Beyond Health Plans

BACKGROUND: Most health insurance plans monitor ambulatory care quality using the Healthcare Effectiveness Data and Information Set (HEDIS), publicly reporting results at the plan level. Plan-level comparisons obscure the influence of patients served or settings where care is delivered. Mental illness, substance abuse, and other physical comorbidities, particularly prevalent among Medicaid beneficiaries, can impact adherence to recommended care. We analyzed individual-level HEDIS measures for diabetes and asthma from 5 Medicaid managed care plans to understand how these factors contribute to quality. METHODS: We used claims and medical records to study HEDIS measures for persistent asthma (n = 9103) and diabetes (n = 1790) among beneficiaries enrolled in Massachusetts' Medicaid program during 2004 and 2005. Logistic regression models included patient-level demographic and health factors, provider type, region, and managed care plan. RESULTS: Alcohol and drug use disorders and emergency department use were associated with lower quality care for most measures. Glycemic control was better for patients with diabetes and severe mental illness. Patients with higher illness burden and with more frequent ambulatory visits received higher quality care for both conditions. Younger adults received recommended care less often than older adults. Quality varied across plans. CONCLUSIONS: Additional efforts to improve quality of care for asthma and diabetes for Medicaid beneficiaries are needed for individuals with substance use disorders and young adults. Although evidence of higher quality for patients with multiple conditions is encouraging, improving quality for comparatively healthier individuals might also produce significant long-term benefits

MEDLINE · Political science · Chronic Disease Management Strategies · Diabetes Management and Education · Medicine · Primary Care and Health Outcomes

• Older Adults’ Inpatient and Emergency Department Utilization for Ambulatory-Care-Sensitive Conditions

  Open Access•Elizabeth S Levy Merrick, Dominic Hodgkin et al.•Journal of Aging and Health•2010

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• Health Care Utilization Patterns of Homeless Individuals in Boston

  Monica Bharel, Carmen Bravo-Villasante et al.•American Journal of Public Health•2013

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• Frequent Emergency Department Visits and Hospitalizations Among Homeless People With Medicaid

  Wen-Chieh Lin, Wen‐Chieh Lin et al.•American Journal of Public Health•2015

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• Associations of Co-Occurring Substance Use Disorder With Diabetes Care Quality, Complications, and Hospitalizations

  Michele Knox, Dominic Hodgkin et al.•Medical Care•2025

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• Mental Comorbidity and Quality of Diabetes Care Under Medicaid

  Benjamin G Druss, Liping Zhao et al.•Medical Care•2012

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• The Effect of a Telephone-based Health Coaching Disease Management Program on Medicaid Members With Chronic Conditions

  Wen-Chieh Lin, K Fellinger et al.•Medical Care•2012

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• Racial Disparities in the Quality of Care for Enrollees in Medicare Managed Care

  Eric C Schneider•JAMA•2002

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• The Effects of Patient Volume on the Quality of Diabetic Care for Medicare Beneficiaries

  Eric S Holmboe, Yun Wang et al.•Medical Care•2006

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• Nonurgent Emergency Department Visits

  Laura A Petersen, Helen Burstin et al.•Medical Care•1998

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• Impact of Sociodemographic Case Mix on the Hedis Measures of Health Plan Quality

  Alan M Zaslavsky, John N Hochheimer et al.•Medical Care•2000

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• Prospective association of anxiety, depressive, and addictive disorders with high utilization of primary, specialty and emergency medical care

  Open Access•Julián D Ford, Robert L Trestman et al.•Social Science & Medicine•2004

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