Joseph P. Anarella

Asthma in medicaid managed care enrollees residing in New York City: Results from a post-world trade center disaster survey

The collapse of the World Trade Center on September 11, 2001, released a substantial amount of respiratory irritants into the air. To assess the asthma status of Medicaid managed care enrollees who may have been exposed, the New York State Department of Health, Office of Managed Care, conducted a mail survey among enrollees residing in New York City. All enrollees, aged 5–56 with persistent asthma before September 11, 2001, were surveyed during summer 2002. Administrative health service utilization data from the Medicaid Encounter Data System were used to validate and supplement survey responses. A total of 3.664 enrollees responded. Multivariate logistic regression models were developed to examine factors associated with self-reported worsened asthma post September 11, 2001, and with emergency department/inpatient hospitalizations related to asthma from September 11, 2001, through December 31, 2001. Forty-five percent of survey respondents reported worsened asthma post 9/11. Respondents who reported worsened asthma were significantly more likely to have utilized health services for asthma than those who reported stable or improved asthma. Residence in both lower Manhattan (adjusted OR=2.28) and Western Brooklyn (adjusted OR=2.40) were associated with self-reported worsened asthma. However, only residents of Western Brooklyn had an elevated odds ratio for emergency department/inpatient hospitalizations with diagnoses of asthma post 9/11 (adjusted OR=1.52). Worsened asthma was reported by a significant proportion of this low-income, largely minority population and was associated with the location of residence. Results from this study provide guidance to health care organizations in the development of plans to ensure the health of people with asthma during disaster situations.

Do Commercial Managed Care Members Rate Their Health Plans Differently than Medicaid Managed Care Members

OBJECTIVE To determine if members of commercial managed care and Medicaid managed care rate the experience with their health plans differently. DATA SOURCES Data from both commercial and Medicaid Consumer Assessment of Health Plan Surveys (CAHPS) in New York State. STUDY DESIGN Regression models were used to determine the effect of population (commercial or Medicaid) on a members rating of their health plan, controlling for health status, age, gender, education, race/ethnicity, number of office visits, and place of residence. DATA COLLECTION Managed care plans are required to submit to the New York State Department of Health (NYSDOH) results of the annual commercial CAHPS survey. The NYSDOH conducted a survey of Medicaid enrollees using Medicaid CAHPS. PRINCIPAL FINDINGS Medicaid managed care members in excellent or very good health rate their health plan higher than commercial members in excellent or very good health. There is no difference in health plan rating for commercial and Medicaid members in good, fair, or poor health. Older, less educated, black, and Hispanic members who live outside New York City are more likely to rate their managed care plan higher. CONCLUSIONS Medicaid members rating of their health care equals or exceeds ratings by commercial members.

Quality measurement in medicaid managed care and fee-for-service: the New York State experience.

New York State has transitioned 1.7 million Medicaid recipients from a fee-for-service delivery system to a managed care model. To evaluate whether managed care has had a positive effect on access and quality, the New York State Department of Health compared rates of performance across standardized measures of quality (ie, childhood immunization, well-child visits, prenatal care in the first trimester, cervical cancer screening, use of appropriate medications for people with asthma, and comprehensive diabetes care) in both systems. For almost all measures, Medicaid managed care rates were statistically higher than Medicaid fee-for-service.

Rationale and design of a comparative effectiveness trial of home- and clinic-based self-management support coaching for older adults with asthma.

Older adults with asthma face numerous barriers to effective self-management and asthma control, and experience worse outcomes than younger asthmatics. Yet, there have been no controlled trials of interventions specifically designed to improve their care and outcomes. Through a multi-stakeholder collaboration (patients, academia, community-based organizations, a state department of health, and an advocacy organization) we developed a multi-component asthma self-management support intervention to address the myriad psychosocial, functional, health status, and cognitive barriers to effective asthma self-management in adults ages 60 and older. We are recruiting 425 New Yorkers in Manhattan and the Bronx for a pragmatic randomized controlled trial with 3 arms: the intervention delivered in primary care settings or in their home, or usual care. In the intervention, care coaches use a novel screening tool to identify the specific barriers to asthma control and self-management they experience. Once identified, the coach and patient choose from a menu of actions to address it. The intervention emphasizes efficiency, flexibility, shared decision making and goal setting, communication strategies appropriate for individuals with limited cognition and literacy skills, and ongoing reinforcement and support. Additionally, we introduced asthma-specific enhancements to the electronic health records of all participating clinical practices, including an asthma severity assessment, clinical decision support, and a patient-tailored asthma action plan. Patients will be followed for 12months and interviewed at baseline, 3, 6, and 12months and data on emergency department visits and hospitalizations will be obtained through the New York State Statewide Planning and Research Cooperative System.

Quality oversight and improvement in Medicaid managed care.

New York State has been collecting performance data from managed care plans that serve the Medicaid population since 1993. The data come to the state via the Quality Assurance Reporting Requirements--a series of quality of care, access, and utilization measures, largely based on the Health Plan Employer Data and Information Set, as well as several New York State-specific measures. In addition to collecting the data, the state publishes the information, works with plans that have below average rates of performance and provides a number of program and financial rewards to plans for rates that demonstrate high quality care. An analysis conducted on quality of care measures indicates that: (1) performance rates are increasing over time, (2) Quality Assurance Reporting Requirements rates are generally higher than national benchmarks, (3) the disparity between commercial plan rates and Medicaid rates is diminishing, and (4) the variability in performance across plans is decreasing. The analysis conducted indicates that the performance measurement system constructed in New York is an effective means to monitor health plan performance, while at the same time enabling the state and local health units to monitor population health and accomplishment of key public health objectives (complete immunization, cancer screening, etc.)

Commercial managed care plans leaving the Medicaid managed care program in New York State: impact on quality and access.

To develop sufficient managed care capacity to accomplish the goal of transitioning Medicaid recipients into managed care, state policymakers have relied on commercial health maintenance organizations to open their panels of providers to the Medicaid population. However, while commercial health maintenance organization involvement in Medicaid managed care was high initially, since 1996 New York State has had 14 commercial plans leave the New York State Medicaid Managed Care Program. It has been speculated that the exodus of these commercial plans would have a negative impact on Medicaid enrolleeś access and quality of care. This paper attempts to evaluate the impact of this departure from the perspective of quality and access measures and plan audit performance. Univariate and multivariate analyses were performed to evaluation the effect of commercial managed care plans leaving the Medicaid program. The overall performance of plans that remained in the program was compared to that of the plans that chose to leave for the two time periods 1996–1997 and 1998–2000. Access to care, quality of care, and annual audit performance data were analyzed. The departure of commercial health plans from the New York State Medicaid Managed Care Program has not had a statistically significant negative effect on the quality of care provided to Medicaid recipients as evaluated by standardized performance measures. In addition, there were no instances when there was a negative impact of the exit of the commercial plans on access to care. Managed care plans that chose to remain in Medicaid passed the Quality Assurance Reporting Requirements audit at a significantly (P<.01) higher rate than plans that chose to leave.

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.

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.

Eliminating Disparities in Asthma Care: Identifying Broad Challenges in Quality Improvement:

Racial disparities in asthma care persist in New York State’s Medicaid Program. African Americans with asthma experience higher rates of emergency department visits and inpatient hospitalizations, coupled with lower rates of long-term control medication use compared to other racial/ethnic groups. Within this context, and with funding from the Centers for Disease Control and Prevention, the New York State Department of Health designed and implemented the Eliminating Disparities in Asthma Care (EDAC) Collaborative to improve the quality of asthma care delivered in 7 provider sites located in Central Brooklyn, New York. EDAC was a partnership of the New York State Medicaid and Asthma Control Programs, 6 New York City–based managed care plans, and community-based health care providers. Over the 5-year funding period, improvements in documented asthma severity diagnosis and control classification were observed. This article describes the EDAC approach, successes, and challenges.