Abstract
BACKGROUND: Childhood asthma is common and associated with extensive racial, ethnic and socioeconomic healthcare inequities and health disparities. Approximately 50% of children with asthma are insured by Medicaid in the U.S. and states have increasingly implemented Accountable Care Organization (ACO) models in their Medicaid programs, but little is known about the effects of ACOs on pediatric asthma quality of care, utilization, and disparities. Seventeen new ACOs were implemented in Massachusetts in 2018. Delivery System Reform Incentive Payments were provided to ACOs that could be used to improve outcomes for chronic diseases, such as asthma, through quality measures, enhanced care coordination, and community health worker staffing. This qualitative study explored caregiver experiences with pediatric asthma care for their Medicaid-insured child following ACO implementation in Massachusetts. METHODS: Semi-structured virtual interviews were conducted with caregivers of Medicaid-insured children with asthma in Massachusetts between July 1-December 31, 2023. Purposive sampling aimed to include a range of participant and practice characteristics. The overarching theoretical framework was an adaptation of the Framework of Asthma Disparities, and data were analyzed using rapid qualitative analytic methods. RESULTS: Of the 26 participants, 96% were female; 23% identified as Black and 39% as Hispanic. Key themes included: (1) Perceived lack of changes in asthma care related to Medicaid ACO implementation; (2) Insurance coverage influences on asthma care; (3) Perceptions of asthma management in primary care; (4) Perceptions of asthma specialist care; (5) Influence of health related social needs on pediatric asthma care and outcomes; and (6) Suggestions for improving pediatric asthma care in Medicaid ACOs. Continuity of care, communication, and asthma education were prominent subthemes. CONCLUSIONS: Medicaid ACOs efforts to transform care delivery through increased resources and improved infrastructure for care coordination and other aspects of care may not have had a substantial influence on asthma care for children in early years of implementation, addressing a gap in knowledge about mixed-age ACOs' effects on pediatric populations. Participants' perceptions of the importance of care continuity, specialty access, and education may warrant further exploration in general and in the context of Medicaid ACO effects on asthma care for children at high risk for asthma disparities.