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Quality of Care for Chronic Conditions Among Disabled Medicaid Enrollees

An Evaluation of a 1915 (b) and (c) Waiver Program

Wegman, Martin P. BS*,†; Herndon, Jill B. PhD*; Muller, Keith E. PhD*; Graham, Garth N. MD, MPH; Vogel, W. Bruce PhD*; Case, Kimberly H. PhD*; Lee, Jason A. MSPH*; Van Voorhis, Matthew F. PhD*; Shenkman, Elizabeth A. PhD*

doi: 10.1097/MLR.0000000000000371
Original Articles

Importance: Examining the impact of Medicaid-managed care home-based and community-based service (HCBS) alternatives to institutional care is critical given the recent rapid expansion of these models nationally.

Objective: We analyzed the effects of STAR+PLUS, a Texas Medicaid-managed care HCBS waiver program for adults with disabilities on the quality of chronic disease care.

Design, Setting, and Participants: We compared quality before and after a mandatory transition of disabled Medicaid enrollees older than 21 years from fee-for-service (FFS) or primary care case management (PCCM) to STAR+PLUS in 28 counties, relative to enrollees in counties remaining in the FFS or PCCM models.

Measures and Analysis: Person-level claims and encounter data for 2006–2010 were used to compute adherence to 6 quality measures. With county as the independent sampling unit, we employed a longitudinal linear mixed-model analysis accounting for administrative clustering and geographic and individual factors.

Results: Although quality was similar among programs at baseline, STAR+PLUS enrollees experienced large and sustained improvements in use of β-blockers after discharge for heart attack (49% vs. 81% adherence posttransition; P<0.01) and appropriate use of systemic corticosteroids and bronchodilators after a chronic obstructive pulmonary disease event (39% vs. 68% adherence posttransition; P<0.0001) compared with FFS/PCCM enrollees. No statistically significant effects were identified for quality measures for asthma, diabetes, or cardiovascular disease.

Conclusion: In 1 large Medicaid-managed care HCBS program, the quality of chronic disease care linked to acute events improved while that provided during routine encounters appeared unaffected.

Departments of *Health Outcomes and Policy

Epidemiology, University of Florida, Gainesville, FL

Aetna Foundation, Hartford, CT

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Present address: Matthew F. Van Voorhis, PhD, Consumer Reports, Yonkers, NY.

Supported in part by the NIH/NCATS Clinical and Translational Science Awards to the University of Florida TL1 TR000066 and UL1 TR000064.

The authors declare no conflict of interest.

Reprints: Elizabeth A. Shenkman, PhD, Department of Health Outcomes and Policy, University of Florida, 2004 Mowry Road, Gainesville, FL 32610. E-mail:

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.