"Not Alone Anymore": The Experiences of Adults With Diabetes in New York's Medicaid Health Home Program

Evaluating Natural Experiments that Impact the Diabetes Epidemic: an Introduction to the NEXT-D3 Network

PURPOSE OF REVIEW

Diabetes is an ongoing public health issue in the USA, and, despite progress, recent reports suggest acute and chronic diabetes complications are increasing.

RECENT FINDINGS

The Natural Experiments for Translation in Diabetes 3.0 (NEXT-D3) Network is a 5-year research collaboration involving six academic centers (Harvard University, Northwestern University, Oregon Health & Science University, Tulane University, University of California Los Angeles, and University of California San Francisco) and two funding agencies (Centers for Disease Control and Prevention and National Institutes of Health) to address the gaps leading to persisting diabetes burdens. The network builds on previously funded networks, expanding to include type 2 diabetes (T2D) prevention and an emphasis on health equity. NEXT-D3 researchers use rigorous natural experiment study designs to evaluate impacts of naturally occurring programs and policies, with a focus on diabetes-related outcomes. NEXT-D3 projects address whether and to what extent federal or state legislative policies and health plan innovations affect T2D risk and diabetes treatment and outcomes in the USA; real-world effects of increased access to health insurance under the Affordable Care Act; and the effectiveness of interventions that reduce barriers to medication access (e.g., decreased or eliminated cost sharing for cardiometabolic medications and new medications such as SGLT-2 inhibitors for Medicaid patients). Overarching goals include (1) expanding generalizable knowledge about policies and programs to manage or prevent T2D and educate decision-makers and organizations and (2) generating evidence to guide the development of health equity goals to reduce disparities in T2D-related risk factors, treatment, and complications.

Impact of New York State's Health Home program on access to care among patients with diabetes

INTRODUCTION

Access to care is essential for patients with diabetes to maintain health and prevent complications, and is important for health equity. New York State's Health Homes (HHs) provide care management services to Medicaid-insured patients with chronic conditions, including diabetes, and aim to improve quality of care and outcomes. There is inconsistent evidence on the impact of HHs, and care management programs more broadly, on access to care.

RESEARCH DESIGN AND METHODS

Using a cohort of patients with diabetes derived from electronic health records from the INSIGHT Clinical Research Network, we analyzed Medicaid data for HH enrollees and a matched comparison group of HH non-enrollees. We estimated HH impacts on several access measures using natural experiment methods.

RESULTS

We identified and matched 11 646 HH enrollees; patients were largely non-Hispanic Black (29.9%) and Hispanic (48.7%), and had high rates of dual eligibility (33.0%), Supplemental Security Income disability enrollment (49.1%), and multiple comorbidities. In the 12 months following HH enrollment, HH enrollees had one more month of Medicaid coverage (p<0.001) and 4.6 more outpatient visits than expected (p<0.001, evenly distributed between primary and specialty care). There were also positive impacts on the proportions of patients with follow-up visits within 7 days (4 percentage points (pp), p<0.001) and 30 days (6pp, p<0.001) after inpatient care, and on the proportion of patients with follow-up visits within 30 days after emergency department (ED) care (4pp, p<0.001). We did not find meaningful differences in continuity of care. We found small positive impacts on the proportion of patients with an inpatient visit and the proportion with an ED visit.

CONCLUSIONS

New York State's HH program improved access to care for Medicaid recipients with diabetes. These findings have implications for New York State Medicaid as well as other providers and care management programs.

Substance Use Disorders and Diabetes Care: Lessons From New York Health Homes

BACKGROUND

Individuals that have both diabetes and substance use disorder (SUD) are more likely to have adverse health outcomes and are less likely to receive high quality diabetes care, compared with patients without coexisting SUD. Care management programs for patients with chronic diseases, such as diabetes and SUD, have been associated with improvements in the process and outcomes of care.

OBJECTIVE

The aim was to assess the impact of having coexisting SUD on diabetes process of care metrics.

RESEARCH DESIGN

Preintervention/postintervention triple difference analysis.

SUBJECTS

Participants in the New York State Medicaid Health Home (NYS-HH) care management program who have diabetes and a propensity-matched comparison group of nonparticipants (N=37,260).

MEASURES

Process of care metrics for patients with diabetes: an eye (retinal) exam, HbA1c test, medical attention (screening laboratory measurements) for nephropathy, and receiving all 3 in the past year.

RESULTS

Before enrollment in NYS-HH, individuals with comorbid SUD had fewer claims for eye exams and HbA1c tests compared with those without comorbid SUD. Diabetes process of care improvements associated with NYS-HH enrollment were larger among those with comorbid SUD [eye exam: adjusted odds ratio (AOR)=1.08; 95% confidence interval (CI): 1.01-1.15]; HbA1c test: AOR=1.20 (95% CI: 1.11-1.29); medical attention for nephropathy: AOR=1.21 (95% CI: 1.12-1.31); all 3: AOR=1.09 (95% CI: 1.02-1.16).

CONCLUSIONS

Individuals with both diabetes and SUD may benefit moderately more from care management than those without comorbid SUD. Individuals with both SUD and diabetes who are not enrolled in care management may be missing out on crucial diabetes care.