Improving Minority Health by Monitoring Medicaid Quality, Disparities and Value

Schizophrenia is a serious and disabling mental illnesses, and is also associated with chronic medical comorbidities and premature mortality. Adequate treatment of persons with schizophrenia requires a broad array of services which are primarily financed by Medicaid. Despite high health care costs, most patients do not receive recommended mental or physical health care. While little is known about disparities in physical health care, minorities are known to be less likely to receive recommended mental health care than whites. A study that assessed overall mental health care quality with a composite measure found that for most of the 2000’s, overall quality of mental health care for fee-for-service (FFS) Medicaid beneficiaries with schizophrenia was only modest, and lower for blacks and Latinos compared to whites. While quality improved over time, racial/ethnic disparities were unchanged. The study also found geographic disparities, with quality varying both among states and among counties within states. County sociodemographic factors did not explain the results, suggesting a role for state and local policies. 

Improving quality of care while reducing quality disparities is a key objective of state Medicaid programs, particularly for high-needs beneficiaries such as those with schizophrenia and other serious mental illnesses (SMI). Achieving this goal is not easy for state governments confronted with multiple other priorities and Medicaid budgets strained by the demands of beneficiary populations that have grown due to larger societal dynamics. In the near term, states may favor policies primarily aimed at containing costs, as evidenced by the growth of Medicaid managed care both across and within states. Hence, state Medicaid programs are unlikely to adopt policies aimed at improving quality and equity of care unless they understand their budget impacts. Said differently, Medicaid programs need to understand these policies’ value and distributional trade-offs, or the cost to the Medicaid state program of producing high-quality care while also reducing quality disparities. While researchers have examined the associations between costs and quality, a framework for measuring and comparing the value of Medicaid-financed SMI care routinely delivered across racial/ethnic groups and locales is required to improve quality of care and reduce quality disparities.

In response to FOA 16-221, we propose a program of research that seeks to reduce health disparities and improve the health of minority populations served in publicly funded settings through measurement of quality disparities and other critical domains of Medicaid-financed care delivered to adults with schizophrenia. Our ultimate goal is to enable evidence-based policymaking by developing a user-friendly interactive tool to monitor quality, quality disparities, costs, and value, and determine cost of eliminating quality disparities. Our focus of inference is the county. Our main data sources include longitudinal Medicaid databases for a multi-year period starting in 2008 from five states (CA, GA, MS, MO, NY), two of which (MO, NY) are state data, that is, the type and breadth of data available to states’ policymakers and Medicaid analysts. Our Specific Aims are to:

AIM 1. Assess racial/ethnic and geographic disparities in quality of mental health care, physical health care, and overall care delivered to beneficiaries with schizophrenia. We will quantify variations in a composite quality measure and its sub-components among racial/ethnic groups, within and among counties and over time. .

AIM 2. Develop and implement a cost-effectiveness framework to assess the value of Medicaid care delivered to beneficiaries with schizophrenia. For each county we will estimate (a) incremental quality of care (the expected quality of care subtracted from that actually delivered); (b) incremental cost of care (the expected cost of care subtracted from the cost of care delivered); and (c) incremental net monetary benefit of care delivered. Counties with positive net monetary benefit will be considered as providing high-value care.

AIM 3. Using the statewide white population as a reference standard, determine the cost of eliminating racial/ethnic quality disparities. We will estimate county-specific racial/ethnic disparities in quality of care and will use the state’s average total health care costs for whites to estimate the cost of eliminating the quality disparities.   

AIM 4. Develop and pilot a user-friendly interactive tool to enable state Medicaid programs to monitor quality, quality disparities, costs, and value of Medicaid-financed schizophrenia care, and determine the cost of eliminating quality disparities. We will develop SAS and R functions for state Medicaid programs to measure and monitor policy-relevant outcomes of Medicaid-financed care. We will pilot the tool in NY and MO and will seek to disseminate to other states.

Research to advance performance measurement is foundational to efforts aimed at improving value of care—a goal of high significance for state Medicaid programs—and to enable evidence-based policymaking. We will use a cost-effectiveness framework to integrate quality and costs, and because value definitions are indifferent to the distributional effects of changes in value, we will quantitatively link disparities and costs of SMI care. Our work will allow policymakers to measure and monitor critical features of Medicaid-financed care.