Medicaid ACOs struggle to improve asthma care for children, study finds

In its first three years of operation, Medicaid's primary care-focused Accountable Care Organizations (ACOs) in Massachusetts showed "no clear evidence of success" in improving asthma care for children, according to research led by the University of Massachusetts Amherst and UMass Chan Medical School-Baystate Health.

The study, published recently in JAMA Pediatrics, compared the asthma care of Medicaid-insured children affiliated with a Medicaid ACO to that of children with private insurance. Senior author Dr. Sarah Goff, a practicing pediatrician and internist and professor of health promotion and policy in the UMass Amherst School of Public Health and Health Sciences, says she was "not terribly surprised" at the findings, in part because it was so early in the post-implementation time period , though she had hypothesized there might be some improvements in the outcomes measured.

"The goal of the Accountable Care Organizations is to improve healthcare value by improving quality of care and reducing costs or holding them steady," she says, adding that Massachusetts' Medicaid program is a leader in the nation, expanding their value formula to include patient experience. "But healthcare systems are really big and really complex. So when you introduce a major change in policy and the way care is delivered, three years is a fairly short time to see a lot of change, but it's still really important to take a look at those first three years." 

More than one-third of the nearly six million children in the U.S. with asthma are insured with Medicaid, the paper notes. Asthma is poorly controlled for more than half of children with the disease. "Racial, ethnic, socioeconomic and geographic disparities in asthma quality of care and outcomes are large and persist despite interventions at the health system, state and national levels," the paper states.

"Understanding the impacts of major changes to state Medicaid policy for children with asthma was particularly important because there are clinical treatments and strategies that we know work to improve asthma control. However, these are underused, particularly among those with Medicaid. This can result in high rates of emergency department use – which is not the ideal place for asthma care," says Kimberley Geissler, formerly a UMass Amherst researcher and now an associate professor of healthcare delivery and population sciences at UMass Chan Medical School-Baystate.

The researchers examined Massachusetts insurance claims data between 2014 and 2020 for several asthma control markers: routine asthma visits, asthma medication ratio and emergency department/hospital care. In 2018, primary care-oriented Medicaid ACOs were launched in Massachusetts. Asthma medication ratio compares the use of controller medications, used on a regular basis, to rescue medications, used in an urgent situation when symptoms are not being controlled by the routine medication. 

The study found no significant change in the rates of routine asthma visits for Medicaid and privately insured children after the implementation of ACOs, meaning that the insurance-based disparities persisted. There was a narrowing in disparities in the appropriate asthma medication rates. However, this was because the rate for privately insured children got worse, rather than the rate for children with Medicaid improving. "So it looks better, but it's really not," Goff explains.

For the third marker, the team found worsening disparities in emergency department/hospital use for children with Medicaid ACOs compared to children with private insurance. 

"We don't know why it looks like emergency visits went up," Goff says. "One of the main foci of the Accountable Care Organizations is to improve care management and coordination," which is in part designed to result in fewer visits to the hospital for care. 

Goff and Geissler say more research is needed as Medicaid ACOs mature to determine the effects they may have on asthma quality of care, outcomes and disparities for children.

The Massachusetts Medicaid program is a national leader in innovation to improve care delivery. It is very important to continue studying impacts of changes to the program over time to ensure that all children receive high-quality, accessible care so that they can thrive." 

Kimberley Geissler, associate professor of healthcare delivery and population sciences at UMass Chan Medical School-Baystate