End-of-life expenditures by Ohio Medicaid beneficiaries dying of cancer

We evaluate the extent to which the Ohio Medicaid Program serves as a safety net to terminally ill cancer patients, and the costs associated with providing care to this patient population. Over a 10-year period, Ohio Medicaid served nearly 45,000 beneficiaries dying of cancer, and spent more than $1 billion in medical care expenditures in their last year of life. Eighty percent of the expenditures were incurred by 67 percent of the decedents who had been enrolled in Medicaid for at least 1 year before death, implying an opportunity for the Medicaid Program to ensure timely transition to palliative care and hospice.     

End of life Medicare and Medicaid expenditures for dually eligible beneficiaries

In 1995, combined Medicare and Medicaid spending in the last year of life for dually eligible beneficiaries was more than $40,000 per beneficiary. Medicaid's share, primarily for long-term care (LTC), constituted about 40 percent of the total. Beneficiaries under age 65, Black persons, and individuals who died in a hospital had higher than average expenditures. The vast majority (86 percent) received some form of supportive services (nursing home, home care, hospice services). It is critical that policy deliberations consider both acute and LTC use concurrently because of their extensive use by dually eligible beneficiaries, as well as the interaction of the two funding sources (Medicare and Medicaid) that cover them.     

Patterns of Medicaid expenditures after AIDS diagnosis

This article examines average monthly Medicaid expenditures after diagnosis of acquired immunodeficiency syndrome (AIDS) for the diagnosis, mid-illness, and death intervals, as well as Kaplan-Meier estimates of expenditures from AIDS diagnosis to death. A clinical severity measure (the Severity Index for Adults with AIDS [SIAA]) designed to be predictive of patient survival was applied to a population of continuously enrolled New York State Medicaid patients who survived at least 6 months after being diagnosed with AIDS. Our findings suggest that groups of more seriously ill patients who appear to have more intense demand for health care services, especially over the diagnosis and mid-illness intervals, can be identified using the SIAA.     

Health care access,use, and satisfaction among disabled Medicaid beneficiaries

Despite being a vulnerable and costly population, little is known about disabled Medicaid beneficiaries. Using data from a 1999-2000 survey, we describe the population and their health care experiences in terms of access, use, and satisfaction with care. Results indicate that disabled beneficiaries are a unique population with wide-ranging circumstances and health conditions. Our results on access to care were indeterminate: by some measures, they had good access, but by others they did not. Beneficiaries' assessments of their health care were more clear: The bulk of the sample rated one or more area of care as being fair or poor.     

The effect of Medicaid payment generosity on access and use among beneficiaries

OBJECTIVE: This study examines the effects of Medicaid payment generosity on access and care for adult and child Medicaid beneficiaries. DATA SOURCE: Three years of the National Surveys of America's Families (1997, 1999, 2002) are linked to the Urban Institute Medicaid capitation rate surveys, the Area Resource File, and the American Hospital Association survey files. STUDY DESIGN: In order to identify the effect of payment generosity apart from unmeasured differences across areas, we compare the experiences of Medicaid beneficiaries with groups that should not be affected by Medicaid payment policies. To assure that these groups are comparable to Medicaid beneficiaries, we reweight the data using propensity score methods. We use a difference-in-differences model to assess the effects of Medicaid payment generosity on four categories of access and use measures (continuity of care, preventive care, visits, and perceptions of provider communication and quality of care). PRINCIPAL FINDINGS: Higher payments increase the probability of having a usual source of care and the probability of having at least one visit to a doctor and other health professional for Medicaid adults, and produce more positive assessments of the health care received by adults and children. However, payment generosity has no effect on the other measures that we examined, such as the probability of receiving preventive care or the probability of having unmet needs. CONCLUSIONS: Higher payment rates can improve some aspects of access and use for Medicaid beneficiaries, but the effects are not dramatic.     

Personal care satisfaction among aged and physically disabled Medicaid beneficiaries

We analyzed survey data from 2,325 Medicaid home and community-based services (HCBS) beneficiaries in six States to estimate satisfaction with personal care services. We constructed an eight-item scale rating various aspects of paid assistance and estimated satisfaction for the total sample and for older and younger persons with disabilities. Younger persons with significant health problems and those residing in group settings were less satisfied. Higher unmet need for assistance with activities of daily living (ADLs), and instrumental activities of daily living (IADLs) was associated with decreased satisfaction, and matching race between a client and paid caregiver was associated with significantly increased satisfaction in all age groups.     

Medicaid expenditures and state responses

This overview summarizes issues addressed in this issue of the Health Care Financing Review, entitled "Medicaid and State Health Reform." Articles cover the following topics: growth in the level of expenditures for Medicaid and creative financing strategies by States to manage these increases; section 1115 demonstration waivers; States' experiences with implementing approved section 1115 demonstrations; how section 1115 demonstration waivers fit into larger State health reform efforts; and other reform efforts in two States.     

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.     

Overcoming problems with dental care for Medicaid beneficiaries

Lack of access to dental care means more than dirty teeth to many vulnerable consumers. It also is related to pain, poor nutrition, and the inability to accomplish tasks of daily living. This issue of States of Health examines the nature of the problem and the variety of ways advocates are addressing it.     

The relationship of post-acute home care use to Medicaid utilization and expenditures

RESEARCH OBJECTIVES: To describe the use of post-acute home care (PAHC) and total Medicaid expenditures among hospitalized nonelderly adult Medicaid eligibles and to test whether health services utilization rates or total Medicaid expenditures were lower among Medicaid eligibles who used PAHC compared to those who did not. STUDY POPULATION: 5,299 Medicaid patients aged 18-64 discharged in 1992-1996 from 29 hospitals in the Cleveland Health Quality Choice (CHQC) project. DATA SOURCES: Linked Ohio Medicaid claims and CHQC medical record abstract data. DATA EXTRACTION: One stay per patient was randomly selected. DESIGN: Observational study. To control for treatment selection bias, we developed a model predicting the probability (propensity) a patient would be referred to PAHC, as a proxy for the patient's need for PAHC. We matched 430 patients who used Medicaid-covered PAHC ("USE") to patients who did not ("NO USE") by their propensity scores. Study outcomes were inpatient re-admission rates and days of stay (DOS), nursing home admission rates and DOS, and mean total Medicaid expenditures 90 and 180 days after discharge. PRINCIPAL FINDINGS: Of 3,788 medical patients, 12.1 percent were referred to PAHC; 64 percent of those referred used PAHC. Of 1,511 surgical patients, 10.9 percent were referred; 99 percent of those referred used PAHC. In 430 pairs of patients matched by propensity score, mean total Medicaid expenditures within 90 days after discharge were $7,649 in the USE group and $5,761 in the NO USE group. Total Medicaid expenditures were significantly higher in the USE group compared to the NO USE group for medical patients after 180 days (p < .05) and surgical patients after 90 and 180 days (p < .001). There were no significant differences for any other outcome. Sensitivity analysis indicates the results may be influenced by unmeasured variables, most likely functional status and/or care-giver support. CONCLUSIONS: Thirty-six percent of the medical patients referred to PAHC did not receive Medicaid-covered services. This suggests potential underuse among medical patients. The high post-discharge expenditures suggest opportunities for reducing costs through coordinating utilization or diverting it to lower-cost settings. Controlling for patients' need for services, PAHC utilization was not associated with lower utilization rates or lower total Medicaid expenditures. Medicaid programs are advised to proceed cautiously before expanding PAHC utilization and to monitor its use carefully. Further study, incorporating non-economic outcomes and additional factors influencing PAHC use, is warranted.     

Managed care and medical expenditures of Medicare beneficiaries

This paper investigates the impact of Medicare HMO penetration on the medical care expenditures incurred by Medicare fee-for-service (FFS) enrollees. We find that increasing penetration leads to reduced spending on FFS beneficiaries. In particular, our estimates suggest that the increase in HMO penetration during our study period led to approximately a 7% decline in spending per FFS beneficiary. Similar models for various measures of health care utilization find penetration-induced reductions consistent with our spending estimates. Finally, we present evidence that suggests our estimated spending reductions are driven by beneficiaries who have at least one chronic condition.