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IIR 19-057 – HSR Study

IIR 19-057
Medicaid Expansion and Quality, Utilization and Coordination of Health Care for Veterans with Chronic Kidney Disease
Laura A Petersen, MD MPH
Michael E. DeBakey VA Medical Center, Houston, TX
Houston, TX
Funding Period: April 2021 - September 2025


Background: [The 2019 US Department of Health and Human Services Advancing American Kidney Health Initiative aims to “improve care coordination…for people living with kidney disease.” Accessing care from multiple systems and insurers can result in lapses in care coordination, and] patients with serious conditions, such as chronic kidney disease (CKD), are especially vulnerable to poorer outcomes from fragmented care. [While Medicaid expansion, as occurred with the Affordable Care Act (ACA),] is effective in improving access to health care and health outcomes for the uninsured, the significant number of Veterans enrolled in VA (who already have access to comprehensive care) who gained access to Medicaid with expansion face increased risk of care fragmentation. Increased use of non-VA care as a result of the MISSION Act poses similar risks.] Significance/Impact: As more Veterans access care from a mixture of VA and non-VA sources, VA needs to adopt strategies for cross-system care coordination to ensure effective and efficient care for Veterans. This requires understanding how Veterans utilize care when multiple options are available. Patients with advanced CKD have highly complex care needs. Lack of well-coordinated care may increase unnecessary care and worsen outcomes for such patients. Examining use and outcomes data will illustrate multiple aspects of access and care coordination for Veterans with chronic conditions and anticipates implementation of the MISSION Act. Innovation: [That some states opted out of ACA Medicaid expansion allows for a natural experiment where changes in quality of care and utilization over time can be compared between states that did and did not expand Medicaid. The team will use VA, Medicare, and recently-released post-expansion Medicaid claims data to evaluate how Medicaid expansion influences Veteran choices of health system use and CKD treatment.] Specific Aims: Aim 1: To determine the characteristics of Veterans and Veterans with CKD who are most likely to enroll in both Medicaid and VA. Aim 2: To determine the impact of dual enrollment on the utilization of health care services for Veterans with advanced CKD and to create a reference tool to enhance coordination for these patients. Aim 3: To evaluate differences in quality of health care and costs among Veterans with advanced CKD in states that have expanded Medicaid and those that have not. Methodology: Claims data [from 17 states (7 that expanded Medicaid in 2014 and 10 that did not) in the Medicaid Analytic eXtract (MAX) file for 2011-2014] are included. A difference-in-difference model will estimate the association of state Medicaid expansion with [changes in Veterans’ dual-enrollment status (VA and Medicaid) and in utilization and outcomes for Veterans with CKD. Utilization analyses will consider outpatient visits, emergency department visits and hospital admissions recorded in VA and Medicaid data. Outcomes to be considered are time-to-mortality, emergent vs. elective initiation of dialysis, and costs to the health care system.] Each analysis contains demographics, comorbidity and illness severity. For all aims, separate models for low-income (Priority 5) Veterans are estimated as a sensitivity check. [In addition, strategies to support enhanced care coordination will be gathered from interviews with renal care teams and organizational leaders then developed into a care coordination reference tool for those who provide care for patients with kidney disease. Input from Veterans and patients will be incorporated at each stage of the interview and reference tool development process. Next Steps/Implementation: Veteran/patient and VA operational (National Kidney Program; Office of Veterans Access to Care) partners will be provided with interim and final findings to guide strategic planning and to inform programs that support optimal care for Veterans with access to multiple sources of care. Results from this project will be of great importance as stakeholders plan for Veteran needs in the form of direct health care services and effective care coordination, and as they make state and national policy recommendations.]

External Links for this Project

NIH Reporter

Grant Number: I01HX002975-01A2

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Journal Articles

  1. O'Mahen PN, Eck CS, Jiang CR, Petersen LA, Jiang CR, Petersen LA. Contextual factors influencing the association between the Affordable Care Act's Medicaid expansion and Veteran VA-Medicaid dual enrollment. Health services research. 2024 Jun 1; 59(3):e14280. [view]
  2. Liaou D, O'Mahen PN, Petersen LA. Medicaid Expansion and Veterans' Reliance on the VA for Depression Care. Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2022 Nov 11; 39(11):436-444. [view]
  3. O'Mahen PN, Petersen LA. Medicaid Expansion's Final Frontier: Breaking State-Level Partisan Opposition. JAMA. 2023 Oct 3; 330(13):1227-1228. [view]
  4. O'Mahen PN, Petersen LA. Will the American Rescue Plan Overcome Opposition to Medicaid Expansion?. Journal of general internal medicine. 2021 Nov 1; 36(11):3550-3552. [view]

DRA: Health Systems, Kidney Disorders
DRE: TRL - Applied/Translational
Keywords: Care Coordination, Outcomes - Patient, Outcomes - System, Utilization
MeSH Terms: None at this time.

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