Effects of Medicaid managed care programs on health services access and use

OBJECTIVE: To estimate the effects of Medicaid managed care (MMC) programs on Medicaid enrollees' access to and use of health care services at the national level. DATA SOURCES/STUDY SETTING: 1991-1995 National Health Interview Surveys (NHIS) and a 1998 Urban Institute survey on state Medicaid managed care programs. STUDY DESIGN: Using multivariate regression models, we estimated the effect of living in a county with an MMC program on several access and use measures for nonelderly women who receive Medicaid through AFDC and child Medicaid recipients. We focus on mandatory programs and estimate separate effects for primary care case management (PCCM) programs, health maintenance organization (HMO) programs, and mixed PCCM/HMO programs, relative to fee-for-service (FFS) Medicaid. We control for individual and county characteristics, and state and year effects. DATA COLLECTION/EXTRACTION METHOD: This study uses pooled individual-level data from up to five years of the NHIS (1991-1995), linked to information on Medicaid managed care characteristics at the county level from the 1998 MMC survey. PRINCIPAL FINDINGS: We find virtually no effects of mandatory PCCM programs. For women, mandatory HMO programs reduce some types of non-emergency room (ER) use, and increase reported unmet need for medical care. The PCCM/HMO programs increase access, but had no effects on use. For children, mandatory HMO programs reduce ER visits, and increase the use of specialists. The PCCM/HMO programs reduce ER visits, while increasing other types of use and access. CONCLUSIONS: Mandatory PCCM/HMO programs improved access and utilization relative to traditional FFS Medicaid, primarily for children. Mandatory HMO programs caused some access problems for women.     

The effect of health insurance coverage on medical care utilization and health outcomes: Evidence from Medicaid adult vision benefits

Increasing the proportion of adults that have regular, comprehensive eye exams and reducing visual impairment due to uncorrected refractive error and other common eye health problems are federal health objectives. We examine the effect of vision insurance on eye care utilization and vision health outcomes by taking advantage of quasi-experimental variation in Medicaid coverage of adult vision care. Using a difference-in-difference-in-difference approach, we find that Medicaid beneficiaries with vision coverage are 4.4 percentage points (p < 0.01) more likely to have seen an eye doctor in the past year, 5.3 percentage points (p < 0.01) less likely to report needing but not purchasing eyeglasses or contacts due to cost, 2.0 percentage points (p < 0.05) less likely to report difficulty seeing with usual vision correction, and 1.2 percentage points (p < 0.01) less likely to have a functional limitation due to vision.     

The impact of Medicaid managed care on hospitalizations for ambulatory care sensitive conditions

OBJECTIVE: To determine whether Medicaid managed care is associated with lower hospitalization rates for ambulatory care sensitive conditions than Medicaid fee-for-service. We also explored whether there was a differential effect of Medicaid managed care by patient's race or ethnicity on the hospitalization rates for ambulatory care sensitive conditions. DATA SOURCES/STUDY SETTING: Electronic hospital discharge abstracts for all California temporary assistance to needy families (TANF)-eligible Medicaid beneficiaries less than age 65 who were admitted to acute care hospitals in California between 1994 and 1999. STUDY DESIGN: We performed a cross-sectional comparison of average monthly rates of admission for ambulatory care-sensitive conditions among TANF-eligible Medicaid beneficiaries in fee-for-service, voluntary managed care, and mandatory managed care. DATA COLLECTION/EXTRACTION METHODS: We calculated monthly rates of ambulatory care-sensitive condition admission rates by counting admissions for specified conditions in hospital discharge files and dividing the monthly count of admissions by the size of the at-risk population derived from a separate monthly Medicaid eligibility file. We used multivariate Poisson regression to model monthly hospital admission rates for ambulatory care-sensitive conditions as a function of the Medicaid delivery model controlling for admission month, admission year, patient age, sex, race/ethnicity, and county of residence. PRINCIPAL FINDINGS: The adjusted average monthly hospitalization rate for ambulatory care-sensitive conditions per 10,000 was 9.36 in fee-for-service, 6.40 in mandatory managed care, and 5.25 in voluntary managed care (p<.0001 for all pairwise comparisons). The difference in hospitalization rates for ambulatory care sensitive conditions in Medicaid fee-for-service versus managed care was significantly larger for patients from minority groups than for whites. CONCLUSIONS: Selection bias in voluntary Medicaid managed care programs exaggerates the differences between managed care and fee-for-service, but the 33 percent lower rate of hospitalizations for ambulatory care sensitive conditions found in mandatory managed care compared with fee-for-service suggests that Medicaid managed care is associated with a large reduction in hospital utilization, which likely reflects health benefits. The greater effect of Medicaid managed care for minority compared with white beneficiaries is consistent with other findings that suggest that managed care is associated with improvements in access to ambulatory care for those patients who have traditionally faced the greatest barriers to health care.     

Medicaid managed care and the unmet need for mental health care among children with special health care needs

OBJECTIVE: To determine the association between Medicaid managed care pediatric behavioral health programs and unmet need for mental health care among children with special health care needs (CSHCN). DATA SOURCE: The National Survey of CSHCN (2000-2002), using subsets of 4,400 CSHCN with Medicaid and 1,856 CSHCN with Medicaid and emotional problems. Additional state-level sources were used. STUDY DESIGN: Multilevel models investigated the association between managed care program type (carve-out, integrated) or fee-for-service (FFS) and reported unmet mental health care need. DATA COLLECTION/EXTRACTION METHODS: The National Survey of CSHCN conducted telephone interviews with a sample representative at both the national and state levels. PRINCIPAL FINDINGS: In multivariable models, among CSHCN with only Medicaid, living in states with Medicaid managed care (odds ratio [OR]=1.81; 95 percent confidence interval: 1.04-3.15) or carve-out programs (OR=1.93; 1.01-3.69) were associated with greater reported unmet mental health care need compared with FFS programs. Among CSHCN on Medicaid with emotional problems, the association between managed care and unmet need was stronger (OR=2.48; 1.38-4.45). CONCLUSIONS: State Medicaid pediatric behavioral health managed care programs were associated with greater reported unmet mental health care need than FFS programs among CSHCN insured by Medicaid, particularly for those with emotional problems.     

Effects of forced disruption in Medicaid managed care on children with asthma

ObjectiveTo evaluate the effect of a forced disruption to Medicaid managed care plans and provider networks on health utilization and outcomes for children with persistent asthma.Data SourcesMedicaid managed care administrative claims data from 2013 to 2016, obtained from a southeastern state.Study DesignA difference‐in‐difference analysis compared patients’ outpatient, inpatient, and emergency department (ED) utilization and receipt of recommended services before and after implementation of a statewide redistribution of patients among nine managed care plans.Data Collection/Extraction MethodsEnrollment data for children with asthma were linked to the administrative claims. Children were included if they had a diagnosis of persistent asthma in 2013 and if they were enrolled continuously throughout 2014‐2016.Principal FindingsAmong the 28 537 children with asthma, 26% were forced to switch their managed care plan after the redistribution. Of these, 67% also switched their primary care provider (PCP). Relative to those who remained in their plan, disruption was associated with an additional 2.1 percentage‐point decrease in the number of children who had an outpatient visit per quarter [95%CI −2.8, −1.3], from 71% to 66% (compared to plan stayers: 74% to 71%). Among children experiencing a change to their plan, there was overall a decrease in the proportion of children receiving an asthma‐specific visit per quarter, but there was less of a decrease in children that also changed their PCP [1.6 percentage points, 95%CI 0.7, 2.5], from 9.7% to 8.3% (compared to those who did not switch their PCP: 12% to 8.6%). Indicators of asthma care quality and emergent care utilization were not significantly different between the two periods.ConclusionsWhile there was a decrease in the number of outpatient visits associated with forced disruption of Medicaid managed care plans for children with persistent asthma, there were no consistent associations with worse asthma quality performance or higher emergent health care utilization.     

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.     

Problems with quality monitoring for Medicaid managed care: Perceptions of institutional and private providers in New York City

The study objective was to examine quality oversight efforts by Medicaid managed care organizations (MCOs) for children in a sample of ambulatory care institutions and private practices in New York City. This was a cross-sectional study of quality assurance priorities and strategies of MCOs and their impact date in institutions in New York City. Data were from structured interviews administered in 1997 to medical directors in the eight largest MCOs; and medical directors, heads of ambulatory pediatrics, and institutional pediatricians in a random sample of 15 institutions and 20 private office-based providers. Medical directors in MCOs reported that their main priority areas were the preventive care measures (e.g., immunization and lead screening) that they must report to the state. Knowledge of these MCO priority areas and monitoring activities was high for medical directors in the random sample, but decreased from these medical directors to heads of ambulatory pediatrics to institutional pediatricians, with the differences between the medical directors and institutional pediatricians significant (P<.05). However, 96% of the institutional pedians reported knowing their own institution's priorities and monitoring activities. In contrast, most private pediatricians reported they knew MCO priorities and monitoring activities (80%). Less than 33% of any group reported activities as “very effective” or felt any incentive to improve performance. There was a high level of overlap in provider networks, with institutions and private providers having children in many MCOs, and MCOs having children in many sites. This study was funded by the Centers for Disease Control and Prevention through contract 97B2644 between researchers and the New York City Department of Health. This paper was presented at the 1999 Health Services Research Symposium sponsored by the Greater New York Hospital Association/United Hospital Fund on November 16, 1999.     

Adult Medicaid benefit generosity and receipt of recommended health services among low-income children: The spillover effects of Medicaid adult dental coverage expansions

Low-income children are less likely to receive recommended health services than their high-income counterparts. This paper examines whether the design of parental Medicaid benefit packages could serve as a mechanism for reducing income-based disparities in unmet health care needs, considering dental benefits as a case study. Leveraging state-level changes to adult dental benefits over time, I find that coverage is associated with increases of 14 and 5 percentage points, respectively, in the likelihood of a recent dental visit among parents and children directly exposed to the policy. Child effects appear to be concentrated among younger children under age 12.     

The effect of health insurance on crime: Evidence from the Affordable Care Act Medicaid expansion

Little evidence exists on the effect of the Affordable Care Act (ACA) on criminal behavior, a gap in the literature that this paper seeks to address. Using a simple model, we argue we should anticipate a decrease in time devoted to criminal activities in response to the expansion, because the availability of the ACA Medicaid coverage raises the opportunity cost of crime. This prediction is particularly relevant for the ACA expansion because it primarily affects childless adults, a population likely to contain individuals who engage in criminal behavior. We validate this forecast empirically using a difference‐in‐differences framework, estimating the expansion's effects on panel datasets of state‐ and county‐level crime rates. Our estimates suggest that the ACA Medicaid expansion was negatively associated with burglary, vehicle theft, homicide, robbery, and assault. These crime‐reduction spillover effects represent an important offset to the government's cost burden for the ACA Medicaid expansion.     

Managed behavioral health care: an instrument to characterize critical elements of public sector programs

OBJECTIVE: To develop an instrument to characterize public sector managed behavioral health care arrangements to capture key differences between managed and "unmanaged" care and among managed care arrangements. STUDY DESIGN: The instrument was developed by a multi-institutional group of collaborators with participation of an expert panel. Included are six domains predicted to have an impact on access, service utilization, costs, and quality. The domains are: characteristics of the managed care plan, enrolled population, benefit design, payment and risk arrangements, composition of provider networks, and accountability. Data are collected at three levels: managed care organization, subcontractor, and network of service providers. DATA COLLECTION METHODS: Data are collected through contract abstraction and key informant interviews. A multilevel coding scheme is used to organize the data into a matrix along key domains, which is then reviewed and verified by the key informants. PRINCIPAL FINDINGS: This instrument can usefully differentiate between and among Medicaid fee-for-service programs and Medicaid managed care plans along key domains of interest. Beyond documenting basic features of the plans and providing contextual information, these data will support the refinement and testing of hypotheses about the impact of public sector managed care on access, quality, costs, and outcomes of care. CONCLUSIONS: If managed behavioral health care research is to advance beyond simple case study comparisons, a well-conceptualized set of instruments is necessary.     

Cost shifting to jails after a change to managed mental health care

OBJECTIVE: To determine whether managed mental health care for Medicaid enrollees in King County, Washington, has led to indirect cost-shifting to substitute treatments, such as jails and state mental hospitals that are free goods to providers. DATA SOURCES: Complete service records for 47,300 adults who used at least one of the following systems from 1993 to 1998: King County jail system, Medicaid, or the King County mental health system. Data were also obtained from the Washington State Hospital System. STUDY DESIGN: A quasi-experimental analysis that compares the difference in outcomes between the pre- and post-managed care periods for Medicaid enrollees compared to non-Medicaid enrollees. The outcomes-jail costs, state hospital costs, and county outpatient mental health costs-were estimated with two-part difference-in-differences models. The regressions control for person-level fixed effects on up to 66 months of data per person. DATA COLLECTION METHODS: Administrative data were collected from the jail, Medicaid, and mental health systems, then merged and cleaned. Additional data on costs were obtained in interviews. PRINCIPAL FINDINGS: There is a striking increase in the probability of jail use for persons on Medicaid following the introduction of managed care. There was a significant decrease in expenditures in the county mental health system for outpatient care. CONCLUSIONS: Managed care led to indirect cost-shifting, probably through poor access to services, which may have led to an increased probability of jail detention.     

Multimethod evaluation of health policy change: an application to Medicaid managed care in a rural state

Objective. To answer questions about the impacts of Medicaid managed care (MMC) at the individual, organizational/community, and population levels of analysis.
Data Sources/Study Setting. Multimethod approach to study MMC in New Mexico, a rural state with challenging access barriers.
Study Design. Individual level: surveys to assess barriers to care, access, utilization, and satisfaction. Organizational/community level: ethnography to determine changes experienced by safety net institutions and local communities. Population level: analysis of secondary databases to examine trends in preventable adverse sentinel events.
Data Collection/Extraction Methods. Survey: multivariate statistical methods, including factor analysis and logistic regression. Ethnography: iterative coding and triangulation to assess documents, field observations, and in-depth interviews. Secondary databases: plots of sentinel events over time.
Principal Findings. The survey component revealed no consistent changes after MMC, relatively favorable experiences for Medicaid patients, and persisting access barriers for the uninsured. In the ethnographic component, safety net institutions experienced increased workload and financial stress; mental health services declined sharply. Immunization rate, as an important sentinel event, deteriorated.
Conclusions. MMC exerted greater effects on safety net providers than on individuals and did not address problems of the uninsured. A multimethod approach can facilitate evaluation of change in health policy.     

The Effect of Medicaid on Management of Depression: Evidence From the Oregon Health Insurance Experiment

Policy Points:

• We take advantage of Oregon's Medicaid lottery to gauge the causal effects of Medicaid coverage on mental health care, how effectively it addresses unmet needs, and how those effects differ for those with and without a history of depression.
• Medicaid coverage reduced the prevalence of undiagnosed depression by almost 50% and untreated depression by more than 60%. It increased use of medications and reduced the share of respondents reporting unmet mental health care needs by almost 40%.
• There are likely to be substantial mental health consequences of policy decisions about Medicaid coverage for vulnerable populations.

Context

Expanding Medicaid to previously uninsured adults has been shown to increase detection and reduce the prevalence of depression, but the ways that Medicaid affects mental health care, how effectively it addresses unmet needs, and how those effects differ for those with and without a history of depression remain unclear.

Methods

We take advantage of Oregon's Medicaid lottery to gauge the causal effects of Medicaid coverage using a randomized‐controlled design, drawing on both primary and administrative data sources.

Findings

Medicaid coverage reduced the prevalence of undiagnosed depression by almost 50% and untreated depression by more than 60%. It increased use of medications frequently prescribed to treat depression and related mental health conditions and reduced the share of respondents reporting unmet mental health care needs by almost 40%. The share of respondents screening positive for depression dropped by 9.2 percentage points overall, and by 13.1 for those with preexisting depression diagnoses, with greatest relief in symptoms seen primarily in feeling down or hopeless, feeling tired, and trouble sleeping—consistent with the increase observed not just in medications targeting depression but also in those targeting sleep.

Conclusions

Medicaid coverage had significant effects on the diagnosis, treatment, and outcomes of a population with substantial unmet mental health needs. Coverage increased access to care, reduced the prevalence of untreated and undiagnosed depression, and substantially improved the symptoms of depression. There are likely to be substantial mental health consequences of policy decisions about Medicaid coverage for vulnerable populations.     

Children's Access to Dental Care in Connecticut's Medicaid Managed Care Program

Objective: To describe dental care utilization and access problems in Connecticut's Medicaid managed care program, using quantitative and qualitative research methods. Methods: Using Medicaid managed care enrollment and encounter data from Connecticut, utilization rates for preventive care and treatment services are determined for 87,181 children who were continuously enrolled in Medicaid managed care for 1 year in 1996–97. Sociodemographic and enrollment factors associated with utilization are identified using bivariate and multivariate methods. Dental providers and practices where children received services are described. Qualitative methods are used to characterize problems experienced by families seeking dental care during the study period. Results: Only 30.5% of children continuously enrolled in Medicaid managed care for 1 year received any preventive dental services; 17.8% received any treatment services. Children who received preventive care were eight times more likely to have received treatment services. Utilization was higher among (a) younger children, (b) children who lived in Hartford and in other counties served by public dental clinics, and (c) children enrolled in health plans that did not subcontract for administration of dental services. Just 5% of providers, primarily those in public dental clinics, performed 50% of the services. Families whose children needed care encountered significant administrative and logistical problems when trying to find willing providers and obtain appointments. Conclusions: Access to dental care is a problem for children in Connecticut's Medicaid managed care program. Several features of managed care have negatively affected access. Public dental clinics served many children across the state and contributed to higher utilization of preventive care and treatment services among children living in Hartford.     

The impact of Medicaid on medical utilization in a vulnerable population: Evidence from COFA migrants

In March 2015, the State of Hawaii stopped covering the majority of migrants from countries belonging to the Compact of Free Association (COFA) in its Medicaid program. COFA migrants were required to obtain private insurance in the exchanges established under the Affordable Care Act. Using statewide hospital discharge data, we show that Medicaid‐funded hospitalizations and emergency room visits declined in this population by 31% and 19%, respectively. Utilization funded by private insurance did increase but not enough to offset the declines in Medicaid‐funded utilization. We show that the expiration of benefits increased uninsured ER visits. Finally, we exploit a feature of the policy change to provide evidence that the declines in utilization are due to higher rates of uninsured migrants rather than higher levels of cost sharing on private plans.