Medicaid Managed Care Population Research Articles

The association of sociodemographic characteristics and comorbidities with post-acute sequelae of SARS-CoV-2 in a Medicaid managed care population with and without HIV.

Understanding how post-acute sequelae of SARS-CoV-2 infection (PASC) affects communities disproportionately affected by HIV is critically needed. This study aimed to identify the prevalence of PASC symptoms among Medicaid enrollees at risk for or living with HIV. Through a web survey, we received 138 valid responses from Medicaid-managed plan members who had received a COVID diagnosis. Participants' mean age was 45.4 years (SD = 11.9) and most were non-Hispanic Black (43.5%) or Hispanic (39.1%). Almost thirty-two percent reported inadequate incomes and 77.5% were HIV-positive. In the overall population, the frequently reported symptoms included neck/back/low back pain, brain fog/difficulty concentrating, bone/joint pain, muscle aches, and fatigue. Findings indicate that there is no statistically significant difference in the prevalence and intensity of PASC symptoms lasting 6 months or more between individuals living with and without HIV. Multiple regression analysis found that the number of PASC symptoms 6 months or longer was independently associated with inadequate incomes and comorbidities (cardiac problems, cancer, fibromyalgia) (R2 = .34). Those with inadequate incomes and comorbidities have more numerous PASC symptoms. Implications for health care delivery and long-term COVID services will be discussed.

Improving Diabetes Control in a Medicaid Managed Care Population With Complex Needs.

People enrolled in Medicaid managed care who struggle with diabetes control often have complex medical, behavioral, and social needs. Here the authors report the results of a program designed to partner with primary care teams to address those needs. A nonprofit organization partnered with a Medicaid managed care plan and a Federally Qualified Health Center in California to enroll people with A1cs >9% in a 12-month program. The program team included a community health worker, certified diabetes care and education specialist/registered dietitian, behavioral health counselor, and registered nurse. They developed patient-led action plans, connected patients to community resources, and supported behavior changes to improve diabetes control. Baseline assessments of behavioral health conditions and social needs were collected. Monthly A1c values were tracked for participants and a comparison group. Of the 51 people enrolled, 83% had at least 1 behavioral health condition. More than 90% reported at least 1 unmet social need. The average monthly A1c among program participants was 0.699 lower than the comparison group post-enrollment (P = .0008), and the disparity in A1c between Hispanic and non-Hispanic White participants at enrollment declined. Participants had high levels of unmet medical, behavioral, and social needs. Addressing these needs resulted in a rapid and sustained improvement in A1c control compared to non-enrollees and a reduction in disparity of control among Hispanic participants. By partnering with a primary care team, a program external to Federally Qualified Health Center primary care can improve clinical outcomes for people with complex needs living with diabetes.

Organizational Health Literacy and Health Among New York State Medicaid Members.

The definition of health literacy has recently expanded beyond the idea of individual skills to include the system and environment the individual interacts with to receive care, known as organizational health literacy (OHL). However, neither the prevalence of OHL nor the impact of OHL on individuals' perceptions of their health and healthcare have been examined in New York's Medicaid managed care population. This study aimed to estimate the prevalence of organizational health literacy in the New York State (NYS) Medicaid Managed Care (MMC) program. A brief measure to assess organizational health literacy was developed from responses to two questions in the 2018 NYS Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Generalized Estimating Equation models were developed to analyze the association between organizational health literacy and three aspects of perceptions of health and health care, controlling for demographic differences and clustering effects from health insurance plans. Missing data were handled using multiple imputation. Among 3,598 members included in the study, 20% of the MMC members reported inadequate organizational health literacy. These members were more likely to be older, less educated, from racial and ethnic minority groups, and less fluent with English. They are more likely to have poorer self-reported health (odds ratio [OR] 1.49), lower perceived access to health care (OR 6.97), and lower satisfaction with their health care (OR 6.49) than members who did not report inadequate organizational health literacy. Our results suggest that a proportion of the NYS MMC population faces inadequate organizational health literacy, which can present a barrier to health care access and result in patients having a significantly poorer health care experience. Using an existing data source that is part of existing data collection allows for routine assessment of organizational health literacy, which can help inform health plans about areas for potential improvement. [HLRP: Health Literacy Research and Practice. 2023;7(3):e154-e164.].

Racial and Ethnic Disparities in SARS-CoV-2 Testing and COVID-19 Outcomes in a Medicaid Managed Care Cohort

IntroductionSocioeconomic differences may confound racial and ethnic differences in SARS-CoV-2 testing and COVID-19 outcomes.MethodsA retrospective cohort study was conducted of racial/ethnic differences in SARS-CoV-2 testing and positive tests and COVID-19 hospitalizations and deaths among adults impaneled at a Northern California regional medical center and enrolled in the county Medicaid managed care plan (N=84,346) as of March 1, 2020. Logistic regressions adjusted for demographics, comorbidities, and neighborhood characteristics.ResultsNearly 30% of enrollees were ever tested for SARS-CoV-2, and 4% tested positive. A total of 19.7 per 10,000 were hospitalized for and 9.4 per 10,000 died of COVID-19. Those identified as Asian, Black, or of other/unknown race had lower testing rates, whereas those identified as Latino had higher testing rates than Whites. Enrollees of Asian or other/unknown race had slightly higher odds of a positive test, and Latinos had much higher odds of a positive test (OR=3.77, 95% CI=3.41, 4.17) than Whites. The odds of hospitalization (OR=2.85, 95% CI=1.85, 4.40) and death (OR=4.75, 95% CI=2.23, 10.12) were higher for Latino than for White patients, even after adjusting for demographics, comorbidities, and neighborhood characteristics.ConclusionsIn a Medicaid managed care population, where socioeconomic differences may be reduced, the odds of a positive SARS-CoV-2 test, COVID-19 hospitalization, and COVID-19 death were higher for Latino but not Black patients than for White patients. Racial/ethnic disparities depend on local context. The substantially higher risk facing Latinos should be a key consideration in California's strategies to mitigate disease transmission and harm.

Predicting opioid use disorder and associated risk factors in a Medicaid managed care population.

Medicaid managed care organizations are developing comprehensive strategies to reduce the impact of opioid use disorder (OUD) among their members. The goals of this study were to develop and validate a predictive model of OUD and to predict future OUD diagnosis, resulting in proactive, person-centered outreach. We utilized machine learning methodology to select a multivariate logistic regression andidentifypredictors. Using 2016-2018 data, we used a staged approach to test and validate the predictive accuracy of our model. We identified OUD, the dependent variable, using an industry-standard definition. We included a series of patient demographic, chronic condition, social determinants of health (SDOH), opioid-related, and health utilization indicators captured in administrative data. Caucasian (odds ratio [OR], 1.65), male (OR, 1.57), and younger (aged 40-64 years compared with 18-39 years: OR, 0.75) members had greater odds of being diagnosed with an OUD. Members with an SDOH vulnerability had 26% higher odds than those without a documented issue. From a prescribing perspective, we found that having an opioid dose of 120 morphine milligram equivalents and contiguous 5-day supply increased odds of OUD by 1.87 times, and an opioid supply of 30 days or longer increased the odds of OUD by 1.56 times. We built the necessary machine learning infrastructure to identify members with greater than 50% probability of developing OUD. The generated list strategically informs and guides person-centered care and interventions. Through application of these results, we strive to proactively reduce OUD-related structural barriers and prevent OUD from occurring.

Identifying Children with Special Health Care Needs Using Medicaid Data in New York State Medicaid Managed Care.

The ability to identify children with special health care needs (CSHCN) is crucial to evaluate disparities in the quality of health care for children in Medicaid Managed Care. We developed and assessed the accuracy of a new method to classify CSHCN. Secondary data analysis was conducted using NYS Medicaid administrative data and the Children with Chronic Conditions Screener (CCC Screener). This study included 5,907 NYS Medicaid beneficiaries (17years old or younger) whose parents completed the CCC Screener in 2014. Medicaid administrative data were used to create a risk score to assess the risk of special needs, and a cut point was identified to differentiate between children with versus without special needs. Diagnostic accuracy of the method was assessed using sensitivity and specificity analyses. Applying the CCC Screener as the "gold standard," the risk score correctly classified the majority of CSHCN as positive (sensitivity=75 percent) and the majority of the children without special needs as negative (specificity=79 percent). This method demonstrated decent diagnostic ability (AUC=0.77). Our method can identify CSHCN in the NYS Medicaid Managed Care population and will help the State monitor the quality of care for this vulnerable population.

PHS101 - Cost Analysis of Medication Therapy Management - Using Propensity Score Matching Method

To compare total health care costs for a cohort of patients who received MTM (Medication therapy management) with controls among an eligible Medicaid managed care population. A post-hoc analysis of a retrospective observational cohort study comparing MTM to usual care. The intervention population included patients aged 18-65 who opted-in to receive MTM services (n=1,007) compared with control patients who opted-out of MTM (n=13,614). All patients were followed for 12 months before the index/enrollment date and 12 months after the index date. Total, inpatient, outpatient, emergency, and pharmacy paid healthcare claims from Medicaid during the 12-month follow-up period was collected for all patients. T-tests and Chi-squared tests were used to compare patients’ differences in baseline characteristics. Stepwise regression was used to select baseline covariates to generate a propensity score based on receipt of MTM. An 8-digits to 1-digit Greedy matching algorithm was adapted for matching cases to controls. Unadjusted difference-in-differences (DID) was used to compare the means of log transformed healthcare costs between cases and controls. After matching, the differences of baseline covariates in cases and controls were reduced by mean absolute bias of -46.8%. The matched population used for analysis included 832 cases and 1664 controls. Mean total DID healthcare costs were significantly higher among the MTM intervention cases (Δ$3,614) compared with matched controls (Δ$-413; p<0.001). Pharmacy (drug) DID costs were significantly higher among the MTM intervention cases (Δ$3,284) compared to controls (Δ$-1,303; p<0.001). Inpatient, outpatient, and emergency department DID costs were not significantly different between cases and controls. The MTM intervention for this Medicaid population increased total healthcare costs. Increasedpharmacy costs appear to drive the overall health care costs for MTM intervention.

PHS156 - Healthcare Burden of cervical cancer in a national Medicaid managed care population

PHS156 - Healthcare Burden of cervical cancer in a national Medicaid managed care population

Predictors of Prenatal and Postpartum Care Adequacy in a Medicaid Managed Care Population

Purpose To examine factors affecting prenatal and postpartum care for an insured, but vulnerable, population. Methods Individual-level data on three measures of care adequacy were obtained for Massachusetts Medicaid Managed Care women who met the National Committee on Quality Assurance’s Healthcare Effectiveness Data and Information Set denominator criteria for the prenatal and postpartum care measures in 2007 ( n = 1,882). We modeled individual compliance with each measure separately as a binomial logistic function with individual and neighborhood characteristics, provider type, and health plan as explanatory variables. Findings In our sample, 85% of women initiated care in the first trimester, but only 62% met the goal of receiving more than 80% of the recommended number of prenatal visits. Just 60% had a timely postpartum care visit. Having a diagnosis of substance abuse or dependence reduced the odds of meeting all measures. Women with disabilities were less likely to attain two of the three measures of adequate care, as were women with other children in the household. Women who enrolled in Medicaid in the first trimester were more likely to receive the recommended number of prenatal visits than those who were enrolled before pregnancy. Conclusion Given the importance of prenatal and postpartum care for maternal and child health and the recent national declining trend in timely care, initiatives to improve rates of timely and adequate care are crucial and must include components tailored toward particularly vulnerable subpopulations.

Understanding the risk factors of trauma center closures: do financial pressure and community characteristics matter?

We analyze whether hazard rates of shutting down trauma centers are higher due to financial pressures or in areas with vulnerable populations (such as minorities or the poor). This is a retrospective study of all hospitals with trauma center services in urban areas in the continental US between 1990 and 2005, identified from the American Hospital Association Annual Surveys. These data were linked with Medicare cost reports, and supplemented with other sources, including the Area Resource File. We analyze the hazard rates of trauma center closures among several dimensions of risk factors using discrete-time proportional hazard models. The number of trauma center closures increased from 1990 to 2005, with a total of 339 during this period. The hazard rate of closing trauma centers in hospitals with a negative profit margin is 1.38 times higher than those hospitals without the negative profit margin (P < 0.01). Hospitals receiving more generous Medicare reimbursements face a lower hazard of shutting down trauma centers (ratio: 0.58, P < 0.01) than those receiving below average reimbursement. Hospitals in areas with higher health maintenance organizations penetration face a higher hazard of trauma center closure (ratio: 2.06, P < 0.01). Finally, hospitals in areas with higher shares of minorities face a higher risk of trauma center closure (ratio: 1.69, P < 0.01). Medicaid load and uninsured populations, however, are not risk factors for higher rates of closure after we control for other financial and community characteristics. Our findings give an indication on how the current proposals to cut public spending could exacerbate the trauma closure particularly among areas with high shares of minorities. In addition, given the negative effect of health maintenance organizations on trauma center survival, the growth of Medicaid managed care population should be monitored. Finally, high shares of Medicaid or uninsurance by themselves are not independent risk factors for higher closure as long as financial pressures are mitigated. Targeted policy interventions and further research on the causes, are needed to address these systems-level disparities.

Multiple Switching in Medicaid Managed Care: A Proportional Hazards Model

This case study (n=41,969) aims to discover managerially useful predictors of multiple switching among HMOs in a Medicaid managed care population observed over 33 months. Cox's proportional hazards model was used to analyze eligibility data for the entire population, claims data for Medicaid services received during six months prior to HMO enrollment (sample n=2,474) and telephone interviews (sample n=656). Each analytic stage involved four comparisons: (1) enrollees with one switch compared with enrollees with no switches; (2) enrollees with multiple switches compared with those having no switches; (3) in relation to making the first switch, enrollees with multiple switches compared with those having one switch; and (4) in relation to making the second switch, multiple compared with those having one switch. Interruptions (which were independent of switches) predicted switching versus non-switching. Medical claims and, weakly, greater age were associated with multiple switching. Managers can use these three predictors to reduce switching and multiple switching. The finding that switching was associated with greater utilization before HMO enrollment contradicts findings for employer-sponsored insurance, but a possible explanation is offered.

Modeling risk of gastrointestinal events among Medicaid NSAID users using propensity scores

The purpose of the study is to evaluate the gastrointestinal risk of nonsteroidal anti-inflammatory drugs compared with cyclooxygenase-2 inhibitors in a Medicaid managed care population. Medical and prescription claims were analyzed for all Medicaid-enrollees aged 18 years and older, who received a cyclooxygenase-2 or other prescription nonsteroidal anti-inflammatory drug between January 6, 2000 and January 6, 2002, and who did not use these drugs for at least 6 months prior. A logistic model was developed of the propensity for either treatment and stratified patients by quintiles of their propensity score, adjusting for demographics, indications for nonsteroidal anti-inflammatory drugs and gastrointestinal risks. The rates of gastrointestinal event (ICD-9 codes 531–534,578) among nonsteroidal anti-inflammatory drug and cyclooxygenase-2 users were compared. The model was adjusted for drug exposure which was calculated using the medication possession ratio. Of the total sample, 73% were female, 43% were Caucasian and 29% were older than 50 years. Both the direct and the propensity adjusted model, controlling for gastroprotective agents, and medication possession ratio showed significantly different rates of gastrointestinal events in nonsteroidal anti-inflammatory drug users as compared with cyclooxygenase-2 users (odds ratio = 1.874, 95% confidence interval 1.056, 3.326) and (odds ratio = 2.088, 95% confidence interval 1.061, 4.110) respectively. A significant difference in gastrointestinal event rates was found among patients in this Medicaid population on nonsteroidal anti-inflammatory drug versus cyclooxygenase-2 inhibitors, when the gastroprotective agent use and the medication possession ratio were controlled for. Misclassification bias was accounted for by adjusting for length of drug exposure.

Prescriptions for Cyclooxygenase-2 Inhibitors and Other Nonsteroidal Anti-inflammatory Agents in a Medicaid Managed Care Population: African Americans Versus Caucasians

To determine whether race is a predictor of a patient's likelihood of being prescribed selective cyclooxygenase-2 inhibitors (COX-2s) versus other nonsteroidal anti-inflammatory agents (NSAIDs) in Medicaid managed care plans (MCO). All medical and prescription claims for Medicaid MCO enrollees receiving at least one prescription for a COX-2 or NSAID between January 2000 and June 2002 were retrieved. Selected for study were adults claiming at least one COX-2 prescription or NSAID prescription with a minimum 30 days of supply after June 2000; having 60 total days of supply or more over the study period was also required for study inclusion. The probability of being prescribed a COX-2 was estimated as a logistic function of patient age, gender, race, city/suburban/rural residence, and history of rheumatoid arthritis, osteoarthritis, chronic back pain, acute pains, gastrointestinal problems, use of anticoagulants or corticosteroids, and comorbidities. Of the 16,868 enrollees meeting the selection criteria, 4,005 (24%) were prescribed a COX-2 and 12,863 another NSAID. Half of those studied were African American, three-quarters were female, and a third were 50-64 years old. After adjusting for confounders, odds of a COX-2 prescription were a third less for African Americans and other races compared to Caucasians (OR, 0.67; 95% confidence intervals, 0.62-0.73). Patient race is a significant predictor of COX-2 prescriptions in the Medicaid population, even after adjusting for other demographic and clinical variables. Cost to the patient was not a factor, as the patient copayment was 1 US dollar for any prescription.

Home-Based Treatment, Rates of Ambulatory Follow-Up, and Psychiatric Rehospitalization in a Medicaid Managed Care Population

Home-Based Treatment, Rates of Ambulatory Follow-Up, and Psychiatric Rehospitalization in a Medicaid Managed Care Population

Using focus groups to evaluate and strengthen public health nursing population-focused interventions.

Nebraska Health Connection Access Medicaid's (NHC AM) public health nursing (PHN) population-focused practice model is designed to provide enrollment, education, and PHN case management interventions for the Medicaid Managed Care population. Evaluation and continuous improvement of these interventions are, in part, completed through a collaborative effort between NHC AM and a quality management team at the University of Nebraska Medical Center College of Nursing. Focus group methodology was used to access non-English-speaking populations to evaluate and strengthen population-focused PHN interventions.

Developing Health Education Guidelines for the Medicaid Managed Care Population: A Case Study From the State of California

Developing Health Education Guidelines for the Medicaid Managed Care Population: A Case Study From the State of California

Combining state administrative databases and provider records to assess the quality of care for children enrolled in Medicaid.

Our objective was to assess the capability of state administrative health care databases to evaluate the quality of immunization rates for a Medicaid managed care population. Data on 5599 2 year olds were obtained from a Medicaid claims database, a health department database, and the records of the children's assigned providers. The study was conducted on 1 managed care program in 1 state. Test performance ratio analyses were used to assess the relative accuracy and contribution of each source of administrative data. We found that of the 67,188 doses needed, 45,511 (68%) were documented as administered per at least 1 of the data sources. Medicaid claims data alone accounted for 18% of immunized children, while health department data used by itself accounted for 12%. Together, these 2 sources identified 34% of immunized children. Large administrative databases, such as Medicaid claims and data from a health department, while valuable sources of information on quality, may underestimate outcomes such as immunization rates. Assessments of the quality of health care should rely on a combination of administrative data and providers' records as sources of information.

Comparison of the Sheffield Birth Score in an Insured Managed Care Population vs. a Medicaid Managed Care Population. † 674

Comparison of the Sheffield Birth Score in an Insured Managed Care Population vs. a Medicaid Managed Care Population. † 674