ImportanceNearly 6 million children in the US have asthma, and over one-third of US children are insured by Medicaid. Although 23 state Medicaid programs have experimented with accountable care organizations (ACOs), little is known about ACOs’ effects on longstanding insurance-based disparities in pediatric asthma care and outcomes.ObjectiveTo determine associations between Massachusetts Medicaid ACO implementation in March 2018 and changes in care quality and use for children with asthma.Design, Setting, and ParticipantsUsing data from the Massachusetts All Payer Claims Database from January 1, 2014, to December 31, 2020, we determined child-years with asthma and used difference-in-differences (DiD) estimates to compare asthma quality of care and emergency department (ED) or hospital use for child-years with Medicaid vs private insurance for 3 year periods before and after ACO implementation for children aged 2 to 17 years. Regression models accounted for demographic and community characteristics and health status. Data analysis was conducted between January 2022 and June 2024.ExposureMassachusetts Medicaid ACO implementation.Main Outcomes and MeasuresPrimary outcomes were binary measures in a calendar year of (1) any routine outpatient asthma visit, (2) asthma medication ratio (AMR) greater than 0.5, and (3) any ED or hospital use with asthma. To determine the statistical significance of differences in descriptive statistics between groups, χ2 and t tests were used.ResultsAmong 376 509 child-year observations, 268 338 (71.27%) were insured by Medicaid and 73 633 (19.56%) had persistent asthma. There was no significant change in rates of routine asthma visits for Medicaid-insured child-years vs privately insured child-years post-ACO implementation (DiD, −0.4 percentage points [pp]; 95% CI, −1.4 to 0.6 pp). There was an increase in the proportion with AMR greater than 0.5 for Medicaid-insured child-years vs privately insured in the postimplementation period (DiD, 3.7 pp; 95% CI, 2.0-5.4 pp), with absolute declines in both groups postimplementation. There was an increase in any ED or hospital use for Medicaid-insured child-years vs privately insured postimplementation (DiD, 2.1 pp; 95% CI, 1.2-3.0 pp), an 8% increase from the preperiod Medicaid use rate.Conclusions and RelevanceIntroduction of Massachusetts Medicaid ACOs was associated with persistent insurance-based disparities in routine asthma visit rates; a narrowing in disparities in appropriate AMR rates due to reductions in appropriate rates among those with private insurance; and worsening disparities in any ED or hospital use for Medicaid-insured children with asthma compared to children with private insurance. Continued study of changes in pediatric asthma care delivery is warranted in relation to major Medicaid financing and delivery system reforms.

中文翻译：

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Medicaid 责任医疗组织和儿科哮喘护理的差异


重要性美国有近 600 万儿童患有哮喘，超过三分之一的美国儿童有 Medicaid 保险。尽管 23 个州的医疗补助计划已经对责任医疗组织 （ACO） 进行了试验，但人们对 ACO 对儿科哮喘护理和结果中长期基于保险的差异的影响知之甚少。目的确定 2018 年 3 月马萨诸塞州医疗补助 ACO 实施与哮喘儿童护理质量和使用变化之间的关联。设计、设置和参与者使用 2014 年 1 月 1 日至 2020 年 12 月 31 日马萨诸塞州所有付款人索赔数据库的数据，我们确定了患有哮喘的儿童年龄，并使用双重差分 （DiD） 估计来比较 2 至 17 岁儿童实施 ACO 前后 3 年的哮喘护理和急诊科 （ED） 或医院使用医疗补助与私人保险。回归模型考虑了人口统计和社区特征以及健康状况。数据分析于 2022 年 1 月至 2024 年 6 月期间进行。主要结局和测量主要结局是 （1） 任何常规门诊哮喘就诊，（2） 哮喘药物比 （AMR） 大于 0.5，以及 （3） 任何 ED 或医院使用哮喘的二元指标。为了确定组间描述性统计差异的统计意义，使用了 χ2 和 t 检验。结果在 376 509 例儿童年观察中，268 338 例 （71.27%） 由医疗补助投保，73 633 例 （19.56%） 患有持续性哮喘。ACO 实施后，医疗补助保险儿童年与私人保险儿童年的常规哮喘就诊率没有显着变化 （DiD， -0.4 个百分点 [pp];95% CI，-1.4 至 0.6 pp）。在实施后期间，医疗补助保险儿童年龄的 AMR 大于 0.5 的比例与私人保险的婴儿年龄的比例有所增加（DiD，3.7 pp;95% CI，2.0-5.4 pp），实施后两组的比例均呈绝对下降。与实施后私人保险相比，医疗补助保险儿童的任何急诊或医院使用有所增加（DiD，2.1 pp;95% CI，1.2-3.0 pp），比月经前医疗补助使用率增加了 8%。结论和相关性马萨诸塞州医疗补助 ACO 的引入与常规哮喘就诊率的持续基于保险的差异有关;由于拥有私人保险的人的适当费率降低，适当 AMR 费率的差距缩小;与拥有私人保险的儿童相比，有 Medicaid 保险的哮喘儿童在急诊室或医院使用方面的差距不断扩大。与重大的 Medicaid 融资和交付系统改革相关的儿科哮喘护理服务的变化是必要的。