About Medicaid Managed Care Data

Asthma Medicaid Managed Care (MMC) information was obtained from the New York State Department of Health, Office of Health Insurance Programs Data Mart.

The majority of Medicaid enrollees are enrolled in the MMC program. Enrollees have access to preventive and primary care, inpatient care, eye care, as well as additional health services. Information obtained from program-based surveillance is not representative of the general population, since only about 16% of the NYS population is served by Medicaid managed care programs. However, these data provide useful information about those who have asthma, including the burden of asthma and the use of health care services and medications prescribed for this population.

About Asthma Prevalence for the Medicaid Managed Care Population

Asthma prevalence is calculated among the Medicaid managed care population (MMC) for two different asthma groups:

  1. MMC enrollees in the asthma universe population
  2. MMC enrollees in the persistent asthma population

Definitions for the asthma universe and persistent asthma groups are based on the technical specifications established by the National Committee for Quality Assurance for the Healthcare Effectiveness Data and Information Set (HEDIS®) 2011.

Asthma Universe: Individuals are identified as being in the asthma universe of patients if they had at least:

  • One outpatient visit with asthma (ICD-9 code 493.XX) as one of the listed diagnoses during a specified 12-month period; or
  • One emergency department (ED) visit with asthma (ICD-9 code 493.XX) as the principal diagnosis during a specified 12-month period; or
  • One acute inpatient discharge with asthma (ICD-9 code 493.XX) as the principal diagnosis during a specified 12-month period; or
  • Four asthma medication dispensing events * (i.e., an asthma medication was dispensed on four occasions) during a specified 12-month period.

Persistent Asthma: Individuals are identified as persistent asthma patients if they met at least one of the criteria below during both 2009 and 2010 (criteria need not be the same across years):

  • Four outpatient visits with asthma (ICD-9 code 493.XX) as one of the listed diagnoses and at least two asthma medication dispensing events during a specified 12-month period; or
  • One ED visit with asthma (ICD-9 code 493.XX) as the principal diagnosis during a specified 12-month period; or
  • One acute inpatient discharge with asthma (ICD-9 code 493.XX) as the principal diagnosis during a specified 12-month period; or
  • Four asthma medication dispensing events * (i.e., an asthma medication was dispensed on four occasions) during a specified 12-month period.

Asthma universe and persistent asthma prevalence rates are presented for the total population, and stratified by age group, gender, race and ethnicity, county of residence, and geographic region (New York City and Rest of State).

Asthma universe prevalence rates were generated for individuals aged 0 to 64 years who were continuously enrolled in a MMC health plan (Health Maintenance Organization (HMO) or Prepaid Health Services Plan (PHSP)) for 12 or more months, as of December of each reporting year. These rates were generated for single years (i.e., 2009 and 2010) by county of residence and as a five-year trend from 2006 to 2010 for the MMC asthma universe population by age group, gender, race and ethnicity and geographic region (New York City and Rest of State).

Persistent asthma prevalence was generated for individuals aged 0 to 64 years who were continuously enrolled in a MMC health plan (HMO or PHSP) for 24 or more months, as of December 2010. These rates were generated for single years by age group, gender, race and ethnicity, county of residence and geographic region (New York City and Rest of State).

For consistency, the same methodology, based on HEDIS® 2011 specifications, was applied to all years.

* A dispensing event is one prescription of an amount lasting 30 days or less; multiple inhalers of the same medication filled on the same date of service should be counted as one dispensing event. There is also a restriction regarding leukotriene dispensing events: for an individual identified as an asthma universe or persistent asthma because of at least four asthma medication dispensing events, and leukotriene modifiers were the sole asthma medication dispensed, the member must meet any one of the other three criteria for inclusion in the asthma universe or persistent asthma population, or have at least one diagnosis of asthma in any setting.

About Asthma-Related Utilization of Health Services for the Medicaid Managed Care Population

Health service utilization data were generated for New York State (NYS) Medicaid managed care (MMC) enrollees in the asthma universe population, aged 0-64 years, who were continuously enrolled in a MMC health plan (Health Maintenance Organization (HMO) or Prepaid Health Services Plan (PHSP)) for 12 or more months as of December 2010.

Encounter (i.e., face-to-face) records were considered to be asthma-related if they had a primary diagnosis code of asthma (International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9 CM) code of 493.XX). Asthma-related pharmacy dispensing events were identified using the National Drug Codes specified in the Healthcare Effectiveness Data and Information Set (HEDIS®) 2011 guidelines indicative of asthma.

For the purpose of these health utilization analyses, services were divided into outpatient, emergency department, hospitalization, and pharmacy dispensing events. A hierarchical approach was taken to categorize the services. All hospitalization records were identified first, followed by emergency department services, pharmacy dispensing events and finally outpatient services. Because all records that were not identified as hospitalization, emergency room, or pharmacy were considered as outpatient services, this category may contain additional areas besides physician and clinic services (e.g., case management, community and rehabilitation services, dentist and dental services and hospice care).

The number and rate of these services and dispensing events per 100 asthma universe population is provided. Results are presented for the total population and stratified by age group, gender, race and ethnicity, and geographic region (New York City and Rest of State).


About Asthma-Related Prevention Quality Indicators and Pediatric Quality Indicators for the Medicaid Managed Care Population

The Agency for Healthcare Research and Quality has created a set of Quality Indicators (QIs) that use hospital inpatient discharge data to assess the quality of asthma care as well as other conditions. QIs are grouped into two modules: Prevention Quality Indicators (PQIs) and Pediatric Quality Indicators (PDIs).

Even though these indicators are based on hospital inpatient data, they provide insights about the community health care system or services outside the hospital setting. For example, patients with asthma may be hospitalized for asthma complications if their conditions are not adequately monitored or if they do not receive the patient education needed for appropriate self-management.

The PQIs can be used as a "screening tool" to help flag potential health care quality problem areas that need further investigation and provide a quick check on primary care access or outpatient services in a community by using patient data found in a typical hospital discharge abstract. The information can also help public health agencies, State data organizations, health care systems, and others interested in improving health care quality in their communities.

The receipt of high-quality, community-based primary care can often prevent hospitalizations for these illnesses. Admittedly, other factors outside the direct control of the health care system, such as poor environmental conditions or lack of patient adherence to treatment recommendations, can result in hospitalization, However, the PQIs/PDIs provide a good starting point for assessing quality of health services in the community.

Two adult asthma-related PQI measures and one child asthma-related PDI measure were generated for the NYS MMC asthma universe population aged 2-64 years, who were continuously enrolled in a MMC health plan (Health Maintenance Organization (HMO) or Prepaid Health Services Plan (PHSP)) for 24 or more months as of December 2010.

The QI rates are presented for the total population and stratified by gender, race and ethnicity, and geographic region (New York City and Rest of State). Because the PQIs/PDIs estimate the number of potentially avoidable hospital admissions, a lower rate is desirable.

Hospital inpatient discharge data from 2010 were used to calculate the following three measures:

Pediatric Quality Indicator #14 -Asthma Admission Rate
  • Numerator: All discharges of children aged 2 to 17 years with ICD-9-CM principal diagnosis code of asthma.
  • Denominator: All discharges ages 2 to 17 years for the asthma universe population, excluding transfers into the hospital, discharges for MDC 14 (pregnancy, childbirth and puerperium), or any discharge with a diagnosis code for cystic fibrosis or anomalies of the respiratory system.
Prevention Quality Indicator #15 - Asthma in Younger Adults Admission Rate
  • Numerator: All discharges of adults aged 18-39 years with ICD-9-CM principal diagnosis code of asthma.
  • Denominator: All discharges of adults aged 18-39 years for the asthma universe population, excluding transfers into the hospital, discharges for MDC 14 (pregnancy, childbirth and puerperium), or any discharge with a diagnosis code for cystic fibrosis or anomalies of the respiratory system.
Prevention Quality Indicator #5 - Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate
  • Numerator: All discharges of adults aged 40 years and older with ICD-9-CM principal diagnosis code for COPD or asthma.
  • Denominator: All discharges of adults aged 40 years and older for the asthma universe population, excluding transfers into the hospital or discharges for MDC 14 (pregnancy, childbirth and puerperium).

About Asthma-Related Costs for the Medicaid Managed Care Population

Payment for Medicaid managed care (MMC) services is provided through a combination of capitation payments and fee-for-service claim expenditures.

Services not covered under capitation are paid by Medicaid on a fee-for-service claim basis (e.g., pharmacy** and mental health). Fee-for-service claim data represent true expenditures.

Services covered under the MMC benefit package and associated costs are reported by managed care plans as encounter records. Reported costs on encounter records are then standardized by the State in order to estimate the true cost of services provided under the capitated benefit (either as a "proxy cost" of a covered benefit, or as a within plan claim expenditure).

Costs for asthma-related services provided for the asthma universe enrollees among the MMC population were estimated by adding the actual expenditures paid on asthma-related claims together with the standardized "proxy" costs for services reported on encounter records for the calendar year 2010 service period.

Encounter records were considered to be asthma-related if they were submitted with a primary diagnosis code of asthma (International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9 CM) code of 493.XX). Asthma-related pharmacy claims were identified using the National Drug Codes specified in the Healthcare Effectiveness Data and Information Set (HEDIS®) 2010 guidelines indicative of asthma.

All members of the MMC asthma universe population had 12 continuous months of enrollment in a MMC health plan (Health Maintenance Organization (HMO) plans, Prepaid Health Services Plans (PHSP), Partial Capitation plans) in 2010. Cost information, however, was only included in analyses if the cost occurred while enrolled for at least one month in either an HMO or PHSP. Therefore, people who were enrolled exclusively in a Partial Capitation plan for the entire 12-month period of 2010 were removed from the denominator of universe asthmatics and no costs acquired for the enrollment period in a Partial Capitation plan were included.

For the purpose of these cost analyses, services were divided into inpatient/hospitalization, emergency department, outpatient, and pharmacy services. A hierarchical approach was taken to categorize the services. All inpatient records were identified first, followed by emergency department services, pharmacy records and finally outpatient services. Because all records that were not identified as inpatient, emergency room, or pharmacy fell into outpatient, this category contains additional areas beyond physician and clinic services, including categories such as case management, community and rehabilitation services, dentist and dental services and hospice care.

Estimated MMC cost information for year 2010 are provided for asthma-related services including: total cost, average cost per asthma-related service, and average cost per asthma universe enrollee. The average cost per enrollee was generated by age group, gender, race and ethnicity, and geographic region (New York City and Rest of State). The distribution of total costs for asthma-related services was analyzed by geographic region.

** Starting October 1, 2011, pharmacy benefits for Medicaid managed care enrollees were provided by health plans.