Download - TEXAS - cdn.ymaws.com
i
PREPARED FOR
Methodist Healthcare Ministries
of South Texas, Inc.
by UT School of Public Health
Charles Begley, Ph.D., Lee Revere, Ph.D., Ellerie Weber, Ph.D., Alissa Ratanatawan, Ph.D. Candidate, Youngran Kim, Ph.D. Candidate, Hsiao Ling Phuar, Ph.D. Candidate
August 2016
TEXAS MEDICAID PERFORMANCE STUDY
2 0 1 6 F I N A L R E P O R T
ACKNOWLED GEMENT
Methodist Healthcare Ministries of South Texas, Inc. gratefully
acknowledges The University of Texas Health Science Center of
Houston School of Public Health and each of the researchers who
contributed their time, expertise and skill in researching and producing
the data and content featured in this report, most especially
Charles Begley, Ph.D., Lee Revere, Ph.D., Ellerie Weber, Ph.D.,
Alissa Ratanatawan, Ph.D. Candidate, Youngran Kim, Ph.D. Candidate
and Hsiao Ling Phuar, Ph.D. Candidate.
Methodist Healthcare Ministries also gratefully acknowledges the
Texas Association of Community Health Plans for their support of this
effort and the technical assistance provided to the researchers.
1
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2–3
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5–7
Well-Child Visits in the First 15 Months of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
HEDIS Measures of Access and Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Related Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6–7
Well Child Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6–7
Cesarean Section Deliveries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Asthma Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8–11
Truven Health Analytic MarketScan Commercial Claims and Encounters . . . . . . . . . . . . . . . . . . . 8–9
Texas Medicaid Claims and Encounters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Access and Quality Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Well Child Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Prenatal Visit and Cesarean Section Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Asthma Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10–11
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12–19
Well-Child Visits in the First 15 Months of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12–13
Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Adolescent Well-Child Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Prenatal Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Cesarean Section Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Asthma Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18–19
Hospitalizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Emergency Department Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20–21
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Appendix 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23–26
Changes in HEDIS Measures for Year 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Changes in HEDIS Measures for Year 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Changes in HEDIS Measures for Year 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Changes in HEDIS Measures for Year 2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Appendix 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27–29
Summary of Medicaid/Commercial Comparison Studies Published Since 2000 . . . . . . . . . . . . . . . . 27–29
TABLE OF CONTENTS
2
EXECUTIVE SUMMARY
As part of the effort to assess and monitor Medicaid
performance under capitated managed care, the
Texas Health and Human Services Commission
(HHSC) contracts with the Institute for Child Health
Policy at the University of Florida as the External
Quality Review Organization (EQRO) to compare
access and quality measures of MCO performance to
state and national standards. To complement the
work of the EQRO, the University of Texas School of
Public Health (UTSPH) is using all payer administrative
claims and encounter data to compare access and
quality measures of Medicaid enrollees to populations
with commercial coverage.
FOR THIS STUDY, WE SELECTED FOUR MEASURES OF ACCESS TO PREVENTIVE CARE AND THREE MEASURES OF QUALITY OF CARE THAT ARE COMMONLY USED TO EVALUATE MCO PERFORMANCE FOR MEDICAID CHILDREN AND PREGNANT WOMEN:
• well child visits in the first 15 months of life,
• well child visits in the third, fourth, fifth and six years of life,
• adolescent well care visits,
• timeliness of prenatal care,
• Cesarean-section deliveries,
• childhood asthma hospitalizations, and
• childhood asthma emergency department visits.
We calculated Medicaid rates for these measures for
2011-2012 using Texas Medicaid enrollment, claims,
and encounter data and commercial rates for
2011-2013 using Truven’s Market Scan claims dataset.
We conducted a statistical test of the differences
between Medicaid MCO and commercial rates
and a logistic regression analysis controlling for
demographic, socioeconomic status (SES), and
geographic differences in the populations.
The results indicate that access and quality in the
Texas Medicaid program is comparable to that in the
commercial PPO insured population. Four out of
seven Medicaid MCO rates (well-child visits for
adolescents, timely prenatal care visits for pregnant
women, C-section deliveries, and inpatient stays for
asthmatic children) were better than PPO rates for
each comparison year, two were worse (well-child
visits for infants 0-15 months and ED visits for
asthmatic children), and one (well-child visits for
children aged 3-6 years) was better for Medicaid
MCO children in 2011 but worse in 2012 (see Table
below). Similarly, in the logistic regression analyses,
three out of seven odds ratios indicating the
likelihood of a well-child visit for adolescents, timely
prenatal care for pregnant women, and inpatient stay
for asthmatic children were significantly better for
Medicaid MCOs, three were better for commercial
PPO children (well-child visits for infants 0-15
months, well-child visits for children aged 3-6 years,
and ED visits for asthmatic children), and there
was no difference for one (the likelihood of a
C-section rate).
3
Medicaid MCO versus Commercial Performance
Rates Rates
Medicaid MCOEnrollees Truven PPO EnrolleesAdjusted Odds Ratio
(95% CI)2011 2012 2013 2011 2012 2013
Six or More Well-Child Visits Infants First 15 Months
61.1* 59.8* NA NA 82.8 93.8 .272 (.260 -. 284)
Well-Child Visits Age 3-6 77.8** 75.1* NA 77.5 81.0 NA .857 (.846 - .868)
Well-Child Visits Adolescents 60.8** 58.7** NA 40.8 43.0 NA 1.823 (1.805 – 1.842)
Timeliness of Prenatal Care 81.0** 75.6** NA 64.7 62.9 NA 2.225 (2.167 – 2.285)
Cesarean Delivery 34.3** 35.2** NA 39.7 39.4 NA .984 (.961 – 1.008)
Asthma Inpatient 122.8** 136.7** NA 383.4 387.8 NA .206 (.191 - .222)
Asthma ED Visits 1,201.0* 1,219.1* NA 771.2 775.2 NA 1.659 (1.550 – 1.775)
* Medicaid MCO rate significantly worse than Commercial PPO
** Medicaid MCO rate significantly better than Commercial PPO
NA – not available
EXECUTIVE SUMMARY
INTRODUCTION
Concerns about the rising cost of medical care and
the growing number of enrollees have led Texas
officials to turn to capitated managed care as the
predominant delivery model for Medicaid and
Children’s Health Insurance Program (CHIP) services.
Under this model, the state pays private managed
care organizations (MCOs) a fixed rate per member
per month, and the MCOs are responsible for the
cost of a defined set of services used by enrollees.
The MCOs may also offer value-added services such
as sports/gym memberships, respite care, pest
control, etc., to attract members. The evolution from
fee-for-service to the capitated MCO model for
Medicaid and CHIP enrollees began in the early
1990s and went through several periods of expansion
to different parts of the state and covered
populations. Currently, there are 19 MCOs serving 13
managed care service areas, with ten areas built
around major metropolitan population centers and
three covering large rural regions of the state.
In 2011, the percentage of the Medicaid population
enrolled in MCOs was 71%. As of November 2013,
81% of Medicaid enrollees were covered by MCOs
and the percentage was expected to exceed 90% by
the end of 2015.1 The two main Medicaid MCO
programs are State of Texas Access Reform (STAR),
which mainly covers acute care for pregnant women
and children, and STAR+PLUS, which combines
acute care with long-term services and supports for
adults and children who have a disability or who are
age 65 and older. STAR+PLUS also includes a large
population of beneficiaries who are dually enrolled in
both Medicaid and Medicare. The STAR Health
program which covers acute care for foster care
children and STAR Kids, which is being phased in this fall to
serve youth and children with disability-related Medicaid.
The federal government requires Texas to assess and
monitor Medicaid performance under capitated
managed care with respect to access and quality. As
part of the monitoring effort, the Health and Human
Services Commission (HHSC) contracts with the
Institute for Child Health Policy at the University of
Florida as the External Quality Review Organization
(EQRO) to compare utilization-based measures of
MCO performance to Medicaid state standards and
national benchmarks.2 To supplement the Medicaid
comparisons approach used by the EQRO for
assessing performance, the University of Texas
School of Public Health (UTSPH) faculty and students
are comparing utilization measures of access and
quality for Medicaid enrollees to that of similar
populations in Texas with commercial coverage using
all payer administrative claims and encounter data.
The specific objectives of the UTSPH study are to: 1)
compare recent trends in Health Effectiveness Data
and Information Set (HEDIS)-based healthcare
utilization rates among Medicaid and commercially
insured populations across the state, and 2)
determine at the individual level if access and quality
measures differ between Medicaid and commercial
enrollees after controlling for a robust set of
demographic, socio-economic, and geographic
covariates. This report provides background
information on access and quality activities of MCOs
and commercial plans, describes HEDIS measures
used in the study, and summarizes recent literature
on Medicaid/commercial performance comparisons
in other states. We then describe our data and
methods, and present results.
4
5
WELL-CHILD VISITS IN THE FIRST 15 MONTHS OF LIFE
The overall stated goal of Texas Medicaid MCOs is to
deliver quality, cost-effective care through the medical
home model. The MCO model is designed to ensure
that enrollees are connected to a primary care provider
and have access to a network of specialty providers.3
In addition, the MCOs participate in a number of
quality assessment and performance improvement
programs and reporting activities required under their
contracts with HHSC.3 MCOs participating in STAR,
STAR+Plus, CHIP, and STAR Health are required to
provide disease management programs covering
Asthma and Diabetes. STAR+Plus plans are also
required to provide these programs for chronic
obstructive pulmonary disease, congetstive heart
failure, and coronary artery disease. The MCOs are also
required to develop value-based purchasing initiatives
and must submit these plans to HHSC outlining the
proposed payment methods that encourage quality
outcomes and reduce inappropriate utilization of
services. In addition, the state’s contract requires each
STAR MCO to have a program for targeting,
outreaching, and educating members who have high
utilization patterns. HHSC has recently launched a
new initiative to conduct individual quarterly calls with
MCOs to maintain an interactive dialogue on priority
areas related to quality and efficiency.
Similar to Medicaid, commercial insurance plans are
experiencing increasing pressure to provide high
quality, lower cost care. The shift to “value-based” care
is a major objective of the Affordable Care Act of 2010.4
Some of the required changes for insurance carriers
under the ACA directly and indirectly impact access,
cost and quality. For example, beginning in 2010
consumers were able to go online to compare and
select amoung health insurance coverage options.
The lifetime cap on coverage benefits was eliminated
and many preventative services no longer require
copayments or cost sharing. Coverage has been
extended to a number of uninsured individuals with
pre-existing conditions as well as young adults who
became eligible under their parents’ insurance plan.
During 2011, large employer commercial plans were
required to spend 85 percent of their premium dollars
on healthcare service and/ or quality improvement.4
These commercial plans typically offer financial
incentives to providers who achieve specific
improvements in the health of members. The plans also
track health metrics in patients and providers may
receive financial rewards and recognition for meeting
the requirments of different quality improvement and
cost containment programs. Many commercial plans
are adopting quality improvement initiatives similar to
those in Medicare and Medicare Advantage plans. In
2012, the ACA established value-based payment
programs, which offer financial incentives to hospitals
to improve the quality of care and publicly reported
performance measures of network providers are being
put in place. In addition, incentives exist for physicians
to join and/or form Accountable Care Organizations
that incentivize doctors and hospitals to coordinate
patient care and improve quality. Implementing
alternative payment models such as bundled
payments, and other initiatives to build a more
competitive and transparent health insurance
marketplace are being piloted. Under the ACA, 2013
required essential health benefits for plans competing
in the small group and individual markets, but not the
large group market and in 2014 insurers were required
to provider coverage regardless of pre-existing
conditions. All told, because of the ACA and responses
to market pressures, access and quality have also been
a major emphasis of commercial plans in recent years.
BACKGROUND
6
BACKGROUND
HEDIS MEASURES OF ACCESS
AND QUALITY
The Healthcare Effectiveness Data and Information Set
(HEDIS) is a set of performance measures designed to
evaluate utilization and outcomes across manage care
plans. The reporting of HEDIS measures was originally
mandated by the Centers for Medicare and Medicaid
Services (CMS) for Medicare Advantage plans but has
since become an industry standard. Health plan
incentive payments are often tied to achieving HEDIS
benchmarks. Employers, consultants, and consumers
often use HEDIS data to help them select the best
health plan for their needs. Because HEDIS measures
are publicly available and are designed to influence
consumer behavior, managed care plans continue to
focus on achieving, improving and surpassing HEDIS
benchmark standards. Currently, HEDIS is used by
more than 90 percent of America’s health plans to
measure performance on important dimensions of care
and service. The HEDIS measures are updated annually
by NCQA’s Committee on Performance Measurement
to assure the measures continue to be relevant.6
Updates to HEDIS measures relevant for this study can
be found in the Appendix 1.
There are 83 HEDIS 2015 measures across five domains
of care. For this report, we selected four HEDIS
measures of access to preventive care that are relevent
to the Medicaid population:
• well child visits in the first 15 months of life,
• well child visits in the third, fourth, fifth and six years of life,
• adolescent well care visits, and
• timeliness of prenatal care (a component of the pre and post natal care measure).
In addition to the preventive care access measures, we
selected three population-relevent quality of care
indicators for the study:
• Cesarean-section delivery rates,
• childhood asthma hospitalization rates, and
• childhood asthma emergency department visit rates.
RELATED LITERATURE
We conducted a literature review to identify and
summarize studies published since 2000 that
compared similar access and quality indicators of
Medicaid and commerically insured populations in
other states. We searched the Pubmed database
using the following key words: Medicaid, commercial
or private insurance, claims, well child visits, prenatal
care, cesarean section, asthma, hospitalization, and
emergency care. After screening titles and abstracts,
we identified eight studies that reported and
compared utilization rates for well-child visits,
Cesarean section deliveries, and asthma care. The
table in Appendix 2 summarizes the key characteristics
of the studies and their major findings. Relevant
findings from the studies are summarized below.
WELL CHILD VISITS: Kenny and Coyer (2012), using
NHIS and MEPS survey data from 2008 and 2009,
reported comparable rates of primary and preventive
care among the two groups. Medicaid children
reported a slightly higher rate of well child visits while
having slightly lower rates of office visits compared to
those with commercial insurance. Ku (2009) also used
MEPS survey data from 2005 to show equivalency
between the average number of office visits and
outpatient hospital visits. A comparison of Medicaid
and commercially insured children conducted by the
7
U.S. Department of Health and Human Services
(Sebelius 2011) using claims data showed mixed
results for different age groups. Fifty-six percent of
Medicaid children 0-15 months of age had 6 or more
well child visits as compared to 76% of commercially
insured children. The gap between Medicaid and
commercially insured was smaller for older children,
and was reversed for adolescents. Sixty-four percent
of Medicaid children 3-6 years of age and 47% of
Medicaid children 12-21 years of age had at least one
well-child visit compared to 71% and 41% respectively
for the commercially insured population.
CESAREAN SECTION DELIVERIES: Only one study
was found comparing Cesarean section (C-section)
rates in Medicaid to commercially insured. It was
completed by linking Michigan medical record and
hospital discharge data by Movsas et al. (2012). The
study found that C-section rates were 29% of births for
Medicaid women and 33% for commercially insured
women during the timeframe of 2004 to 2008.
ASTHMA CARE: Merrick et al. (2001) found asthmatic
children on Medicaid had slightly longer lengths of
hospital stays compared to commercially insured
children. Medicaid children with asthma were more
likely to be re-admitted for hospitalization following a
hospital discharge for asthma. Peters et al (2008)
found that hospitalizations and ED visit rates of
Medicaid adults with severe or difficult-to-treat
asthma were significantly higher than commercially
insured (OR 3.08; 95% CI 2.11 - 4.50). Similarly,
Finkelstein et al (2000), in comparisons of asthma care
for Medicaid and commercially insured children within
the same HMO using 1991–1996 medical records and
claims data, found Medicaid children were more likely
to receive care in the ED (IRR 1.4; 95% CI 1.2 – 1.5) and
were more likely to be hospitalized for their asthma
(IRR1.3; 95% CI 1.1 – 1.5). Both groups had similar
rates of ambulatory visits for asthma.
Fingar and Washington (2015) reported a higher
percentage of potentially preventable pediatric
inpatient stays for asthma in Medicaid enrollees
compared to commercially insured populations using
the Nationwide Inpatient Sample (NIS) data during
2003-2012. In 2003, the two groups had almost
equivalent rates of 46.9% and 46.4%.. However, by
2012 the Medicaid rate had increased to 58.1% while
the rate for commercially insured children decreased
to 35.5%.
SUMMARY: The findings from the literature are
mixed. Three studies showed equivalency between
Medicaid and commercially insured based on rates for
well-child visits for children in different age groups.
One study suggested better performance for
Medicaid based on lower rates of C-section deliveries.
All four studies comparing hospitalization rates,
lengths of stays, and ED visits of Medicaid and
commercially insured children and adults with asthma
found higher rates for Medicaid.
BACKGROUND
8
METHODS
We selected a total of seven measures that summarize various aspects of access and quality among Medicaid and
commercially insured women and children. Three of these measures are well-child visit rates, two are pregnancy and
birth related rates, and two are asthma related rates. We calculated the rates for the entire Medicaid population and
for Medicaid MCO enrollees using the Texas Medicaid enrollment, claims, and encounter data obtained from the
Texas HHSC. We calculated commercial rates for PPO members using Truven’s Market Scan claims dataset. The
years of interest for both populations were 2011-2013 but due to administrative delays we have only been able to
include 2011 and 2012 data from Medicaid.
TRUVEN HEALTH ANALYTIC
MARKETSCAN COMMERCIAL CLAIMS
AND ENCOUNTERS
The Truven MarketScan database includes active
employees, early retirees, COBRA enrollees, and
dependents, all of whom are insured through
employer self-insured (ESI) plans. ESI plans are
regulated by the federal Employee Retirement
Income Security Act (ERISA). Employers who self-fund
their health plans pay the costs of their employee’s
health care themselves, rather than buying coverage
from an insurance company or HMO. Coverages may
vary by plan and employer. Employers who self-fund
their health plans may require employees to
contribute to the cost of the plan.
Federal law exempts large-group ESI plans from the
essential health benefits requirement of the ACA and
rating requirements that apply to individual and
small-group plans. Like other comprehensive health
plans, however, large-employer ESI plans must
provide preventive services with no copayments or
deductibles. Depending on age and gender, regular
check-ups, blood pressure and diabetes testing,
contraceptives, mammograms, cancer screenings,
and flu shots are covered free of copayments or
deductibles. The plans may not have lifetime or
annual dollar limits on coverage, and they can’t
deny coverage because of preexisting conditions
or health history.
Information on healthcare coverage eligibility and
individual level healthcare service use is included in
the Truven dataset. The data are divided into eight
tables which include: 1) inpatient admission records;
2) facility claims data; 3) individual facility and
professional encounters and services that the
inpatient admission record comprises; 4) outpatient
encounters and claims for services that were rendered
in a doctor’s office, hospital outpatient facility,
emergency room, or other outpatient facility; 5)
aggregated population tables which provide quarterly
counts of covered lives for medical/surgical and
outpatient pharmaceutical claims data for calculating
rate-based statistics; 6) outpatient pharmaceutical
claims; 7) annual enrollment summary tables;
and 8) person-level enrollment records with
demographic and plan information on users
and non-users of services.
The enrollment files contain information on age, birth
year, employee classification, employment status,
geographic location of employee, relation of enrollee
9
to employee, enrollment data, health plan type,
industry type, metropolitan statistical area (MSA),
gender, and three-digit zip code. The claims and
encounter files contain diagnosis codes (ICD 9 CM
diagnosis and DRG), procedure codes (ICD 9 CM
procedure, HCPCS, and CPT), revenue code, place of
service, provider type, along with information on type
of claim, date when claim was filed, dates of service
and payment information.
The commercial population selected for this study
were children 21 years of age and pregnant women
who were enrolled in PPO plans. These plans
represent the vast majority of individuals with
coverage in the Truven database. The study
population was linked to the medical claims and
encounter files and utilization rates were calculated
for each of the study’s outcome measures.
TEXAS MEDICAID CLAIMS
AND ENCOUNTERS
The Texas Medicaid data for 2011 and 2012 were
made available to UTSPH through an agreement with
HHSC. The Medicaid data consist of six files for each
year: 1) enrollment files with demographic, eligibility
and enrollment information in a per member per
month basis; 2) claim files containing the utilization
information for fee-for-service and primary care case
management Medicaid enrollees; 3) encounter files
containing utilization information for enrollees in
MCOs; 4) diagnosis files containing 25 additional
diagnosis fields apart from the primary diagnoses
contained in the claims files; 5) prescription drug files;
6) provider files with information about health care
providers who delivered the services. Texas Medicaid
rates were derived by linking the enrollment, claim
and encounter data for the study period. Medicaid
children < 21 years of age and pregnant women
whose enrollment was due to low-income status or
pregnancy were selected. Those enrolled due to
disability, foster care, social security income receipt,
legal or illegal immigrant status but requiring
emergency care, adoption subsidy receipt, or
dual-eligibility for Medicare and Medicaid
were excluded.
METHODS
10
METHODS
ACCESS AND QUALITY MEASURES
WELL-CHILD VISITS: As an indicator of access to
preventive services, the following well-child visit rates
were computed and compared for all continuously
enrolled Medicaid children, Medicaid children
enrolled in MCO plans, and children in Truven PPO
plans (Table 1):
• Children age 0 through 15 months with 6 or more well-child visits
• Children age 3 , 4, 5, or 6 with at least one well-child visit
• Adolescents age 12 – 21 years with at least one well-child visit
PRENATAL VISIT AND CESAREAN SECTION RATES: As indicators of acess and quality, the
following pregnancy related measures of utilizaiton
were computed for all continuously enrolled Medicaid
women, Medicaid women enrolled in MCO plans, and
women in Truven PPO plans (Table 1):
• Deliveries in which the mother received a prenatal care visit in the first trimester or within 42 days of enrollment
• Births by Cesarean section
ASTHMA CARE: The following asthma-related
utilization rates were computed for Medicaid children,
Medicaid children enrolled in MCO plans, and
children in Truven PPO plans (Table 1):
• Asthma related hospitalizations per 1,000 asthmatic children per year
• Asthma related emergency department visits per 1,000 asthmatic children per year
ANALYSIS
To assess performance based on rate comparisons,
we compared our seven measures of utilization for
Texas Medicaid enrollees with Texans who have
employer-based commercial PPO insurance using the
Truven database. We compared rates for each
measure for three covered populations for each year:
Medicaid, Medicaid MCO, and commercial PPO. To
assess whether the yearly rates between Medicaid and
the commercial PPO population were significantly
different, we completed a statistical test of the
differences in proportions between the Medicaid
MCO and commercial PPO population, given two
independent samples, using a z-score. Each outcome
measure is considered a proportion (e.g. the
Table 1. Measures Used to Assess Performance
Well-Child VisitsWell-Child Visits in the First 15 Months of Life
Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life Adolescent Well-Care Visits
Pregnancy Related Outcomes Timeliness of Prenatal Care
Cesarean Section Deliveries
Asthma CareAsthma Inpatient Utilization
Asthma Emergency Department Utilization
11
proportion of children 0-15 months receiving well-
child visits), and the independent samples are the
Medicaid MCO and commercial PPO populations.
The null hypothesis is that a particular outcome
measure is the same for both populations, while the
alternative is that they are significantly different.
The test statistic used to test the hypothesis was :
where ^Pm is the estimated outcome measure in the
Medicaid MCO population, ^Pc is the estimated
outcome measure in the commercial PPO population, ^P is the estimated outcome measure in pooled
populations (Medicaid MCO and commercial PPO
together), Nm is the number of Medicaid MCO
enrollees, and Nc is the number of commercial PPO
enrollees. If the test statistic is greater than the upper
critical value (1.96), or lower than the lower critical
value (-1.96), then we rejected the null hypothesis at
the 5% significance level.
The second method used to test differences in each
measure across the two populations was a regression
analysis to determine the likelihood of a particular
outcome measure while controlling for underlying
demographic, socioeconomic status (SES), and
geographic differences in the populations that may
be correlated with the outcome measures. For this
method, we ran the following regression at the
individual enrollee level:
where Yi is the outcome measure of interest for
specific individuals in the Medicaid MCO and
commercial PPO population, Insi is a binary variable
that indicates whether the individual has Medicaid
MCO or commercial PPO insurance, Zi is a set of
control variables, including gender and age, SES
characteristics, and a geographic access indicator, and
Ei is uncontrolled error.
The main variable of interest is Insi, and the coefficient
on this variable tells us whether having commercial
insurance vis-à-vis Medicaid MCO coverage leads to
significantly better or worse outcomes, while
controlling for the remaining model variables. Gender
was coded as male or female and age a continuous
whole number variable for years old. Neither the
Medicaid nor Truven datasets contain individual-level
SES variables on employment, income, or education.
However, they contain zip code identifiers that were
used to obtain aggregate zip code-level SES variables
from the US Census data. Individuals within Medicaid
MCO and Truven PPO were given the SES and access
variables which corresponding to the zip code in
which they live. The SES zip-code level control
variables included: percent unemployed of the civilian
labor force age 16 years and over; percent of the
population with income in the past 12 months below
the federal poverty level; median rent in dollars for
occupied units paying rent; and percent of the
population with a bachelor’s degree or higher. The
geographic access control variable was the number of
primary care physicians per 100,000 population within
the member’s zip code area.
10
populations. The null hypothesis is that a particular outcome measure is the same for both populations, while the alternative is that they are significantly different. The test statistic used to test the hypothesis was :
𝑍𝑍 = �̂�𝑝𝑚𝑚 − �̂�𝑝𝑐𝑐
√�̂�𝑝(1 − �̂�𝑝) ( 1𝑛𝑛𝑚𝑚
+ 1𝑛𝑛𝑐𝑐
)
where �̂�𝑝𝑚𝑚 is the estimated outcome measure in the Medicaid MCO population, �̂�𝑝𝑐𝑐 is the estimated outcome measure in the commercial PPO population, 𝑝𝑝 ̂is the estimated outcome measure in pooled populations (Medicaid MCO and commercial PPO together), 𝑛𝑛𝑚𝑚 is the number of Medicaid MCO enrollees, and 𝑛𝑛𝑐𝑐 is the number of commercial PPO enrollees. If the test statistic is greater than the upper critical value (1.96), or lower than the lower critical value (-1.96), then we rejected the null hypothesis at the 5% significance level.
The second method used to test differences in each measure across the two populations was a regression analysis to determine the likelihood of a particular outcome measure while controlling for underlying demographic, socioeconomic status (SES), and geographic differences in the populations that may be correlated with the outcome measures. For this method, we ran the following regression at the individual enrollee level:
𝑦𝑦𝑖𝑖 = 𝛼𝛼 + 𝛽𝛽1𝐼𝐼𝑛𝑛𝐼𝐼𝑖𝑖 + 𝛾𝛾𝑍𝑍𝑖𝑖 + 𝜀𝜀𝑖𝑖 where 𝑦𝑦𝑖𝑖 is the outcome measure of interest for specific individuals in the Medicaid MCO and commercial PPO population, 𝐼𝐼𝑛𝑛𝐼𝐼𝑖𝑖 is a binary variable that indicates whether the individual has Medicaid MCO or commercial PPO insurance, 𝑍𝑍𝑖𝑖 is a set of control variables, including gender and age, SES characteristics, and a geographic access indicator, and 𝜀𝜀𝑖𝑖 is uncontrolled error.
The main variable of interest is 𝐼𝐼𝑛𝑛𝐼𝐼𝑖𝑖, and the coefficient on this variable tells us whether having commercial insurance vis-à-vis Medicaid MCO coverage leads to significantly better or worse outcomes, while controlling for the remaining model variables. Gender was coded as male or female and age a continuous whole number variable for years old. Neither the Medicaid nor Truven datasets contain individual-level SES variables on employment, income, or education. However, they contain zip code identifiers that were used to obtain aggregate zip code-level SES variables from the US Census data. Individuals within Medicaid MCO and Truven PPO were given the SES and access variables which corresponding to the zip code in which they live. The SES zip-code level control variables included: percent unemployed of the civilian labor force age 16 years and over; percent of the population with income in the past 12 months below the federal poverty level; median rent in dollars for occupied units paying rent; and percent of the population with a bachelor’s degree or higher. The geographic access control variable was the number of primary care physicians per 100,000 population within the member’s zip code area.
10
populations. The null hypothesis is that a particular outcome measure is the same for both populations, while the alternative is that they are significantly different. The test statistic used to test the hypothesis was :
𝑍𝑍 = �̂�𝑝𝑚𝑚 − �̂�𝑝𝑐𝑐
√�̂�𝑝(1 − �̂�𝑝) ( 1𝑛𝑛𝑚𝑚
+ 1𝑛𝑛𝑐𝑐
)
where �̂�𝑝𝑚𝑚 is the estimated outcome measure in the Medicaid MCO population, �̂�𝑝𝑐𝑐 is the estimated outcome measure in the commercial PPO population, 𝑝𝑝 ̂is the estimated outcome measure in pooled populations (Medicaid MCO and commercial PPO together), 𝑛𝑛𝑚𝑚 is the number of Medicaid MCO enrollees, and 𝑛𝑛𝑐𝑐 is the number of commercial PPO enrollees. If the test statistic is greater than the upper critical value (1.96), or lower than the lower critical value (-1.96), then we rejected the null hypothesis at the 5% significance level.
The second method used to test differences in each measure across the two populations was a regression analysis to determine the likelihood of a particular outcome measure while controlling for underlying demographic, socioeconomic status (SES), and geographic differences in the populations that may be correlated with the outcome measures. For this method, we ran the following regression at the individual enrollee level:
𝑦𝑦𝑖𝑖 = 𝛼𝛼 + 𝛽𝛽1𝐼𝐼𝑛𝑛𝐼𝐼𝑖𝑖 + 𝛾𝛾𝑍𝑍𝑖𝑖 + 𝜀𝜀𝑖𝑖 where 𝑦𝑦𝑖𝑖 is the outcome measure of interest for specific individuals in the Medicaid MCO and commercial PPO population, 𝐼𝐼𝑛𝑛𝐼𝐼𝑖𝑖 is a binary variable that indicates whether the individual has Medicaid MCO or commercial PPO insurance, 𝑍𝑍𝑖𝑖 is a set of control variables, including gender and age, SES characteristics, and a geographic access indicator, and 𝜀𝜀𝑖𝑖 is uncontrolled error.
The main variable of interest is 𝐼𝐼𝑛𝑛𝐼𝐼𝑖𝑖, and the coefficient on this variable tells us whether having commercial insurance vis-à-vis Medicaid MCO coverage leads to significantly better or worse outcomes, while controlling for the remaining model variables. Gender was coded as male or female and age a continuous whole number variable for years old. Neither the Medicaid nor Truven datasets contain individual-level SES variables on employment, income, or education. However, they contain zip code identifiers that were used to obtain aggregate zip code-level SES variables from the US Census data. Individuals within Medicaid MCO and Truven PPO were given the SES and access variables which corresponding to the zip code in which they live. The SES zip-code level control variables included: percent unemployed of the civilian labor force age 16 years and over; percent of the population with income in the past 12 months below the federal poverty level; median rent in dollars for occupied units paying rent; and percent of the population with a bachelor’s degree or higher. The geographic access control variable was the number of primary care physicians per 100,000 population within the member’s zip code area.
METHODS
12
RESULTS
WELL-CHILD VISITS IN THE FIRST 15 MONTHS OF LIFE
We calculated the rates of well-child visits in the first 15 months of life for continuously enrolled Medicaid children
and Medicaid MCO children in 2011 and 2012. We calculated comparative rates for commercial PPO children in
2012 and 2013.
Medicaid children had lower rates compared to commercial PPO insured children and all Medicaid children had
lower rates compared to Medicaid MCO children (Table 2). The 2012 Medicaid MCO rate was statistically
significant and lower than the commercial PPO rate. It is noteworthy that the rate for commercial PPO insured
children in Texas is also higher than the HEDIS national PPO rate, which was 76.1% in 2011 and 76.4% in 2012.
Further evaluation shows nearly all (99%) of Medicaid MCO children receive at least one visit and the majority
(over 88%) receive four or more visits (Table 3).
Table 2: Well-Child Visits in the First 15 Months of Life (6 or More Visits)
Year Medicaid Medicaid MCO Truven PPO
Eligible Population Percent Eligible
Population Percent Eligible Population Percent
2011 137,936 28.28% 49,989 61.08% - -
2012 119,985* 26.43% 41,379 59.77% 14,902 82.75%
2013 - - - - 6,185 93.79%
*The 2012 population for Texas Medicaid contains data only for the first 8 months of the calendar year.
Table 3: Well-Child Visits in the First 15 Months of Life (Number of Visits)
Year Insurance Eligible Population 0 Visits 1 Visits 2 Visits 3 Visits 4 Visits 5 Visits 6 Visits
2011Medicaid 137,936 35.47% 2.96% 4.39% 7.26% 10.47% 11.16% 28.28%Medicaid 49,989 1.00% 1.71% 2.97% 5.61% 10.25% 17.38% 61.08%MCO
2012
Medicaid 119,985 20.50% 9.96% 8.42% 9.53% 12.99% 12.16% 26.43%Medicaid 41,379 1.18% 1.74% 3.02% 5.45% 10.47% 18.37% 59.77%MCOTruven 14,902 8.48% 0.40% 0.74% 1.091% 1.81% 4.723% 82.75%PPO
2013Truven 6,185 0.37% 0.29% 0.50% 0.78% 1.39% 2.88% 93.79%PPO
*The 2012 population for Texas Medicaid contains data only for the first 8 months of the calendar year.
13
After controlling for demographic, SES, and gographic access differences, the likelihood of a Medicaid MCO
infant having six visits from age 0-15 months was only 27% of a commercial PPO insured infant (Table 4).
Table 4: Well-Child Visits in the First 15 Months of Life Regression Results
Six or More Visits Odds Ratios [95% CI]MedicaidMCO* 0.272 0.260 0.284
Percent Female 1.008 0.982 1.035
Percent Unemployed 0.997 0.988 1.006
Percent Below Poverty* 0.993 0.992 0.995
Median Rent 1.000 1.000 1.000
Percent with Bachelor's Degree* 1.004 1.002 1.005
Primary Care Providers per 100,000 1.000 1.000 1.000
Constant 6.155 5.650 6.707
Number of obs = 105284
Prob > chi2 = 0.0000
Pseudo R2 = 0.0418
RESULTS
14
RESULTS
WELL-CHILD VISITS IN THE THIRD, FOURTH, FIFTH AND SIXTH YEARS OF LIFE:
We calculated the rates of well-child visits in years three through six for Medicaid children and Medicaid MCO
children in 2011 and 2012. We calculated comparative rates for commercial PPO children in 2012 and 2013.
Medicaid MCO rates for well-child visits in years three through six are slightly lower in 2012 than for commericial
PPO insured children, but substantially higher than the Medicaid population (Table 5). Medicaid rates showed
significant improvement between 2011 and 2012, but remained significantly lower than the rates of Medicaid
MCO and commercial PPO insured children. The Medicaid MCO rate was statistically significant, higher than the
commercial PPO rate in 2011, and lower than the commercial PPO rate in 2012.
Table 5: Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (Percent Children with at Least 1 Visit)
Year Medicaid Medicaid MCO Truven PPOEligible
Population Percent Eligible Population Percent Eligible
Population Percent
2011 554,692 48.85% 255,651 77.82% 157,771 77.53%
2012 585,827 63.51% 309,492 75.06% 162,229 81.04%
* Texas Medicaid data is based on fiscal year and Truven data is based on calendar year.
After controlling for demographic, SES, and geographic access differences, the likelihood of a Medicaid MCO
child age three, four, five, or six having a well-child visit was 86% of a commercial PPO insured child (Table 6).
Table 6: Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life Regression Results
Well-Child Visits Odds Ratios [95% CI]MedicaidMCO* 0.857 0.846 0.868
Percent Female* 0.976 0.966 0.986
Age* 0.737 0.734 0.741
Percent Unemployed* 1.041 1.038 1.045
Percent Below Poverty* 1.008 1.008 1.009
Median Rent 1.000 1.000 1.000
Percent with Bachelor's Degree* 1.013 1.012 1.013
Primary Care Providers per 100,000 1.000 0.999 1.000
Constant 8.084 7.775 8.405
Number of obs = 845776
Prob > chi2 = 0.0000
Pseudo R2 = 0.0216
15
ADOLESCENT WELL-CHILD VISITS
The percentage of Medicaid MCO adolescents between the ages of 12 and 21 who had at least one well-child
visit is higher than the percentage for commercial PPO insured and for all Medicaid adolescents (Table 7).
Medicaid rates increased between 2011 and 2012, and in 2012 were higher than commercial PPO insured. The
Medicaid MCO rate was statistically significant and higher than the commercial PPO rate in both years.
Table 7: Adolescent Well-Child Visits (% of Children with at Least 1 Visit)
Year Medicaid Medicaid MCO Truven PPOEligible
Population Percent Eligible Population Percent Eligible
Population Percent
2011 418,938 35.71% 180,636 60.79% 446,449 40.79%
2012 459,616 49.54% 235,286 58.67% 501,613 42.96%
* Texas Medicaid data is based on fiscal year and Truven data is based on calendar year.
After controlling for demographic, SES, and gographic access differences, the likelihood of a Medicaid MCO
adolescent having a well-child visit was 1.8 times greater than a commercial PPO insured adolescent (Table 8).
Table 8: Adolescent Well-Child Visits Regression Result
Well-Child Visits Odds Ratios [95% CI]MedicaidMCO* 1.823 1.805 1.842
Percent Female* 1.392 1.382 1.402
Age (years)* 0.848 0.847 0.849
Percent Unemployed* 1.068 1.064 1.071
Percent Below Poverty* 1.007 1.007 1.008
Median Rent 1.000 1.000 1.000
Percent with Bachelor's Degree* 1.020 1.019 1.020
Primary Care Providers per 100,000 0.999 0.999 0.999
Constant 3.047 2.947 3.150
Number of obs = 1328224
Prob > chi2 = 0.0000
Pseudo R2 = 0.0618
RESULTS
16
RESULTS
PRENATAL VISITS
Texas Medicaid MCO rates for the the percent of deliveries with a timely prenatal care visit exceeded those of
both commercial PPO insured and all Medicaid (Table 9). The Medicaid MCO rate was statistically significant and
higher than the commercial PPO rate in both years.
Table 9: Percent of Deliveries with Timely Prenatal Care
Year Medicaid Medicaid MCO Truven PPOEligible
Population Percent Eligible Population Percent Eligible
Population Percent
2011 144,338 57.83% 85,479 81.04% 9,302 64.72%
2012 96,039 54.52% 76,506 75.62% 43,530 62.91%
After controlling for demographic, SES, and gographic access differences, the likelihood of a Medicaid MCO
pregnant woman having a timley prenatal care visit was 2.2 times greater than for a commercial PPO insured
pregnant woman (Table 10).
Table 10: Percent of Deliveries with Timely Prenatal Care Regression Results
Timely Prenatal Care Odds Ratios [95% CI]MedicaidMCO* 2.225 2.167 2.285
Age 20-24* 1.293 1.247 1.340
Age 25-29* 1.302 1.255 1.352
Age 30-34* 1.394 1.340 1.452
Age 35+* 1.610 1.537 1.686
Percent Unemployed* 1.019 1.011 1.027
Percent Below Poverty* 1.004 1.002 1.005
Median Rent 1.000 1.000 1.000
Percent with Bachelor's Degree* 1.002 1.001 1.003
Primary Care Providers per 100,000 1.000 1.000 1.000
Constant 1.066 0.993 1.144
Number of obs = 191238
Prob > chi2 = 0.0000
Pseudo R2 = 0.0226
17
CESAREAN SECTION RATES
The percentage of Cesarean section deliveries was higher for commercial PPO insured women than Medicaid
MCO and all Medicaid women (Table 11). The Medicaid MCO rate was statistically significant and lower than the
commercial PPO rate in both years.
Table 11: Cesarean Section Delivery
Year Medicaid Medicaid MCO Truven PPOEligible
DeliveriesPercent of C-section
Eligible Deliveries
Percent of C-section
Eligible Deliveries
Percent of C-section
2011 94,584 35.49% 52,391 34.32% 41,274 39.72%
2012 59,065 35.20% 57,718 35.18% 45,342 39.39%
*The 2012 population for Texas Medicaid contains data only for the first 8 months of the calendar year.
After controlling for demographic, SES, and gographic access differences, the likelihood of a Medicaid MCO
woman having a C-section delivery was not significantly different from a commercial PPO insured woman (Table 12).
Table 12: Cesarean Section Delivery Regression Result
Cesarean Section Delivery Odds Ratios [95% CI]MedicaidMCO* 0.984 0.961 1.008
Age 20-24* 1.425 1.370 1.482
Age 25-29* 1.798 1.728 1.871
Age 30-34* 2.195 2.106 2.287
Age 35+* 3.029 2.895 3.168
Percent Unemployed* 0.991 0.984 0.999
Percent Below Poverty* 1.005 1.003 1.006
Median Rent 1.000 1.000 1.000
Percent with Bachelor's Degree* 0.998 0.997 0.999
Primary Care Providers per 100,000 1.000 1.000 1.000
Constant 0.326 0.304 0.350
Number of obs = 181193
Prob > chi2 = 0.0000
Pseudo R2 = 0.0153
RESULTS
18
RESULTS
ASTHMA CARE
HOSPITALIZATIONS: The Texas Medicaid MCO asthmatic population has lower rates of inpatient stays per 1,000
asthmatic children per year compared to the Texas commercial PPO insured population for 2011 and 2012 (Table
13). This is also true comparing the Medicaid MCO to the entire Medicaid population. The Medicaid MCO rate
was statistically significant and lower than the commercial PPO rate in both years.
Table 13: Asthma Inpatient Stays Among Asthmatic Children(Inpatient Stays/1,000 Member Years)
Year Medicaid Medicaid MCO Truven PPOEligible
PopulationHospitalization
RateEligible
PopulationHospitalization
RateEligible
PopulationHospitalization
Rate
2011 39,397 104.47 25,242 122.82 1,985 383.38
2012 41,613 107.73 40,622 136.65 2,484 387.84
* Texas Medicaid data is based on fiscal year and Truven data is based on calendar year.
After controlling for demographic, SES, and gographic access differences, the likelihood of a Medicaid MCO
asthmatic child having a hospitalization was only 21% as likely as a commercial PPO insured child (Table 14).
Table 14: Asthma Inpatient Stays Among Asthmatic Children Regression Results
Asthma Inpatient Odds Ratios [95% CI]MedicaidMCO* 0.206 0.191 0.222
Percent Female 0.954 0.905 1.005
Age (years)* 0.941 0.935 0.947
Percent Unemployed* 0.967 0.951 0.983
Percent Below Poverty* 0.997 0.994 1.000
Median Rent ($) 1.000 1.000 1.000
Percent with Bachelor's Degree 0.999 0.996 1.002
Primary Care Providers per 100,000 1.000 0.999 1.000
Constant 1.082 0.920 1.273
Number of obs = 64547
Prob > chi2 = 0.0000
Pseudo R2 = 0.0448
19
EMERGENCY DEPARTMENT VISITS: ED visits for enrollees identified as asthmatics were lower for commercial
PPO insured children compared to both Texas Medicaid and Medicaid MCO enrollees (Table 15). The rate for all
Medicaid was lower than Medicaid MCO. The rates for commercial PPO insured and Medicaid MCO children were
stable over the two years, while the Medicaid rate increased. The Medicaid MCO rate was statistically significant
and higher than the commercial PPO rate in both years.
Table 15: Asthma ED Visits Among Asthmatic Children(ED Visits/1,000 Member Years)
Year Medicaid Medicaid MCO Truven PPOEligible
Population ED Visit Rate Eligible Population ED Visit Rate Eligible
Population ED Visit Rate
2011 39,397 873.81 25,242 1,201.02 1,985 771.21
2012 41,613 958.53 40,622 1,219.11 2,484 775.24
* Texas Medicaid data is based on fiscal year and Truven data is based on calendar year.
After controlling for demographic, SES, and gographic access differences, the likelihood of a Medicaid MCO
child having an ED visit was 1.7 times greater than a commercial PPO insured child (Table 16).
Table 16: Asthma ED Visits Among Asthmatic Children Regression Results
Asthma ED Odds Ratios [95% CI]MedicaidMCO* 1.659 1.550 1.775
Percent Female* 0.916 0.884 0.949
Age (years)* 1.016 1.011 1.020
Percent Unemployed* 1.081 1.069 1.093
Percent Below Poverty* 0.974 0.972 0.976
Median Rent ($)* 1.000 1.000 1.000
Percent with Bachelor's Degree 0.999 0.997 1.001
Primary Care Providers per 100,000* 1.001 1.001 1.001
Constant 1.440 1.278 1.621
Number of obs = 64547
Prob > chi2 = 0.0000
Pseudo R2 = 0.016
RESULTS
20
CONCLUSION
We compared seven measures of access and quality
for children and pregnant women living in Texas with
Medicaid MCO coverage versus commercial PPO
insurance on both aggregate rates and at the
individual level controlling for demographic, SES, and
geographic access. The results provide mixed
evidence on how well the Texas Medicaid MCO
program is doing in closing the gap in access and
quality of care for this population compared to the
commercially covered PPO populations.
Four out of seven aggregate rates (well-child visits for
adolescents, timely prenatal care visits for pregnant
women, C-section rates of deliveries, and inpatient stays
for asthmatic children) are statistically significant and
better for Medicaid MCOs for each comparison year
while three of the outcome measures are better for
commercial PPO insured children (well-child visits for
infants 0-15 months, well-child visits for children aged 3-6
years, and ED visits for asthmatic children) (Table 17).
Similarly, in the individual level analyses controlling for
population differences in demographic, SES, and
geographic access, three out of seven odds ratios
(well-child visits for adolescents, timely prenatal care
visits for pregnant women, and inpatient stays for
asthmatic children) were statistically significant and
better for Medicaid MCOs, while three were better for
commercial PPO insured children (well-child visits for
infants 0-15 months, well-child visits for children aged
3-6 years, and ED visits for asthmatic children), and
there was no difference for one indicator (the
likelihood of a C-section rate) (Table 17).
Table 17: Medicaid versus Commercial Performance Scorecard
Rates Rates
Medicaid MCOEnrollees Truven PPO EnrolleesAdjusted Odds Ratio
(95% CI)2011 2012 2013 2011 2012 2013
Well-Child Visits Infants 61.1* 59.8* NA NA 82.8 93.8 .272 (.260 -. 284)
Well-Child Visits Age 3-6 77.8** 75.1* NA 77.5 81.0 NA .857 (.846 - .868)
Well-Child Visits Adolescents 60.8** 58.7** NA 40.8 43.0 NA 1.823 (1.805 – 1.842)
Timeliness of Prenatal Care 81.0** 75.6** NA 64.7 62.9 NA 2.225 (2.167 – 2.285)
Cesarean Delivery 34.3** 35.2** NA 39.7 39.4 NA .984 (.961 – 1.008)
Asthma Inpatient 122.8** 136.7** NA 383.4 387.8 NA .206 (.191 - .222)
Asthma ED Visits 1,201.0* 1,219.1* NA 771.2 775.2 NA 1.659 (1.550 – 1.775)
* Medicaid MCO rate significantly worse than Commercial PPO
** Medicaid MCO rate significantly better than Commercial PPO
NA – not available
21
The individual level analyses also indicate particularly
large differences in the likelihood ratios for the MCO
population compared to commercial PPO insured on
certain measures. Infants were only .27 as likely to
have six visits over first 15 months. Pregnant women 2.2
times more likely to have timely prenatal care. Asthmatic
children were only .21 as likely to have a hospitalization
but 1.7 times more likely to have an ED visit.
Compared to the literature, our findings suggest
Texas Medicaid MCOs may be doing better in asthma
care for children as indicated by lower hospitalization
rates compared to commercial PPO children.
However, like the national comparisons, ED visit rates
for Medicaid MCO children with asthma were
substantially higher. Texas Medicaid MCOs are not
doing as well on well-child visits for infants and young
children. Yet, the literature indicates roughly
equivalent rates of access to well-child visits between
Medicaid and commercially insured children in all age
groups in other States. In Texas, infants and young
children in Medicaid MCOs had significantly lower
rates of well-child visits than commercial PPO insured
children. However, it is noteworthy that the majority
of Texas Medicaid MCO infants had more than four
visits, indicating the gap primarily lies in achieving
more than four visits. Medicaid adolescents enrolled
in MCOs had higher rates of receiving a well-child visit
than their commercial PPO counterparts. Texas
Medicaid MCO outcomes for births, measured both
by timeliness of prenatal care and C-section rates,
were also better than commercial PPO rates globally;
however, the individual level analyses indicated no
difference. This finding is consistent with one other
study found in the literature.
In conclusion, the aggregate and individual level
comparisons suggest that access and quality in the
Texas Medicaid program is comparable to that in the
commercial PPO insured population, e.g, it is doing
better on some measures and worse on others. This
conclusion is based on both aggregate rate
comparisons and on individual likelihood analyses
controlling for demographic, SES, and geographic
access differences between the populations.
CONCLUSION
22
REFERENCES
1. Texas Health and Human Services Commission, Texas Medicaid and CHIP in Perspective, 10th Edition, February 2015.
2. The Institute for Child Health Policy, University of Florida, External Quality Review Organization, Summary of Activities and Trends in Healthcare Quality, Contract Year 2014.
3. Texas Health and Human Services Commission. Quality Based Payment and Delivery Reforms in Medicaid and the Children’s Health Insurance Program. February 2016.
4. U.S. Department of Health and Human Services. Key Features of the Affordable Care Act By Year. Retrieved August 11, 2016, from http://www.hhs.gov/healthcare/facts-and-features/key-features-of-aca-by-year/index.html#2011
5. Koonsman, G. Changes in Commercial Insurance Coverage & The Impact on Health System Value. 2016 March 31. Retrieved August 11, 2016, from http://www.hfma.org/uploadedFiles/Education/Capital_Conference/VMG%20Health%20Presentation_HFMA%20Capital.pdf
6. HEDIS® and Quality Compass®. (n.d.). Retrieved August 11, 2016, from http://www.ncqa.org/hedis-quality-measurement/what-is-hedis
7. Kenney GM and Coyer C. National Findings on Access to Health Care and Service Use for Children Enrolled in Medicaid or CHIP. MACPAC Contractor Report No. 1. Urban Institute. March 2012.
8. Ku L. Medical and Dental Care Utilization and Expenditures under Medicaid and Private Health Insurance. Med Care Res Rev. 2009 Aug;66(4):456-71. doi: 10.1177/1077558709334896. Epub 2009 Apr 23.
9. Sebelius K. Annual Report on the Quality of Care for Children in Medicaid and CHIP, U.S. Department of Health and Human Services, December 2011.
10. Movsas TZ, Wells E, Mongoven A, Grigorescu V. Does Medical Insurance Type (Private vs Public) Influence the Physician's Decision to Perform Caesarean Delivery? J Med Ethics. 2012 Aug;38(8):470-3. doi: 10.1136/medethics-2011-100209. Epub 2012 May 5.
11. Merrick N, Houchens R, Tillisch S, and Berlow B. Quality of Hospital Care of Children with Asthma: Medicaid Versus Privately Insured Patients. Journal of Health Care for the Poor and Underserved, Vol. 12, No. 2 (2001), pp. 192–207.
12. Peters AT, Klemens JC, Haselkorn T, Weiss ST, Grammer LC, Lee JH, Chen H. TENOR Study Group. Insurance Status and Asthma-related Health Care Utilization in Patients with Severe Asthma. Ann Allergy Asthma Immunol. 2008 Apr;100(4):301-7. doi: 10.1016/S1081-1206(10)60590-X.
13. Finkelstein JA, Barton MB, Donahue JG, Algatt-Bergstrom P, Markson LE, Platt R. Comparing Asthma Care for Medicaid and Non-Medicaid Children in a Health Maintenance Organization. Arch Pediatr Adolesc Med. 2000 Jun;154(6):563-8.
14. Fingar K, Washington R. Potentially Preventable Pediatric Hospital Inpatient Stays for Asthma and Diabetes, 2003–2012: Statistical Brief #192. Healthcare Cost and Utilization Project.
23
APPENDIX 1
CHANGES IN RELEVANT HEDIS MEASURES 2011-2014
Because the HEDIS measures are a focus for managed care plans, it is plausible that managed care organizations
adjust resources to assure their achievement. Each year managed care organizations assess their HEDIS
performance and may adjust benefit designs and/ or resources, as needed. Table 1 – 4 summarizes changes in the
relevant HEDIS measures between 2011 and 2014.
Changes in HEDIS Measures for Year 2011
HEDIS Measure Commercial Medicaid Modifications
Well-Child Visits in the First 15
Months of Life Yes Yes
Added ICD-9-CM Diagnosis code
V20.3 to Table W15-A.
Well-Child Visits in the Third,
Fourth, Fifth and Sixth Years of LifeYes Yes No changes to this measure.
Adolescent Well-Care Visits Yes Yes No changes to this measure.
Prenatal and Postpartum Care Yes Yes
• Clarified step 1 in the Administrative Specification.
• Added CPT code 99500 to Table PPC-C (Decision Rules 2, 3 and 4).
• Added LOINC codes 56990-5, 56991-3, 57321-2, 57743-7 to Table PPC-C (Decision Rules 2 and 3).
• Added CPT code 99500 to Table PPC-D.
• Added CPT code 99501 to Table PPC-E.
• Clarified that ultrasounds and lab results alone should not be considered a visit in the Note section.
• Added a practitioner type requirement to the Postpartum Care numerator.
24
APPENDIX 1
Changes in HEDIS Measures for Year 2012
HEDIS Measure Commercial Medicaid Modifications
Well-Child Visits in the First
15 Months of Life Yes Yes HCPCS codes G0438, G0439 t.
Well-Child Visits in the
Third, Fourth, Fifth and Sixth
Years of Life
Yes Yes HCPCS codes G0438, G0439 t
Adolescent Well-Care Visits Yes YesAdded HCPCS codes G0438, G0439 to Table
AWC-A
Prenatal and Postpartum
CareYes Yes
• Moved CPT code 99500 from Part A to Part D in Table PPC-C Decision Rule 2.
• Added LOINC codes 972-0, 978-7, 1305-2 to Table PPC-C (Decision Rules 2 and 3).
• Deleted CPT code 99500 and HCPCS codes H1000-H1005 from Table PPC-C Decision Rule 3; this eliminates redundancy because members with these codes are identified in Decision Rule 4.
• Moved CPT code 99500 from Part A to Part C in Table PPC-C Decision Rule 4.
• Moved CPT code 99500 from Part C to Part A in Table PPC-D.
• Clarified in the Note section that the most recent estimated date of delivery (EDD) should be used if multiple dates are documented and that a single date (date of delivery or EDD) must be used to define the start and end of the first trimester.
• Clarified in the Note section that postpartum visits with physician assistants, nurse practitioners, midwives and registered nurses are acceptable.
• Clarified in the Note section that the intent of the measure is to assess whether prenatal and preventive care was rendered on a routine, outpatient basis.
25
Changes in HEDIS Measures for Year 2013
HEDIS Measure Commercial Medicaid Modifications
Well-Child Visits in the First
15 Months of Life Yes Yes
• Revised example in continuous enrollment to account for leap year.
• Deleted obsolete CPT code 99432 from Table W15-A.
Well-Child Visits in the
Third, Fourth, Fifth and Sixth
Years of Life
Yes Yes No changes to this measure
Adolescent Well-Care Visits Yes Yes No changes to this measure
Prenatal and Postpartum
CareYes Yes
Clarified in the Note section that the organization must define a method to determine which EDD to use and use one date consistently if multiple dates are documented.
APPENDIX 1
26
Changes in HEDIS Measures for Year 2014
HEDIS Measure Commercial Medicaid Modifications
Well-Child Visits in the First
15 Months of Life Yes Yes
• Removed coding tables and replaced all coding table references with value set references.
• Revised example in continuous enrollment to account for a year that is not a leap year.
• Clarified that visits must be on different dates of services for the numerators in the Administrative Specification
Well-Child Visits in the
Third, Fourth, Fifth and Sixth
Years of Life
Yes YesRemoved coding tables and replaced all coding
table references with value set references.
Adolescent Well-Care Visits Yes YesRemoved coding tables and replaced all coding
table references with value set references.
Prenatal and Postpartum
CareYes Yes
• Removed coding tables and replaced all coding table references with value set references.
• Removed Definition section.
• Moved steps to identify the eligible population (previously steps 1 and 2 under the Denominator section in the Administrative specification) to the Eligible Population section.
• Removed references to —family practitioner and —midwife because these practitioners are included in the definitions of PCP and OB/GYN and other prenatal care practitioners, respectively.
• Consolidated the steps for identifying numerator events.
• Consolidated four decision rules (formerly in Table
PPC-C) into three decision rules.
APPENDIX 1
27
Summary of Medicaid/Commercial Comparison Studies Published Since 2000
Indicator Publication Data Source and Year
Comparison Groups Measure Results
Well Child Visits
Kenney and Coyer (2012)
- National Health Interview Survey (NHIS)
- Medical Expenditure Panel Survey (MEPS) - 2008-09
- Medicaid children
- Children with employer sponsored commercial insurance
Well-child visit in previous 12 months
Medicaid 81.7%; ESI 81.6% *
Office visit in previous 12 months
Medicaid 93.9%; ESI 94.5% *
Usual source of care
Medicaid 95.5%; ESI 97.3%
Ku (2009) MEPS – 2005 Low-income children 0-18
- Medicaid children
- Children with commercial insurance
Annual number of office visits
Medicaid 2.49; Commercial 2.87 (p > 0.05)
Annual number of hospital outpatient visits
Medicaid .10; Commercial .18 (p > 0.05)
Sebelius (2011)
- CMS Medicaid claims data
- National Committee for Quality Assurance (NCQA) report - 2010
- Medicaid/ CHIP children
- Children with commercial insurance
6+ well child visits, 0-15 months
Medicaid/CHIP 56%; Commercial 76% *
1+ well child visits, 3 – 6 years
Medicaid/CHIP 64%; Commercial 71% *
1+ well child visits, 12 – 21 years
Medicaid/CHIP 47%; Commercial 41% *
Cesarean section deliveries
Movsas et al (2012)
- Michigan Vital Records
- Michigan Inpatient Hospital Database - 2004-08
- Medicaid births
- Births of women with commercial insurance
C-section rate Medicaid 29%; Private 33% *
C-section odds ratio
Commercial vs. Medicaid 1.20, 95% CI (1.19 - 1.22)
*Results of statistical significance not provided
APPENDIX 2
28
APPENDIX 2
Summary of Medicaid/Commercial Comparison Studies Published Since 2000
Indicator Publication Data Source and Year
Comparison Groups Measure Results
Asthma
Peters et al (2008)
Multicenter study interview questionnaire -2001-04
-Medicaid adults wih severe or difficult-to-treat asthma
- Adults with severe or difficult-to-treat asthma with commercial insurance
Hospitalization for asthma
Medicaid 18%; Commercial 7% (p < 0.001)
ED visits for asthma
Medicaid 40%; Commercial 17% (p < 0.001)
Hospitalization or ED visits for asthma
Medicaid 41%; Commercial 18% (p < 0.001)
Hospitalization or ED visits for asthmatics, odds ratio
Medicaid vs Commercial 3.08, 95% CI (2.11- 4.50)
Merrick et al
(2001)
Medical records for California, Georgia and Michigan children -1991
Children - Medicaid - All Commercial
Average LOS for asthma (days)
California: Medicaid 2.87; Commercial 2.27 (p 0.001)
Georgia: Medicaid 3.14; Commercial 2.80 (p 0.007)
Michigan: Medicaid 2.81; Commercial 2.63 (p 0.101)
Prior admission within 2 weeks for asthma
California: Medicaid 2.3%; Commercial 0.8% (p 0.083)
Georgia:
Medicaid 1.6%; Commercial 1.4% (p 0.803)
Michigan: Medicaid 3.8%; Commercial 2.0 (p 0.113)
*Results of statistical significance not provided
29
Summary of Medicaid/Commercial Comparison Studies Published Since 2000
Indicator Publication Data Source and Year
Comparison Groups Measure Results
Asthma
Rate of ED visits Medicaid vs Commercial IRR 1.4; 95% CI
(1.2 – 1.5)
Rates of Medicaid vs.
Fingar and Washington (2015)
Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) -2003-11
- Medicaid children
- Children with commercial insurance
% potentially preventable pediatric inpatient stays for asthma
2003: Medicaid 46.9%; Commercial 46.4%
2012: Medicaid 58.1%; Commercial 35.5% *
*Results of statistical significance not provided
APPENDIX 2
Corporate Headquarters4507 Medical Dr., San Antonio, TX 78229
MHM.org
Wesley Health & Wellness Center
1406 Fitch Street, San Antonio, TX 78211
Bishop Ernest T. Dixon, Jr. Clinic
1954 E. Houston St., Ste. 201, San Antonio, TX 78202
School Based Health Center at Krueger Elementary
217 West Otto Street, Marion, TX 78124
School Based Health Center at Schertz Elementary
757 Curtiss Ave., Schertz, TX 78154
Methodist Healthcare Ministries of South Texas, Inc. is a private, faith-based,
not-for-profit organization dedicated to creating access to health care for
uninsured and low-income families through programs and services, strategic
grant-making and advocacy in 74 counties across South Texas.
The mission of Methodist Healthcare Ministries is “Serving Humanity to Honor
God” by improving the physical, mental and spiritual health of those least served
in the Rio Texas Conference area of The United Methodist Church.
The mission also includes Methodist Healthcare Ministries’ one-half ownership of
the Methodist Healthcare System – the largest healthcare system in South Texas.
This creates a unique avenue to ensure that Methodist Healthcare System
continues to be a benefit to the community by providing quality care to all and
charitable care when needed.