Impact of New York State's Medicaid Breast Cancer Selective Contracting Policy on Access and Quality of Care Outcomes.

The New York State Medicaid Breast Cancer Selective Contracting policy was implemented in 2009 and mandates that Medicaid enrollees receive breast cancer surgery at high-volume hospital and ambulatory surgery facilities. This article evaluates the policy's impact on 8 access and quality of care measures prepolicy and postpolicy implementation. Linked New York State (NYS) Cancer Registry, Statewide Planning and Research Cooperative System, and NYS Medicaid encounter and claim data were used to calculate measures. Interrupted time series analysis was conducted to estimate the change in measure rates prepolicy and postpolicy implementation. Findings indicate that the policy was successful in shifting surgeries from low- to high-volume facilities and that high-volume facilities outperformed low-volume facilities on several access and quality of care measures.

The impact of financial incentives on utilization and outcomes of diabetes prevention programs among Medicaid managed care adults in New York state.

Diabetes prevalence has risen rapidly and has become a global health challenge. The Diabetes Prevention Program (DPP) has been shown to prevent or delay the development of diabetes among individuals with prediabetes. Yet, diabetes prevention studies within the Medicaid population are limited and results are mixed. This study aimed to evaluate the impact of different financial incentive strategies on the utilization of the DPP for Medicaid managed care adults in New York State. A four-arm randomized controlled trial was conducted among Medicaid managed care adult enrollees diagnosed with prediabetes and/or obesity. Study participants were offered a 16-week DPP with various incentive strategies based on class attendance and weight loss as follows: Attendance-Only, Weight-Loss Only, and both Attendance and Weight-Loss. A control group was offered DPP with no incentives for attendance or weight loss. We evaluated the impact of incentives on achievement of the program completion and weight-loss milestone. Participants who received incentives for the Attendance-Only class were least likely to be lost to follow-up, more likely to complete the program, and had two times higher percentage of meeting the weight-loss milestone compared to the control group. Results for the other incentive cohorts were mixed. A strong positive association was observed for participants who attended 9 or more classes and weight-loss regardless of incentive strategies. Providing monetary incentives for DPP class attendance had a positive impact on program completion and achieving the weight-loss milestone. However, the results from this study indicate that participant enrollment and retention remained challenges despite the incentives.

Effect of Process- and Outcome-Based Financial Incentives on Weight Loss Among Prediabetic New York Medicaid Patients: A Randomized Clinical Trial.

PURPOSE: To determine whether different financial incentives are effective in promoting weight loss among prediabetic Medicaid recipients. DESIGN: Four-group, multicenter, randomized clinical trial. SETTING AND PARTICIPANTS: Medicaid managed care enrollees residing in New York, aged 18 to 64 years, and diagnosed as prediabetic or high risk for diabetes (N = 703). INTERVENTION: In a 16-week program, participants were randomly assigned to one of 4 arms: (1) control (no incentives), (2) process incentives for attending weekly Diabetes Prevention Program sessions, (3) outcome incentives for achieving weekly weight loss goals, and (4) combined process and outcome incentives. MEASURES: Weight loss over a 16-week period; proportion who completed educational sessions; proportion who met weight loss goals. ANALYSIS AND RESULTS: No intervention arm achieved greater reduction in weight than control (outcome incentive -6.6 lb [-9.1 to -4.1 lb], process incentive -7.3 lb [-9.5 to -5.1 lb], combined incentive -5.8 lb [-8.8 to -2.8 lb], control -7.9 lb [-11.1 to -4.7 lb]; all P > .29). Session attendance in the process incentive arm (50%) was significantly higher than control (31%; P < .0001) and combined incentive arms (28%; P < .0001), but not significantly higher than the outcome incentive arm (38%). CONCLUSION: Process incentives increased session attendance, but when combined at half strength with outcome incentives did not achieve that effect. There were no significant effects of either process or outcomes incentives on weight loss.

Financial Incentives for Chronic Disease Management: Results and Limitations of 2 Randomized Clinical Trials With New York Medicaid Patients.

PURPOSE: To identify whether financial incentives promote improved disease management in Medicaid recipients diagnosed with hypertension or diabetes, respectively. DESIGN: Four-group, multicenter, randomized clinical trials. SETTING AND PARTICIPANTS: Between 2013 and 2016, New York State Medicaid managed care members diagnosed with hypertension (N = 920) or with diabetes (N = 959). INTERVENTION: Participants in each 6-month trial were randomly assigned to 1 of 4 arms: (1) process incentives-earned by attending primary care visits and/or receiving prescription medication refills, (2) outcome incentives-earned by reducing systolic blood pressure (hypertension) or hemoglobin A1c (HbA1c; diabetes) levels, (3) combined process and outcome incentives, and (4) control (no incentives). MEASURES: Systolic blood pressure (hypertension) and HbA1c (diabetes) levels, primary care visits, and medication prescription refills. Analysis and Results: At 6 months, there were no statistically significant differences between intervention arms and the control arm in the change in systolic blood pressure, P = .531. Similarly, there were no significant differences in blood glucose control (HbA1c) between the intervention arms and control after 6 months, P = .939. The majority of participants had acceptable systolic blood pressure (<140 mm Hg) or blood glucose (<8.0%) levels at baseline and throughout the study. CONCLUSION: Financial incentives-regardless of whether they were delivered based on disease-relevant outcomes, process activities, or a combination of the two-have a negligible impact on health outcomes for Medicaid recipients diagnosed with either hypertension or diabetes in 2 studies in which, among other design and operational limitations, the majority of recipients had relatively well-controlled diseases at the time of enrollment.

Paying for Outcomes in Medicaid: The Time Is Now.

Medicaid can improve quality and reduce costs by adopting a transparent quality measurement system based on outcomes that will improve quality and reduce costs.

Improving Adjuvant Hormone Therapy Use in Medicaid Managed Care-Insured Women, New York State, 2012-2014.

INTRODUCTION: In 2010, national guidelines recommended that women with nonmetastatic, hormone receptor-positive breast cancer take adjuvant hormone therapy for 5 years. As results from randomized clinical trials became available, guidelines were revised in 2014 to recommend 10 years of therapy. Despite evidence of its efficacy, low initiation rates have been documented among women insured by New York State Medicaid. This article describes a coordinated quality improvement pilot conducted by a state department of health and Medicaid managed care plans to engage women in guideline-concordant adjuvant hormone therapy. METHODS: Women enrolled in Medicaid managed care with nonmetastatic, hormone receptor-positive breast cancer and who had surgery from May 1, 2012, through November 30, 2012, were identified using linked Medicaid and Cancer Registry data. Adjuvant hormone therapy status was determined from Medicaid pharmacy data. Contact information for nonadherent women was supplied to health plan care managers who conducted outreach activities. Adjuvant hormone therapy status in the 6 months following outreach was evaluated. RESULTS: In the 6 months postoutreach, 61% of women in the contacted group filled at least 1 prescription, compared with 52% in the noncontacted group. Among those with at least 1 filled prescription, 50% of the contacted group were adherent, compared with 25% in the noncontacted group. CONCLUSION: This pilot suggests outreach conducted by health plan care managers, facilitated by linked Medicaid and Cancer Registry data, is an effective method to improve adjuvant hormone therapy initiation and adherence rates in Medicaid managed care-insured women.

Opioid Prescriptions Among Women of Reproductive Age Enrolled in Medicaid - New York, 2008-2013.

Exposure to opioids during pregnancy can lead to adverse infant outcomes, including neonatal abstinence syndrome (1) and birth defects (2). Ascertaining opioid prescriptions for women who become pregnant or have no indication of contraceptive use is important to determine the number of women who are at potential risk for adverse fetal outcomes. The New York State (NYS) Department of Health (DOH) analyzed data for women aged 15-44 years (i.e., reproductive-aged women) enrolled in Medicaid to examine opioid drug prescriptions during 2008-2013. On the basis of Medicaid drug claims for any drug with an opioid ingredient, prescriptions were identified for the enrolled population of reproductive-aged women and for three subgroups: women whose diagnosis, procedure, and drug codes indicated contraceptive use or infertility; women who were not using contraceptives and not infertile; and women who had had a live birth during the reporting year. During 2008-2013, among all women of reproductive age, 20.0% received a prescription for a drug with an opioid component; the proportion was highest (27.3%) among women with an indication of contraceptive use or infertility, intermediate (17.3%) among women who had no indication of contraceptive use, and lowest (9.5%) among women who had had a live birth. Although New York's proportion of opioid prescriptions among female Medicaid recipients who had a live birth is lower than a recent U.S. estimate (3), these results suggest nearly one in 10 women in this group may have been exposed to opioids in the prenatal period.

High Intensity of End-of-Life Care Among Adolescent and Young Adult Cancer Patients in the New York State Medicaid Program.

BACKGROUND: Little is known about the care that adolescent and young adult (AYA) cancer patients receive at the end of life (EOL). OBJECTIVE: To evaluate use of intensive measures and hospice and location of death of AYA cancer patients insured by Medicaid in New York State. DESIGN: Using linked patient-level data from the New York State Cancer Registry and state Medicaid program, we identified 705 Medicaid patients who were diagnosed with cancer between the ages of 15 and 29 in the years 2004-2011, who subsequently died, and who were continuously enrolled in Medicaid in the last 60 days of life. We evaluated use of intensive EOL measures (chemotherapy within 14 d of death; intensive care unit care, >1 emergency room visit, and hospitalizations in the last 30 d of life), hospice use, and location of death (inpatient hospice, long-term care facility, acute care facility, home with hospice, home without hospice). RESULTS: 75% of AYA Medicaid decedents used at least 1 aspect of intensive EOL care. 38% received chemotherapy in the last 2 weeks of life; 21% received intensive care unit care, 44% had >1 emergency room visit, and 64% were hospitalized in the last month of life. Only 23% used hospice. 65% of patients died in acute care settings, including the inpatient hospital or emergency room. CONCLUSIONS: Given the high rates of intensive measures and low utilization of hospice at the EOL among AYA Medicaid enrollees, opportunities to maximize the quality of EOL care in this high-risk group should be prioritized.

Underuse of hospice care by Medicaid-insured patients with stage IV lung cancer in New York and California.

PURPOSE: Medicare patients with advanced cancer have low rates of hospice use. We sought to evaluate hospice use among patients in Medicaid, which insures younger and indigent patients, relative to those in Medicare. PATIENTS AND METHODS: Using linked patient-level data from California (CA) and New York (NY) state cancer registries, state Medicaid programs, NY Medicare, and CA Surveillance, Epidemiology, and End Results-Medicare data, we identified 4,797 CA Medicaid patients and 4,001 NY Medicaid patients ages 21 to 64 years, as well as 27,416 CA Medicare patients and 16,496 NY Medicare patients ages ≥ 65 years who were diagnosed with stage IV lung cancer between 2002 and 2006. We evaluated hospice use, timing of enrollment, and location of death (inpatient hospice; long-term care facility or skilled nursing facility; acute care facility; home with hospice; or home without hospice). We used multiple logistic regressions to evaluate clinical and sociodemographic factors associated with hospice use. RESULTS: Although 53% (CA) and 44% (NY) of Medicare patients ages ≥ 65 years used hospice, fewer than one third of Medicaid-insured patients ages 21 to 64 years enrolled in hospice after a diagnosis of stage IV lung cancer (CA, 32%; NY, 24%). A minority of Medicaid patient deaths (CA, 19%; NY, 14%) occurred at home with hospice. Most Medicaid patient deaths were either in acute-care facilities (CA, 28%; NY, 36%) or at home without hospice (CA, 39%; NY, 41%). Patient race/ethnicity was not associated with hospice use among Medicaid patients. CONCLUSION: Given low rates of hospice use among Medicaid enrollees and considerable evidence of suffering at the end of life, opportunities to improve palliative care delivery should be prioritized.

Initiation of adjuvant hormone therapy by Medicaid insured women with nonmetastatic breast cancer.

Hormone therapy is the mainstay of adjuvant treatment for hormone receptor positive (HR-positive) nonmetastatic breast cancer. We evaluated adjuvant hormone therapy (AHT) initiation among Medicaid-insured women aged 21-64 years with stage I-III HR-positive breast cancer. We used multivariable logistic regression to identify independent predictors of AHT initiation. Within 1 year of diagnosis, 68% (1049/1538) initiated AHT; by 18 months, 80% (1168/1461) initiated AHT. In multivariable analysis, women less likely to initiate AHT had more comorbidity (≥ 2 vs none: adjusted odds ratio (AOR) = 0.55; 95% CI = 0.32 to 0.97), more advanced disease (stage III vs I: AOR = 0.27; 95% CI = 0.18 to 0.39), and no radiation after breast conserving surgery (AOR = 0.15; 95% CI = 0.10 to 0.22). Race, age, and history of mental health disorders were not independently associated with initiation of AHT. Among initiators of AHT, 58% (604/1049) were adherent to treatment for the year after initiation. Despite comprehensive prescription coverage, only 39% (604/1538) received optimal AHT including prompt initiation and adherence for the year after treatment. Partnerships between Medicaid programs and cancer registries may help identify at-risk women and facilitate the implementation of quality improvement strategies.

Measuring colorectal cancer care quality for the publicly insured in New York State.

The extent to which concordance with colorectal cancer treatment quality metrics varies by patient characteristics in the publicly insured is not well understood. Our objective was to evaluate the quality of colorectal cancer care for publicly insured residents of New York State (NYS). NYS cancer registry data were linked to Medicaid and Medicare claims and hospital discharge data. We identified colorectal cancer cases diagnosed from 2004 through 2006 and evaluated three treatment quality measures: adjuvant chemotherapy within 4 months of diagnosis for American Joint Cancer Committee (AJCC) stage III colon cancer, adjuvant radiation within 6 months of diagnosis for AJCC stage IIB or III rectal cancer, and adjuvant chemotherapy within 9 months of diagnosis for AJCC stage II-III rectal cancer. Concordance with guidelines was evaluated separately for Medicaid-enrollees under age 65 years and Medicare-enrollees aged 65-79 years. For adjuvant chemotherapy for colon cancer, 79.4% (274/345) of the Medicaid cohort and 71.8% (585/815) of the Medicare cohort were guideline concordant. For adjuvant radiation for rectal cancer, 72.3% (125/173) of the Medicaid cohort and 66.9% (206/308) of the Medicare cohort were concordant. For adjuvant chemotherapy for rectal cancer, 89.5% (238/266) of the Medicaid cohort and 76.0% (392/516) of the Medicare cohort were concordant. Younger age was associated with higher adjusted odds of concordance for all three measures in the Medicare cohort. Racial differences were not evident in either cohort. There is room for improvement in concordance with accepted metrics of cancer care quality. Feedback about performance may assist in targeting efforts to improve care.

Can prenatal care impact future well-child visits? The experience of a low income population in New York State Medicaid managed care.

To examine the association between maternal characteristics and care patterns and the subsequent utilization of well-child visits in a low income population in New York State (NYS). We analyzed Medicaid managed care birth data from 2004 to 2005 linked to an administrative database to obtain information on preventive well-care visits for the child. The outcome variable was whether the child had five or more well-child visits (WCVs) in their first 15 months of life. Of the 101,461 children in this study 67% had received five or more well-child visits by 15 months of age. This varied by region with a lesser proportion of children receiving well-child visits in New York City (NYC) and a higher proportion in the rest-of-state. Children born to mothers with intensive and adequate prenatal care were significantly more likely to have the necessary well-child visits. Foreign born women were more likely than US born women to bring their children in for well-child visits across all racial and ethnic groups. This study indicated that women who received adequate prenatal care were more likely to bring their children to well-child visits even after adjusting for maternal and infant characteristics. Maternal birthplace modified the association between race and well-child visits. The black-white disparity typically seen in WCVs in the United States was not found in NYC among children of US born women in Medicaid managed care.

Preventive care for chronically ill children in medicaid managed care.

OBJECTIVES: To determine whether there is an association between the quality of child preventive care received and the existence of 1 or more chronic conditions. STUDY DESIGN: A retrospective study of all New York State children and adolescents enrolled in Medicaid managed care in 2008. METHODS: Using a cohort identified through mandatory annual quality reporting, a clinical algorithm was applied to administrative data to assign children to 3 health status levels: healthy/ acute, minor chronic, and significant chronic. We performed bivariate and logistic regression analyses to compare the quality of care received by these 3 groups on 10 child-relevant preventive care services. RESULTS: One-fourth of the children in our cohort were deemed to have either minor or significant chronic health conditions. Children with chronic conditions generally had a higher or equal probability of receiving recommended preventive care compared with healthy or acutely ill children, even after controlling for member characteristics. For those services where children with chronic conditions were significantly more likely to receive a preventive care service, the risk ratios ranged from 1.03 to 1.11 for minor chronic children and from 1.03 to 1.17 for significant chronic children. CONCLUSIONS: The quality of preventive health care for children with chronic conditions in New York State Medicaid managed care is equivalent to or better than that for healthy or acutely ill children. Investigating quality concerns for subpopulations of members by combining existing standardized quality measures with administrative health status data is a useful tool for informing state quality-improvement initiatives.

Cancer disparities in the context of Medicaid insurance: a comparison of survival for acute myeloid leukemia and Hodgkin's lymphoma by Medicaid enrollment.

BACKGROUND: Because poverty is difficult to measure, its association with outcomes for serious illnesses such as hematologic cancers remains largely uncharacterized. Using Medicaid enrollment as a proxy for poverty, we aimed to assess potential disparities in survival after a diagnosis of acute myeloid leukemia (AML) or Hodgkin's lymphoma (HL) in a nonelderly population. METHODS: We used records from the New York (NY) and California (CA) state cancer registries linked to Medicaid enrollment records for these states to identify Medicaid enrolled and nonenrolled patients aged 21-64 years with incident diagnoses of AML or HL in 2002-2006. We compared overall survival for the two groups using Kaplan-Meier curves and Cox proportional hazards analyses adjusted for sociodemographic and clinical factors. RESULTS: For HL, the adjusted risk for death for Medicaid enrolled compared with nonenrolled patients was 1.98 (95% confidence interval [CI], 1.47-2.68) in NY and 1.89 (95% CI, 1.43-2.49) in CA. In contrast, for AML, Medicaid enrollment had no effect on survival (adjusted hazard ratio, 1.00; 95% CI, 0.84-1.19 in NY and hazard ratio, 1.02; 95% CI, 0.89-1.16 in CA). These results persisted despite adjusting for race/ethnicity and other factors. CONCLUSIONS: Poverty does not affect survival for AML patients but does appear to be associated with survival for HL patients, who, in contrast to AML patients, require complex outpatient treatment. Challenges for the poor in adhering to treatment regimens for HL could explain this disparity and merit further study.

Building capacity to assess cancer care in the Medicaid population in New York State.

OBJECTIVE: To link data from a central cancer registry with Medicaid enrollment and claims files in order to assess cancer care in an economically disadvantaged population. DATA SOURCES: Over 500,000 cancer patients diagnosed between 2002 and 2006 reported to the New York State Cancer Registry were linked with New York State Medicaid enrollment and claims records. STUDY DESIGN: A probabilistic linkage was performed between the two data sources. The resulting Medicaid and non-Medicaid populations were compared in terms of demographics and stage at diagnosis. DATA COLLECTION METHODS: Existing databases were used. PRINCIPAL FINDINGS: One-quarter of cancer patients were enrolled in Medicaid at or near the time of cancer diagnosis. The Medicaid cohort was younger, more likely to be an ethnic minority, foreign born, never married, live in either an inner-city or remote rural area, and have a higher stage at diagnosis. CONCLUSIONS: The linked dataset will permit detailed analysis of cancer treatment and cancer treatment disparities among historically understudied groups. The linkage has also resulted in improvements in Cancer Registry quality through the identification of errors and missing values. The linkage did present technical challenges in the form of immense file sizes not easily adaptable to desktop computers.

Patterns of injury and childhood psychiatric disorder in a low-income population.

This study examined cross-sectional patterns of association between childhood psychiatric disorders and non-fatal injuries. The study population consisted of 763,251 youth between the ages of five and 18 years. Having any psychiatric diagnosis increased the odds of injury by a factor of two (OR = 2.12, CI 2.08-2.16). Strong associations were found between poisoning and unipolar depression (OR = 5.45, 95% CI 5.02-5.93), bipolar mood disorders (OR = 7.00, 95% CI 6.15-7.95) and major depression (OR = 9.63; 95% CI 8.51-10.89). Medicaid data provide an important resource to examine the intersection of psychiatric diagnosis and injury on a population basis.

Bariatric surgery for obesity: surgical approach and variation in in-hospital complications in New York State.

BACKGROUND: The purpose of this study was to demonstrate the relationship between the surgical approach employed for adults undergoing bariatric surgery for obesity in New York State and in-hospital postoperative complications. Understanding the differences among surgical approaches in terms of the type, extent, and likelihood of postoperative complications and the patient characteristics associated with them, particularly as the annual volume of bariatric surgery increases, can inform decisions about the appropriate bariatric surgical approach for patients with particular characteristics. METHODS: Using New York's inpatient hospital discharge database, we identified 8,413 adults who underwent a bariatric surgical procedure during calendar year 2006. The three most common bariatric surgical approaches were identified, postoperative complication rates and descriptive statistics for the demographic characteristics and comorbidities for patients of each surgical approach were generated, and a logistic regression model was constructed to predict the likelihood of postoperative complications. RESULTS: Of all bariatric surgical patients, 8.1% experienced a postoperative complication, but complication rates varied dramatically across the surgical approaches, with open bypass patients having the highest complication rate and laparoscopic banding patients having the lowest rate. Different complications were associated with the three surgical approaches, as were the various patient demographic characteristics and comorbidities. The multivariate logistic regression indicated that open bypass patients were 5.4 times and laparoscopic bypass patients were 3.2 times more likely to experience a complication compared to laparoscopic banding patients. CONCLUSION: Analyses of bariatric postoperative surgical complications must take into account the surgical approach employed.

Integration of data and management tools into the new york state medicaid managed care encounter data system.

The New York State Department of Health has created a data warehouse to analyze and evaluate the Medicaid managed care program. Online query tools and reports, grouping tools such as Diagnostic Related Groups, and measurement tools such as Health Plan Data and Information Set (HEDIS) measures have been incorporated into the data warehouse. Other public health data sets including birth certificate data have also been integrated. The result is a powerful data set that can analyze information quickly and efficiently, with built-in data intelligence. Developed over time, this system can provide states, health insurance companies, and health data consortiums a roadmap on how to implement an integrated data warehouse solution.