Can Medicaid Managed Care mitigate race/ethnic health disparities in diabetes?

Modified Abstract Section

This study represents a timely investigation that addresses differences in type 2 diabetes (T2DM) care using the most up-to-date encounter data post 2016 (ICD switch). T2DM is a burdensome chronic condition that disproportionately impacts certain populations; of note, there are stark disparities in T2DM care goals, emergency department (ED) visits, and hospitalizations across states. Medicaid covers 25% of Americans with T2DM. More than 80% of Medicaid beneficiaries nationally receive at least some of their care from Medicaid managed care organizations (MMCOs).

States contract with private (non-profit or for-profit) MMCOs to lower costs, increase quality, and pass on the financial risks of covering Medicaid beneficiaries. Heterogeneity across and within state programs can have implications for the quality of T2DM care and, specifically, health outcomes by affecting MMCO entry and post-entry behavior. At the same time state policymakers have significant influence over the marketplaces in which MMCOs compete for Medicaid recipients, which can also have consequences for health outcomes. Little is known about whether and how MMCOs and the state programs they operate in influence adherence to T2DM care standards and, if or how any recent events (e.g., the rise in telehealth) changed the trajectory of healthcare delivery.

We propose to answer these unknowns using a convergent mixed-methods approach: we will compile a database of MMCO and state program features that could influence differences in T2DM care using a healthcare conceptual framework (Aim 1); We will empirically explore healthcare variations among adults with T2DM and whether these differences vary with MMCO/state features using updated comprehensive data from the Transformed Medicaid Statistical Information System over 2016-2025 (Aims 2 and 3); and we will collect and analyze qualitative data from Medicaid health care delivery stakeholders to triangulate and contextualize the quantitative findings (Aim 4). We focus on non-disabled, non-pregnant 18-64-year-old adults with T2DM who tend to remain relatively stably covered by Medicaid over time. Analytically, we will focus our analyses on 12 states and the District of Columbia that mandate enrollment in comprehensive MMCOs, to reduce selection bias. We will use panel data models to examine receipt of key T2DM care and need for hospital care, overall and by MMCO/state program features, for beneficiaries enrolled over 2016-2019.

We will then follow those cohorts over time to assess if and how MMCO/ state program features moderate the effects on T2DM outcomes. Sensitivity analyses will explore the influence of churn in beneficiaries over time. Further, using data from our preliminary analyses, we have selected to conduct interviews in two distinct states (Kentucky and Florida) to examine what aspects of state MMCO design and implementation might explain the lowest and greatest differences in T2DM care, respectively. This highly policy-relevant work can provide critical quantitative and qualitative insight into how Medicaid managed care programs can be designed to reduce small area variations in T2DM disease burden.

Grant Number: 5R01MD017071-04
NIH Institute/Center: NIH
Principal Investigator: Maria Alva