No abstract

Medicaid enrollees are about twice as likely as the general US population to smoke tobacco: 32 percent of people in the program identify themselves as smokers. This article provides the first data about the effectiveness of state Medicaid programs in promoting smoking cessation. Our analysis of Medicaid enrollees’ use of cessation medications found that about 10 percent of current smokers received cessation medications in 2013. Every state Medicaid program covers cessation benefits, but the use of these medications varies widely, with the rate in Minnesota being thirty times higher than that in Texas. Most states could increase their efforts to help smokers quit, working with public health agencies, managed care plans, and others. In 2013 Medicaid spent $103 million on cessation medications—less than 0.25 percent of the estimated cost to Medicaid of smoking-related diseases. Additionally, states that have not expanded Medicaid eligibility in the wake of the Affordable Care Act have higher smoking prevalence and lower utilization rates of cessation medication, compared to expansion states. Given these factors, nonexpansion states will have a greater public health burden related to smoking. Medicaid and public health agencies should work together to make smoking cessation a priority for Medicaid beneficiaries.

Community health centers are at the forefront of ambulatory care practices in their use of nonphysician clinicians and team-based primary care. We examined medical staffing patterns, the contributions of different types of staff to productivity, and the factors associated with staffing at community health centers across the United States. We identified four different staffing patterns: typical, high advanced-practice staff, high nursing staff, and high other medical staff. Overall, productivity per staff person was similar across the four staffing patterns. We found that physicians make the greatest contributions to productivity, but advanced-practice staff, nurses, and other medical staff also contribute. Patterns of community health center staffing are driven by numerous factors, including the concentration of clinicians in communities, nurse practitioner scope-of-practice laws, and patient characteristics such as insurance status. Our findings suggest that other group medical practices could incorporate more nonphysician staff without sacrificing productivity and thus profitability. However, the new staffing patterns that evolve may be affected by characteristics of the practice location or the types of patients served.

Graduate medical education (GME) defines the overall number, specialty make-up and geographic distribution of the U.S. physician workforce. Medicare GME payments represent the largest single public investment in health workforce development but it is an inflexible system that is drawing scrutiny for its rationale, effectiveness and balance. We analyzed Medicare hospital cost reports for teaching hospitals and found large state level differences in the number of Medicare sponsored residents per population, total Medicare GME payments, payments per person (ranging from $1.94 to $103.63 per person in Montana and New York, respectively), and average payments per trainee (ranging from $63,811 to $155,135 per trainee in Louisiana and Connecticut, respectively). Options to address these imbalances include ensuring those states that receive less Medicare GME are prioritized or protected in the case of increases or decreases in funding and the re-examination of the Medicare GME formulas. The state level variation highlights that the GME system badly needs flexibility and the capability to deliberate and make policy about public investments in graduate medical education.