Medicaid used as primary source of insurance coverage for more than half of participants

1. Medicaid used as primary source of insurance coverage for more than half of participants
Abstract: https://www.acpjournals.org/doi/10.7326/M22-1313
Editorial: https://www.acpjournals.org/doi/10.7326/M22-3315
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A study of more than one million Medicaid beneficiaries has found that more than half were enrolled in Medicaid for at least a decade and experienced substantial lapses in coverage. The authors recommend that, based on this pattern, it would be beneficial to justify increasing investments in the program to improve long-term health outcomes. The study is published in Annals of Internal Medicine.

The Medicaid program was created in 1965 as supplemental insurance coverage for the temporarily indigent. The increasing number of beneficiaries, as well as changes made to the program, place into question whether the program still exclusively serves as a temporary safety net. If Medicaid now serves as a long-run insurer, it may require a different infrastructure than a temporary safety net.

Researchers from the Yale School of Public Health studied 3.97 million Medicaid beneficiaries in Michigan enrolled between 2011 and 2020 to assess patterns of short- and long-term enrollment. The authors found that Medicaid was the primary, long-run source of insurance coverage for most beneficiaries. They report that among a cohort of 1.23 million beneficiaries enrolled in 2011, 53 percent were also enrolled in Medicaid in June 2020, spending, on average, two-thirds of that period on Medicaid. The authors report, however, that beneficiaries experienced significant lapses in coverage, with only 25 percent continuously enrolled throughout the period. Enrollment was less stable when assessed from the perspective of newly enrolled beneficiaries, of whom only 37% remained enrolled at the end of the study period. According to the authors, states are likely to reap the benefits of policies that improve the long-term health of beneficiaries and stabilize coverage for those new to the Medicaid program.

An accompanying editorial from The George Washington University highlights how disruptions in Medicaid coverage can disrupt the continuity of patient–physician relations, reduce medical care use, cause patients to stop medications, and worsen medical problems that are avoidable with proper care. The author calls for states to stabilize their Medicaid coverage, but cautions that policymakers may need to more fundamentally reconsider elements of Medicaid eligibility so that low-income Americans have stable coverage comparable to that available to the elderly on Medicare or to middle-income working families with employer-sponsored insurance.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Chima D. Ndumele, PhD, email chima.ndumele@yale.edu.
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2. Dapagliflozin reduces risk for hospitalization in patients with CKD with or without diabetes
Abstract: https://www.acpjournals.org/doi/10.7326/M22-2115
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Dapagliflozin, a sodium-glucose cotransporter-2 (SGLT2) inhibitor, reduced the risk for hospitalization for any cause in patients with chronic kidney disease (CKD) with and without type 2 diabetes. The findings suggest that dapagliflozin should be considered in such patients. The study is published in Annals of Internal Medicine.

Patients with CKD are often hospitalized, contributing to lower quality of life and higher health care costs. Prior studies have shown that SGLT2 inhibitors can reduce cardiovascular events and slow progression to kidney damage in patients with or without diabetes. The effect of these drugs on hospitalizations in patients with CKD is less clear.

Researchers from University of Groningen, Groningen, the Netherlands conducted a post hoc analysis of the DAPA-CKD trial which was a randomized, double-blind trial of dapagliflozin versus placebo to determine the effects of dapagliflozin on first hospitalizations and all hospitalizations among patients with CKD. The study included 4,304 adults with CKD with and without type 2 diabetes from 386 outpatient facilities in 21 countries. After an average follow-up of about 2 years, the researchers found that dapagliflozin reduced the risk for hospitalization and increased the number of days alive and out of the hospital for patients with CKD with or without diabetes. According to the authors, these findings highlight additional benefits of dapagliflozin beyond those seen for cardiovascular and kidney events, all-cause and cause-specific mortality, eGFR slope, and albuminuria.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Hiddo J.L. Heerspink, PhD, please contact directly at h.j.lambers.heerspink@umcg.nl or +31 50 361 4071.
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3. Computerized decision support system helps to reduce cardiovascular risk factors in patients with diabetes
Abstract: https://www.acpjournals.org/doi/10.7326/M22-1950
URL goes live when the embargo lifts
Compared with team-based care alone, the addition of a computerized clinical decision support system (CDSS) significantly reduced cardiovascular risk factors in patients with diabetes. These findings may have important public health and clinical significance in low- and middle-income countries where there is a lack of diabetes specialists to manage patients. The findings are published in Annals of Internal Medicine.

Diabetes has become a major public health challenge in low- and middle-income countries and patients with diabetes often have multiple comorbid conditions such as obesity, hypertension, dyslipidemia, and cardiovascular disease (CVD). A major barrier to care in these countries is the insufficient number of diabetes specialists. A CDSS that helps health care providers implement protocol-based treatment could improve both adherence to clinical guidelines and clinical outcomes.

Researchers from the First Affiliated Hospital of Xiamen university, Xiamen, China and Tulane University School of Public Health and Tropical Medicine randomly assigned 38 community health centers to either team-based care with a CDSS or team-based care alone interventions. A total of 11,132 individuals aged ≥50 years with uncontrolled type 2 diabetes and comorbidities were enrolled to compare the effectiveness of CDSS for controlling glycemia, lipids, and blood pressure. The CDSS was fully integrated with team-based care to help primary care physicians and health coaches make decisions about care based on clinical guidelines. During the 18-month intervention, the authors found that patients in the CDSS group had significantly but modestly lower HbA1C levels, LDL-C levels, and systolic BP than those at centers without a computerized CDSS. This system could help to solve real-world issues in diabetes management by helping health care providers without sufficient training in diabetes care manage patients. According to the authors, these findings support widespread adoption of this implementation strategy in community primary care settings in China and other low- and middle-income countries to reduce CVD risk among patients with diabetes.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with an author, please contact Andrew Yawn at ayawn@tulane.edu.
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