Exploring the impact of state-based variation in Medicaid managed care administration on evaluation rates among patients seeking kidney transplant Público

Abstract

Background & Aim: Individuals with end-stage kidney disease (ESKD) who receive Medicaid insurance coverage are less likely to be waitlisted for or receive a transplant as compared with those enrolled in other insurance programs. Whether state-level Medicaid policies further impact access is unknown. Therefore, in this study, we explore whether a state’s mode of Medicaid administration is associated with rates of starting the medical evaluation for transplant among Medicaid enrollees with ESKD.

Methods: We identified all adults (aged 18-80 years) with ESKD referred to one of 37 transplant centers in the Early Steps to Transplant Registry between January 2015 and December 2020, with follow-up through 2021. We restricted our sample to those receiving Medicaid coverage (n=12,226). Our primary outcome was evaluation within six months of first referral date. Using multivariable logistic regression, we examined the association between state’s mode of Medicaid administration (mandatory managed care organization (MCO) enrollment, voluntary MCO enrollment, or state fee-for-service (FFS) program) and the likelihood of evaluation adjusting for several patient and neighborhood-level characteristics.

Results: Among our study population, median age was 50 years old (IQR: 38-59), 47.6% were women, and 51.5% identified as non-Hispanic Black. 65.1%, 26.5%, and 8.4% were enrolled in mandatory MCO, voluntary MCO, and FFS, respectively. In total, 5,995 (49.0%) were evaluated within 6-months of referral, including 40.8% of mandatory MCO, 64.7% of voluntary MCO, and 63.2% of FFS. ESKD adults covered by Medicaid in states with voluntary MCO and FFS programs were 25% (adjusted odds ratio (aOR) = 1.25, [95% CI: 1.05, 1.45]) and 92% (aOR = 1.77, [1.49, 2.12]) more likely to be evaluated within 6 months as compared with mandatory MCO, respectively.

Conclusion: Mode of Medicaid managed care administration appears to impact rates of evaluation for individuals seeking kidney transplants. Mechanisms leading to this differential should be explored to identify ways to mitigate this inequity. 

Table of Contents

Abbreviations - 1

Introduction - 2

Study Aim - 10

Methods - 11

Results- 15

Discussion - 17

Conclusion - 21

References - 22

Appendices - 31

About this Honors Thesis

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School	Emory College
Department	Human Health
Degree	B.A.
Submission	Honors Thesis
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Medicine and Surgery
Palabra Clave	Medicaid kidney transplant evaluation end-stage kidney disease Medicaid managed care organizations kidney transplant disparities health services and outcomes
Committee Chair / Thesis Advisor	Jessica Harding, Emory University
Committee Members	Logan Edwards, Emory University Sara Markowitz, Emory University

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