Publications by authors named "Erica Solway"

28 Publications

  • Page 1 of 1

Use of Online Physician Ratings and Reviews by Older U.S. Adults: Results of a National Survey.

Ann Intern Med 2021 Apr 13. Epub 2021 Apr 13.

University of Michigan Institute for Healthcare Policy and Innovation and University of Michigan Medical School, Ann Arbor, Michigan (D.A.H.).

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http://dx.doi.org/10.7326/M20-7600DOI Listing
April 2021

Beneficiaries' perspectives on improved oral health and its mediators after Medicaid expansion in Michigan: a mixed methods study.

J Public Health Dent 2021 Mar 22. Epub 2021 Mar 22.

University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA.

Objective: To investigate self-reported improved oral health and its mediators, and job-related outcomes, of Medicaid expansion beneficiaries in Michigan.

Methods: This cross-sectional mixed-methods study of adult "Healthy Michigan Plan" (HMP) Medicaid expansion beneficiaries included qualitative interviews with a convenience sample of 67 beneficiaries enrolled for ≥6 months, a stratified random sample survey of 4,090 beneficiaries enrolled for ≥12 months; and Medicaid claims data. We examined unadjusted associations between demographic variables and awareness of dental coverage, self-reported dental care access, dental visits, and self-reported oral health; and between improved oral health and job seeking and job performance. Multivariate analysis examined factors associated with self-reported oral health improvement, adjusting for sociodemographic characteristics, prior health insurance, and having at least one dental visit claim.

Results: Among surveyed beneficiaries, 60 percent received ≥1 dental visit and 40 percent reported improved oral health. Adjusted odds ratios (aOR) for improved oral health were higher for African-American beneficiaries [aOR = 1.61; confidence interval (CI) = 1.28-2.03] and those previously uninsured for ≥12 months (aOR = 1.96; CI = 1.58-2.43). Beneficiaries reporting improved oral health were more likely to report improved job seeking (59.9 percent vs 51 percent; P = 0.04) and job performance (76.1 percent vs 65.0 percent; P < 0.001) due to HMP. Interviewees described previously unmet oral health needs, and treatments that improved oral health, functioning, appearance, confidence, and employability.

Conclusion: Michigan's Medicaid expansion contributed to self-reported improved oral health, which was associated with improved job outcomes. Policymakers should consider the importance of Medicaid dental coverage in reducing oral health disparities and improving the health and socioeconomic well-being of low-income adults and communities when considering this optional benefit.
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http://dx.doi.org/10.1111/jphd.12447DOI Listing
March 2021

Prevalence of Central Nervous System-Active Polypharmacy Among Older Adults With Dementia in the US.

JAMA 2021 03;325(10):952-961

School of Social Policy and Practice, University of Pennsylvania, Philadelphia.

Importance: Community-dwelling older adults with dementia have a high prevalence of psychotropic and opioid use. In these patients, central nervous system (CNS)-active polypharmacy may increase the risk for impaired cognition, fall-related injury, and death.

Objective: To determine the extent of CNS-active polypharmacy among community-dwelling older adults with dementia in the US.

Design, Setting, And Participants: Cross-sectional analysis of all community-dwelling older adults with dementia (identified by International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes; N = 1 159 968) and traditional Medicare coverage from 2015 to 2017. Medication exposure was estimated using prescription fills between October 1, 2017, and December 31, 2018.

Exposures: Part D coverage during the observation year (January 1-December 31, 2018).

Main Outcomes And Measures: The primary outcome was the prevalence of CNS-active polypharmacy in 2018, defined as exposure to 3 or more medications for longer than 30 days consecutively from the following classes: antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics, and opioids. Among those who met the criterion for polypharmacy, duration of exposure, number of distinct medications and classes prescribed, common class combinations, and the most commonly used CNS-active medications also were determined.

Results: The study included 1 159 968 older adults with dementia (median age, 83.0 years [interquartile range {IQR}, 77.0-88.6 years]; 65.2% were female), of whom 13.9% (n = 161 412) met the criterion for CNS-active polypharmacy (32 139 610 polypharmacy-days of exposure). Those with CNS-active polypharmacy had a median age of 79.4 years (IQR, 74.0-85.5 years) and 71.2% were female. Among those who met the criterion for CNS-active polypharmacy, the median number of polypharmacy-days was 193 (IQR, 88-315 polypharmacy-days). Of those with CNS-active polypharmacy, 57.8% were exposed for longer than 180 days and 6.8% for 365 days; 29.4% were exposed to 5 or more medications and 5.2% were exposed to 5 or more medication classes. Ninety-two percent of polypharmacy-days included an antidepressant, 47.1% included an antipsychotic, and 40.7% included a benzodiazepine. The most common medication class combination included an antidepressant, an antiepileptic, and an antipsychotic (12.9% of polypharmacy-days). Gabapentin was the most common medication and was associated with 33.0% of polypharmacy-days.

Conclusions And Relevance: In this cross-sectional analysis of Medicare claims data, 13.9% of older adults with dementia in 2018 filled prescriptions consistent with CNS-active polypharmacy. The lack of information on prescribing indications limits judgments about clinical appropriateness of medication combinations for individual patients.
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http://dx.doi.org/10.1001/jama.2021.1195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944381PMC
March 2021

Interest in Sex and Conversations About Sexual Health with Health Care Providers Among Older U.S. Adults.

Clin Gerontol 2021 May-Jun;44(3):299-306. Epub 2021 Feb 20.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.

: Sexual health is an important component of overall health and well-being for older adults. Despite this, little is known about the importance of sex to quality of life, as part of romantic relationships for older adults, and potential drivers of interactions between healthcare providers and older adults about sexual health. In this study using a nationally representative population, we describe perceptions and experiences of sex among older adults.: A nationally representative, cross-sectional sample of community-dwelling U.S. adults aged 65-80 was surveyed about their sexual health and interaction with their health care providers about sexual health.: The survey completion rate was 75% (N = 1,002). Overall, 50.9% of men and 30.8% of women reported being sexually active. In all, 17.3% of adults aged 65-80 reported speaking to their health care provider about sexual health in the past two years and of those, 60.5% of patients initiated the conversation. Multivariable logistic regression demonstrated that sexual activity (yes/no), interest in sex, and satisfaction with sex life are major drivers of sexual health conversations between patients and healthcare providers.: Many adults aged 65-80 are interested in and engage in sexual activity. While the majority of older adults reported a willingness to discuss their sexual health with their health care providers, few had done so, and most conversations were initiated by patients. Iterest in sex and satisfaction with sex life may be targets for intervention and offer a segue for providers as they begin the conversation to engage with older adults about their sexual health.: Providers may have conversations with older adults about sexual health and may need sexual health training to have effective discussions; age nor chronic conditions should preclude this essential conversation. Clinical gerontologists may be helpful in this training and in encouraging patients to bring up sexual health concerns during their medical appointments.
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http://dx.doi.org/10.1080/07317115.2021.1882637DOI Listing
February 2021

Use and perceptions of antibiotics among US adults aged 50-80 years.

Infect Control Hosp Epidemiol 2021 May 5;42(5):628-629. Epub 2021 Feb 5.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.

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http://dx.doi.org/10.1017/ice.2021.19DOI Listing
May 2021

Self-reported disposal of leftover opioids among US adults 50-80.

Reg Anesth Pain Med 2020 12 6;45(12):949-954. Epub 2020 Oct 6.

Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA.

Objective: To test the association between self-reported opioid disposal education and self-reported disposal of leftover opioids among older adults.

Design: Web-based survey from the National Poll on Healthy Aging (March 2018) using population-based weighting for nationally representative estimates.

Subjects: Older adults aged 50-80 years who reported filling an opioid prescription within the past 2 years.

Methods: Respondents were asked whether they received education from a prescriber or pharmacist on how to dispose of leftover opioids and whether they disposed of leftover opioids from recent prescriptions. The association between self-reported opioid disposal education and self-reported disposal of leftover opioids was estimated with multivariable logistic regression, testing for interactions with respondent demographics.

Results: Among 2013 respondents (74% response rate), 596 (28.9% (26.8%-31.2%)) were prescribed opioids within the past 2 years. Education on opioid disposal was reported by 40.1% of respondents (35.8%-44.5%). Among 295 respondents with leftover medication, 19.0% (14.6%-24.5%) disposed of the leftover medications. Opioid disposal education was associated with a greater likelihood of self-reported disposal of leftover opioids among non-white respondents as compared with white non-Hispanic respondents (36.7% (16.8%-56.6%) vs 7.8% (0.1%-15.6%), p<0.01).

Conclusions: In this nationally representative survey, 49% had leftover opioids, yet only 20% of older adults reported disposal of leftover opioids. Opioid disposal education was variable in delivery, but was associated with disposal behaviors among certain populations. Strategies to promote disposal should integrate patient education on the risks of leftover opioid medications and explore additional barriers to accessing opioid disposal methods.
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http://dx.doi.org/10.1136/rapm-2020-101544DOI Listing
December 2020

Food insecurity is associated with multiple chronic conditions and physical health status among older US adults.

Prev Med Rep 2020 Dec 20;20:101211. Epub 2020 Sep 20.

Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, USA.

In the past two decades, food insecurity has increased by 45% among older adults but its relationship to health outcomes has not been extensively studied. The objective of this study was to examine the associations between food insecurity, multiple chronic conditions, and self-reported health status among a nationally representative sample of older U.S. adults. Data came from the National Poll on Healthy Aging, a national cross-sectional survey conducted in December 2019 among 2,048 individuals aged 50-80 years. Food insecurity was assessed using the six-item short form of the USDA Food Security Survey Module. The primary outcomes of interest were the number of self-reported chronic conditions and self-reported physical health status. Multinomial logistic regression models were used to examine the associations between food security status and the outcomes of interest, adjusting for sociodemographic characteristics. The overall prevalence of food insecurity among older adults was 14%. After adjustment for sociodemographic characteristics, food insecurity was positively associated with multiple chronic conditions (RRR 1.60, 95% CI 1.08, 2.36, for 2-3 conditions vs. 0-1; RRR 2.59, 95% CI 1.55, 4.33 for 4-10 chronic conditions vs. 0-1). Food insecurity was also associated with lower self-reported health status (RRR 1.84, 95% CI 1.16, 2.93 for good vs. excellent/ very good health; RRR 5.13, 95% CI 3.08, 8.52 for fair/poor vs. excellent/very good health). Food insecurity is an important social determinant of health among older adults. These findings can contribute to clinical and public health efforts to simultaneously alleviate food insecurity and promote health behaviors among older adults.
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http://dx.doi.org/10.1016/j.pmedr.2020.101211DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7502278PMC
December 2020

Correlates of Formal Support Service Use among Dementia Caregivers.

J Gerontol Soc Work 2021 Mar 12;64(2):135-150. Epub 2020 Sep 12.

Department of Health Behavior and Health Education, University of Michigan School of Public Health , Ann Arbor, MI, USA.

Informal caregivers for persons with dementia frequently report needing assistance, yet formal support service use has been low. To better understand factors associated with service use, correlates of self-reported service use (e.g., support groups, family mediation, family leave, classes/trainings, and respite care) among dementia caregivers were assessed. The National Poll on Healthy Aging conducted a nationally representative web-based survey of adults aged 50-80 (N = 2,131) using Ispos' KnowledgePanel®; 148 reported caregiving for an adult with memory loss [61.5% female; 25% nonwhite, 54.1% aged 50-64]. Multivariable logistic regression analyzes assessed caregiver and care recipient characteristics associated with service use within the prior year. Nearly 25% of caregivers used at least one service. Caregiver characteristics associated with greater likelihood of service use included not working [7.5 OR; 2.73, 20.62 CI]; income <$30,000/year [5.9 OR; 1.27, 27.17 CI]; and residing in Western US [7.5 OR; 2.73, 20.62 CI]. Ability of care recipient to be left alone safely for only three hours or less [5.1 OR; 1.66, 15.46 CI] was associated with greater likelihood of use. Support service use remains low. Findings suggest need to consider caregivers' employment status, income, and geographical location in service design and implementation.
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http://dx.doi.org/10.1080/01634372.2020.1816589DOI Listing
March 2021

Examination of Changes in Health Status Among Michigan Medicaid Expansion Enrollees From 2016 to 2017.

JAMA Netw Open 2020 07 1;3(7):e208776. Epub 2020 Jul 1.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.

Importance: Evidence about the health benefits of Medicaid expansion has been mixed and has largely come from comparing expansion and nonexpansion states.

Objective: To examine the self-reported health of enrollees in Michigan's Medicaid expansion, the Healthy Michigan Plan (HMP), over time.

Design, Setting, And Participants: A telephone survey from January 1 to October 31, 2016 (response rate, 53.7%), and a follow-up survey from March 1, 2017, to January 31, 2018 (response rate, 83.4%), were conducted in Michigan, which expanded Medicaid in 2014 through a Section 1115 waiver permitting state-specific modifications. Four thousand ninety HMP beneficiaries aged 19 to 64 years with at least 12 months of HMP coverage and at least 9 months in a Medicaid health plan were eligible to participate. Data were analyzed from April 1 to November 30, 2018.

Main Outcomes And Measures: Surveys measured demographic characteristics and health status. Analyses included weights for sampling probability and nonresponse. Comparisons between 2016 and 2017 included those who responded to both surveys (n = 3097).

Results: Of the 3097 respondents to the 2017 follow-up survey, 2388 (77.1%) were still enrolled in HMP (current enrollees) and 709 (22.9%) were no longer enrolled when surveyed (former enrollees). Among all follow-up respondents, a weighted 37.5% (95% CI, 35.3%-39.9%) were aged 19 to 34 years, 34.0% (95% CI, 31.8%-36.2%) were aged 35 to 50 years, and 28.5% (95% CI, 26.7%-30.3%) were aged 51 to 64 years; 53.0% (95% CI, 50.8%-55.3%) were female. Respondents who reported fair or poor health decreased from 30.7% (95% CI, 28.7%-32.8%) in 2016 to 27.0% (95% CI, 25.1%-29.0%) in 2017 (adjusted odds ratio [AOR], 0.66 [95% CI, 0.53-0.81]; P < .001), with the largest decreases observed in respondents who were non-Hispanic black (from 31.5% [95% CI, 27.1%-35.9%] in 2016 to 26.0% [95% CI, 21.9%-30.1%] in 2017; P = .009), from the Detroit metropolitan area (from 30.7% [95% CI, 27.0%-34.4%] in 2016 to 24.9% [95% CI, 21.6%-28.3%] in 2017; P = .001), and with an income of 0% to 35% of the federal poverty level (from 37.6% [95% CI, 34.2%-40.9%] in 2016 to 32.3% [95% CI, 29.1%-35.5%] in 2017; P < .001). From 2016 to 2017, the mean number of days of poor physical health in the past month decreased significantly from 6.9 (95% CI, 6.5-7.4) to 5.7 (95% CI, 5.3-6.0) (coefficient, -6.10; P < .001), including among current (from 7.0 [95% CI, 6.5-7.5] to 5.6 [95% CI, 5.1-6.0]; P < .001) and former (from 6.8 [95% CI, 5.9-7.7] to 5.8 [95% CI, 5.0-6.7]; P = .02) enrollees, those with 2 or more chronic conditions (from 9.9 [95% CI, 9.3-10.6] to 8.5 [95% CI, 7.8-9.1]; P < .001), across all age groups (19-34 years, from 4.3 [95% CI, 3.7-4.9] to 3.0 [95% CI, 2.5-3.5]; P < .001; 35-50 years, from 8.2 [95% CI, 7.3-9.0] to 6.9 [95% CI, 6.1-7.7]; P = .002; 51-64 years, from 9.0 [95% CI, 8.2-9.8] to 7.6 [95% CI, 6.9-8.3]; P = .001), and among non-Hispanic white (from 7.5 [95% CI, 7.0-8.1] to 6.1 [95% CI, 5.6-6.6]; P < .001) and black (from 5.9 [95% CI, 5.1-6.8] to 4.4 [95% CI, 3.6-5.1]; P < .001) respondents. No changes in days of poor mental health or usual activities missed owing to poor physical or mental health were observed.

Conclusions And Relevance: These findings suggest that HMP enrollees in Michigan have experienced improvements in self-reported health over time, including minority groups with a history of health disparities and enrollees with chronic health conditions.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.8776DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7352154PMC
July 2020

Predictors of Emergency Preparedness Among Older Adults in the United States.

Disaster Med Public Health Prep 2020 Jun 1:1-7. Epub 2020 Jun 1.

Institute for Healthcare Policy and Innovation, Ann ArborMichigan.

Objectives: Emergency preparedness becomes more important with increased age, as older adults are at heightened risk for harm from disasters. In this study, predictors of preparedness actions and confidence in preparedness among older adults in the United States were assessed.

Methods: This nationally representative survey polled community-dwelling older adults ages 50-80 y (n = 2256) about emergency preparedness and confidence in addressing different types of emergencies. Logistic regression was used to identify predictors of reported emergency preparedness actions and confidence in addressing emergencies.

Results: Participants' mean age was 62.4 y (SD = 8); 52% were female, and 71% were non-Hispanic white. Living alone was associated with lower odds of having a 7-d supply of food and water (adjusted odds ratio [aOR] = 0.74; 95% confidence interval [CI]: 0.56-0.96), a stocked emergency kit (aOR = 0.64; 95% CI: 0.47-0.86), and having had conversations with family or friends about evacuation plans (aOR = 0.59; 95% CI: 0.44-0.78). Use of equipment requiring electricity was associated with less confidence in addressing a power outage lasting more than 24 h (aOR = 0.66; 95% CI: 0.47-0.94), as was use of mobility aids (OR = 0.65; 95% CI: 0.45-0.93).

Conclusions: These results point to the need for tailored interventions to support emergency preparedness for older adults, particularly among those who live alone and use medical equipment requiring electricity.
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http://dx.doi.org/10.1017/dmp.2020.80DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704536PMC
June 2020

Health Insurance Affordability Concerns and Health Care Avoidance Among US Adults Approaching Retirement.

JAMA Netw Open 2020 02 5;3(2):e1920647. Epub 2020 Feb 5.

Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City.

Importance: As US adults approach Medicare eligibility at age 65 years, they face important decisions about health care and employment. Recent legislative, regulatory, and legal challenges to the Affordable Care Act may add new uncertainties to this decision-making.

Objective: To understand adults' perspectives on health insurance, health care, and employment near retirement.

Design, Setting, And Participants: In October 2018, a cross-sectional online survey study of community-dwelling US adults aged 50 to 64 years was conducted with Ipsos KnowledgePanel, a nationally representative internet survey panel (completion rate, 62%). The initial data analysis was conducted from November 2018 to March 2019, and additional analyses were conducted in November 2019.

Main Outcomes And Measures: Confidence in affording health insurance, keeping a job or delaying retirement to have employer-sponsored health insurance, concerns about potential changes to health insurance associated with changes in federal policies, and avoidance of medical care or medication because of cost.

Results: Among 1028 respondents aged 50 to 64 years (mean [SD] age, 57.0 [4.2] years), 51.8% (95% CI, 48.6%-55.0%) were female, 40.4% (95% CI, 37.2%-43.7%) had a high school education or less, 65.2% (95% CI, 62.1%-68.3%) were employed, and 34.8% (95% CI, 31.7%-37.9%) were retired or not working. Approximately one-fourth of respondents (27.4%; 95% CI, 24.6%-30.4%) had little to no confidence in being able to afford health insurance over the next year, and nearly one-half (44.6%; 95% CI, 41.4%-47.8%) had little to no confidence in their ability to afford health insurance when they retire; 14.1% (95% CI, 12.0%-16.5%) reported keeping a job and 11.4% (95% CI, 9.6%-13.6%) reported delaying or considering delaying retirement to have employer-sponsored health insurance. Most respondents (67.7%; 95% CI, 64.6%-70.6%) were very or somewhat concerned about potential changes to their health insurance associated with changes in federal policies. In the past year, 13.2% (95% CI, 11.2%-15.5%) of respondents did not get medical care and 11.9% (95% CI, 9.9%-14.1%) avoided filling a prescription medication because of cost. After adjusting for demographic and health characteristics, individuals with low confidence in health insurance affordability during either the next year or retirement were significantly more likely than those with higher confidence to avoid medical care (adjusted odds ratio, 2.89; 95% CI, 1.86-4.49; P < .001) and to avoid filling a prescription medication (adjusted odds ratio, 2.87; 95% CI, 1.71-4.80; P < .001) because of cost concerns.

Conclusions And Relevance: Many adults aged 50 to 64 years worry about their ability to afford health insurance during retirement and about potential future changes to their health insurance options associated with changes in federal policy. Policy solutions are needed to help patients better understand their coverage options and navigate health care in this critical transition period before Medicare eligibility.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.20647DOI Listing
February 2020

Association of Medicaid Expansion With Enrollee Employment and Student Status in Michigan.

JAMA Netw Open 2020 01 3;3(1):e1920316. Epub 2020 Jan 3.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.

Importance: Medicaid community engagement requirements (work, school, job searching, or community service) are being implemented by several states for the first time, but the association of Medicaid coverage with enrollees' employment and school attendance is unclear.

Objective: To assess longitudinal changes in enrollees' employment or student status after Michigan's Medicaid expansion.

Design, Setting, And Participants: This survey study included 4090 nonelderly, adult Healthy Michigan Plan enrollees from March 1, 2017, to January 31, 2018.

Main Outcomes And Measures: Self-reported employment or student status. Proportionate sampling was stratified by income and geographic region. Mixed-effects regression models with time indicators were used to assess longitudinal changes in the proportion of enrollees who were employed or students.

Results: The response rate for the initial survey was 53.7% and for the follow-up survey was 83.4%. Of the 3104 respondents to the 2017 follow-up survey (mean [SD] age in 2017, 42.2 [13.0] years; 1867 [53.0%] female), 54.3% were employed or students in 2016, and this number increased to 60.0% in 2017 (percentage point change, 5.7; P < .001). Non-Hispanic black enrollees had significantly larger gains in employment or student status compared with non-Hispanic white enrollees (percentage point change, 10.7 vs 3.5; P = .02). Changes in employment or student status were not associated with improved health status.

Conclusions And Relevance: Employment or student status increased from 2016 to 2017 among Michigan Medicaid expansion enrollees. These findings provide information about whether Medicaid coverage or community engagement requirements are best to promote the desired outcomes of employment and student status.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.20316DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042869PMC
January 2020

Health Risk Assessments in Michigan's Medicaid Expansion: Early Experiences in Primary Care.

Am J Prev Med 2020 03 15;58(3):e79-e86. Epub 2020 Jan 15.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan. Electronic address:

Introduction: Michigan is one of 3 states that have implemented health risk assessments for enrollees as a feature of its Medicaid expansion, the Healthy Michigan Plan. This study describes primary care providers' early experiences with completing health risk assessments with enrollees and examines provider- and practice-level factors that affect health risk assessment completion.

Methods: All primary care providers caring for ≥12 Healthy Michigan Plan enrollees (n=4,322) were surveyed from June to November 2015, with 2,104 respondents (55.5%). Analyses in 2016-2017 described provider knowledge, attitudes, and experiences with the health risk assessment early in Healthy Michigan Plan implementation; multivariable analyses examined relationships of provider- and practice-level characteristics with health risk assessment completion, as recorded in state data.

Results: Of the primary care provider respondents, 73% found health risk assessments very or somewhat useful for identifying and discussing health risks, although less than half (47.2%) found them very or somewhat useful for getting patients to change health behaviors. Most primary care provider respondents (65.3%) were unaware of financial incentives for their practices to complete health risk assessments. Nearly all primary care providers had completed at least 1 health risk assessment. The mean health risk assessment completion rate (completed health risk assessments/number of Healthy Michigan Plan enrollees assigned to that primary care provider) was 19.6%; those who lacked familiarity with the health risk assessment had lower completion rates.

Conclusions: Early in program implementation, health risk assessment completion rates by primary care providers were low and awareness of financial incentives limited. Most primary care provider respondents perceived health risk assessments to be very or somewhat useful in identifying health risks, and about half of primary care providers viewed health risk assessments as very or somewhat useful in helping patients to change health behaviors.
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http://dx.doi.org/10.1016/j.amepre.2019.10.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7085853PMC
March 2020

Primary Care, Health Promotion, and Disease Prevention with Michigan Medicaid Expansion.

J Gen Intern Med 2020 03 2;35(3):800-807. Epub 2019 Dec 2.

Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.

Background: Medicaid expansion in Michigan, known as the Healthy Michigan Plan (HMP), emphasizes primary care and preventive services.

Objective: Evaluate the impact of enrollment in HMP on access to and receipt of care, particularly primary care and preventive services.

Design: Telephone survey conducted during January-November 2016 with stratified random sampling by income and geographic region (response rate = 53.7%). Logistic regression analyses accounted for sampling and nonresponse adjustment.

Participants: 4090 HMP enrollees aged 19-64 with ≥ 12 months of HMP coverage MAIN MEASURES: Surveys assessed demographic factors, health, access to and use of health care before and after HMP enrollment, health behaviors, receipt of counseling for health risks, and knowledge of preventive services' copayments. Utilization of preventive services was assessed using Medicaid claims.

Key Results: In the 12 months prior to HMP enrollment, 33.0% of enrollees reported not getting health care they needed. Three quarters (73.8%) of enrollees reported having a regular source of care (RSOC) before enrollment; 65.1% of those reported a doctor's office/clinic, while 16.2% reported the emergency room. After HMP enrollment, 92.2% of enrollees reported having a RSOC; 91.7% had a doctor's office/clinic and 1.7% the emergency room. One fifth (20.6%) of enrollees reported that, before HMP enrollment, it had been over 5 years since their last primary care visit. Enrollees who reported a visit with their primary care provider after HMP enrollment (79.3%) were significantly more likely than those who did not report a visit to receive counseling about health behaviors, improved access to cancer screening, new diagnoses of chronic conditions, and nearly all preventive services. Enrollee knowledge that some services have no copayments was also associated with greater utilization of most preventive services.

Conclusions: After enrolling in Michigan's Medicaid expansion program, beneficiaries reported less forgone care and improved access to primary care and preventive services.
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http://dx.doi.org/10.1007/s11606-019-05370-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080942PMC
March 2020

Engagement with Health Risk Assessments and Commitment to Healthy Behaviors in Michigan's Medicaid Expansion Program.

J Gen Intern Med 2020 02 2;35(2):514-522. Epub 2019 Dec 2.

Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.

Background: Health risk assessments (HRAs) and healthy behavior incentives are increasingly used by state Medicaid programs to promote enrollees' health.

Objective: To evaluate enrollee experiences with HRAs and healthy behavior engagement in the Healthy Michigan Plan (HMP), a state Medicaid expansion program.

Design: Telephone survey conducted in Michigan January-October 2016.

Participants: A random sample of HMP enrollees aged 19-64 with ≥ 12 months of enrollment, stratified by income and geographic region.

Main Measures: Self-reported completion of an HRA, reasons for completing an HRA, commitment to a healthy behavior, and choice of healthy behavior.

Key Results: Among respondents (N = 4090), 49.3% (95% CI 47.3-51.2%) reported completing an HRA; among those with a primary care provider (PCP) (n = 3851), 85.2% (95% CI 83.5-86.7%) reported visiting their PCP during the last 12 months. Most enrollees having a recent PCP visit reported discussing healthy behaviors with them (91.1%, 95% CI 89.6-92.3%) and were more likely to have completed an HRA than enrollees without a recent PCP visit (52.7%, 95% CI 50.5-52.8% vs. 36.2%, 95% CI 31.7-41.1%; p < 0.01). Among enrollees completing an HRA, nearly half said they did it because their PCP suggested it (45.9%, 95% CI 43.2-48.7%), and most reported it helped their PCP understand their health needs (89.7%). Awareness of financial incentives was limited (28.1%, 95% CI 26.3-30.0%), and very few reported it as the primary reason for HRA completion (2.5%, 95% CI 1.8-3.4%). Most committed to a healthy behavior (80.7%, 95% CI 78.5-82.8%), and common behaviors chosen were nutrition/diet (57.2%, 95% CI 54.2-60.2%) and exercise/activity (52.6%, 95% CI 49.5-55.7%).

Conclusions: In the Healthy Michigan Plan, PCPs appeared influential in enrollees' completion of HRAs and healthy behavior engagement, while knowledge of financial incentives was limited. Additional study is needed to understand the relative importance of financial incentives and PCP engagement in impacting healthy behaviors in state Medicaid programs.
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http://dx.doi.org/10.1007/s11606-019-05562-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7018899PMC
February 2020

Association of Expanded Medicaid Coverage With Health and Job-Related Outcomes Among Enrollees With Behavioral Health Disorders.

Psychiatr Serv 2020 01 25;71(1):4-11. Epub 2019 Sep 25.

Institute for Healthcare Policy and Innovation (Tipirneni, Patel, Goold, Kieffer, Ayanian, Clark, Lee, Bryant, Kirch, Solway), School of Public Health (Patel), School of Social Work (Kieffer), Child Health Evaluation and Research Center (Clark), and Institute for Social Research (Lee), all at the University of Michigan, Ann Arbor; Department of Internal Medicine (Tipirneni, Goold, Ayanian, Bryant, Luster), Center for Bioethics and Social Sciences in Medicine (Lewallen), and Department of Psychiatry (Zivin), all at the University of Michigan Medical School, Ann Arbor; Center for Clinical Management Research, U.S. Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor (Zivin).

Objectives: The study objective was to assess the impact of Medicaid expansion on health and employment outcomes among enrollees with and without a behavioral health disorder (either a mental or substance use disorder).

Methods: Between January and October 2016, the authors conducted a telephone survey of 4,090 enrollees in the Michigan Medicaid expansion program and identified 2,040 respondents (48.3%) with potential behavioral health diagnoses using claims-based diagnoses.

Results: Enrollees with behavioral health diagnoses were less likely than enrollees without behavioral health diagnoses to be employed but significantly more likely to report improvements in health and ability to do a better job at work. In adjusted analyses, both enrollees with behavioral health diagnoses and those without behavioral health diagnoses who reported improved health were more likely than enrollees without improved health to report that Medicaid expansion coverage helped them do a better job at work and made them better able to look for a job. Among enrollees with improved health, those with a behavioral health diagnosis were as likely as those without a behavioral health diagnosis to report improved ability to work and improved job seeking after Medicaid expansion.

Conclusions: Coverage interruptions for enrollees with behavioral health diagnoses should be minimized to maintain favorable health and employment outcomes.
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http://dx.doi.org/10.1176/appi.ps.201900179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6939140PMC
January 2020

Diagnosis and Care of Chronic Health Conditions Among Medicaid Expansion Enrollees: a Mixed-Methods Observational Study.

J Gen Intern Med 2019 11 11;34(11):2549-2558. Epub 2019 Sep 11.

Institute for Healthcare Policy and Innovation (IHPI), University of Michigan, Ann Arbor, MI, USA.

Background: It is uncertain how Medicaid expansion under the Affordable Care Act influences the diagnosis of chronic health conditions, and the care and health of enrollees with chronic conditions.

Objective: Describe the prevalence of new and pre-existing chronic health conditions among Medicaid expansion enrollees. Examine whether perceived changes in specific types of access and self-rated health status differed between enrollees with chronic conditions and those without. Examine how gaining Medicaid coverage affected chronic disease management and well-being.

Design: Mixed-methods study including a telephone survey and semi-structured interviews.

Setting: Michigan's Medicaid expansion, the "Healthy Michigan Plan" (HMP).

Participants: 4090 survey respondents (response rate 54%) with ≥ 12 months HMP enrollment and 67 interviewees with ≥ 6 months enrollment.

Main Measures: Self-reported chronic condition diagnoses, changes in physical/mental health, and healthcare access. Descriptive survey data were adjusted for survey design and nonresponse. Semi-structured interview questions about how gaining HMP coverage led to changes in health status.

Key Results: Among enrollees, 68% had a self-reported diagnosis of a chronic health condition; 42% of those were newly diagnosed since HMP enrollment. In multivariable models, enrollees with chronic conditions were significantly more likely to report improved physical (adjusted odds ratio (aOR) 1.70, 95% CI (1.40, 2.07)) and mental health (aOR 1.75, (1.43, 2.15)) since HMP enrollment than enrollees without chronic conditions. Among enrollees with chronic conditions, the strongest predictors of improvements in health were having seen a primary care physician, improved mental health care access, and improved medication access. Interviewees with chronic conditions described how increased access to health care led to improvements in both physical and mental health.

Conclusions: Enrollees with expanded Medicaid coverage commonly reported detection of previously undiagnosed chronic conditions. Perceived health status and access improved more often among enrollees with chronic health conditions. Improved access was associated with improved physical and mental health among this vulnerable group.
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http://dx.doi.org/10.1007/s11606-019-05323-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6848397PMC
November 2019

Self-reported Eye Care Use Among US Adults Aged 50 to 80 Years.

JAMA Ophthalmol 2019 Sep;137(9):1061-1066

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.

Importance: Contemporary data on use of eye care by US adults are critical, as the prevalence of age-related eye disease and vision impairment are projected to increase in the coming decades.

Objectives: To provide nationally representative estimates on self-reported use of eye care by adults aged 50 to 80 years, and to describe the reasons that adults do and do not seek eye care.

Design, Setting, And Participants: The National Poll on Healthy Aging, a cross-sectional, nationally representative online survey was conducted from March 9 to 24, 2018, among 2013 individuals aged 50 to 80 years.

Main Outcomes And Measures: The proportion of US adults who received an eye examination within the past 2 years as well as the sociodemographic and economic factors associated with receipt of eye care.

Results: Among 2013 adults aged 50 to 80 years (survey-weighted proportion of women, 52.5%; white non-Hispanic, 71.1%; mean [SD] age, 62.1 [9.0] years), the proportion reporting that they underwent an eye examination in the past year was 58.5% (95% CI, 56.1%-60.8%) and in the past 2 years was 82.4% (95% CI, 80.4%-84.2%). Among those with diabetes, 72.2% (95% CI, 67.2%-76.8%) reported undergoing an eye examination in the past year and 91.3% (95% CI, 87.7%-93.9%) in the past 2 years. The odds of having undergone an eye examination within the past 2 years were higher among women (adjusted odds ratio [AOR], 2.00; 95% CI, 1.50-2.67), respondents with household incomes of $30 000 or more (AOR, 1.57; 95% CI, 1.08-2.29), and those with a diagnosed age-related eye disease (AOR, 3.67; 95% CI, 2.37-5.69) or diabetes (AOR, 2.30; 95% CI, 1.50-3.54). The odds were lower for respondents who were unmarried (AOR, 0.71; 95% CI, 0.53-0.96), from the Midwest (AOR, 0.55; 95% CI, 0.34-0.87) or West (AOR, 0.60; 95% CI, 0.38-0.94), or reported fair or poor vision (AOR, 0.43; 95% CI, 0.28-0.65). Reasons reported for not undergoing a recent eye examination included having no perceived problems with their eyes or vision (41.5%), cost (24.9%), or lack of insurance coverage (23.4%).

Conclusions And Relevance: In this study, the rate of eye examinations was generally high among US adults aged 50 to 80 years, yet there were several significant demographic and socioeconomic differences in the use of eye care. These findings may be relevant to health policy efforts to address disparities in eye care and to promote care for those most at risk for vision problems.
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http://dx.doi.org/10.1001/jamaophthalmol.2019.1927DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6587143PMC
September 2019

Factors influencing primary care providers' decisions to accept new Medicaid patients under Michigan's Medicaid expansion.

Am J Manag Care 2019 03;25(3):120-127

Division of General Medicine, Department of Internal Medicine, University of Michigan, North Campus Research Complex, Bldg 16, Room 419W, 2800 Plymouth Rd, Ann Arbor, MI 48109-2800. Email:

Objectives: Michigan expanded Medicaid under the Affordable Care Act (ACA) through a federal waiver that permitted state-mandated features, including an emphasis on primary care. We investigated the factors associated with Michigan primary care providers (PCPs)' decision to accept new Medicaid patients under Medicaid expansion.

Study Design: Statewide survey of PCPs informed by semistructured interviews.

Methods: After Michigan expanded Medicaid on April 1, 2014, we surveyed 2104 PCPs (including physician and nonphysician providers, such as nurse practitioners and physician assistants) with 12 or more assigned Medicaid expansion enrollees (response rate, 56%). To guide survey development and interpretation, we interviewed a separate group of 19 PCPs with Medicaid expansion enrollees from diverse urban and rural regions. Survey questions assessed PCPs' current acceptance of new Medicaid patients.

Results: Of the 2104 surveyed PCPs, 78% reported that they were currently accepting additional Medicaid patients; 58% reported having at least some influence on the decision. Factors considered very/moderately important to the Medicaid acceptance decision included practice capacity to accept any new patients (69%), availability of specialists for Medicaid patients (56%), reimbursement amount (56%), psychosocial needs of Medicaid patients (50%), and illness burden of Medicaid patients (46%). PCPs accepting new Medicaid patients tended to be female, minorities, nonphysician providers, specialized in internal medicine, paid by salary, or working in practices with Medicaid-predominant payer mixes.

Conclusions: In the era after Medicaid expansion, PCPs placed importance on practice capacity, specialist availability, and patients' medical and psychosocial needs when deciding whether to accept new Medicaid patients. To maintain primary care access for low-income patients with Medicaid, future efforts should focus on enhancing the diversity of the PCP workforce, encouraging healthcare professional training in underserved settings, and promoting practice-level innovations in scheduling and integration of specialist care.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7169442PMC
March 2019

Association of Access to Family Planning Services With Medicaid Expansion Among Female Enrollees in Michigan.

JAMA Netw Open 2018 08 3;1(4):e181627. Epub 2018 Aug 3.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.

Importance: To date, 32 states and the District of Columbia have expanded Medicaid programs under the Patient Protection and Affordable Care Act. It is vital to understand whether expanded health insurance coverage of low-income individuals improves access to family planning services as a first step toward improving reproductive health outcomes.

Objective: To evaluate the association of Medicaid expansion coverage with access to birth control and family planning services among women of reproductive age enrolled in the Michigan expansion plan.

Design, Setting, And Participants: In a survey study, from January 13 through December 15, 2016, telephone surveys of a stratified sample of enrollees in Michigan's Section 1115 Medicaid Expansion waiver program, the Healthy Michigan Plan (HMP), were conducted. Interviewers completed surveys for 4090 sampled enrollees, of whom 1166 were women aged 19 to 44 years. Surveys were conducted with a computer-assisted telephone interviewing system in English, Arabic, and Spanish. The sample was weighted to 113 565 women. Dates of data analysis were from January 27 through September 18, 2017.

Main Outcomes And Measures: Self-reported change in access to birth control and family planning services through HMP (better, worse, about the same, or don't know/doesn't apply), compared with before enrollment.

Results: Among the 1166 survey respondents aged 19 to 44 years (mean [SD] age, 31.0 [0.3] years) and the weighted sample of 113 565, 74.7% (95% CI, 72.2%-76.9%) lived in very-low-income households (<100% federal poverty level), 64.0% (95% CI, 60.5%-67.3%) reported at least 1 chronic medical condition, 23.5% (95% CI, 20.6%-26.6%) reported fair or poor health, and 17.7% (95% CI, 15.7%-19.9%) lived in rural settings. Overall, 35.5% (95% CI, 32.2%-39.0%) reported increased access to family planning services. After adjusting, those most likely to report increased access were women without health insurance coverage in the year preceding HMP enrollment (adjusted odds ratio [aOR], 2.02; 95% CI, 1.41-2.89) compared with women with health insurance for the full 12 months preceding enrollment; younger women (aOR for 19-24 years, 2.80 [95% CI, 1.75-4.50]; aOR for 25-34 years, 2.35 [95% CI, 1.60-3.45]) compared with women aged 35 to 44 years; and women with a recent visit to a primary care clinician (aOR 1.69; 95% CI, 1.03-2.76) compared with women without a primary care visit in the preceding 12 months.

Conclusions And Relevance: One in 3 women of reproductive age reported better ability to access birth control and family planning services through HMP compared with before enrollment. This finding suggests that Medicaid expansion is associated with improved access to family planning services, which may enable low-income women to maintain optimal reproductive health.
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http://dx.doi.org/10.1001/jamanetworkopen.2018.1627DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6324283PMC
August 2018

Changes in Health and Ability to Work Among Medicaid Expansion Enrollees: a Mixed Methods Study.

J Gen Intern Med 2019 02 5;34(2):272-280. Epub 2018 Dec 5.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.

Background: Michigan expanded Medicaid under the Affordable Care Act (Healthy Michigan Plan [HMP]) to improve the health of low-income residents and the state's economy.

Objective: To understand HMP's impact on enrollees' health, ability to work, and ability to seek employment DESIGN: Mixed methods study, including 67 qualitative interviews and 4090 computer-assisted telephone surveys (response rate 53.7%) PARTICIPANTS: Non-elderly adult HMP enrollees MAIN MEASURES: Changes in health status, ability to work, and ability to seek employment KEY RESULTS: Half (47.8%) of respondents reported better physical health, 38.2% better mental health, and 39.5% better dental health since HMP enrollment. Among employed respondents, 69.4% reported HMP helped them do a better job at work. Among out-of-work respondents, 54.5% agreed HMP made them better able to look for a job. Among respondents who changed jobs, 36.9% agreed HMP helped them get a better job. In adjusted analyses, improved health was associated with the ability to do a better job at work (aOR 4.08, 95% CI 3.11-5.35, p < 0.001), seek a job (aOR 2.82, 95% CI 1.93-4.10, p < 0.001), and get a better job (aOR 3.20, 95% CI 1.69-6.09, p < 0.001), but not with employment status (aOR 1.08, 95% CI 0.89-1.30, p = 0.44). In interviews, several HMP enrollees attributed their ability to get or maintain employment to improved physical, mental, and dental health because of services covered by HMP. Remaining barriers to work cited by enrollees included older age, disability, illness, and caregiving responsibilities.

Conclusions: Many low-income HMP enrollees reported improved health, ability to work, and job seeking after obtaining health insurance through Medicaid expansion.
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http://dx.doi.org/10.1007/s11606-018-4736-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6374260PMC
February 2019

Prescription and Nonprescription Sleep Product Use Among Older Adults in the United States.

Am J Geriatr Psychiatry 2019 01 14;27(1):32-41. Epub 2018 Sep 14.

Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Medicine, University of Michigan, Ann Arbor, MI.

Objective: Older adults commonly use products that may be used to promote sleep, such as benzodiazepines and over-the-counter medications, but the current extent of use of both prescription and nonprescription products specifically for sleep in the United States is unknown.

Methods: Respondents in this cross-sectional, nationally representative survey (the National Poll on Healthy Aging) of community-dwelling older adults aged 65-80 (n = 1,065) reported difficulty initiating sleep or early awakening ("sleep symptoms") and use of prescription medication or nonprescription aids to promote sleep ("sleep product"), including prescription sleep medication, over-the-counter (OTC) sleep aids, prescription pain medication, and herbal/natural sleep aids. Logistic regression was used to determine the association of respondent sociodemographic and clinical characteristics with the use of sleep products.

Results: Sleep symptoms were endorsed by 67.7% of respondents (95% confidence interval [CI] 64.7%-70.7%). Use of a sleep product was reported by 35.4% (95% CI 32.4%-38.6%), with 21.9% (95% CI 19.4%-24.7%) using OTC sleep aids, 12.5% using herbal/natural aids (95% CI 10.6%-14.8%), 8.3% using prescription sleep medication (95% CI 6.7%-10.3%), and 5.0% using prescription pain medication (95% CI 3.8%-6.7%). Self-reported fair/poor mental health (relative to excellent/very good) was associated with increased odds of sleep product use (adjusted odds ratio 2.28, 95% CI 1.10-4.72, p = 0.03).

Conclusion: More than a third of older adults use medications or aids to help with sleep-most commonly OTC aids. Clinicians should routinely ask older patients about sleep-related difficulties and the use of nonprescription sleep aids.
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http://dx.doi.org/10.1016/j.jagp.2018.09.004DOI Listing
January 2019

Primary Care Clinicians' Views About the Impact of Medicaid Expansion in Michigan: A Mixed Methods Study.

J Gen Intern Med 2018 08 12;33(8):1307-1316. Epub 2018 Jun 12.

Department of Internal Medicine, Medical School, University of Michigan, 2800 Plymouth Road, 425W, Ann Arbor, MI, 48109, USA.

Background: Michigan's approach to Medicaid expansion, the Healthy Michigan Plan (HMP), emphasizes primary care, prevention, and incentives for patients and primary care practitioners (PCPs).

Objective: Assess PCPs' perspectives about the impact of HMP on their patients and practices.

Design: In 2014-2015, we conducted semi-structured interviews then a statewide survey of PCPs.

Setting: Interviewees came from varied types of practices in five Michigan regions selected for racial/ethnic diversity and a mix of rural and urban settings. Surveys were sent via mail.

Participants: Interviewees were physician (n = 16) and non-physician practitioners (n = 3). All Michigan PCPs caring for ≥ 12 HMP enrollees were surveyed (response rate 55.5%, N = 2104).

Measurements: PCPs' experiences with HMP patients and recent changes in their practices.

Results: Interviews include examples of the impact of Medicaid expansion on patients and practices. A majority of surveyed PCPs reported recent increases in new patients (52.3%) and patients who had not seen a PCP in many years (56.2%). For previously uninsured patients, PCPs reported positive impact on control of chronic conditions (74.4%), early detection of serious illness (71.1%), medication adherence (69.1%), health behaviors (56.5%), emotional well-being (57.0%), and the ability to work, attend school, or live independently (41.5%). HMP patients reportedly still had more difficulty than privately insured patients accessing some services. Most PCPs reported that their practices had, in the past year, hired clinicians (53.2%) and/or staff (57.5%); 15.4% had colocated mental health care. Few (15.8%) reported established patients' access to urgent appointments worsened.

Limitations: PCP reports of patient experiences may not be accurate. Results reflect the experiences of PCPs with ≥ 12 Medicaid patients. Differences between respondents and non-respondents present the possibility for response bias.

Conclusions: PCPs reported improved patient access to care, medication adherence, chronic condition management, and detection of serious illness. Established patients' access did not diminish, perhaps due to reported practice changes.
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http://dx.doi.org/10.1007/s11606-018-4487-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6082204PMC
August 2018

The lived experiences of tobacco use, dependence, and cessation: insights and perspectives of people with mental illness.

Health Soc Work 2011 Feb;36(1):19-32

Older Adult Day Support Center/Community Integration Services, Family Service Agency of San Francisco, CA 94121, USA.

Even as the rate of smoking in the U.S. population overall has decreased dramatically during the last four decades, people with mental illness continue to use tobacco at alarmingly high rates. In the last two years, national initiatives have developed to address smoking within this population, yet there has not been an attempt to understand the perspectives of people with mental illness themselves regarding the role tobacco plays in their lives. This grounded theory study, based on focus group interviews with 26 individuals with various smoking statuses receiving outpatient mental health services, attempted to develop a theory to understand this high prevalence from the perspectives of people with mental illness. The article explores the experiences ofpeople with mental illness related to never smoking, smoking, and quitting; the role of tobacco use for people with mental illness; the other forces that promote or discourage tobacco use; and the tensions and complexities in understanding the "problem" of tobacco use in this population. It concludes by highlighting directions for future research, policy considerations, and the important role social workers can play in addressing this significant cause of health disparities.
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http://dx.doi.org/10.1093/hsw/36.1.19DOI Listing
February 2011

Access barriers to mental health services for older adults from diverse populations: perspectives of leaders in mental health and aging.

J Aging Soc Policy 2010 Oct;22(4):360-78

Older Adult Day Support Center/Community Integration Services, Family Service Agency, San Francisco, California 94109, USA.

This project is based on the results of telephone surveys with 52 local, state, and national informed respondents including policymakers, county leaders, planners, and advocates in mental health and aging with a particular focus on the states of California and Florida. This article addresses challenges to access to mental health services for diverse older adults including barriers related to race and ethnicity, socioeconomic status, location, age, gender, immigrant status, language, sexual orientation, and diagnosis. The article also highlights broad themes that emerged including (1) the importance of outreach and transportation tailored to diverse elders, and (2) recruitment of diverse staff and training related to diversity. The article concludes with policy and practice recommendations to reduce these disparities in access to mental health services for diverse populations of older adults.
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http://dx.doi.org/10.1080/08959420.2010.507650DOI Listing
October 2010

Windows of opportunity for culture change around tobacco use in mental health settings.

Authors:
Erica Solway

J Am Psychiatr Nurses Assoc 2009 Feb;15(1):41-9

Department of Social & Behavioral Sciences, and Smoking Cessation Leadership Center, University of California, San Francisco, San Francisco, CA,

Background: Smoking rates among individuals with mental illnesses are significantly higher than in the general population and contribute to increased rates of morbidity and mortality.

Objective: The purpose of this study was to generate a theory of the process by which to lower the prevalence of smoking in this population.

Study Design: Grounded theory methods, including constant comparison and theoretical sampling, were used to uncover the emerging process of addressing tobacco use in mental health settings from the perspective of national leaders.

Results: Participants suggested that the culture in mental health settings around tobacco use significantly contributes to the high rates of smoking and described barriers to and opportunities for culture change.

Conclusions: The findings highlight several windows of opportunity that have begun to be explored. Leaders described current signs of change within mental health settings and expressed optimism about the possibility to lower future rates of smoking among mental health consumers and staff members.
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http://dx.doi.org/10.1177/1078390308329885DOI Listing
February 2009