Impact of Financial Incentives on Health Outcomes and Costs of Care among Medicaid Beneficiaries with Diabetes in Hawai'i.

The Hawai'i Patient Reward And Incentives to Support Empowerment (HI-PRAISE) project, part of the Medicaid Incentives for Prevention of Chronic Diseases program of the Affordable Care Act, examined the impact of financial incentives on Medicaid beneficiaries with diabetes. It included an observational pre-post study which was conducted at nine Federally Qualified Health Centers (FQHCs) between 2013 to 2015. The observational study enrolled 2,003 participants. Participants could earn up to $320/year in financial incentives. Primary outcomes were change in hemoglobin A1c, blood pressure, and cholesterol; secondary outcomes included compliance with American Diabetes Association (ADA) standards of diabetes care and cost effectiveness. Generalized estimating equation models were used to assess differences in clinical outcomes and general linear models were utilized to estimate the medical costs per patient/day. Changes in clinical outcomes in the observational study were statistically significant: mean hemoglobin A1c decreased from 8.56% to 8.24% (P < .0001); mean systolic blood pressure decreased from 125.16 to 124.18 mm Hg (P = .0137); mean diastolic blood pressure decreased from 75.54 to 74.78 mm Hg (P = .0005); total cholesterol decreased from 180.77 to 174.21 mg/dl (P < .0001); and low-density lipoprotein decreased from 106.17 to 98.55 mg/dl (P < .0001). Improved ADA compliance was also observed. A key limitation was a reduced sample size due to participant's fluctuating Medicaid eligibility status. HI-PRAISE showed no reduction in total health cost during the project period.

A Randomized Controlled Trial of Financial Incentives for Medicaid Beneficiaries with Diabetes.

BACKGROUND: The Medicaid Incentives for Prevention of Chronic Diseases program was authorized by the Affordable Care Act to determine the effectiveness of providing financial incentives. OBJECTIVE: To examine the impact of incentives on adult Medicaid beneficiaries' diabetes self-management using the Hawaii Patient Reward And Incentives to Support Empowerment project. METHODS: A randomized controlled trial study was conducted at Kaiser Permanente Hawaii with 320 participants (159 intervention group/161 control group). Participants could earn up to $320/y of financial incentives, distributed in the form of a debit card. Evaluation measures included 1) clinical outcomes of change in hemoglobin A1C, blood pressure, and cholesterol; 2) compliance with American Diabetes Association standards; 3) cost effectiveness; 4) quality of life; 5) self-management activities; and 6) satisfaction with incentives. RESULTS: No significant differences in clinical outcomes were found between groups. There were no differences in observance of American Diabetes Association standards of medical care between the intervention and control group. The project also did not show reduction in health cost. However, participants in the intervention group reported significantly higher adherence with the recommended general diet than those in the control group during the course of the study. They also reported statistically better physical health than their control counterparts at the midpoint of the study; however, the perception of increased physical health didn't sustain to the end of the study. Participants' satisfaction with incentives was high. CONCLUSION: Overall, this study found no conclusive evidence that financial incentives alone had beneficial effects on improving standards of medical care in diabetes.

Financial Incentives for Medicaid Beneficiaries With Diabetes: Lessons Learned From HI-PRAISE, an Observational Study and Randomized Controlled Trial.

PURPOSE: The Hawaii Patient Reward and Incentives to Support Empowerment (HI-PRAISE) project examined the impact of financial incentives on Medicaid beneficiaries with diabetes. DESIGN: Observational pre-post study and randomized controlled trial (RCT). SETTING: Federally qualified health centers (FQHCs) and Hawaii Kaiser Permanente. PARTICIPANTS: The observational study included 2003 Medicaid beneficiaries with diabetes from FQHCs. The RCT included 320 participants from Kaiser Permanente. INTERVENTION: Participants could earn up to $320/year of financial incentives for a minimum of 1 year. MEASURES: (1) Clinical outcomes of change in hemoglobin A1c (HbA1c), blood pressure, and cholesterol; (2) compliance with American Diabetes Association (ADA) standards of diabetes care; and (3) cost effectiveness. ANALYSIS: Generalized estimating equation models were used to assess differences in clinical outcomes. General linear models were utilized to estimate the medical costs per patient/day. RESULTS: Changes in clinical outcomes in the observational study were statistically significant. Mean HbA1c decreased from 8.56% to 8.24% ( P < .0001) and low-density lipoprotein decreased from 106.17 mg/dL to 98.55 mg/dL ( P < .0001). No significant differences were found between groups in the RCT. Improved ADA compliance was observed. No reduction in total health cost during the project period was demonstrated. CONCLUSION: The HI-PRAISE found no conclusive evidence that financial incentives had beneficial effect on diabetes clinical outcomes or cost saving measures.

Risk of Diabetes Mellitus Among Medicaid Beneficiaries in Hawaii.

INTRODUCTION: Medicaid is the largest primary health insurance for low-income populations in the United States, and it provides comprehensive benefits to cover treatment and services costs for chronic diseases, including diabetes. The standardized per capita spending on diabetes by Medicare beneficiaries enrolled in the fee-for-service program in Hawaii increased from 2012 to 2015. We examined the difference in odds of diabetes between Medicaid and non-Medicaid populations in major racial/ethnic groups in Hawaii. METHODS: We used data from 2013 through 2015 from the Hawaii Behavioral Risk Factor Surveillance System in this cross-sectional study to compare the difference in risk for self-reported diabetes between Medicaid (n = 1,889) and non-Medicaid (n = 17,207) beneficiaries. We used multivariate logistic regression models that could accommodate the complex sampling design to examine the difference in odds of diabetes between the 2 populations. RESULTS: In Hawaii, the Medicaid population was younger, was less educated, had more health impairments, and was more likely to be obese and Native Hawaiian/Other Pacific Islander (NH/OPI) than the non-Medicaid population. The unadjusted prevalence of diabetes in the Medicaid population in Hawaii was higher than that for the non-Medicaid population (10.3% vs 8.9%, P = .02). After adjusting for confounding variables, the odds of diabetes in the Medicaid population was still significantly higher than those in the non-Medicaid population (adjusted odds ratio [AOR] = 1.75; 95% confidence interval [CI], 1.33-2.31). Adjusted analysis stratified by race/ethnicity showed that non-Hispanic Asian (AOR = 2.23; 95% CI, 1.31-3.78) and NH/OPI (AOR = 3.17; 95% CI, 1.05-9.54) Medicaid beneficiaries had significantly higher odds of diabetes than their non-Medicaid counterparts. CONCLUSION: The odds of diabetes was significantly higher among the Hawaii Medicaid population than among the non-Medicaid population. Diabetes prevention programs should address the challenges and barriers that the Medicaid population faces. Our findings can be used to promote culturally competent diabetes education programs.