Date of Award


Document Type

Dissertation - MUSC Only

Degree Name

Doctor of Health Administration


College of Health Professions

First Advisor

Jillian B. Harvey

Second Advisor

James S Zoller

Third Advisor

Bruce Gould


Background: Medicaid is the long-time government-sponsored program that provides health care services to the underserved, low income populations in the United States. First enacted in 1965, Medicaid has been criticized for its cost, efficacy and efficiency. The expansion of Medicaid under the Affordable Care Act, the growth in the Medicaid population and the rise in associated medical costs has called into question the viability of the program and placed every state Medicaid program under greater scrutiny (Luhby, 2017). Medicaid spending typically represents the second largest line item in most state budgets (Claxton et al., 2016); therefore any growth in the population or increase in illness or severity drives renewed program assessment, management questions and eligibility reviews. Most states have lacked innovation in design and historically have applied a traditional fee for service model to these health programs. Under that construct, Medicaid clients have been relatively unmanaged populations when compared to commercial insurance beneficiaries (KFF, 2013). Over the past decade, studies on commercial populations have shown that various types of incentives can trigger therapy adherence, chronic health improvement, fitness uptake and wellness activities (Krawford, 2014). Health and wellness incentives have proven themselves beneficial in those populations and adoption in commercial benefit design is now considered mainstream (Madison, 2015). As State Medicaid Directors seek options to improve the health status of their populations, and maintain the viability of this state and federal partnership program, policy proposals leading to waiver pilot programs have been implemented to advance incentive strategies and apply behavioral economic principles to this population (Madison, 2015). However, little formal study has been applied to these populations. Chronic disease management has been particularly attractive to incentive constructs, given its high cost and potential ROI. Asthma, the leading chronic disorder in childhood, affects an estimated 5.6 million children under 17 years of age, which translates to one in eleven children in the United States (ALA, 2017). Minority children and children living in poverty have a greater burden from asthma compared with non-Hispanic whites not living in poverty; the same children are less likely to receive adequate treatment, comply with recommended therapies and are less likely to have family or community support for their asthma management. For these reasons, hospitalization for asthma is 40-100% more likely for minority children compared to other children (NIH, 2013). Children in low-income communities and minority families often face a higher incidence of asthma, because of environmental factors, housing conditions and the presence and interaction of pollution and allergens (Ellen & Glied, 2015). Finding mechanisms to apply incentives to improve medication adherence can improve the health of this population. Approximately 50% of prescriptions dispensed in the United States are not taken as prescribed, resulting in 125,000 deaths, 10% of hospitalizations, and $100-300 billion dollars in healthcare costs each year (Bosworth, et al., 2011). Many types of incentives for health behavior change have been studied, however, information about patient perceptions of, and preferences for, incentives for medication adherence in underserved populations is lacking. Research Objectives: Health care stakeholders are working together to address health disparities in underserved communities. Chronic diseases disproportionately affect racial and ethnic minorities. Children are especially vulnerable and often have multiple risk factors for poor health. Children represent 25% of the U.S. population; yet 41% of all children live in low-income families and nearly one in every five live in poor families (Addy, Engelhardt & Skinner, 2013). Moreover, the population of children is becoming increasingly more ethnically and racially diverse. The association between poverty, health status, race, ethnicity, geographic location, and access to quality health care is well documented. Black and Hispanic children are less likely to receive preventive services, and when they do, they have lower rates of adherence with therapy regimens. The challenge of finding ways to help underserved populations better manage their health is a problem worth addressing as health care reform again takes hold in the United States. There is a growing interest in understanding the financial triggers and specific incentives that drive positive health improvement behavior changes among this growing population (CMS, 2017). It is known that the behavior of patients can be changed by providing financial rewards for wellness activities and chronic care management. However, there is little empirical evidence to guide state Medicaid directors and public health officials in developing the specific strategies and targeted incentive programs in Medicaid populations. The purpose of this study is to determine the attitudes of parents and caregivers towards financial incentives for medication adherence in asthmatic children and to further assess the attitudes towards direct payments versus lottery based prizes. Increasing medication adherence is critical to improving patient health outcomes and provider performance on value-based care (VBC) and related quality initiatives (Simone, 2013). Non-adherence with prescribed asthma medication is considered to be a major problem in value-based care models (Williams, 2014). Study Design: Using a survey approach, we examined the attitudes of parents and caregivers towards financial incentives for asthma medication adherence in children. This study explored the following research question, which has several underlying hypotheses: Do parents and caregivers for a Medicaid-served child with asthma with poor medication compliance express more interest in an incentive program or in certain types of incentives? The Health Incentive Program Questionnaire (HIP-Q) produced to optimize the development of incentive-based workplace wellness programs and public health policies will be applied to measure target group acceptability and identify preferred incentive program structures for asthma medication adherence. The study includes the demographics of individuals, their interest in incentives, and the expectations of incentives to improve medication adherence. Population Studied: This thesis examined parents and caregivers in the Hartford, Connecticut metropolitan area. Cohorts of parents and caregivers were surveyed through a community-based social services setting. The objective was to obtain approximately thirty responses. The survey was conducted from January 1st to January 30th of 2018. Purposeful sampling was applied. A five point Likert scale was used in the HIP-Q survey. The study has been reviewed by the Medical University of South Carolina Institutional Review Board (IRB). Results: The results indicate that this population expressed substantial interest in participating in an incentive program. However, individuals with good asthma medication adherence do not significantly differ from those with poor asthma medication adherence when answering specific survey questions. Those questions address attitudes toward incentive programs and types and amounts of rewards. The type of insurance (Husky A or B) is associated with general attitudes toward effectiveness and usefulness of incentive programs, with Husky A recipients responding more positively to those questions. Conclusions: This study revealed interest in incentive programs, and indicated that parents and caregivers of children with asthma would be willing to commit to participating for long periods in these programs. Preferences for rewards trended towards cash and grocery vouchers. Incentive programs may need to be specialized for each Medicaid insurance plan, Husky A and Husky B. Individuals with the Husky A plan appear to show the most interest in an incentive program, and participation by those individuals may be higher. Further, this study provided detailed context on how flexible incentive strategy can shape behavior and provide optionality in Medicaid benefit design to respond to a changing health care environment.


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