Methadone Maintenance and State Medicaid Managed Care Programs

Coverage for methadone services in state Medicaid plans may facilitate access to the most effective therapy for heroin dependence. State Medicaid plans were reviewed to assess coverage for methadone services, methadone benefits in managed care, and limitations on methadone treatment. Medicaid does not cover methadone maintenance medication in 25 states (59 percent). Only 12 states (24percent) include methadone services in Medicaid managed care plans. Moreover, two of the 12 states limit coverage for counseling or medication and others permit health plans to set limits. State authorities for Medicaid and substance abuse can collaborate to ensure that appropriate medication and treatment services are available for Medicaid recipients who are dependent on opioids andto construct payment mechanisms that minimize incentives that discourage enrollment among heroin-dependent individuals.     

Commercial managed care plans leaving the Medicaid Managed Care Program in New York State: Impact on quality and access

To develop sufficient managed care capacity to accomplish the goal of transitioning Medicaid recipients into managed care, state policymakers have relied on commercial health maintenance organizations to open their panels of providers to the Medicaid population. However, while commercial health maintenance organization involvement in Medicaid managed care was high initially, since 1996 New York State has had 14 commercial plans leave the New York State Medicaid Managed Care Program. It has been speculated that the exodus of these commercial plans would have a negative impact on Medicaid enrolleeś access and quality of care. This paper attempts to evaluate the impact of this departure from the perspective of quality and access measures and plan audit performance. Univariate and multivariate analyses were performed to evaluation the effect of commercial managed care plans leaving the Medicaid program. The overall performance of plans that remained in the program was compared to that of the plans that chose to leave for the two time periods 1996–1997 and 1998–2000. Access to care, quality of care, and annual audit performance data were analyzed. The departure of commercial health plans from the New York State Medicaid Managed Care Program has not had a statistically significant negative effect on the quality of care provided to Medicaid recipients as evaluated by standardized performance measures. In addition, there were no instances when there was a negative impact of the exit of the commercial plans on access to care. Managed care plans that chose to remain in Medicaid passed the Quality Assurance Reporting Requirements audit at a significantly (P<.01) higher rate than plans that chose to leave.     

Key policies emerging to govern delivery of family planning in Medicaid managed care

Originally enacted in 1965, Medicaid is a joint federal-state program under which the federal government sets broad parameters for the delivery of health care and family planning, while individual states control program administration. Recognizing the evolution of Medicaid over the past decade from a program based upon traditional fee-for-service payments to one dominated by managed care, Congress, as part of the 1997 Balanced Budget Act, freed states from having to obtain federal waivers before insisting that Medicaid enrollees obtain their care through managed care systems. That freedom was granted, however, on the condition that states meet uniform minimum national standards for Medicaid managed care. In September 1998, the Department of Health and Human Services' Health Care Financing Administration (HCFA) published proposed federal regulations to implement the uniform standards. Public input on the rule was solicited throughout the fall, and the agency is now making final policy decisions. The proposed regulations are discussed as they relate to freedom of choice and direct access to family planning services, cost sharing, informing enrollees of their rights as Medicaid recipients, and the provision which allows entire Medicaid managed care plans to refuse to provide, reimburse for, or provide coverage of a counseling or referral service based upon religious or moral grounds.     

Access and use of health services by chronically mentally ill Medicaid beneficiaries

This article has two objectives: to quantify the access and utilization of services received by chronically mentally ill Medicaid recipients, and to compare service utilization and access under prepayment and fee-for-service (FFS) payment. The study setting is Hennepin County (Minneapolis), Minnesota, where 35 percent of Medicaid recipients were randomly assigned to receive services from prepaid plans. An algorithm was developed to identify recipients with chronic mental illness, resulting in 739 study participants, split approximately evenly between prepayment and FFS Medicaid. Data were collected through in-person surveys at baseline, and after 1 year. We found slight improvements in the majority of access measures studied and no significant decreases in the use of inpatient or outpatient services for enrollees in prepaid health plans. The results support efforts to expand the use of prepaid health plans to meet the needs of non-institutionalized chronically mentally ill Medicaid beneficiaries.     

Setting capitations for Medicaid: a case study

This article examines the methodology New York State used to set capitation rates for a Medicaid health maintenance organization. By examining the methods used and the assumptions made in a particular case, some general lessons are drawn about the ratesetting process. Greater reliance on statewide data to assure fair and statistically stable estimates is needed. Although the article focuses on one State and its ratesetting for one particular plan (Health Care Plus), the issues raised have general interest for other plans and for other States concerned with the setting of capitation rates for Medicaid enrollees in prepaid plans.     

Do Commercial Managed Care Members Rate Their Health Plans Differently than Medicaid Managed Care Members?

OBJECTIVE: To determine if members of commercial managed care and Medicaid managed care rate the experience with their health plans differently. DATA SOURCES: Data from both commercial and Medicaid Consumer Assessment of Health Plan Surveys (CAHPS) in New York State. STUDY DESIGN: Regression models were used to determine the effect of population (commercial or Medicaid) on a member's rating of their health plan, controlling for health status, age, gender, education, race/ethnicity, number of office visits, and place of residence. DATA COLLECTION: Managed care plans are required to submit to the New York State Department of Health (NYSDOH) results of the annual commercial CAHPS survey. The NYSDOH conducted a survey of Medicaid enrollees using Medicaid CAHPS. PRINCIPAL FINDINGS: Medicaid managed care members in excellent or very good health rate their health plan higher than commercial members in excellent or very good health. There is no difference in health plan rating for commercial and Medicaid members in good, fair, or poor health. Older, less educated, black, and Hispanic members who live outside New York City are more likely to rate their managed care plan higher. CONCLUSIONS: Medicaid members rating of their health care equals or exceeds ratings by commercial members.     

Medicaid managed care in New York: problems and promise for childhood immunizations.

New York State is aggressively pursuing mandatory Medicaid managed care. Under managed care, physicians and plans have a defined population for which they are responsible, quality assurance monitoring emphasizes immunization rates along with other preventive services, and population-based incentives are possible. The literature does not offer compelling evidence, however, that immunization coverage is any better in managed care than under fee-for-service. If reimbursement is low and physician capacity insufficient, immunization rates may be considerably worse. In New York, care needs to be taken so that expansion does not outstrip the capacity of managed care plans to absorb additional enrollees.     

Complacency,abortion politics obstacles to improved health of pregnant women and children

Worldwide, the provision of family planning (FP) services is seen as essential for reducing incidence of maternal mortality and morbidity, which is especially high in developing countries. In the US, the maternal-child health advocacy community focuses almost exclusively on meeting the needs of children. During the past two decades, studies have revealed that nearly 600,000 women fall victim to maternal mortality each year, and 30 times that number experience debilitating morbidity. Thus, recent international conferences have promoted safe motherhood initiatives, including the provision of FP services. Despite the fact that the US has about 1000 maternal deaths each year and 800,000 cases of morbidity, with these adverse conditions more prevalent among Black than White women, the focus on children led Medicaid to expand its access to prenatal care to reduce infant mortality. Recently, states have sought permission to extend FP services to Medicaid recipients. This emphasis on the use of FP to time and space births in an optimal manner and, thus, reduce maternal mortality and morbidity in the US is welcome. However, when considered as a reproductive rights issue, FP is almost always regarded either as a service that increases abortion by promoting promiscuity or that reduces the need for abortion. To secure adequate levels of government financing, supporters of FP should promote all of its dimensions, rather than simply its impact on abortion.     

Consumer perspectives on information needs for health plan choice

The premise that competition will improve health care assumes that consumers will choose plans that best fit their needs and resources. However, many consumers are frustrated with currently available plan comparison information. We describe results from 22 focus groups in which Medicare beneficiaries, Medicaid enrollees, and privately insured consumers assessed the usefulness of indicators based on consumer survey data and Health Employer Data Information Set (HEDIS)-type measures of quality of care. Considerable education would be required before consumers could interpret report card data to inform plan choices. Policy implications for design and provision of plan information for Medicare beneficiaries and Medicaid enrollees are discussed.     

Medicaid prenatal care: a comparison of use and outcomes in fee-for-service and managed care.

BACKGROUND. To control rising costs, state Medicaid agencies are enrolling recipients in managed care health plans (MCPs). We performed this study to assess this policy's impact on accessibility and outcomes of Medicaid-funded prenatal care. METHODS. We performed a retrospective, controlled study with three cohorts: a study group of 1106 Medicaid recipients enrolled in three MCPs, a matched comparison group of 4830 recipients receiving care in the fee-for-service (FFS) system, and a second matched comparison group of 4434 non-Medicaid enrollees of the same MCPs. Data on prenatal care use and birth outcomes were obtained through linkage of claims and discharge files with birth certificate files. RESULTS. Medicaid recipients enrolled in MCPs used prenatal care similarly to those in the FFS system and showed equal or modestly improved birth-weight distributions. However, Medicaid MCP enrollees showed poorer use of prenatal care and birth outcomes compared with non-Medicaid enrollees of the same plans. CONCLUSIONS. Enrollment in MCPs has a neutral or small beneficial effect on the prenatal care received by the Medicaid population. However, providing financial access and modifying the system of care for this population did not result in parity with the general population.     

The evolving role and care management approaches of safety-net medicaid managed care plans

This article provides new empirical data about the viability and the care management activities of Medicaid managed-care plans sponsored by provider organizations that serve Medicaid and other low-income populations. Using survey and case study methods we studied these “safety-net” health plans in 1998 and 2000. Although the number of safety-net plans declined over this period, the surviving plans were larger and enjoying greater financial success than the plans we surveyed in 1998. We also found that, based on a partnership with providers, safety-net plans are moving toward more sophisticated efforts to manage the care of their enrollees. Our study suggests that, with supportive state policies, safety-net plans are capable of remaining viable. Contracting with safety-net plans may not be an efficient mechanism for enabling Medicaid recipients to “enter the mainstream of American health care,” but it may provide states with an effective way to manage and coordinate the care of Medicaid recipients, while helping to maintain the health care safety-net for the uninsured.     

Asthma in medicaid managed care enrollees residing in New York City: Results from a post-world trade center disaster survey

The collapse of the World Trade Center on September 11, 2001, released a substantial amount of respiratory irritants into the air. To assess the asthma status of Medicaid managed care enrollees who may have been exposed, the New York State Department of Health, Office of Managed Care, conducted a mail survey among enrollees residing in New York City. All enrollees, aged 5–56 with persistent asthma before September 11, 2001, were surveyed during summer 2002. Administrative health service utilization data from the Medicaid Encounter Data System were used to validate and supplement survey responses. A total of 3.664 enrollees responded. Multivariate logistic regression models were developed to examine factors associated with self-reported worsened asthma post September 11, 2001, and with emergency department/inpatient hospitalizations related to asthma from September 11, 2001, through December 31, 2001. Forty-five percent of survey respondents reported worsened asthma post 9/11. Respondents who reported worsened asthma were significantly more likely to have utilized health services for asthma than those who reported stable or improved asthma. Residence in both lower Manhattan (adjusted OR=2.28) and Western Brooklyn (adjusted OR=2.40) were associated with self-reported worsened asthma. However, only residents of Western Brooklyn had an elevated odds ratio for emergency department/inpatient hospitalizations with diagnoses of asthma post 9/11 (adjusted OR=1.52). Worsened asthma was reported by a significant proportion of this low-income, largely minority population and was associated with the location of residence. Results from this study provide guidance to health care organizations in the development of plans to ensure the health of people with asthma during disaster situations.     

Medicaid managed care in New York City: recent performance and coming challenges

OBJECTIVES: This study evaluated New York City's voluntary Medicaid managed care program in terms of health care use and access. METHODS: A survey of adults in Medicaid managed care and fee-for-service programs during 1996-1997 was analyzed. RESULTS: Responses showed significant favorable risk selection into managed care but little difference in use of health care services. Although some measures of access favored managed care, many others showed no difference between the study groups. CONCLUSIONS: The early impact of mandatory enrollment will probably include an increase in the average risk of managed care enrollees with little change in beneficiary use and access to care.     

Monitoring quality in Medicaid managed care: Accomplishments and challenges at the year 2000

This paper reviews the major developments during the late 1990s in quality monitoring for Medicaid managed care and offers an assessment of major challenges faced at the year 2000. We highlight the dramatic increase in activities to ensure and improve quality in Medicaid managed care. Prior to these developments, little was known about the actual level of quality of care. Thus, a major accomplishment of the late 1990s is that we now know more about quality, through some key indicators, and that states and plans have implemented activities and structures designed to improve quality. Despite this achievement, there is still a critical gap in our understanding about which activities and structures effectively improve the health of beneficiaries. There are also three operational challenges. First, as state quality assurance and improvement systems become increasingly comprehensive, states are challenged to keep them well coordinated and well targeted to key issues. Second, the dynamics of both plan turnover and enrollment—including steep drops in Medicaid enrollment—present a challenge for measuring and improving quality. A third challenge is to ensure that quality assurance and improvement programs work for enrollees with special health care needs. Finally, devoting sufficient resources to quality monitoring and improvement is a challenge for both states and plans since managed care programs are expected to save money as well as improve quality.     

Nothing Exceeds like Success: Managed Care Comes to Medicaid in New York City

Nearly every state is encouraging or requiring Medicaid beneficiaries to enroll in managed care delivery systems. In New York City, Medicaid officials began with an incremental, but not insignificant, managed care initiative. Buoyed by its success, New York policy makers tried, and failed, to accelerate the transition to managed care. The legacy of that failure still plagues them. A comparison of such initiatives in other states indicates that most state officials have remembered what New York's leaders temporarily forgot, namely, that Medicaid managed care is a complex exercise that demands consultation and consensus building.     

Quality oversight and improvement in Medicaid managed care.

New York State has been collecting performance data from managed care plans that serve the Medicaid population since 1993. The data come to the state via the Quality Assurance Reporting Requirements--a series of quality of care, access, and utilization measures, largely based on the Health Plan Employer Data and Information Set, as well as several New York State-specific measures. In addition to collecting the data, the state publishes the information, works with plans that have below average rates of performance and provides a number of program and financial rewards to plans for rates that demonstrate high quality care. An analysis conducted on quality of care measures indicates that: (1) performance rates are increasing over time, (2) Quality Assurance Reporting Requirements rates are generally higher than national benchmarks, (3) the disparity between commercial plan rates and Medicaid rates is diminishing, and (4) the variability in performance across plans is decreasing. The analysis conducted indicates that the performance measurement system constructed in New York is an effective means to monitor health plan performance, while at the same time enabling the state and local health units to monitor population health and accomplishment of key public health objectives (complete immunization, cancer screening, etc.)     

Findings from the Medicaid Competition Demonstrations: a guide for states

The Medicaid Competition Demonstrations were initiated in 1983-84 in six States (California, Florida, Minnesota, Missouri, New Jersey, and New York). State experiences in implementing the demonstrations are presented in this article. Although problems of enrolling Medicaid recipients in prepaid plans or with primary care case managers under these demonstrations proved challenging to States, lessons were learned in three key areas: program design and administration, health plan and provider relations, and beneficiary acceptance. Therefore, States considering similar programs in the future could benefit from these findings.     

Physician use of disease management programs.

This paper examines differences in availability, use, and perceived usefulness of disease management programs as reported by generalist and specialist physicians functioning as primary care providers in health plans. Implications of these differences are discussed in terms of the three types of purchasers: private insurers, Medicare, and Medicaid. The design is a cross-sectional mail and telephone mixed-mode survey. The data come from 23 health plans in five states (Florida, New York, Colorado, Pennsylvania, and Washington), including six metropolitan areas: Seattle, New York City, Miami, Pittsburgh, Philadelphia, and Denver. The study participants are 1,244 generalist and specialist physicians who contracted with health plans as primary care providers. They were drawn from a 2001 mail and telephone survey of 2,105 generalist and 1,693 specialist physicians serving commercial, Medicaid, and Medicare patients. Physician responses about use of disease management for their patients in the health plan and how useful they thought it was were regressed on physician, physician organization, and physician-health plan relationship characteristics. While generalist physicians are likely to report having disease management programs available and using them, specialists vary greatly in their response to the disease management programs. In contrast to physicians associated with commercial plans, implementation of disease management programs among physicians associated with Medicaid plans varied across states. Primary care providers trained in generalist areas of practice are more likely than specialists functioning as primary care providers to report that disease management programs are available and to use them. They also find them more useful than do specialists.     

Use of preventive services by managed care enrollees: an updated perspective

We examined whether enrollees in managed care plans received more preventive services than enrollees in non-managed care plans did, by conducting an updated literature synthesis of studies published between 1990 and 1998. We found that 37 percent of comparisons indicated that managed care enrollees were significantly more likely to obtain preventive services; 3 percent indicated that they were significantly less likely to do so; and 60 percent found no difference. Enrollees in group/staff-model health maintenance organizations (HMOs) were more likely to receive preventive services, but there was little evidence, outside of Medicaid managed care, that managed care plans are worse at providing preventive services. However, most of the evidence is equivocal: Provision of preventive services was neither better nor worse in managed versus non-managed care plans. Because of the blurred distinctions among types of health plans, more research is needed to identify which plan characteristics are most likely to encourage appropriate utilization.     

Home-care use and expenditures among Medicaid beneficiaries with AIDS

This article compares the use and cost of home-care services among traditional Medicaid recipients with acquired immunodeficiency syndrome (AIDS) and among participants in a statewide Human Immunodeficiency Virus (HIV)/AIDS-specific home and community-based Medicaid waiver program in New Jersey, using Medicaid claims and AIDS surveillance data. Waiver program participation appears to mitigate racial and risk group differences in the probability of home-care use. However, the program's successes are confined to its enrollees of which subgroups of the AIDS population are underrepresented. Our findings suggest the need to expand access to home-care programs to racial minorities and injection drug users (IDUs) with HIV/AIDS.