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，但许多美国人仍然对风险因素控制不力 例如血糖、血压和胆固醇。因此，糖尿病仍然是一个主要原因， 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 丧失和截肢许多成年糖尿病患者仍然无法获得协调的医疗团队， 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，或随访以早期发现和治疗合并症 和并发症。证据和实践之间的这种差距不成比例地影响了老年人， 残疾人和穷人。作为这些弱势群体的主要健康保险人，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有可能 改善医疗保健参与、交付和结果。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医疗改革。 资格、覆盖面、人口管理服务和筹资方面的差异。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 糖尿病负担最重的弱势群体的糖尿病护理和结果发生变化。 我们建议建立一个自然实验研究中心，评估：1） 医疗补助管理式医疗保健方法在药房利用管理方面的州特异性变化 成本高但获益独特的新型糖尿病药物：SGLT 2抑制剂;和2）中等- ACA扩大成人糖尿病健康保险覆盖范围的长期影响。我们将 利用我们对两个独特的纵向数据集的访问：（i）来自UnitedHealth Group的国家索赔数据， 在27个州为600万人提供主要的医疗补助管理护理提供者;以及（ii）多州（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有关的电子健康记录。感兴趣的结果将包括 药物依从性、糖尿病护理质量、心脏代谢风险因素控制、急性糖尿病并发症， 其他形式的医疗保健利用和成本。评估国家药物使用政策 管理，我们将使用差异中的差异设计，涉及在以下状态中匹配的比较器： 不同的政策。我们将在新的混合回归中使用来自三个州的相关EHR索赔数据 不连续性（RD）和DiD设计，以研究ACA保险扩张的长期影响。 通过参与国的合作者和数据贡献者的直接参与，我们的研究 是围绕着涉及特定项目有效性的高优先级问题设计的。这些研究 对所有州的州医疗补助计划及其管理式医疗合作伙伴都很感兴趣，我们的结果 将向他们传达这些信息，以指导政策决定，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.