We assert that this role belongs to the nursing home medical director in an often overlooked and yet critically important partnership with the administrator, director of nursing and infection preventionist.
  • Improving Performance with Flowcharts

    Aboagye, Ruth (2020-08-26)
    Blog post to AEA365, a blog sponsored by the American Evaluation Association (AEA) dedicated to highlighting Hot Tips, Cool Tricks, Rad Resources, and Lessons Learned for evaluators. The American Evaluation Association is an international professional association of evaluators devoted to the application and exploration of program evaluation, personnel evaluation, technology, and many other forms of evaluation. Evaluation involves assessing the strengths and weaknesses of programs, policies, personnel, products, and organizations to improve their effectiveness.
  • Opioid Overdoses Among High-Risk Medicaid Members: Healthcare Cost, Service Utilization, and Risk Factor Analysis

    Savageau, Judith A.; Brindisi, Melissa; Miller, Faye; Sefton, Laura A.; Stoler, Adam; Harvey, Margaret; Bernson, Dana (2020-07-28)
    Research Objective: Identify risk factors associated with opioid overdoses among three high-risk populations of Medicaid members related to cost and service utilization. Study Design: Repeated cross-sectional study using five years of Massachusetts Medicaid (MassHealth) claims and state agency data. Population Studied: MassHealth members aged 11-64 years considered to be high-risk (homeless, unstably housed, and/or criminal justice-involved) and in need of support services, especially those with extensive behavioral health (BH) needs. These three populations were identified as being particularly vulnerable to non-fatal and/or fatal opioid overdoses. Principal Findings: MassHealth members who were both justice-involved and unstably housed were at much higher risk of an opioid overdose than the MassHealth population overall, especially those with a substance use disorder (SUD) or a serious mental illness (SMI). Experiencing both homelessness and justice involvement substantially compounded members’ non-fatal overdose risk, regardless of BH diagnosis. Co-occurring SUD/SMI was a key driver of high overdose prevalence, particularly among the justice-involved. Compared to MassHealth members in general, those with justice involvement and unstable housing had costs that were 50-65% higher; members who experienced homelessness had triple the costs. Healthcare service use both before and after an overdose was relatively low, including the timeframe between multiple non-fatal overdoses. In multivariate analyses, all three high-risk factors (i.e., populations) were significantly related to an increased opioid overdose risk after controlling for additional risk factors (BH diagnoses, chronic medical conditions, and demographic characteristics). Males and whites were more likely to have an opioid overdose; those with diabetes or hypertension were less likely. These results were similar when assessing various opioid overdose outcomes (non-fatal and/or fatal). Conclusions: These findings helped inform MassHealth’s understanding of its members’ experiences regarding medical and BH services, especially among high-risk populations with an opioid overdose. The identification of risk factors most predictive of a subsequent overdose may help address the needs of these high-risk groups. For most of the populations studied, prevalence of co-occurring BH diagnoses was much higher than MassHealth members in general and appeared to impact opioid overdose rates. Most members received services for 1-2 months in both the pre- and post-overdose periods; service use was relatively low in the year following a non-fatal overdose, suggesting retention was also low. Multivariate analyses consistently showed that gender and race were significantly associated with increased overdose risk. Implications for Policy or Practice: Understanding opioid overdose risk factors and identifying service utilization gaps and missed opportunities are important. As payment reforms evolve under the umbrella of accountable care organizations, BH community partnership models are key for collaborating with healthcare and social service providers, and community resources for care management, care coordination, and referrals to support services. Our study initially developed an in-depth descriptive analysis of individuals with SUD, SMI, or both identified as being at high risk for an opioid overdose. Understanding service trajectory and outcomes through additional analyses was critical for planning and prioritizing appropriate services. As payors are actively making decisions about effective systems of care, they are particularly interested in understanding the need for community-based and residential services, particularly for those with housing instability and/or criminal justice involvement.
  • Improving Care Coordination between Accountable Care Organizations and Community Partners: Early Findings from the Massachusetts Delivery System Reform Incentive Payment (DSRIP) Program

    Kachoria, Aparna; Leary, Amy; Miller, Faye; Sefton, Laura A.; Nicholson, Joanne; Himmelstein, Jay (2020-07-28)
    Research Objective: The Massachusetts’ Medicaid and Children’s Health Insurance Program (MassHealth/MH) initiated the Delivery System Reform Incentive Payment (DSRIP) program in 2017, as part of its section 1115 Demonstration, to coordinate care for Medicaid members, reduce healthcare costs and improve patient outcomes. Central to this program was a requirement that Accountable Care Organizations (ACOs) develop relationships with all behavioral health and at least 2 long-term care service MH contracted Community Partner agencies (CPs) operating in their service areas to be responsible for coordinating care and developing care plans for members. This presentation will describe barriers and facilitators to developing ACO-CP relationships identified in the first 1.5 years of program implementation. Study Design: This paper focuses on ways in which ACOs and CPs are responding to new contracting requirements and programmatic expectations related to the MA 1115 DSRIP. Semi-structured interviews were conducted with individuals in leadership positions at all 17 ACOs and 27 CPs by pairs of trained interviewers, in person, or via video or teleconference. Interview data were analyzed qualitatively, using a framework approach informed by the literature, the program logic model, and the evaluation design. Population Studied: ACOs/CPs nominated 2 to 3 individuals best positioned to speak to implementation topics including governance and organizational structure, workforce development, ACO-CP relationships, provider engagement, care coordination, quality improvement, and environmental factors including the role of MassHealth. Ninety-four interviews were conducted with 99 interviewees across the 44 organizations. The majority of interviewees were female and typically held managerial roles, ranging from program managers to executives. A majority were with their organizations prior to or at the time of DSRIP inception. Principal Findings: Communication and information sharing were identified as key ingredients to coordinating member health care between ACOs and CPs; the absence of effective means to communicate and share information were identified as major barriers. Strategies for enhancing communication included scheduling regular meetings to discuss shared patients (i.e., within and between organizations), designating points of contact (e.g., staff liaisons), and clarifying roles regarding member-facing activities. Information sharing was found to be most effective when organizations agreed on processes, particularly around the use of electronic medical records or other information exchange technologies. ACO and CP interviewees indicated that successful communication and information sharing led to the development of stronger and more positive partner relationships (e.g., between an ACO and the CPs with which they share information and coordinate care well). Participants also described ways in which MassHealth has actively responded to challenges within the original design of the ACO-CP relationship to improve coordination and member experience. Conclusions: Designated points of contact, well-conceived and executed communication strategies, and effective information exchange are essential for developing relationships and coordinating care between ACOs and community-based organizations. Implications for Policy or Practice: States need to consider the complexity of coordinating care with multiple community-based agencies and the importance of standardized processes for effective information sharing when promoting care coordination between health care and human service entities. States should also incorporate means of ongoing technical support and rapid cycle feedback to allow for continuous policy improvement in Medicaid delivery systems.
  • Uptake of Direct Acting Antivirals for Hepatitis C Virus in a New England Medicaid Population, 2014-2017

    Clements, Karen M.; Kunte, Parag; Greenwood, Bonnie C.; Pratt, Carter; Sefton, Laura A.; Clark, Melissa; Person, Sharina D.; Gurewich, Deborah (2020-07-20)
    Introduction Introduction of the direct acting antiviral (DAA) sofosbuvir (SOV) in 2013 offered significant improvement over previous options for hepatitis C virus (HCV) treatment. Initial uptake was low in Medicaid and other populations, perhaps in part due to high drug cost and prior authorization (PA) restrictions related to fibrosis stage, prescribing provider specialty, and sobriety. Both the subsequent introduction of ledipasvir/sofosbuvir (LDV/SOV), an all-oral regimen for most genotypes, and lifting of PA restrictions were expected to increase overall uptake, but little is known about recent prescribing patterns. We examined trends in DAA uptake in a Medicaid population and identified the effect of these two events on treatment initiation. Study Design An interrupted time series (ITS) design utilized enrollment, medical, and pharmacy claims from Medicaid enrollees in three New England states, 12/2013-12/2017. Trends in treatment uptake, defined as 1+ pharmacy claim for a DAA, were examined overall, by demographic characteristics, and prior to and after two time points: 10/2014 (LDV/SOV approval date) and 7/2016 (date PA restrictions affecting two-thirds of members were lifted). Chi-square evaluated demographic differences, segmented regression models examined trends. Study Population The population included members ages 18-64 years with HCV (2+ claims with ICD-9/10 code for HCV or 1+ claim for chronic HCV). Eligible individuals remained in the sample until treatment initiation or Medicaid disenrollment. Findings The analytic sample averaged 30,433 members with HCV per month, mean age 42.9 years, 60% male. In 2014 3.3% of eligible members initiated treatment, increasing to 7.7% in 2017 (p = Conclusion While initial uptake of DAAs was low in this multi-state Medicaid population, treatment initiation among eligible members increased through 2017. Introduction of new medications and lifting of PA restrictions led to an immediate increase in uptake followed by relatively flat monthly utilization. Policy implications Sharp increases in uptake after LDV/SOV introduction may indicate warehousing of members in anticipation of LDV/SOV approval; increases after PA restrictions were lifted indicates demand for treatment among those affected by restrictions. As a large percentage of the Medicaid HCV population remains untreated, planned provider interviews will help to understand barriers and facilitators of treatment for HCV.
  • Advancing the implementation and sustainment of medication assisted treatment for opioid use disorders in prisons and jails

    Ferguson, Warren J.; Johnston, Joan; Clarke, Jennifer G.; Koutoujian, Peter J.; Maurer, Kathleen; Gallagher, Colleen; White, Julie; Nickl, Dyana; Taxman, Faye S. (2019-12-12)
    BACKGROUND: Opioid use disorder (OUD) is among the most prevalent medical condition experienced by incarcerated persons, yet medication assisted therapy (MAT) is uncommon. Four jail and prison systems partnered with researchers to document their adoption of MAT for incarcerated individuals with opioid use disorders (OUD) using their established treatment protocols. Employing the EPIS (Exploration, Planning, Implementation, and Sustainment) framework, programs report on systematic efforts to expand screening, treatment and provide linkage to community-based care upon release. RESULTS: All four systems were engaged with implementation of MAT at the outset of the study. Thus, findings focus more on uptake and penetration as part of implementation and sustainment of medication treatment. The prevalence of OUD during any given month ranged from 28 to 65% of the population in the participating facilities. All programs developed consistent approaches to screen individuals at intake and provided care coordination with community treatment providers at the time of release. The proportion of individuals with OUD who received MAT ranged considerably from 9 to 61%. Despite efforts at all four sites to increase utilization of MAT, only one site achieved sustained growth in the proportion of individuals treated over the course of the project. Government leadership, dedicated funding and collaboration with community treatment providers were deemed essential to adoption of MAT during implementation phases. Facilitators for MAT included increases in staffing and staff training; group education on medication assisted therapies; use of data to drive change processes; coordination with other elements of the criminal justice system to expand care; and ongoing contact with individuals post-release to encourage continued treatment. Barriers included lack of funding and space and institutional design; challenges in changing the cultural perception of all approved treatments; excluding or discontinuing treatment based on patient factors, movement or transfer of individuals; and inability to sustain care coordination at the time of release. CONCLUSIONS: Adoption of evidence-based medication assisted therapies for OUD in prisons and jails can be accomplished but requires persistent effort to identify and overcome challenges and dedicated funding to sustain programs.
  • Why does the adverse effect of inappropriate MRI for LBP vary by geographic location? An exploratory analysis

    Shraim, Mujahed; Cifuentes, Manuel; Willetts, Joanna L.; Marucci-Wellman, Helen R.; Pransky, Glenn (2019-11-30)
    BACKGROUND: Early magnetic resonance imaging (eMRI) for nonspecific low back pain (LBP) not adherent to clinical guidelines is linked with prolonged work disability. Although the prevalence of eMRI for occupational LBP varies substantially among states, it is unknown whether the risk of prolonged disability associated with eMRI varies according to individual and area-level characteristics. The aim was to explore whether the known risk of increased length of disability (LOD) associated with eMRI scanning not adherent to guidelines for occupational LBP varies according to patient and area-level characteristics, and the potential reasons for any observed variations. METHODS: A retrospective cohort of 59,360 LBP cases from 49 states, filed between 2002 and 2008, and examined LOD as the outcome. LBP cases with at least 1 day of work disability were identified by reviewing indemnity service records and medical bills using a comprehensive list of codes from the International Classification of Diseases, Ninth Edition (ICD-9) indicating LBP or nonspecific back pain, excluding medically complicated cases. RESULTS: We found significant between-state variations in the negative impact of eMRI on LOD ranging from 3.4 days in Tennessee to 14.8 days in New Hampshire. Higher negative impact of eMRI on LOD was mainly associated with female gender, state workers' compensation (WC) policy not limiting initial treating provider choice, higher state orthopedic surgeon density, and lower state MRI facility density. CONCLUSION: State WC policies regulating selection of healthcare provider and structural factors affecting quality of medical care modify the impact of eMRI not adherent to guidelines. Targeted healthcare and work disability prevention interventions may improve work disability outcomes in patients with occupational LBP.
  • Transformation Support Provided Remotely to a National Cohort of Optometry Practices

    Adler, Ronald N.; Ferguson, Warren J.; Antar, Hussein; Steinkrauss, Michael; Bjoern, Brian; Konar, Valerie; Flanagan, Jay; Polakoff, David F. (2019-08-12)
    PURPOSE: We describe the results of a practice transformation project conducted within a national cohort of optometry practices participating in the Southern New England Practice Transformation Network. METHODS: Participants were 2,997 optometrists in 1,706 practices in 50 states. The multicomponent intervention entailed curriculum dissemination through a preexisting network of optometrists supported by specialized staff and resources, and data collection through a web portal providing real-time feedback. Outcomes included practices reporting data, urgent optometry visits for target conditions, and projected cost savings achieved by reducing emergency department (ED) use through increased provision of urgent care for conditions amenable to management in optometry practices. RESULTS: Over 13 months, 69.9% of practices reported data for a mean of 6.7 months. Beginning with the fourth month, the number of urgent optometry visits increased steadily. Among reporting practices, the total cost savings were estimated at $152 million (176,703 ED visits avoided at an average cost differential of $860 per visit). Monthly projected cost savings per optometrist were substantially greater in rural vs urban practices ($10,800 vs $7,870; P < .001). CONCLUSIONS: Technical assistance to promote practice transformation can be provided remotely and at scale at low per-practice cost. Through the provision of timely, easily accessed ambulatory care, optometrists can improve the patient experience and reduce ED use, thereby reducing costs. The cost savings opportunities are immense because of the large volume and high expense of ED visits for ocular conditions that might otherwise be managed in ambulatory optometry practices.
  • Impact of Sequential Opioid Dose Reduction Interventions in a State Medicaid Program Between 2002 and 2017

    Garcia, Maria M.; Lenz, Kimberly J.; Greenwood, Bonnie C.; Angelini, Michael C.; Thompson, Tyson; Clements, Karen M.; Mauro, Rose; Jeffrey, Paul L. (2019-08-01)
    Policies that address opioid dose limits may help to decrease high-risk opioid prescribing. We evaluated 3 sequential and progressive decreases in high-dose (HD) opioid limits implemented by Massachusetts Medicaid over 15 years. The study population included members ages 18 to 64 years with > /=1 claim for a schedule II opioid between January 2002 and March 2017. The 3 interventions consisted of prior authorization requirements for prescriptions exceeding the morphine equivalent dose (MED) HD dose limits: > 360 mg (intervention 1a and 1b), > 240 mg (intervention 2), and > 120 mg (intervention 3). A segmented regression evaluated the change in natural log of the average daily MED (AD_MED). The natural log of the AD_MED decreased during the 6 quarters after intervention 1a (P < .001), immediately after intervention 1b (P=.0002), and continued to decrease over the following 8 quarters (P=.023). The natural log of the AD_MED decreased immediately after intervention 2 (P=.002) and again after intervention 3 (P < .001). The percentage of users exceeding the HD limits of 360 mg, 240 mg, and 120 mg MED decreased by 87.3%, 79.8%, and 75.2% from baseline, respectively. The natural log of the AD_MED decreased among members after implementation of 3 sequential and progressive HD prior authorization limits, as did the percentage of members exceeding each of the HD limits. PERSPECTIVE: This study demonstrates the longitudinal impact of a prior authorization policy-based HD limit in a Medicaid population. This study contributes to options for policymakers and other Medicaid programs as a potential strategy to assist in addressing the opioid epidemic.

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