In the US, nearly 6 million children have asthma, and over a third are covered by Medicaid. Although there are 23 state Medicaid programs that have experimented with the implementation of accountable care organizations (ACOs), little is known about the effects of ACOs on long-standing insurance-based disparities within the pediatric asthma care space and outcomes. The authors of a study published in JAMA Pediatrics assessed associations of Massachusetts Medicaid ACO implementation with changes in 2 common pediatric asthma quality measures and emergency department (ED) visits and/or hospitalizations for asthma.
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This cross-sectional study used data from the Massachusetts All-Payer Claims Database from January 1, 2014 to December 31, 2020. The study followed the Guidelines for Strengthening the Reporting of Observational Studies in Epidemiologic Reports as well as fully reported Medicaid beneficiaries and private insurance plans with optional reporting from self-insured employer plans.
In addition, the researchers included child-year observations for January 1, 2015, through December 31, 2020, for children ages 2 to 17 years with 12 months of primary Medicaid or private insurance and residence in Massachusetts. Researchers identified child-years with asthma for children who met at least 1 of the following criteria: 1 or more inpatient or observation hospital stay or ED visit with a diagnosis of asthma (using the diagnosis codes from International Classification of Diseases, Ninth Revision or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision); 2 or more outpatient visits with a diagnosis of asthma; or at least 1 outpatient visit with a diagnosis of asthma and at least 1 asthma medication.
Findings showed that among 376,509 child-years for 174,467 children, approximately 71.27% child-years (n = 268,338) were insured under Medicaid, and those with Medicaid were significantly more likely to have persistent asthma, -high comorbidity risk scores and are younger than those who had private insurance. Additionally, each child contributed an average of 2.16 observations per child year. The researchers also observed significant differences in unadjusted outcomes between the 2 groups, with lower rates of each routine asthma visit, lower asthma medication ratio (AMR) rates greater than 0.5, and higher rates of emergency medical care or hospital use among Medicaid-insured child-years compared to privately insured child-years.
Additionally, the rate of any routine asthma visit was lower among those with Medicaid (66.9%) compared with private insurance (74.1%) during the baseline period. The researchers also observed a nonsignificant decrease of 0.4 percentage points (95% CI, -1.4 to 0.6 percentage points) in the change in frequency of each routine visit from pre-ACO implementation to post-ACO implementation for those with Medicaid compared with those with private insurance. In patients with persistent asthma, increases in the ratio with an AMR greater than 0.5 from before to after for those with Medicaid compared with those who had private insurance (3.7 percentage points; 95% CI, 2.0 -5.4 percentage points) and there were absolute declines in both groups from pre-implementation to post-implementation, with larger declines present among those with private insurance.
In addition, ED or hospital use for asthma was higher among those with Medicaid (27.2%) compared with those who were privately insured (19.0%) during the baseline period. The estimate showed that the change in any emergency care or hospital use between the pre-ACO and post-ACO periods was about 2.1 percentage points higher (95% CI, 1.2-3.0 percentage points) for those , who had Medicaid compared to private insurance, which is approximately an 8% relative increase from the pre-period Medicaid rate. The researchers noted that this was due to changes in the use of each ED visit, with no changes in hospitalizations. There was also a statistically significant increase in the change in any ED visit from before to after for those with Medicaid compared with those with private insurance (DiD, 2.3 pp; 95% CI, 1.4-3 ,2 pp). According to the authors, there were no differences in the change in hospitalizations from pre-ACO to post-ACO between the two insurance groups.
Study limitations include lack of generalizability, potential ACO start-up problems were reflected in the results because the first 3 years of Medicaid ACO contracts were included, and self-insured employers were no longer required to report their data as of 2016 The authors also note that claims data may not provide a clear picture of asthma control and care delivery, and pre-period trends for the treatment and control groups are not parallel. The researchers suggest that additional research that includes a mixed-methods study is needed to more robustly evaluate the effects of ACOs on quality of care, outcomes, and disparities in pediatric asthma.