Effects of Medicaid Coverage and State-Level Delivery Approaches on Healthcare Quality, Outcomes, and Costs for Adults with Diabetes

项目摘要 尽管在糖尿病方面取得了巨大的进步，但许多美国人对风险因素的控制仍然很差 比如血糖、血压和胆固醇。因此，糖尿病仍然是主要原因。 死亡和许多可预防的并发症，如心脏病、中风、慢性肾脏疾病、视力 损失和截肢。许多患有糖尿病的成年人仍然无法获得协调的医疗团队，而且 完成循证预防服务，接受可能改善疾病的药物或技术 护理、参与自我管理行为，或对合并症的早期发现和治疗进行随访 和并发症。证据和实践之间的差距对老年人、那些有 残疾人和穷人。作为这些弱势群体的主要健康保险公司，医疗补助政策 扩大资格要求或降低启动高价值药物的门槛可能会 改善医疗服务参与度、提供情况和结果。各州在管理方面有很大的灵活性 医疗补助计划、《平价医疗法案》和其他医疗改革进一步催化了州一级的 在资格、覆盖范围、人口管理服务和融资方面的差异。这种变化呈现出一种 自然实验评估政策的相对有效性和成本的巨大机会 在糖尿病负担最重的弱势群体中，对糖尿病的护理和结果的转变。 我们建议建立一个自然实验研究中心，它将评估：1)健康和经济影响 医疗补助管理保健方法在药房利用管理中的州特有差异影响 成本较高但疗效独特的新型糖尿病药物：SGLT2抑制剂；以及2)中- ACA扩大成人糖尿病医疗保险覆盖范围的较长期影响。我们会 利用我们对两个独特的纵向数据集的访问：(I)UnitedHealth Group的国家索赔数据，a 为27个州的600万人提供主要的医疗补助管理保健提供者；以及(Ii)多个州(伊利诺伊州，印第安纳州， 威斯康星州)与医疗补助和医疗保险索赔相关的电子健康记录。感兴趣的结果将包括 服药依从性、糖尿病护理质量、心脏代谢危险因素控制、急性糖尿病并发症、 其他形式的医疗保健利用，以及成本。评估国家用药政策 管理，我们将使用差异中的差异设计，在具有 不同的政策。我们将在新的混合回归中使用来自三个州的关联EHR-索赔数据 不连续性(RD)和DID设计来研究ACA保险扩展的长期影响。 通过参与州的合作者和数据贡献者的直接参与，我们的研究 围绕涉及特定计划有效性的高优先级问题进行设计。这些研究 对各州的医疗补助计划和他们在各州的管理医疗合作伙伴高度感兴趣，以及我们的结果 将传达给他们，以指导政策决策，并促进未来新的自然实验。

Project Summary Despite tremendous advances in diabetes, many Americans continue to have poor control over risk factors such as blood glucose, blood pressure, and cholesterol. As a result, diabetes continues to be a leading cause of death and many preventable complications, such as heart disease, stroke, chronic kidney disease, visual loss, and amputation. Many adults with diabetes still lack access to a coordinated healthcare team and do not complete evidence-based preventive services, receive medications or technologies that may improve disease care, participate in self-management behaviors, or follow-up for early detection and treatment of comorbidities and complications. This gap between evidence and practice disproportionately impacts the aged, those with disabilities, and the poor. As the primary health insurer for these vulnerable groups, Medicaid policies that expand eligibility requirements or lower barriers for initiating high value medications have the potential to improve healthcare engagement, delivery, and outcomes. States have a great deal of flexibility in administering Medicaid programs, and the Affordable Care Act and other health reforms further catalyzed state-level variation in eligibility, coverage, population management services, and financing. This variation presents a tremendous opportunity for natural experiments to evaluate the comparative effectiveness and costs of policy shifts on the care and outcomes of diabetes in vulnerable groups for whom the burden of diabetes is highest. We propose a Natural Experimental Research Center that will evaluate: 1) health and economic effects of state-specific variation in Medicaid managed care approaches for pharmacy utilization management affecting a newer class of diabetes medications with high costs but unique benefits: SGLT2 inhibitors; and 2) the medium- to longer-term effects of ACA expansion of health insurance coverage for adults with diabetes. We will leverage our access to two unique longitudinal datasets: (i) national claims data from UnitedHealth Group, a major Medicaid managed care provider for 6 million people in 27 states; and (ii) multi-state (Illinois, Indiana, Wisconsin) electronic heath records linked to Medicaid and Medicare claims. Outcomes of interest will include medication adherence, diabetes care quality, cardiometabolic risk factor control, acute diabetes complications, other forms of healthcare utilization, and costs. To evaluate state policies for medication utilization management, we will use difference-in-differences designs involving matched comparators in states with different policies. We will use the linked EHR-claims data from three states in novel, hybrid regression discontinuity (RD) and DiD designs to study the longer-term effects of ACA insurance expansion. Through direct engagement of collaborators and data contributors in participating states, our studies have been designed around high priority questions involving the effectiveness of particular programs. These studies are of high interest to state Medicaid programs and their managed care partners in all states, and our results will be communicated to them to guide policy decisions and to facilitate new natural experiments in the future.