Surge in Newly Identified Diabetes Among Medicaid Patients in 2014
Surge in Newly Identified Diabetes Among Medicaid Patients in 2014
We identified 215,398 patients overall and 26,237 Medicaid patients who met our definition of newly identified diabetes within the first 6 months of calendar year 2013 (control period). The expansion of Medicaid resulted in a 23% surge in Medicaid patients newly identified with diabetes in the expansion states versus a minimal 0.4% increase in the nonexpansion states. By definition, all of the patients who were new to Medicaid in 2014 had used medical services and Quest Diagnostics laboratory services in 2013. Thus, it is intriguing that the expansion of Medicaid coincided with the surge in newly identified Medicaid patients. It is likely that changes in access to health care for patients with Medicaid contributed to testing for diabetes at an earlier stage of disease. There were no other significant changes to Quest Diagnostics services during the period of this analysis.
The lower mean hemoglobin A1c results with a smaller SD in the expansion states support the observation that the newly identified patients with diabetes in the expansion states are more likely at an earlier state of their disease than within the nonexpansion states. We postulate that these Medicaid patients with newly identified diabetes will experience better management of their disease than if diagnoses had been made later. This could be anticipated to lead to fewer long-term complications.
For the other patient population, there was a minimal increase of 0.03% (from the control period in 2013 to the study period in 2014) in the number of patients with newly identified diabetes. There are many less dramatic differences between groups and changes observed in this study. For example, when both Medicaid enrollees and nonenrollees are considered, nonexpansion states had a greater overall increase in newly identified patients with diabetes (2.6%) than did the expansion states (0.8%). Two main factors drove this finding. First, the number of newly identified other patients with diabetes actually decreased by 2.2% in the expansion states while increasing 3.0% in the nonexpansion states. This difference is small in clinical impact, and the overall change may be compatible with data from the Centers for Disease Control and Prevention suggesting that the diabetes epidemic may be reaching a plateau. Second, this difference was magnified because other patients vastly outnumbered the Medicaid patients. These observations warrant further analysis to see whether these changes are due to shifts among payers, small shifts in Quest Diagnostics business in these states, or underlying differences in the growth of diabetes in the expansion versus nonexpansion states. Of note, 9 of the 11 states (AL, GA, IN, LA, MS, NC, SC, TN, and VA) with high rates of stroke, cardiovascular disease, and obesity are represented in the nonexpansion states and may account for faster growth in new diabetes in the nonexpansion states. The other two states, AR and KY, expanded Medicaid.
The general observations were similar when analyzed by sex. For men, the change in the number of Medicaid patients with newly identified diabetes was 25.5% in the expansion states and only 4.6% in the nonexpansion states (P < 0.0001). For women, the change in the number of Medicaid patients with newly identified diabetes was 22% in the expansion states and declined 1.4% in the nonexpansion states (P < 0.0001). Women comprised 58% of patients newly identified with diabetes across both periods. Yet, the percent change in newly identified diabetes was more striking among men than women. In the other patient population, the changes were modest for both men and women in both the states with and the states without Medicaid expansion, with men always having a slightly higher rate of newly identified patients with diabetes in the study versus control periods. Two hypotheses are that women have had a more consistent pattern of medical service utility and that men are at greater risk of developing diabetes within the 19–64 age range.
In like fashion, the observations were similar when analyzed according to age-groups: younger (ages 19–49 years) and older (ages 50–64 years) patients. For younger patients, the change in the number of Medicaid patients with newly identified diabetes was nearly 15% in the expansion states; there was essentially no change in the nonexpansion states. For older patients, the change in the number of Medicaid patients with newly identified diabetes was 31% in the expansion states and increased 0.5% in the nonexpansion states (P < 0.0001). The percent change in newly identified diabetes was more striking among older patients than younger patients. This difference based on age may reflect the higher risk of diabetes in older patients.
The lower mean and higher percentage of hemoglobin A1c results of 6.5–6.9% (48–52 mmol/mol) for other patients compared with Medicaid patients suggest that other patients may be identified at an earlier stage of disease than Medicaid patients. This may reflect different demographics or access to medical services.
Our definition of newly identified diabetes reflects the limitations of our approach. We lacked clinical information and relied on the provision of ICD-9 codes from ordering physicians and hemoglobin A1c testing performed only at Quest Diagnostics. Some of these patients may have been diagnosed previously but lacked the specified testing in the preceding calendar year or received testing from other clinical laboratories. Some patients might have had alternative explanations for an elevated hemoglobin A1c, and in some cases, the test requisition might have been incorrectly coded by the ordering physician. Further, there are regional differences in clinical practice and access to medical care throughout the U.S. We postulate that such differences were insignificant when comparing the 26 states and District of Columbia to the 24 nonexpansion states. Overall, we believe that our findings closely approximate the actual number of newly diagnosed patients with diabetes. Another consideration is that Medicaid enrollment increased 18.5% in the expansion states that opted to accept the conditions of the ACA. Medicaid enrollment enlarged 4.0% in the nonexpansion states that chose not to accept Federal funds for the expansion. The comparison between the expansion and nonexpansion states was slightly confounded by this voluntary expansion of Medicaid enrollment. Also, some of the patients categorized as Medicaid patients in the control and study periods may have been Medicaid enrollees in the preceding calendar years.
In summary, this Quest Diagnostics Health Trends report provides insight into the impact of the national Medicaid expansion under the ACA. Medicaid expansion states had a 23% increase in newly identified Medicaid patients with diabetes compared with a year earlier; the change was 0.4% in the nonexpansion states. This large difference between expansion states versus nonexpansion states was observed in men and in women and in younger and older patients within the 19–64 age range. These observations were based on comparing only the first 6 months of Medicaid expansion under the ACA. The data suggest that new enrollees in Medicaid are being screened for diabetes and that screening was productive. Since we do not have clinical data, we cannot comment as to whether such screening was targeted using criteria such as those suggested by the American Diabetes Association. The subject of screening is controversial. One trial showed no mortality benefit over 5 years with the early diagnosis obtained from such screening. However, the timeline of that study was likely too short to see a mortality benefit. The U.S. Preventive Services Task Force has recently endorsed screening for type 2 diabetes for patients ≥45 years old and for patients with other risk factors. Additional follow-up will be required to establish whether these trends continue.
Our data suggest that Medicaid expansion has led to an increased number of Medicaid patients being newly diagnosed with diabetes. Beyond diabetes, the trends we observed in the current study are likely to affect diagnosis of other chronic medical conditions such as hypertension, hypercholesterolemia, and chronic kidney disease. Such a pattern has already been reported for the diagnosis of HIV, where diagnosis occurred at an earlier stage among Medicaid patients in expansion states. Improved access and use of medical services may in turn lead to earlier diagnosis of associated diseases and permit earlier intervention to reduce long-term complications.
Conclusions
We identified 215,398 patients overall and 26,237 Medicaid patients who met our definition of newly identified diabetes within the first 6 months of calendar year 2013 (control period). The expansion of Medicaid resulted in a 23% surge in Medicaid patients newly identified with diabetes in the expansion states versus a minimal 0.4% increase in the nonexpansion states. By definition, all of the patients who were new to Medicaid in 2014 had used medical services and Quest Diagnostics laboratory services in 2013. Thus, it is intriguing that the expansion of Medicaid coincided with the surge in newly identified Medicaid patients. It is likely that changes in access to health care for patients with Medicaid contributed to testing for diabetes at an earlier stage of disease. There were no other significant changes to Quest Diagnostics services during the period of this analysis.
The lower mean hemoglobin A1c results with a smaller SD in the expansion states support the observation that the newly identified patients with diabetes in the expansion states are more likely at an earlier state of their disease than within the nonexpansion states. We postulate that these Medicaid patients with newly identified diabetes will experience better management of their disease than if diagnoses had been made later. This could be anticipated to lead to fewer long-term complications.
For the other patient population, there was a minimal increase of 0.03% (from the control period in 2013 to the study period in 2014) in the number of patients with newly identified diabetes. There are many less dramatic differences between groups and changes observed in this study. For example, when both Medicaid enrollees and nonenrollees are considered, nonexpansion states had a greater overall increase in newly identified patients with diabetes (2.6%) than did the expansion states (0.8%). Two main factors drove this finding. First, the number of newly identified other patients with diabetes actually decreased by 2.2% in the expansion states while increasing 3.0% in the nonexpansion states. This difference is small in clinical impact, and the overall change may be compatible with data from the Centers for Disease Control and Prevention suggesting that the diabetes epidemic may be reaching a plateau. Second, this difference was magnified because other patients vastly outnumbered the Medicaid patients. These observations warrant further analysis to see whether these changes are due to shifts among payers, small shifts in Quest Diagnostics business in these states, or underlying differences in the growth of diabetes in the expansion versus nonexpansion states. Of note, 9 of the 11 states (AL, GA, IN, LA, MS, NC, SC, TN, and VA) with high rates of stroke, cardiovascular disease, and obesity are represented in the nonexpansion states and may account for faster growth in new diabetes in the nonexpansion states. The other two states, AR and KY, expanded Medicaid.
The general observations were similar when analyzed by sex. For men, the change in the number of Medicaid patients with newly identified diabetes was 25.5% in the expansion states and only 4.6% in the nonexpansion states (P < 0.0001). For women, the change in the number of Medicaid patients with newly identified diabetes was 22% in the expansion states and declined 1.4% in the nonexpansion states (P < 0.0001). Women comprised 58% of patients newly identified with diabetes across both periods. Yet, the percent change in newly identified diabetes was more striking among men than women. In the other patient population, the changes were modest for both men and women in both the states with and the states without Medicaid expansion, with men always having a slightly higher rate of newly identified patients with diabetes in the study versus control periods. Two hypotheses are that women have had a more consistent pattern of medical service utility and that men are at greater risk of developing diabetes within the 19–64 age range.
In like fashion, the observations were similar when analyzed according to age-groups: younger (ages 19–49 years) and older (ages 50–64 years) patients. For younger patients, the change in the number of Medicaid patients with newly identified diabetes was nearly 15% in the expansion states; there was essentially no change in the nonexpansion states. For older patients, the change in the number of Medicaid patients with newly identified diabetes was 31% in the expansion states and increased 0.5% in the nonexpansion states (P < 0.0001). The percent change in newly identified diabetes was more striking among older patients than younger patients. This difference based on age may reflect the higher risk of diabetes in older patients.
The lower mean and higher percentage of hemoglobin A1c results of 6.5–6.9% (48–52 mmol/mol) for other patients compared with Medicaid patients suggest that other patients may be identified at an earlier stage of disease than Medicaid patients. This may reflect different demographics or access to medical services.
Our definition of newly identified diabetes reflects the limitations of our approach. We lacked clinical information and relied on the provision of ICD-9 codes from ordering physicians and hemoglobin A1c testing performed only at Quest Diagnostics. Some of these patients may have been diagnosed previously but lacked the specified testing in the preceding calendar year or received testing from other clinical laboratories. Some patients might have had alternative explanations for an elevated hemoglobin A1c, and in some cases, the test requisition might have been incorrectly coded by the ordering physician. Further, there are regional differences in clinical practice and access to medical care throughout the U.S. We postulate that such differences were insignificant when comparing the 26 states and District of Columbia to the 24 nonexpansion states. Overall, we believe that our findings closely approximate the actual number of newly diagnosed patients with diabetes. Another consideration is that Medicaid enrollment increased 18.5% in the expansion states that opted to accept the conditions of the ACA. Medicaid enrollment enlarged 4.0% in the nonexpansion states that chose not to accept Federal funds for the expansion. The comparison between the expansion and nonexpansion states was slightly confounded by this voluntary expansion of Medicaid enrollment. Also, some of the patients categorized as Medicaid patients in the control and study periods may have been Medicaid enrollees in the preceding calendar years.
In summary, this Quest Diagnostics Health Trends report provides insight into the impact of the national Medicaid expansion under the ACA. Medicaid expansion states had a 23% increase in newly identified Medicaid patients with diabetes compared with a year earlier; the change was 0.4% in the nonexpansion states. This large difference between expansion states versus nonexpansion states was observed in men and in women and in younger and older patients within the 19–64 age range. These observations were based on comparing only the first 6 months of Medicaid expansion under the ACA. The data suggest that new enrollees in Medicaid are being screened for diabetes and that screening was productive. Since we do not have clinical data, we cannot comment as to whether such screening was targeted using criteria such as those suggested by the American Diabetes Association. The subject of screening is controversial. One trial showed no mortality benefit over 5 years with the early diagnosis obtained from such screening. However, the timeline of that study was likely too short to see a mortality benefit. The U.S. Preventive Services Task Force has recently endorsed screening for type 2 diabetes for patients ≥45 years old and for patients with other risk factors. Additional follow-up will be required to establish whether these trends continue.
Our data suggest that Medicaid expansion has led to an increased number of Medicaid patients being newly diagnosed with diabetes. Beyond diabetes, the trends we observed in the current study are likely to affect diagnosis of other chronic medical conditions such as hypertension, hypercholesterolemia, and chronic kidney disease. Such a pattern has already been reported for the diagnosis of HIV, where diagnosis occurred at an earlier stage among Medicaid patients in expansion states. Improved access and use of medical services may in turn lead to earlier diagnosis of associated diseases and permit earlier intervention to reduce long-term complications.
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