August 15, 2008
HOLES
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Holes: Great for cheese, bad for studies that affect Medicaid policy |
Editorial by Ginny Shubert
Earlier this month, the New York State Department of Health (DOH) issued a press release innocently titled "Comparison of Fee-for-Service, Mainstream Managed Care and HIV Special Needs Plans (SNPs) Shows Better Quality in Managed Care." The comparison study is, in fact, the State's key piece of evidence in justifying a cost-saving move to force tens of thousands of Medicaid recipients living with HIV/AIDS into HMO plans.
The Department of Health should be applauded for attempting an evidence-based approach to health policy decisions. There is nothing more important to the lives of New Yorkers living with HIV than the delivery of health care. Any change to HIV health care delivery systems can only be justified by clear, strong evidence that the change will result in improved access, continuity, and quality of care.
The DOH's study comparing three health care systems for people with HIV/AIDS on Medicaid—Special Needs Plans (SNPs), fee-for-service care and mainstream managed care (HMOs)—may be a beginning in our understanding of how existing health care systems are working, but the reported results simply do not support policy change. As the DOH acknowledges, in order to save money and get quick results, the study was limited to billing and encounter data, which tell us nothing about clinical outcomes, the true test of health care. Since only one year of administrative claims data were examined, the study period is too short to tell us anything meaningful about continuity of care. These major weakness aside, the preliminary results included in the press release raise more questions than they answer.
Numbers don't add up
It's not easy to evaluate the results of the DOH's comparison study, since so little information has been provided in the press release. Some major problems with the study are acknowledged in the press release—false positives, insufficiently detailed claims data and incomplete encounter data—and the fact that reporting requirements for fee for service, managed care and the SNPS differ. Other methodological questions and gaps in the data are not explained.
The state must have data available that would help refine the study results and answer some pressing questions.
- How many individuals in each service delivery system were studied? We know that Special Needs Plan (SNP) capacity is limited, so we assume that the number of SNP participants studied is much smaller than the other groups. Where are fee-for-service patients receiving their care, and do results differ for those in Designated AIDS Centers?
- Why does the comparison study include all persons over 2 years of age? It would be more informative to compare adults only or children only, since patterns of care are very different for children and adults.
- On what basis were the study's various measures chosen? Is data available on viral load? CD4 counts? Opportunistic infections?
- The study results have been adjusted to take into account certain demographic differences, but what comorbidities does the study control for? Physical only, or also substance use and mental illness? We know that the co-occurrence of these conditions is substantial and that, untreated, these conditions are associated with poor adherence and health outcomes. Measures of behavioral medicine (drug treatment and mental health care) are not reported, even though there are likely important differences between people at risk for these conditions and those that are not.
- How do the systems of health care compare for persons at different stages of HIV disease? Stage of illness needs to be taken into account since it likely has a significant impact on the number of inpatient admissions, antiretroviral therapy and other key measures in the study.
The study also measures averages in health care delivery, not the best measure in a study of this kind. The numbers here are large (21,745 patients). Averages are often skewed by groups of patients that are doing much better — or much worse — than the majority. That's why "median" is more often used in rigorous research of this kind. At the very least, one would need to know the range of results for each measure, and the standard deviation from the average.
Problems all around
Putting aside the major methodological problems in the comparison study, its findings do not support pushing people living with HIV/AIDS on Medicaid into managed care. Some results for all three health care delivery systems are disheartening: Only 40 to 55 percent of patients on antiretroviral medications are getting regular viral load tests. Forty percent off all persons studied used emergency rooms for care during the study period.
While SNPs appear to be marginally better than fee-for-service and mainstream managed care on each measure reported, there aren't significant differences among the three systems of care. For example, the statewide average of patients prescribed antiretroviral medications is 73.7 percent, compared to 73.9 percent for fee-for-service patients, 76.3 percent for SNPs, and 69.2 percent for mainstream managed care.
Indeed, on all the measures presented in the press release, fee-for-service is equal to or above the statewide average in every area except health screenings, where both managed care and SNPs show substantially higher percentages. This may reflect a difference in billing and encounter data, or the fact that reporting these preventative procedures is mandated in managed care (which makes it curious that only 53 to 55 percent receive them).
It's also important to note that given a large sample such as this one, extremely small differences can be found to be "statistically significant," but statistical significance says nothing about the practical significance of the difference. Again, it would be helpful if the DOH would share their findings on the "confidence intervals" calculated for the reported differences.
Moving forward
What we do know through years of experience and research is that an unacceptable number of HIV-positive New Yorkers remain outside or marginal to health care. Recent findings from the CHAIN study show that 39 percent of people living with HIV/AIDS in care had delayed initial entry into care and/or reported one or more periods of dropping out of care. Persons living with HIV/AIDS who are not receiving medical care are significantly more likely than others to have multiple non-medical needs (three quarters reported a housing need, for example). There are proportionately more chronic homeless and seriously mentally ill among the currently unconnected.
What is needed urgently are innovative interventions to increase engagement and consistent utilization of HIV care. This requires a multipronged approach to reach and engage those who are unconnected to care, and to maintain those in care who are marginally connected. Innovative outreach approaches are needed for persons at different stages of engagement with the health care system. We also know that consumer choice and patient-provider communication are important factors impacting engagement in care. We need to remove barriers to initiating and maintaining care among persons with multiple needs—not create new ones.
Ginny Shubert cofounded Housing Works and the consulting firm Shubert Botein Policy Associates (Shubertbotein.com).
On September 11, 2008, GMHC will host a meeting for people living with HIV/AIDS, AIDS advocates and others to strategize about mandatory HMO enrollment at 3:30pm in the 12th floor cafeteria. For more information, contact Matthew Lesieur at the New York AIDS Coalition: mlesieur@nyaidsc.org; 212 629 3075 x108