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Addressing Local Mental Health Needs via County-level Property Tax – 2019

by Lindsey Nienstedt, BA, Abigail Barker, PhD, Leah Kemper, MPH, and Timothy McBride, PhD | November 2019

The county-level property-based mill tax is used in some Missouri counties to strengthen mental health programs, services and supports.  This brief examines how this tax works and serves as an informational resource for local governments and organizations looking at a mill tax as a way to address the unmet mental health needs of their communities.

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Addressing Local Mental Health Needs via County-level Property Tax – 2021

by Abigail Barker, PhD, Lauren Kempton, MSW, MPH, and Leah Kemper, MPH | December 2021

The county-level property-based mill tax is used in some Missouri counties to strengthen mental health programs, services and supports.  This brief examines how this tax works and serves as an informational resource for local governments and organizations looking at a mill tax as a way to address the unmet mental health needs of their communities.

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Analysis of the Fiscal Impact of Medicaid Expansion in Missouri

February 2019

Researchers at the Center for Health Economics and Policy recently analyzed the fiscal impact of a potential Medicaid expansion in Missouri from a state budgetary perspective. This report was commissioned by the Missouri Foundation for Health in the wake of other analyses at the national level and represents a non-partisan estimate of the direct impact of expansion on the Medicaid budget. The estimate is based upon a set of assumptions documented and discussed in the report, which also acknowledges various uncertainties and the role those uncertainties play in producing the estimate.

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Assessing the Primary Care Workforce in St. Louis

July 2020

This report uses data from primary care organizations that serve uninsured and safety net patients, combined with other St. Louis population demographic data, healthcare utilization trends, and the locations of primary care providers in order to identify the gaps in the primary care workforce in St. Louis. The report also sheds light on the under-served geographic areas where people struggle to access needed services.

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Change in Children’s Enrollment in MO HealthNet

Source: Missouri Monthly Management Reports, U.S. Census Bureau, Population Division, April 1, 2010- July 1, 2017

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Disparities in Access to Specialists Explain Higher Preventable Hospitalization and Mortality Rates for Rural Medicare Patients: Implications for Missouri

by Kenton J. Johnston, Hefei Wen, Timothy L. Wiemken, Kristine Huang, and Karen E. Joynt Maddox | February 2020
Affiliations: Saint Louis University, Harvard Medical School,  Washington University in St. Louis

Rural Medicare beneficiaries age 65 and older with complex chronic conditions had higher preventable hospitalization and mortality rates than their urban peers.  These research findings show that access to care, and particularly a lack of access to specialists, explained a substantial portion of the difference in clinical outcomes between rural and urban beneficiaries. Overall, these results have implications for Missouri health policy and suggest that interventions to increase access to specialty care may be particularly high-impact among Medicare beneficiaries age 65 and older.

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Effects of Medicaid Expansion on Coverage, Access, Outcomes, and Costs: Implications for Missouri

by Kristine Huang, BA; Leah Kemper, MPH; Timothy D. McBride, PhD, MS; and Karen E. Joynt Maddox, MD. MPH | September 2019

Multiple studies have explored the effects of state Medicaid expansion on coverage, access, outcomes, and costs. This review provides an overview of the findings about Medicaid expansion and its possible implications for Missouri.

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Estimated New Enrollees as Percent of County Population

Data sources: 2019 American Community Survey for total estimated enrollees and 2018 Small Area Health Insurance Estimates (SAHIE) for county enrollee estimates

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Estimated New Enrollees based on Overall County Population

Data sources: 2019 American Community Survey for total estimated enrollees and 2018 Small Area Health Insurance Estimates (SAHIE) for county enrollee estimates

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Expanding the Primary Care Health Home Model

by Tamara Sánchez Ortíz, MD/MPH candidate and Abigail Barker, PhD, Center for Health Economics & Policy, Washington University in St. Louis | August 2021

Missouri’s Primary Care Health Home program (PCHH) offers a promising cost-effective model for taking care of patients with chronic conditions, and it has the potential to do so in greater volumes and with a wider scope of patients. In August 2020, Missourians voted to expand Medicaid (also known as MO HealthNet Division, MHD) in the state by July 2021. Given an influx of new enrollees, the time is ripe for MHD to re-evaluate how to best take care of its Medicaid population, particularly those that are disproportionately incurring high healthcare costs from inadequately managed chronic health conditions. Building on the success of Missouri’s nearly one-decade-old, comprehensive, patient-centered PCHH model, this white paper outlines recommendations for expanding the program to further advance the state’s goals in pursuit of the “Triple Aim” of healthcare: lowering costs, improving population health, and providing higher quality care.

These recommendations were developed after close evaluation of Missouri’s PCHH program, research on other states’ programs, and interviews with different PCHH team members at various PCHH sites across Missouri.

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Financial Impact of Accounting for Social Risk in the Hospital Readmissions Reduction Program

by Karen E. Joynt Maddox, MD MPH; Mat Reidhead, BS MA; Andrew C. Qi, BS; Kristine Huang, BA; and David R. Nerenz, PhD | October 2019

This research investigates the impact of stratification on hospital penalties under Medicare’s Hospital Readmissions Reduction Program (HRRP).

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High Levels of Social Distancing Lower the Projected Impact of COVID-19 in Missouri

by Abigail Barker PhD,  Kristine Huang BA, Leah Kemper MPH, Linda Li MPH, Timothy D. McBride PhD, and Karen E. Joynt Maddox MD MPH | May 2020

This brief describes the potential effects of different levels of social distancing on the COVID-19 infection, hospitalization, and death rates in Missouri.  Researchers used an epidemiological model adjusted for population density and age distribution in each county to project outcomes over a six month period.

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Impact of State Laws Governing Physical Education on Attendance among U.S. High School Students, 2003-2017

by Ruopeng An, PhD; Mengmeng Ji, MS; Caitlin Clarke, PhD; Chenghua Guan, PhD | January 2020

Schools play a critical role in promoting physical activity among children through physical education (PE), which helps students gain necessary knowledge, skills, and confidence to practice sports and adopt an active lifestyle. Government policies and regulations profoundly influence local schools’ decisions and practices in delivering PE and promoting physical activity among students. This policy brief assessed the influence of state laws governing PE on weekly PE class attendance among U.S. high school students.

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Implementing Medicaid Reimbursement for Home Visiting in Missouri

by Celeste Sanger and Abigail Barker, PhD | October 2023

Home visiting has the potential to make a positive impact on the landscape of infant and maternal health in Missouri. The variety of frameworks available make it possible to customize services to meet a family’s need and set them on a pathway to success in the future. Missouri has the opportunity to craft its own unique approach to reimbursing home visiting services through Medicaid, to make the intervention more accessible to more families across the state. Collaboration between MO HealthNet, home visiting agencies, and other home visiting and Medicaid stakeholders is necessary to address each consideration in this report and invest the time to craft the most effective approach with the greatest impact.

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Initial View of the Medicaid Expansion and Public Health Emergency on Hospital Encounters in Missouri

by Timothy McBride, PhD and Eliot Jost, MBA,MPH | September 2023

An expansion of the Missouri Medicaid program was approved by voters in Missouri through the passage of a constitutional amendment in August 2020, later upheld by the Missouri Supreme Court in July 2021. This policy brief reviews changes in hospital encounters over time in Missouri, before and after the start of the Medicaid expansion, concentrating on emergency department encounters and inpatient encounters, and the “payer mix” of those visits, which is the source of payment the hospitals receive.

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Lack of Issuer Participation Associated with Higher Marketplace Premiums in Rural Areas in Missouri

by Abigail R. Barker PhD, Kristine Huang BA, and Leah Kemper MPH | March 2020

This brief describes the changes in the 2020 Health Insurance Marketplace pre- and post-subsidy premiums in Missouri compared to national trends as well as changes in issuer participation.  The findings suggest that policies that would increase insurer participation, especially in rural areas, would likely lower premium costs and lower the financial burden of subsidies for the federal government.

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Maternal Health Policy Recommendations

THM, Part V | October 2021

Transforming Healthcare in Missouri, Part V — Policies & Partnerships to Advance Pregnancy Outcomes — convened managed care organization representatives, clinicians, program
leaders, advocates, and other stakeholders in Missouri pregnancy care. These attendees
heard from presenters and panelists who shared information on models of pregnancy
care that are known to be effective. 
Attendees discussed these models and other ideas of interest that may advance quality care for pregnant women in Missouri.

This paper seeks to succinctly summarize those ideas and, where applicable, to describe the programs in Missouri that are successfully implementing them in some form. One key goal is to articulate the areas of concern across stakeholders within the present system and to document levels of agreement and support for specific solutions to those challenges.

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Maternal Mortality in Missouri: A Review of Challenges and State Policy Options

by Jessica Engel, BA; Lindsey Nienstedt, BA; and Leah Kemper, MPH | October 2019 

Missouri ranks 44th in the nation in maternal mortality with 40.7 maternal deaths estimated per 100,000 live births in 2019. This brief examines the risk factors, causes and barriers to access that contribute to this alarming trend, as well as some of the policy options available to the State of Missouri to address this critical public health issue.

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Medicaid Expansion Enrollment and Eligibility Update: Characteristics of Expansion Enrollees

by Saint Louis University Center for Health Law Studies &
Washington University Center for Health Economics and Policy | February 2021

Missouri is to expand Medicaid to include all adults age 19-64 earning up to 138% of the federal poverty line FPL ($29,974 for a family of three), starting July 1, 2021. This Fact Sheet lays out preliminary estimates of the number of people likely to enroll in the expansion during the first year, July 2021 to July 2022, as well as the key demographic characteristics of those who enroll. The number of expected enrollees and their demographic characteristics may be important background information for the implementation of the Medicaid expansion efforts, including plans for outreach, access to care and costs. In addition, these numbers can be used to help estimate any increases in the demand for health care services across the State.

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Medicaid Expansion Enrollment and Eligibility Update: Geographic Distribution of Healthcare Providers

Washington University in St. Louis Center for Health Economics & Policy and Saint Louis University Center for Health Law Studies | May 2021

This fact sheet describes the geographic distribution of healthcare providers in Missouri, including primary care professionals, mental health providers, and dentists. The aim of this document is to provide important background information for the state, local communities, providers, and community service organizations as they prepare to serve the newly eligible Medicaid enrollees, as well as estimate the current supply of health care services across the State.

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Medicaid Expansion Enrollment and Eligibility Update: Geographic Distribution of Medicaid Enrollees

by Saint Louis University Center for Health Law Studies &
Washington University Center for Health Economics and Policy | March 2021

This Fact Sheet outlines the geographic distribution of the 247,500 adults that are expected to enroll during the first year of the expansion, July 2021 to July 2022. The distribution of the new Medicaid enrollees in Missouri is important background information for the State of Missouri, the communities, providers, and other community service organizations as they prepare to serve the newly eligible enrollees. The numbers provided here can be used to help estimate the expected demand for health care services across the state.

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Medicaid Expansion Enrollment and Eligibility Update: Health Status of Expected New Expansion Enrollees

Washington University in St. Louis, Center for Health Economics & Policy and Saint Louis University Center for Health Law Studies | April 2021

Missouri is implementing an expansion of the Medicaid program to include all adults age 19-64 earning up to 138% of the federal poverty line FPL ($30,305 for a family of three), starting July 1, 2021. It is expected that approximately 274,000 adults will enroll in Medicaid expansion within the first year, according to an estimate from Governor Parson.

This Fact Sheet describes the health status and current healthcare access of expected new enrollees.

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Medicaid Expansion Enrollment Update: February 2022

by Ethan Bradley, BA; Abigail R. Barker, PhD; Leah Kemper, MPH; and Timothy D. McBride, PhD | February 2022

The Medicaid program in Missouri began enrolling newly eligible beneficiaries on October 1, 2021.  At the end of February 2022, 70,909 people were enrolled in the new adult expansion group of Missouri Medicaid.  Medicaid enrollment has grown in every county in Missouri during this time as the newly eligible Medicaid beneficiaries are enrolling into one of three Medicaid managed care plans.  Enrollment into the Medicaid expansion group has been slower than originally predicted; however, many that would be included in the expansion are likely already enrolled in Medicaid due to the current Public Health Emergency.

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Medicaid Expansion Infographic – Regional Variation

June 2020

This infographic displays the regional impacts of a potential Medicaid expansion in Missouri.  The figure shows that all Missouri areas will have increases in Medicaid coverage and that rural areas and areas outside of the St. Louis area will have greater increases in Medicaid coverage, relative to their population.

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Medicaid Managed Care Hospital Networks in Missouri: Too Far to Travel

Saint Louis University Center for Health Law Studies & Washington University Center for Health Economics and Policy | August 2021

Three Medicaid managed care organizations (MCOs)—Healthy Blue, Home State Health, and UnitedHealthcare—serve Medicaid beneficiaries across Missouri. To assure that enrollees have adequate access to in-network providers, Medicaid MCO contracts and state regulations require that each health plan have geographically accessible in-network hospital service. Basic hospital services, such as an emergency department, should be available to enrollees within 30 miles; secondary hospital services within 50 miles; and Trauma I/II, neonatal intensive care, and other highly specialized tertiary hospital services within 100 miles.

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Medicaid Reimbursement for Doula Services: Definitions and Policy Considerations

by Ethan Bradley, BA; Abigail R. Barker, PhD; Hakima Payne, MSN, RN; Okunsola M. Amadou, CPM; and Jesse A. Davis, MD, MBA | April 2022

Community-based doulas come from the under-resourced communities they serve and are trained at organizations that focus their care model on that community's culture. Emerging research suggests that these community-based doulas can improve birth outcomes and reduce racial disparities by providing wrap-around support throughout the pregnancy, birth and postpartum periods. The challenge for authorizing Medicaid payment for doula care is that this form of care operates outside of traditional clinical provider organizations.  The purpose of this brief is to explain the opportunities provided by doula care, summarize the current training and credentialing options of doula organizations in Missouri, and identify policy considerations.

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Medicaid Work Requirements: The Relationship between Work and Health

by Linda Li, MPH, Abigail Barker, PhD, Leah Kemper, MPH, Timothy McBride, PhD | February 2019

Whether work requirements in Medicaid promote health and align with the aims of the program has become a central question in the current policy debate. In this third of three briefs, we assess the relationship between work and health by using longitudinal data to analyze the effects of employment and health status over time. We evaluate the effect of health on work and then examine whether work improves health. Policy implications of current Medicaid work requirements and recommendations follow based on our findings.

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Missouri Active Physician Counts per 10,000 Population and Total Counts: 2019-2020

Data Sources: 2019-2020 Area Health Resource File, American Medical Association Physician Masterfiles, American Dental Association Masterfile, Centers for Medicare and Medicaid Services National Provider Identifier Files

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Missouri Healthcare Provider Counts

MO county-level healthcare provider counts, by population, by type of provider including non-physicians, and by age category.

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Missouri Medicaid Enrollment by County

Source: MO Department of Social Services Family Support and MO HealthNet Divisions monthly management report, January 2017

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Missouri Medicaid Enrollment Dashboard

This dashboard provides an interactive display of public data from the MO HealthNet monthly management reports, monthly managed care reports, and monthly caseload counter.

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MO and IL Marketplace Premiums Net of Subsidies

Missouri and Illinois Health Insurance Marketplace 2014 to 2017 net-of-subsidy 2nd-lowest silver premium analysis for 27-year-old individuals

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Multidisciplinary Cardio-OB Clinic (MYHEART): Baseline characteristics, health care utilization, and spending

by Kathryn J. Lindley, MD, Tierney Lanter, BS, RJ Waken, PhD, Molly Stout, MD, MSCI, Kristine Huang, BA, Nicole El Helou, MPH, and Karen E. Joynt Maddox MD MPH | September 2022

Clinicians at Washington University established the multidisciplinary postpartum
MYHEART clinic, aimed at providing enhanced postpartum follow-up care for
women with hypertensive diseases of pregnancy. This brief describes baseline
characteristics, health care utilization, and spending among enrolled women, and compares
them to women who were eligible but did not enroll, and to women who were ineligible for
the clinic.

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Percent of Missouri Population Enrolled in Medicaid by County

Data Source: January 2020 Monthly Management Department of Social Services

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Policy and Community Strategies on Diabetes and Obesity

by Abigail Barker, PhD; Hadeer Hegazy, MsC, BCNSP, BS Pharm; Ethan Bradley, MPH; and Leah Kemper, MPH | September 2022

In April 2022, the Center for Health Economics and Policy held a Transforming Healthcare in Missouri meeting to discuss ways to improve outcomes for diabetes and obesity in Missouri.  These conditions are critical problems for pediatric and adult populations in Missouri, with Missouri ranking 26th and 32nd among US states for health outcomes related to diabetes and obesity respectively.  Experts presented research and intervention models targeted at addressing diabetes and obesity, and event participants discussed these models and other ideas that have the potential to improve outcomes.  This paper summarizes the models presented, articulates the collective viewpoints of the stakeholders in attendance and provides policy recommendations developed at the meeting.

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Rapid Response Review of MO HealthNet – Summary of Findings

THM, Part IV | 2020

This summary of findings from the Rapid Response Review of MO HealthNet by McKinsey & Co. and additional considerations was used as background information for Transforming Healthcare in Missouri, Part IV: Recommendations for Missouri Medicaid Transformation.

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Recommendations for Missouri Medicaid Transformation: Paying for value & prioritizing the social determinants of health

Dec. 2020

This executive summary and white paper illustrates stakeholder feedback and innovative ideas culminating from the fourth in a series of Transforming Healthcare in Missouri events presented by the Center for Health Economics and Policy at the Institute for Public Health and the Clark-Fox Policy Institute at the Brown School.

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Regional Distribution of New Adult Enrollees

Data sources: 2017 American Community Survey for total estimated enrollees, 2018 Small Area Health Insurance Estimates (SAHIE) for regional enrollee estimates and Missouri Census Data Center: Regional definitions

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Social Risk and Dialysis Facility Penalties Under the End-Stage Renal Disease Quality Incentive Program

by Andrew C. Qi BS, Anne M. Butler PhD, Kristine Huang BA, and Karen E. Joynt Maddox MD, MPH | September 2019

Introduced in 2012, Medicare’s End-Stage Renal Disease Quality Incentive Program (ESRD QIP) is a mandatory pay-for-performance program for U.S. dialysis facilities that penalizes facilities up to 2% of their Medicare payments based on their performance on a set of quality measures. This program has had an impact on dialysis facilities in low-income areas and those with high proportions of Black or dually Medicare and Medicaid enrolled patients. The analysis showed that facilities serving these vulnerable populations have lower quality scores and higher financial penalties. Consequently, the ESRD QIP could cause facilities to avoid caring for high-risk patients, or could worsen facility quality by taking away valuable resources. However, the penalties could also spur facilities to improve quality, which could reduce disparities. The impact of the program needs to continue to be monitored to ensure the program is as equitable as possible.

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State and Federal Shares of Medicaid Costs Prior to Expansion, 2013

Medicaid Federal Matching Assistance Percentages in Expansion and Non-Expansion States

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The Intersection of Medicaid Expansion and Transformation in Missouri

by Lauren Kempton, BA; Leah M. Kemper, MPH; and Karen Joynt Maddox, MD, MPH | April 2021

Currently, Missouri Medicaid is limited in its ability to control costs while improving population health because there is no real opportunity to work on the underlying causes of poor health. Medicaid expansion in Missouri creates an opportunity to improve population health – to move the needle on many metrics for which the state’s ranking has fallen significantly over the past 30 years – by redesigning its program in key ways.

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The Medicaid Coverage Gap in Missouri: Implications for Healthcare Access Due to Increasing Out-of-Pocket Burden

by Abigail R. Barker, PhD; Leah M. Kemper, MPH; Lindsey M. Nienstedt, MPH, MSW; Karen E. Joynt Maddox, MD, MPH; and Timothy D. McBride, PhD | June 2020

Low-income individuals and families in Missouri face rising healthcare costs in a policy environment that offers uneven levels of assistance. This brief compares estimated healthcare utilization that would be sought – if out-of-pocket cost were not an issue – to the percent of annual income that would be required to meet that need. In addition, we provide historical context by comparing out-of-pocket burden in 1996 to current burden.

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The Medicaid Coverage Gap in Missouri: Implications for Healthcare Access Due to Increasing Out-of-Pocket Burden

by Abigail R. Barker, PhD; Leah M. Kemper, MPH; Lindsey M. Nienstedt, MPH, MSW; Karen E. Joynt Maddox, MD, MPH; and Timothy D. McBride, PhD | June 2020

Low-income individuals and families in Missouri face rising healthcare costs in a policy environment that offers uneven levels of assistance. This brief compares estimated healthcare utilization that would be sought – if out-of-pocket cost were not an issue – to the percent of annual income that would be required to meet that need. In addition, we provide historical context by comparing out-of-pocket burden in 1996 to current burden.

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The Role of Culturally Congruent Community-based Doula Services in Improving Key Birth Outcomes in Kansas City

by Ria Hegde, BA; H. Ellis McCormick, BA; Hakima Payne, MSN, RN; Abigail R. Barker, PhD | November 2022

This brief reports on data from Uzazi Village, a Kansas City organization providing culturally congruent, community-based doula services since 2012. Improvements in three key health outcomes (gestational age, birthweight, and APGAR scores) were associated with doula services provided by Uzazi Village, in comparison to Kansas City birth outcome data for the same ZIP codes. This evidence can help inform the policy discussion regarding the addition of Medicaid coverage for doula services in Missouri.

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The Tradeoffs of High-Risk Pools

Risk Pool Analysis Data source is the 2013 Medical Expenditure Panel Survey.

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Transforming Healthcare in Missouri: Bridging the Gaps with Community Health Workers from Global to Local and Back

by Shria Bucha, BA Candidate; Khavya C Avula, MBBS, MPH; Megha Dabas, MSc, MPharm, BPharm; Venkatesh Satheeskumar, BS; and Abigail Barker, PhD | January 2024

In September 2023, the Center for Advancing Health Services, Policy & Economics Research convened a diverse stakeholder group, including significant representation from MO HealthNet, Missouri policymakers, university and community partners, and a large number of CHWs representing different settings. The group gathered to discuss possibilities for new reimbursement models for Community Health Worker (CHW) services. This white paper summarizes the discussions of our keynote speaker, panelists, and stakeholder breakout sessions while highlighting prominent policy themes and takeaways.

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Transforming Healthcare in Missouri: Implementing Accountable Care within Medicaid

by Abigail Barker, PhD, and Venkatesh Satheeskumar, BS | March 2023

In September 2022, the Center for Health Economics and Policy convened stakeholders from a variety of organizations as part of our Transforming Healthcare in Missouri series. In addition to summarizing the event, this white paper summarizes the models presented and describes related policies in Missouri and the programs that have been successfully implemented.