Accomplishments and challenges in Medicaid mental health

Although Medicaid was not designed as a mental health program, it is now a major source of financing for mental health services and care, especially for the chronically mentally ill. This paper examines the role Medicaid plays today for the low-income population with mental health needs and then reviews some of the current pressures and challenges in the program that could reshape this role.     

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.     

The evolution of quality management in Medicaid managed care

Since the early 1990s almost all states have moved some or all of their Medicaid beneficiaries to Medicaid managed care (MMC). Critics have worried about quality since MMC's inception. Proponents argued that state Medicaid agencies, as large-scale purchasers of care, would pursue "value-based purchasing" and other strategies to stimulate quality improvements. In this paper we extend and update previous evaluations of the use of managed care for the Medicaid population, the extent to which beneficiaries receive care from Medicaid only and from commercial health plans, and the quality management programs that state Medicaid agencies supported during 2001.     

System change: quality assessment and improvement for Medicaid managed care

Rising Medicaid health expenditures have hastened the development of State managed care programs. Methods to monitor and improve health care under Medicaid are changing. Under fee-for-service (FFS), the primary concern was to avoid overutilization. Under managed care, it is to avoid underutilization. Quality enhancement thus moves from addressing inefficiency to addressing insufficiency of care. This article presents a case study of Virginia's redesign of Quality Assessment and Improvement (QA/I) for Medicaid, adapting the guidelines of the Quality Assurance Reform Initiative (QARI) of the Health Care Financing Administration (HCFA). The article concludes that redesigns should emphasize Continuous Quality Improvement (CQI) by all providers and of multi-faceted, population-based data.     

Medicaid managed care: problems and promise

Medicaid spending is an increasing burden on already stressed state budgets. The states find themselves trapped between these growing costs and mounting pressure to ensure access of the underserved to health care services. States are hopeful that managed care is the answer to meeting the seemingly diametric needs of reducing costs while increasing access. However, evidence of performance measured in cost, access, and quality, and financial viability is inconclusive. Nevertheless, there have been some successes and, clearly, Medicaid managed care has potential. The unanswered question is the extent to which states can meet the diverse challenges of both Medicaid and managed care and tap that potential.     

Medicaid managed care and infant health

This paper provides estimates of the effects of Medicaid managed care on prenatal care adequacy and infant birthweights, using a census of 1994 Medicaid births in Wisconsin, where some Medicaid recipients were enrolled in fully capitated health maintenance organizations (HMOs) while others remained in traditional fee-for-service (FFS) systems. The results indicate that while Medicaid patients enrolled in managed care programs may be more likely to receive adequate prenatal care, birth outcomes under managed care are not significantly different from those under FFS financing systems. We conclude that cost savings generated by Wisconsin Medicaid managed care are not coming at the expense of maternity patients' or infants' welfare.     

Medicaid managed care and provider consolidation

In the thrust toward constructing economic value, health care provider firms have been consolidating at a marked rate. Medicaid managed care programs have been rapidly emerging with the objectives of containing health care costs and improving services for beneficiaries. However, there are concerns that the trend toward achieving market efficiency through merger is largely incongruent with the economic and health value objectives of Medicaid managed care programs in the states. Discordance among value objectives arises primarily because of inefficient and market concentrating horizontal merger strategies employed by firms and disruptions in quality of care that occur during the transition to integrated health care systems. By promoting vertical integration strategies and filling in the quality gaps created by an active merger environment, Medicaid offices advance state objectives of cost containment and quality while recognizing that providers operate in a complex and competitive environment that necessitates consolidation for organizational survival.     

Periods of unmanaged care in Medicaid managed care

Churning in Medicaid has been long recognized as a problem leading to breaks in coverage. Tenure in Medicaid managed care has received less attention. Recent reports indicate that children's tenures in health plans are far shorter than tenures in Medicaid itself, but explanations for the difference are not given. In the research reported here, we conducted case studies in five states to determine difference in tenure and reasons for the difference. Our investigation showed that children were enrolled in Medicaid two to four months longer than in specific Medicaid health plans. The major reasons for the gap were retroactive enrollment in Medicaid and delays in selecting a health plan. Frequent and burdensome Medicaid renewal processes exacerbate the problem, resulting in breaks in enrollment and the need to reenroll. The task of managing the care of Medicaid children is difficult without adequate tenures in health plans.     

Incantations in the dark: Medicaid, managed care, and maternity care

Public program reforms in the 1980s have substantially increased the numbers of poor pregnant women potentially eligible for Medicaid coverage. Structural deficiencies in the Medicaid program, together with inadequate arrangements in managed-care plans, however, have not led to generally acceptable levels of maternity care. Demonstration projects indicate that Medicaid can be modified cost effectively to underwrite early, continuous, and comprehensive care delivery. Recommendations are suggested for eligibility guarantees, enrollment safeguards, benefit and treatment protocols, provider recruitment, quality control, and sufficient payment rates to overcome barriers to adequate levels of material health care.     

Medicaid managed care. From cost savings to accountability and quality improvement

Medicaid managed care is a work in progress. This article provides a brief historical overview of Medicaid managed care from the early 1980s to the late 1990s and offers insight into some of the major operational, fiscal, and political realities of implementing managed care in a Medicaid context. This article also attempts to show that a major advantage of managed care is having a more accountable health care system. Accountability can bring quality improvements to a system that often lacked the ability to measure performance and results under Medicaid fee-for-service. Subsequent articles in this journal demonstrate how states working together with managed care organizations and quality review organizations can better define, measure, and use quality information to improve their Medicaid managed care programs.     

Medicaid managed care in Chicago: changes in utilization

In 1993, Illinois implemented Healthy Moms/Healthy Kids (HM/HK) in Chicago, a Medicaid managed care program for pregnant women and children. This study examines changes in immunizations for children (n = 134,072), prenatal care use for pregnant women (n = 5,151), and inpatient stays for mothers (n = 5,151) and newborns (n = 2,699) under the HM/HK program as compared with fee-for-service Medicaid in 1992 and 1993. HM/HK children were 10 percent more likely to receive any immunizations, and HM/HK pregnant women were 13 percent more likely to receive some prenatal care. Mothers' inpatient stays at delivery did not change under HM/HK. The length of newborn stays fell between 1992 and 1993, with both the HM/HK and the Medicaid 1993 comparison group deliveries associated with statistically shorter stays. During the early months of the program, improvements in the quantity of expected preventive care received were evident among children and women.     

Perils of pioneering: monitoring Medicaid managed care

This article reviews Federal and State oversight of section 1115 Medicaid managed care demonstrations in Hawaii, Oklahoma, Rhode Island, and Tennessee from 1994 to 1998. Under Medicaid managed care, the Federal Government and States have had to shift their focus and resources into oversight functions that barely existed in fee-for-service (FFS) Medicaid. We find that managed care monitoring was slow to begin and not always adequate in these demonstrations. While State and Federal monitoring have improved over time, monitoring is not yet at the point of ensuring access and quality.