Changes in North Carolina maternal health service use and outcomes among medicaid-enrolled pregnant women during state budget cuts.

OBJECTIVES: The recent recession has weakened the US health and human service safety net. Questions about implications for mothers and children prompted this study, which tested for changes in maternal service use and outcomes among North Carolina women with deliveries covered through Medicaid before and after a year of significant state budget cuts. METHODS: Data for Medicaid covered deliveries from April-June 2009 (pre) and from April-June 2010 (post) were derived from birth certificates, Medicaid claims and eligibility files, and WIC (Special Supplemental Food Program for Women, Infants and Children) records. These time periods represent the quarter immediately before as well as the final quarter of a state fiscal year 2010 (July 2009-June 2010) characterized by substantial state budget cuts, including an October 2009 reduction in reimbursement rates for maternity care coordination. We examined how often women received medical care, maternity care coordination, family planning services, and the average numbers of obstetrical encounters, as well as the prevalence of excessive pregnancy weight gain, preterm delivery, and low birth weight. RESULTS: By the end of a year of substantial state budget cuts, women covered through Medicaid had fewer obstetrical visits in all trimesters as well as postpartum (P < .001). Maternal weight gain, preterm delivery, and low birth weight were stable. CONCLUSIONS: One key aspect of medical service use decreased for women enrolled in Medicaid by the end of a year of major state health and human services budget cuts. Maternal and infant child health outcomes measured in this study did not change during that year. Future monitoring is warranted to ensure that maternal health service access remains adequate.

Cost of breast cancer treatment in Medicaid: implications for state programs providing coverage for low-income women.

BACKGROUND: To date, no study has reported on the cost of treating breast cancer among Medicaid beneficiaries younger than 65 years of age. This information is essential for assessing the funding required for treatment programs established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000. OBJECTIVE: This study assesses the incremental cost of breast cancer treatment among Medicaid beneficiaries aged below 65 years. RESEARCH DESIGN: Administrative data from the North Carolina Medicaid program linked with cancer registry data were analyzed to derive monthly Medicaid costs for cancer patients and the incremental costs of breast cancer treatment at 6, 12, and 24 months from diagnosis. We compared 848 beneficiaries diagnosed with cancer during the years 2002 to 2004 with 1696 comparison cases matched on age. RESULTS: With the exception of in situ cancers, the cost of cancer care continued to increase beyond the initial 6-month period. The incremental costs at 6 months after diagnosis are $14,341, $24,002, and $34,469 for those with local, regional, and distant breast cancers, respectively; and these costs increased to $22,343, $41,005, and $117,033 at 24 months. CONCLUSIONS: The extended period of health care utilization, beyond the immediate 6-month period after diagnosis, indicates that Medicaid coverage may be required for many months after diagnosis to complete treatment. Continuous Medicaid coverage should be provided for an adequate time period to ensure that complete and comprehensive treatment is provided.

Medical care costs for diabetes associated with health disparities among adult Medicaid enrollees in North Carolina.

BACKGROUND: Health disparities for many diseases are large and long-standing in North Carolina and the nation. This study examines medical care costs for diabetes associated with health disparities among adults (age, > or =78 years) enrolled in Medicaid in North Carolina during state fiscal year (SFY) 2007-2008 (i.e., July 7, 2007, through June 30, 2008). METHODS: North Carolina Medicaid paid claims and enrollment data were used to calculate the prevalence of and medical care expenditures for diabetes among adult Medicaid enrollees overall and by white, African American, and American Indian race. The impacts of racial and economic health disparities on medical care costs for diabetes were determined by first calculating the proportionate differences between the diabetes prevalence for whites, African Americans, and American Indians enrolled in Medicaid and the diabetes prevalence among all whites in North Carolina. Then it was assumed that medical care costs for white, African American, and American Indian Medicaid recipients could be reduced by the same proportion if the overall prevalence among whites was achieved. RESULTS: The diabetes prevalence among adult Medicaid enrollees was 75.7%, compared with 9.1% for all North Carolina adults. During SFY 2007-2008, the state Medicaid program in North Carolina spent $525 million for diabetes-related medical care and prescription drugs among adults. An estimated $225 million in diabetes-related expenditures could be saved each year by the North Carolina Medicaid program if both racial and economic disparities in the diabetes prevalence were eliminated. LIMITATIONS: We did not have data on non-Medicaid paid health care expenditures for the Medicaid enrollees in our study. The costs of interventions to eliminate health disparities associated with diabetes are not included in the calculation of the potential savings. CONCLUSIONS: The diabetes prevalence in the Medicaid population is much greater than that for all North Carolinians, and the Medicaid costs associated with this elevated prevalence are large. North Carolina health-policy makers and health-program managers should carefully evaluate investments in interventions to reduce these race- and economic-based differences in diabetes prevalence, which could potentially reduce Medicaid costs.

Cost of cervical cancer treatment: implications for providing coverage to low-income women under the Medicaid expansion for cancer care.

BACKGROUND: To date, no study has reported on the cost of treating cervical cancer among Medicaid beneficiaries younger than 65 years of age. This information is essential for assessing the cost effectiveness of screening interventions for low-income women and the funding required for treatment programs established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000. METHODS: Administrative data from the North Carolina Medicaid program linked with cancer registry data were used to analyze total Medicaid costs for these patients and the incremental costs of cervical cancer care at 6 and 12 months from diagnosis. We compared 207 beneficiaries diagnosed with cancer during the years 2002 to 2004 with 414 controls. FINDINGS: Total Medicaid costs at 6 months after diagnosis were $3,807, $23,187, $35,853, and $45,028 for in situ, local, regional, and distant cancers, respectively. The incremental cost of cancer treatment for local and regional cancers was $13,935 and $26,174 and by 12 months increased to $15,868 and $30,917, respectively. CONCLUSION: Medicaid coverage may be required for many months after diagnosis to ensure the provision of comprehensive care, especially for women with late-stage cancers. Given the great differences in cost of early versus late-stage cancers, interventions aimed at increasing screening among low-income women are likely to be cost effective.

Health system correlates of receipt of radiation therapy after breast-conserving surgery: a study of low-income Medicaid-enrolled women.

OBJECTIVE: To describe patient and healthcare system correlates of receipt of recommended care in North Carolina (NC) as indicated by receipt of adjuvant radiation therapy (RT) after breast-conserving surgery (BCS). STUDY DESIGN: Retrospective cohort study. METHODS: Subjects were 344 women diagnosed as having primary breast cancer in 1998 and 1999, who were classified as being alive at least 12 months after treatment with BCS. Medicaid claims were used to supplement central cancer registry (CCR) data about adjuvant RT, and hospital medical record verification was performed when no RT was documented. Health system characteristics (size and volume) were obtained from existing databases. RESULTS: Of 344 NC women enrolled in Medicaid and treated with BCS, one third did not receive RT. The following patient and health system characteristics were associated with lack of receipt of adjuvant RT after BCS: older age (>or=65 years), residing in a low-population density county, receiving BCS at a smaller hospital, and living in a county classified as a whole-county specialist scarcity area. CONCLUSIONS: Some low-income women do not access RT following BCS, placing them at risk for worse outcomes than those associated with standard mastectomy. We identify geographic isolation and scarcity of healthcare specialists as possible leverage points for interventions.

Relationship between body mass index and medical care expenditures for North Carolina adolescents enrolled in Medicaid in 2004.

INTRODUCTION: Many studies document that overweight and obese adults have substantially higher medical care expenditures than do adults of normal weight, but comparable data for children or adolescents are few. This study examines patterns of expenditure for medical care and use of medical care services among a sample of North Carolina adolescents enrolled in Medicaid, stratified by body mass index categories. METHODS: North Carolina public health records, which include clinically measured height and weight, were linked to 2004 North Carolina Medicaid enrollment records to find adolescents aged 12-18 years whose records matched. We then examined all paid claims for 2004 of the 3528 adolescents whose records matched. Total expenditures by sex and race, hospital costs, physician costs, and prescription drug costs were tabulated and stratified by body mass index. We also examined, by body mass index, the percentage of adolescents who had a paid claim for selected diagnosed health conditions. RESULTS: Overall, and for most demographic and service categories, overweight adolescents and at-risk-for-overweight adolescents had higher average Medicaid expenditures than did normal-weight adolescents. Some of these differences were statistically significant. Overweight adolescents were significantly more likely to have a paid claim for services related to diabetes, asthma, or other respiratory conditions. CONCLUSION: Although based on a small sample, our results suggest that overweight has negative health consequences as early as adolescence. Further studies with larger samples could help confirm the findings of our study.

Comparison of medication adherence and associated health care costs after introduction of pioglitazone treatment in African Americans versus all other races in patients with type 2 diabetes mellitus: a retrospective data analysis.

OBJECTIVE: The aim of this study was to compare treatment adherence and health care costs in African Americans versus all other races (All Others) in patients with type 2 diabetes mellitus starting treatment with pioglitazone. METHODS: In this retrospective cohort study, the North Carolina Medicaid database was used (query dates: July 1, 2000, to June 30, 2003). Using at least 1 code from the International Classification of Diseases, Ninth Revision, Clinical Modification for type 2 diabetes (250.xx) and 1 National Drug Code for antidiabetic medication, we identified a cohort of male and female patients aged > or =18 years with type 2 diabetes who maintained continuous Medicaid eligibility for the entire 36-month follow-up period. Race was categorized as African American and All Others (white, Asian, Native American, Pacific Islander, other) based on self-reported data collected at the time of Medicaid enrollment. Medication adherence was expressed as medication possession ratio (calculated as the number of days of antidiabetic prescription supply dispensed [eg, a 30-day supply] divided by the number of days between the first and last dispensation). Reimbursements made by Medicaid were used to calculate diabetes-related and total health care costs, which included medical and dental care, including costs for regular checkups, office visits, home health care, inpatient and outpatient care, long-term care facility care, and prescription drugs. To compare the differences in medication adherence and annual total and diabetes-related health care costs between African Americans and All Others, multivariate regression analysis was performed using only data from the year after (year 2) the year in which pioglitazone treatment was started (year 1). RESULTS: Among the 1073 patients treated with pioglitazone (26.1% men; mean [SD] age, 49.5 [10.6] years; 50.2% African American; mean [SD] total health care costs in year 1, US $7906 [$12,256]; year 2, $9546 [$14,861]), African Americans had significantly higher adherence (62%) to pioglitazone treatment compared with All Others (57%) (P < 0.05) on unadjusted analysis. However, no significant differences in rates of adherence to the medication were found between African Americans and All Others on multivariate regression analysis. African American race was not found to be an independent predictor of increased or decreased annual total health care costs in this population. Significant reductions in total health care costs (2% for every 10% increase in adherence; P < 0.001) and diabetes-related costs (4% for every 10% increase in adherence; P < 0.01) with increased adherence were found. CONCLUSIONS: On multivariate analysis, this study found no significant differences in treatment adherence between African Americans versus all other races in this population of diabetic patients enrolled in a Medicaid program (query dates: July 1, 2000, to June 30, 2003). A higher adherence rate was associated with significantly lower diabetes-related and total health care costs in this population.

Race and medication adherence in Medicaid enrollees with type-2 diabetes.

OBJECTIVE: The association of medication adherence with race has been inadequately studied previously in type-2 diabetes patients. The study objective was to determine the association between race and medication adherence among type-2 diabetes patients. METHODS: This was a retrospective cohort study, which compared medication adherence among different races of Medicaid insured patients with type-2 diabetes newly starting oral antidiabetic medication. A total of 1,527 African-American patients newly starting antidiabetic medication between July 2001 and June 2002 were compared with 1,128 white patients and 514 patients of other race. Medication adherence was measured as medication possession ratio using prescription refill patterns. Multivariate regression analyses were used to determine the difference in adherence rates adjusting for other covariates. RESULTS: Medication adherence rate was significantly higher for whites [0.59 (0.31)] as compared to African Americans [0.54 (0.31), (p<0.05)]. In multivariate analyses, the adherence rate of African-American patients was found to be significantly lower by 12% as compared to whites after adjusting for other covariates. Metformin users were associated with a 62% decrease in adherence rate as compared with the sulfonylureas group (p<0.05). CONCLUSION: The antidiabetic medication adherence was associated with race. Future research should investigate patient-related factors affecting medication adherence in type-2 diabetes patients.

Children who are medically fragile in North Carolina: using Medicaid data to estimate prevalence and medical care costs in 2004.

OBJECTIVES: The purpose of this paper is to demonstrate a method of using medical insurance paid claims and enrollment data to estimate the prevalence of selected health conditions in a population and to profile associated medical care costs. The examples presented here use North Carolina Medicaid data to produce estimates for children ages 0-19 who are medically fragile. These children with serious health conditions are a small subset of all children with special health care needs. METHODS: The children who are medically fragile were identified through selected procedure and durable medical equipment codes. We profiled the expenditures for all medical services provided to these children during 2004. RESULTS: 1,914 children ages 0-19 enrolled in Medicaid were identified as medically fragile (0.22 percent). The amount paid by Medicaid for these children during 2004 for all medical services was $133.8 million, or $69,906 per child. By comparison, the average expenditure by Medicaid during 2004 for a randomly selected group of children receiving well-child care visits was $3,181 per child. The $133.8 million of Medicaid expenditures for the children who are medically fragile represents 6.8 percent of the nearly $2 billion spent by Medicaid in 2004 for all medical services for all children ages 0-19. CONCLUSIONS: This study presents a standard methodology to identify children with specific health conditions and describe their medical care costs. Our example uses Medicaid claims and enrollment data to measure prevalence and costs among children who are medically fragile. This approach could be replicated for other health care payer data bases and also in other geographic areas.

Outcomes associated with initiation of different controller therapies in a Medicaid asthmatic population: a retrospective data analysis.

BACKGROUND: Outcomes in asthmatic patients may vary depending on the controller medication used. Observational studies of outcomes of asthma therapy are needed to understand the implications of choice of controller in different populations. OBJECTIVES: To determine whether there are differences in health care use and costs of asthma treatment in asthma patients treated with montelukast compared with fluticasone proponiate 44 microg. METHOD: Using data from the North Carolina Medicaid program, we compared continuously enrolled asthmatic patients starting either fluticasone propionate 44 microg (FP44), an inhaled corticosteroid (ICS) (n = 312), or montelukast 5 and 10 mg, an oral leukotriene modifier (LM) (n = 398) between the years 1998 and 1999. A secondary analysis compared continuously enrolled asthmatic patients already using ICS as controller therapy initiating either salmeterol (long-acting beta-agonist) (n = 97) or montelukast (n = 101) in the year 1998. Patients were followed for 1 year pre- and postcontroller or additional controller initiation for health care service use, medication refill patterns, and costs. RESULTS: There were no significant differences in the adjusted asthma-related health care costs between the montelukast and FP44 groups. In both groups, physician visits were significantly higher in year 2 (p < 0.01) than in year 1. We found montelukast users to be more adherent with prescription refills (using measures of medication possession) even after allowing for a wider adherence range for FP (RR = 2.53; 95% CI = 1.50-4.26), although patients using montelukast were more likely than patients with fluticasone to switch controller pharmacotherapy (RR = 1.53; 95% CI = 1.12-2.09). Similarly, there were no differences in health care service use and costs between the montelukast and salmeterol groups, with the exception of a 33% reduction (p < 0.01) in number of inhaled corticosteroid refills in the second year in the salmeterol group. CONCLUSION: There were no cost and major health care use differences between the two primary or secondary controller therapies in the postinitiation year. Although FP was associated with lower rate of controller switch, montelukast use was associated with significantly better treatment adherence in patients with treatment persistence in this population of Medicaid-enrolled asthmatic patients. The addition of salmeterol as additional controller was associated with a significant decrease in inhaled corticosteroid use, suggesting decreased adherence in patients on the two-drug regimen.

Healthcare costs and prescription adherence with introduction of thiazolidinedione therapy in Medicaid type 2 diabetic patients: a retrospective data analysis.

OBJECTIVES: Outcomes in patients with type 2 diabetes may vary depending on the antidiabetic medication used. Observational studies of outcomes of diabetes pharmacotherapy are needed to understand the implications of choice of controller in different populations. This study compared differences in total health care costs, medication adherence, and persistence in patients with type 2 diabetes enrolled in the North Carolina Medicaid Program that were newly started on thiazolidinedione (TZD) therapy with patients starting other oral antidiabetics during the same period. In addition differences among the TZDs with respect to these outcomes were examined. METHODS: A total of 1774 patients newly starting TZD therapy between July 2001 and June 2002 were compared to 1709 patients starting other oral antidiabetic medication (metformin or sulfonylureas) for health care costs and outcomes in the post-medication start year. In addition, a sub-group analysis of health care costs in patients starting either TZD (pioglitazone [n = 1086] versus rosiglitazone [N = 688]) was compared. All included patients had complete enrollment for the 24 months of follow-up. Multivariate techniques incorporating health care utilization in the year prior to start of new therapy were utilized to determine the cost impact of one therapy versus another. RESULTS: Results of multiple regression analyses suggest that patients starting TZD have better treatment adherence and persistence in the post-medication start year compared to patients starting other oral antidiabetics (13% increase in Medication Possession Ratios, and 10% increase in therapy persistence index, both p < 0.001). In addition, patients starting TZDs had 16.1% lower total annual health care costs (p < 0.01) compared to patients starting other oral antidiabetics. There were no differences in adherence and cost outcomes between the 2 TZDs. CONCLUSIONS: Introduction of thiazolidinedione therapy in a Medicaid-enrolled type 2 diabetic population was associated with significantly improved treatment adherence, persistence, and lower annual health care costs in the post-start year compared to patients starting other oral antidiabetics.

Differences in use of health services between White and African American children enrolled in Medicaid in North Carolina.

OBJECTIVES: Racial differences in health status and use of health services persist in the United States and are not completely explained by differences in socioeconomic status. This study examines differences in use of health services between White and African American children enrolled in Medicaid, controlling for other factors that affect service use. We make comparisons for use of primary preventive services, diagnosis and treatment of selected common childhood illnesses, and Medicaid expenditures. METHODS: We linked Medicaid enrollment records, Medicaid paid claims data, and data on use of child WIC services to birth certificates for North Carolina children born in 1992 to measure use of health services and Medicaid expenditures by race for children ages 1, 2, 3, and 4. Logistic and Tobit regression models were used to estimate the independent effect of race, controlling for other variables such as low birth weight, WIC participation, and mother's age, education, and marital status. Since all children enrolled in Medicaid are in families of relatively low income, racial differences in socioeconomic status are partially controlled. RESULTS: African American children had consistently lower Medicaid expenditures and lower use of health services than did White children, after statistically controlling for other maternal and infant characteristics that affect health service use, including child WIC participation. For example, total annual Medicaid expenditures were 207-303 dollars less for African American children than for White children, controlling for other variables. African America children were significantly less likely to receive well-child and dental services than were White children. CONCLUSIONS: African American children enrolled in Medicaid use health services much less than White children, even when controlling for socioeconomic status and other factors that affect service use. Linking state administrative databases can be a cost-effective way of addressing important issues such as racial disparities in health service use.

Child participation in WIC: Medicaid costs and use of health care services.

OBJECTIVES: We used data from birth certificates, Medicaid, and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) to examine the relationship of child participation in WIC to Medicaid costs and use of health care services in North Carolina. METHODS: We linked Medicaid enrollment, Medicaid paid claims, and WIC participation files to birth certificates for children born in North Carolina in 1992. We used multiple regression analysis to estimate the effects of WIC participation on the use of health care services and Medicaid costs. RESULTS: Medicaid-enrolled children participating in the WIC program showed greater use of all types of health care services compared with Medicaid-enrolled children who were not WIC participants. CONCLUSIONS: The health care needs of low-income children who participate in WIC may be better met than those of low-income children not participating in WIC.