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Comparative Study
. 2025 May 22;20(5):e0321208.
doi: 10.1371/journal.pone.0321208. eCollection 2025.

Comparative analysis of influenza healthcare disparities in the United States using retrospective administrative claims from Medicaid and commercial databases, 2015-2019

Jennifer L Matas  1 , Kira Raskina  2 , Sabine Tong  3 , Derrick Forney  1 , Bruno Scarpellini  4 , Mario Cruz-Rivera  5 , Gary Puckrein  6 , Liou Xu  1
Affiliations
Comparative Study

Comparative analysis of influenza healthcare disparities in the United States using retrospective administrative claims from Medicaid and commercial databases, 2015-2019

Jennifer L Matas et al. PLoS One. .

Abstract

Background: Influenza-related healthcare utilization among Medicaid patients and commercially insured patients is not well-understood. This study compared influenza-related healthcare utilization and assessed disease management among individuals diagnosed with influenza during the 2015-2019 influenza seasons.

Methods: This retrospective cohort study identified influenza cases among adults (18-64 years) using data from the Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) Research Identifiable Files (RIF) and Optum's de-identified Clinformatics® Data Mart Database (CDM). Influenza-related healthcare utilization rates were calculated per 100,000 patients by setting (outpatient, emergency department (ED), inpatient hospitalizations, and intensive care unit (ICU) admissions) and demographics (sex, race, and region). Rate ratios were computed to compare results from both databases. Influenza episode management assessment included the distribution of the index point-of-care, antiviral prescriptions, and laboratory tests obtained.

Results: The Medicaid population had a higher representation of racial/ethnic minorities than the CDM population. In the Medicaid population, influenza-related visits in outpatient and ED settings were the most frequent forms of healthcare utilization, with similar rates of 652 and 637 visits per 100,000, respectively. In contrast, the CDM population predominantly utilized outpatient settings. Non-Hispanic Blacks and Hispanics exhibited the highest rates of influenza-related ED visits in both cohorts. In the Medicaid population, Black (64.5%) and Hispanic (51.6%) patients predominantly used the ED as their index point-of-care for influenza. Overall, a greater proportion of Medicaid beneficiaries (49.8%) did not fill any influenza antiviral prescription compared to the CDM population (37.0%).

Conclusion: Addressing disparities in influenza-related healthcare utilization between Medicaid and CDM populations is crucial for equitable healthcare access. Targeted interventions are needed to improve primary care and antiviral access and reduce ED reliance, especially among racial/ethnic minorities and low-income populations.

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Conflict of interest statement

The authors have read the journal's policy and declare the following competing interests: This research study was funded by Opella through grant award 22-SAN-INFLU (Matas, JL; Forney, D; Xu,L; Puckrein, G), and some authors received salary support as employees of Opella (Tong, S.; Scarpellini, B; Raskina, K, Cruz-Rivera, M). This does not alter our adherence to PLOS ONE policies on sharing data and materials. However, individual-level data cannot be shared publicly due to CMS and Optum regulations that require data use and licensing agreements for access. Researchers who meet the criteria for access to confidential data may obtain the data from CMS/Optum. All other relevant aggregated data are within the paper and its supporting information files. There are no patents, products in development, or marketed products associated with this research to declare.

Figures

Fig 1
Fig 1. Prevalence of Influenza in Medicaid and CDM beneficiaries aged 18-64 during the study period and 2015/2016 to 2018/2019 influenza seasons.
Fig 2
Fig 2. Influenza-related healthcare utilization (Outpatient, ED, Inpatient, and ICU) in Medicaid and CDM beneficiaries aged 18-64, during the 2015/2016 to 2018/2019 influenza seasons.
Fig 3
Fig 3. Influenza index point-of-care healthcare settings in Medicaid and CDM beneficiaries aged 18-64, during the 2015/2016 to 2018/2019 influenza seasons.
Fig 4
Fig 4. Influenza index point-of-care healthcare settings by race/ethnicity in Medicaid and CDM influenza episodes aged 18-64, during the 2015/2016 to 2018/2019 influenza seasons.
Fig 5
Fig 5. Influenza antiviral prescription patterns in the overall study population and across all index point-of-care healthcare settings in Medicaid and CDM influenza episodes aged 18-64, during the 2015/2016 to 2018/2019 influenza seasons.
Fig 6
Fig 6. Influenza laboratory testing performed in Medicaid and CDM influenza episodes aged 18-64, during the 2015/2016 to 2018/2019 influenza seasons.
See this image and copyright information in PMC

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