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Medicaid Accountable Care Organizations and Disparities in Pediatric Asthma Care
Kimberley H Geissler1, Meng-Shiou Shieh1, Arlene S Ash2
1Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School-Baystate, Springfield.
Insights
Massachusetts Medicaid Accountable Care Organizations (ACOs) did not improve routine asthma visits for children. While appropriate asthma medication ratios improved for Medicaid patients, emergency room use increased, worsening disparities for children with asthma.
Area of Science:
- Health Services Research
- Pediatric Asthma Care
- Health Disparities
Background:
- Millions of US children have asthma, with many relying on Medicaid.
- Accountable Care Organizations (ACOs) are being adopted by state Medicaid programs, but their impact on pediatric asthma care disparities is unclear.
Purpose of the Study:
- To assess the impact of Massachusetts Medicaid ACO implementation on asthma care quality and utilization for children.
- To examine changes in insurance-based disparities in pediatric asthma care following ACO adoption.
Main Methods:
- Utilized Massachusetts All Payer Claims Database (2014-2020) for children aged 2-17 with asthma.
- Employed difference-in-differences (DiD) analysis to compare outcomes for Medicaid vs. privately insured children before and after March 2018 ACO implementation.
- Adjusted for demographic, community, and health status factors.
Main Results:
- No significant change in routine asthma visit rates between Medicaid and privately insured children post-ACO implementation.
- An increase in appropriate asthma medication ratios (AMR > 0.5) for Medicaid-insured children, but absolute rates declined overall.
- Increased emergency department or hospital use for Medicaid-insured children compared to privately insured children post-ACO implementation.
Conclusions:
- Massachusetts Medicaid ACOs did not eliminate disparities in routine asthma visits.
- Disparities in appropriate asthma medication ratios narrowed due to declines in privately insured groups.
- ACO implementation was associated with worsening disparities in emergency care utilization for children with asthma.
- Further research is needed on Medicaid financing and delivery system reforms' impact on pediatric asthma care.
Importance:
Nearly 6 million children in the US have asthma, and over one-third of US children are insured by Medicaid. Although 23 state Medicaid programs have experimented with accountable care organizations (ACOs), little is known about ACOs' effects on longstanding insurance-based disparities in pediatric asthma care and outcomes.
Objective:
To determine associations between Massachusetts Medicaid ACO implementation in March 2018 and changes in care quality and use for children with asthma.
Design, Setting, And Participants:
Using data from the Massachusetts All Payer Claims Database from January 1, 2014, to December 31, 2020, we determined child-years with asthma and used difference-in-differences (DiD) estimates to compare asthma quality of care and emergency department (ED) or hospital use for child-years with Medicaid vs private insurance for 3 year periods before and after ACO implementation for children aged 2 to 17 years. Regression models accounted for demographic and community characteristics and health status. Data analysis was conducted between January 2022 and June 2024.
Exposure:
Massachusetts Medicaid ACO implementation.
Main Outcomes And Measures:
Primary outcomes were binary measures in a calendar year of (1) any routine outpatient asthma visit, (2) asthma medication ratio (AMR) greater than 0.5, and (3) any ED or hospital use with asthma. To determine the statistical significance of differences in descriptive statistics between groups, χ2 and t tests were used.
Results:
Among 376 509 child-year observations, 268 338 (71.27%) were insured by Medicaid and 73 633 (19.56%) had persistent asthma. There was no significant change in rates of routine asthma visits for Medicaid-insured child-years vs privately insured child-years post-ACO implementation (DiD, -0.4 percentage points [pp]; 95% CI, -1.4 to 0.6 pp). There was an increase in the proportion with AMR greater than 0.5 for Medicaid-insured child-years vs privately insured in the postimplementation period (DiD, 3.7 pp; 95% CI, 2.0-5.4 pp), with absolute declines in both groups postimplementation. There was an increase in any ED or hospital use for Medicaid-insured child-years vs privately insured postimplementation (DiD, 2.1 pp; 95% CI, 1.2-3.0 pp), an 8% increase from the preperiod Medicaid use rate.
Conclusions And Relevance:
Introduction of Massachusetts Medicaid ACOs was associated with persistent insurance-based disparities in routine asthma visit rates; a narrowing in disparities in appropriate AMR rates due to reductions in appropriate rates among those with private insurance; and worsening disparities in any ED or hospital use for Medicaid-insured children with asthma compared to children with private insurance. Continued study of changes in pediatric asthma care delivery is warranted in relation to major Medicaid financing and delivery system reforms.
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