Quality of Care for Chronic Conditions Among Disabled Medicaid Enrollees: An Evaluation of a 1915 (b) and (c) Waiver Program

Wegman MP, Herndon JB, Muller KE, Graham GN, Vogel WB, Case KH, Lee JA, Van Voorhis MF, Shenkman EA
Source: Med Care
Publication Year: 2015
Patient Need Addressed: Chronic Conditions
Population Focus: Medicaid beneficiaries, Vulnerable/disadvantaged
Demographic Group: Adult
Intervention Type: Service redesign
Study Design: Pre-post with Comparison Group
Type of Literature: White
link: https://www.ncbi.nlm.nih.gov/pubmed/26035044
Abstract

IMPORTANCE:
Examining the impact of Medicaid-managed care home-based and community-based service (HCBS) alternatives to institutional care is critical given the recent rapid expansion of these models nationally.

OBJECTIVE:
We analyzed the effects of STAR+PLUS, a Texas Medicaid-managed care HCBS waiver program for adults with disabilities on the quality of chronic disease care.

DESIGN, SETTING, AND PARTICIPANTS:
We compared quality before and after a mandatory transition of disabled Medicaid enrollees older than 21 years from fee-for-service (FFS) or primary care case management (PCCM) to STAR+PLUS in 28 counties, relative to enrollees in counties remaining in the FFS or PCCM models.

MEASURES AND ANALYSIS:
Person-level claims and encounter data for 2006-2010 were used to compute adherence to 6 quality measures. With county as the independent sampling unit, we employed a longitudinal linear mixed-model analysis accounting for administrative clustering and geographic and individual factors.

RESULTS:
Although quality was similar among programs at baseline, STAR+PLUS enrollees experienced large and sustained improvements in use of β-blockers after discharge for heart attack (49% vs. 81% adherence post transition; P<0.01) and appropriate use of systemic corticosteroids and bronchodilators after a chronic obstructive pulmonary disease event (39% vs. 68% adherence post transition; P<0.0001) compared with FFS/PCCM enrollees. No statistically significant effects were identified for quality measures for asthma, diabetes, or cardiovascular disease. CONCLUSION: In 1 large Medicaid-managed care HCBS program, the quality of chronic disease care linked to acute events improved while that provided during routine encounters appeared unaffected.

Insights Results

Overview of article

  • There has been rapid growth in the use of managed care to provide LTSS through 1915 (b)/(c) managed care/HCBS waivers or 1115 demonstration waivers, increasing from 8 state Medicaid programs in 2004 to 18 programs in 2014. However, little is known about the quality of care delivered through these programs
  • The purpose of this study was to examine the effects of a large acute care and HCBS program delivered through managed care organizations (MCOs) in Texas Medicaid – the STAR+PLUS program – on the quality of chronic disease care for adults with disabilities (AWD)
    Methods
  • This study used Texas Medicaid administrative data from January 2006–December 2010 to estimate the treatment effect of the STAR+PLUS program on chronic care quality, focusing on the 2007 program expansions to allow for sufficient post-transition data for analysis
  • The study population included individuals 21–64 years old who were enrolled during the study time period and qualified for Supplemental Security Income (SSI) and Medicaid due to disability. Dual Medicare-Medicaid eligible were excluded because Medicare data were not available for those enrollees. Individuals < 21 years old were excluded because STAR+PLUS enrollment was voluntary for this group

Results

  • Results demonstrate large and sustained improvements in care following both heart attack and COPD exacerbation. However, differences were not observed in the quality of ambulatory care for diabetics or asthmatics, or for cholesterol screening for those with cardiovascular conditions
  • Overall, the quality of chronic disease care linked to acute events improved while that provided during routine encounters appeared unaffected. Additional research is needed to further evaluate and refine care for this vulnerable population

Key takeaways/implications

  • This study examined the effect of the Texas STAR+PLUS HCBS waiver program on the quality of chronic disease care for Medicaid AWD. The results demonstrate large and sustained improvements in care following both heart attack and COPD exacerbation. However, differences were not observed in the quality of ambulatory care for diabetics or asthmatics, or for cholesterol screening for those with cardiovascular conditions
  • Further research is necessary to identify the pathways through which the observed improvements were achieved and the reasons why improvements were not seen in all the measures. However, it is worth noting that the 2 measures that the study found significant improvements, Persistence of Beta Blockers after a Heart Attack and Pharmacotherapy for COPD Exacerbation, focus on care processes linked to an acute event. Thus, it may be that managed care quality improvement protocols were more readily implemented in the context of an acute event
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