Can Medicaid Managed Care mitigate race/ethnic health disparities in diabetes?

摘要 这项研究是一项针对2型糖尿病(T2 DM)种族/民族差异的及时调查 在包括重大大流行休克在内的一段时间内提供护理。T2 DM负担沉重，影响不成比例 弱势和被剥夺公民权的人群；值得注意的是，在T2 DM护理目标方面存在明显的种族/民族差异， 急诊科就诊和住院治疗。医疗补助覆盖了25%患有T2 DM的美国人。更多 全国超过80%的医疗补助受益人至少从医疗补助管理的医疗保健中获得部分护理 组织(MMCO)。各州与私营(非营利性或营利性)MMCO签订合同，以降低成本，增加 质量，并转嫁覆盖医疗补助受益人的财务风险。跨州和州内的异质性 这些计划可能会对T2 DM的护理质量产生影响，特别是通过以下方式影响种族/民族差异 通过慷慨或通过影响MMCO进入和进入后的行为来受益。州政府政策制定者也有 对MMCO竞争的市场产生重大影响，这可能会对 种族/民族差异，因为医疗补助不成比例地覆盖了非白人人口。鲜为人知 关于MMCO及其运营的国家项目是否以及如何影响T2 DM医疗保健方面的差异 以及，新冠肺炎大流行是否或如何改变健康差距的轨迹。我们建议回答 使用收敛的混合方法研究这些未知数：我们将编制一个MMCO/STATE数据库 使用健康差距概念框架(目标1)可能影响护理的方案特点；我们将 经验性地探讨成年T2 DM患者的种族/民族差异，以及这些差异是否因MMCO/州而异 使用转换后的医疗补助统计数据的功能和新冠肺炎前后的综合数据 2016-2025年的信息系统(目标2和目标3)；我们将从以下方面收集和分析定性数据 医疗补助利益攸关方对量化结果进行三角测量和背景分析(目标4)。我们专注于非 残疾、未怀孕的-18岁患有T2 DM的成年人，往往保持稳定的医疗补助覆盖范围 时间到了。为了减少选择偏差，我们将分析重点放在12个州和哥伦比亚特区 参加综合性的MMCO课程。我们将使用面板数据模型来检查种族/民族和特定性别 接受关键的T2 DM服务以及急诊科就诊和住院治疗，总体上和按MMCO/州功能划分。我们会 我还关注2020-2025年持续登记的队列，以评估MMCO/州计划是否以及如何发挥作用 缓和大流行对2型糖尿病差异的影响。敏感度分析将探索员工流失的影响。 此外，我们的初步分析发现，肯塔基州和佛罗里达州在 我们将在这些州进行访谈，以检查MMCO/州的哪些特征和 实施或许可以解释这些差异。这项与政策相关的工作将为以下方面提供关键的见解 医疗补助管理保健计划可以设计为减少慢性病负担方面的差异。

ABSTRACT This study represents a timely investigation that addresses race/ethnic disparities in type 2 diabetes (T2DM) care over a period that included a major pandemic shock. T2DM is burdensome and disproportionately impacts vulnerable and disenfranchised populations; of note, there are stark race/ethnic disparities in T2DM care goals, emergency department (ED) visits, and hospitalizations. Medicaid covers 25% of Americans with T2DM. More than 80% of Medicaid beneficiaries nationally receive at least some of their care from Medicaid managed care organizations (MMCO). States contract with private (non-profit or for-profit) MMCOs to lower costs, increase quality, and pass on financial risks of covering Medicaid beneficiaries. Heterogeneity across and within state programs can have implications for quality of T2DM care and, specifically, race/ethnic disparities through benefit generosity or by affecting MMCO entry and post-entry behavior. State policymakers also have significant influence over marketplaces in which MMCOs compete, which can have consequences for race/ethnic disparities, given that Medicaid disproportionately covers non-white populations. Little is known about whether and how MMCOs and the state programs they operate in influence disparities in T2DM care and, if or how the COVID-19 pandemic changed the trajectory of health disparities. We propose to answer these unknowns using a convergent mixed-methods study: we will compile a database of MMCO/state program features that could influence care using a health disparities conceptual framework (Aim 1); we will empirically explore race/ethnic disparities among adults with T2DM and whether these vary by MMCO/state features and pre-/post-COVID-19 using comprehensive data from the Transformed Medicaid Statistical Information System over 2016-2025 (Aims 2 and 3); and we will collect and analyze qualitative data from Medicaid stakeholders to triangulate and contextualize the quantitative findings (Aim 4). We focus on non- disabled, non-pregnant 18-64-year-old adults with T2DM who tend to remain stably covered by Medicaid over time. To reduce selection bias, we focus our analyses on 12 states and the District of Columbia that mandate enrollment in comprehensive MMCOs. We will use panel data models to examine race/ethnic and sex-specific receipt of key T2DM services and ED visits and hospitalizations, overall and by MMCO/state features. We will also follow a continuously enrolled cohort over 2020-2025 to assess if and how MMCO/state program features moderate the pandemic’s effects on T2DM disparities. Sensitivity analyses will explore the influence of churn. Further, our preliminary analyses identify Kentucky and Florida as having the lowest and highest disparities in T2DM care, respectively; we will conduct interviews in these states to examine what MMCO/state features and implementation might explain these disparities. This policy-relevant work will provide critical insights into how Medicaid managed care programs can be designed to reduce disparities in chronic disease burdens.