Effects of Cash and Counseling on Personal Care and Well-Being

Objective. To examine how a new model of consumer-directed care changes the way that consumers with disabilities meet their personal care needs and, in turn, affects their well-being.
Study Setting. Eligible Medicaid beneficiaries in Arkansas, Florida, and New Jersey volunteered to participate in the demonstration and were randomly assigned to receive an allowance and direct their own Medicaid supportive services as Cash and Counseling consumers (the treatment group) or to rely on Medicaid services as usual (the control group). The demonstration included elderly and nonelderly adults in all three states and children in Florida.
Data Sources. Telephone interviews administered 9 months after random assignment.
Methods. Outcomes for the treatment and control group were compared, using regression analysis to control for consumers' baseline characteristics.
Principal Findings. Treatment group members were more likely to receive paid care, had greater satisfaction with their care, and had fewer unmet needs than control group members in nearly every state and age group. However, among the elderly in Florida, Cash and Counseling had little effect on these outcomes because so few treatment group members actually received the allowance. Within each state and age group, consumers were not more susceptible to adverse health outcomes or injuries under Cash and Counseling.
Conclusions. Cash and Counseling substantially improves the lives of Medicaid beneficiaries of all ages if consumers actually receive the allowance that the program offers.     

How Caregivers and Workers Fared in Cash and Counseling

Objectives. To assess the effects of Cash and Counseling on Medicaid beneficiaries' primary informal caregivers and describe the experiences of their directly hired workers.
Study Setting. Beneficiaries in Arkansas, Florida, and New Jersey voluntarily enrolled in the demonstration and were randomly assigned to direct their own Medicaid supportive services as Cash and Counseling consumers (the treatment group) or to rely on Medicaid services as usual (the control group). Beneficiaries identified their primary informal caregiver during a baseline interview and their primary paid worker during a 9-month follow-up interview.
Data Sources. Data were collected through telephone interviews with caregivers and workers. These interviews were conducted about 10 months after beneficiaries' random assignment, between February 2000 and May 2003, depending on the state.
Data Analysis Methods. We estimated program effects with regression and logit models and compared the mean characteristics of directly hired workers and agency workers, by state.
Principal Findings. Compared with caregivers in the control group, those in the treatment group had modestly to substantially better outcomes for measures of satisfaction with care, worry, and physical and financial strain. For hours of care and emotional strain, outcomes in the treatment group were similar to or somewhat better than those in the control group. Directly hired workers reported greater satisfaction with wages, similar satisfaction with working conditions, and similar rates of injuries as agency workers. Workers who were related to the beneficiary reported more emotional strain than agency workers.
Conclusions. Cash and Counseling can lessen some of the burden associated with caring for a child or adult with disabilities. The experiences of hired workers suggest consumer direction is a sustainable option, but support networks for workers might be a welcome program improvement.     

Outsourcing administrative functions: service organization demonstrations and Florida Medicaid PCCM program costs

This study examines the cost implications of outsourcing Medicaid functions to the private sector. We examine the expenditures for enrollees in three Medicaid primary care case management (PCCM) demonstration projects compared to Florida's PCCM program from February 2002-February 2003. The RAND two-part model was used to analyze the medica expenditures for enrollees in each program. After adjusting for sociodemographic factors and the probability of service use, we found that all three demonstration projects reduced expenditures compared to the PCCM program. The implications from the study are that Medicaid programs may want to consider outsourcing PCCM functions after further studies examine the utilization experience for enrollees in these programs.     

Changes in per member per month expenditures after implementation of Florida's Medicaid reform demonstration

Objective. To determine the impact of Florida's Medicaid Reform Demonstration on per member per month (PMPM) Medicaid expenditures. Data. Florida Medicaid claims data from the two fiscal years before implementation of the Demonstration (FY0405, FY0506) and the first two fiscal years after implementation (FY0607, FY0708) from two reform counties and two nonreform counties. Study Design. A difference‐in‐difference approach was used to compare changes in expenditures before and after implementation of reforms between the reform counties and the nonreform counties. Data Extraction. Medicaid claims and eligibility files were extracted for enrollees in the reform and nonreform counties and collapsed into monthly amounts (N=16,875,467). Principal Findings. When examining the entire population, the reforms had little impact on PMPM expenditures, particularly among SSI enrollees. PMPM expenditures for SSI enrollees increased by an additional U.S.$0.35 in the reform counties compared with the nonreform counties and increased by an additional U.S.$2.38 for Temporary Assistance for Needy Families (TANF) enrollees. An analysis that limited the sample to individuals with at least 3 or 6 months of observations pre‐ and postimplementation, however, showed reduced PMPM expenditures of U.S.$11.15–U.S.$19.44 PMPM for both the SSI and TANF populations. Conclusions. Although Medicaid reforms in Florida did not result in significant reductions in PMPM expenditures when examining the full population, it does appear that expenditure reductions may be achieved among Medicaid enrollees with more stable enrollment, who have more exposure to managed care activities and may have more health care needs than the overall Medicaid population.     

Healthcare Foundation to manage care in Florida

The Florida Agency for Health Care Administration is creating what might be the largest HIV disease management program in the United States. The program, called Positive Healthcare/Florida will eventually manage care, and provide other health services, for 7,500 of Florida's estimated 12,500 Medicaid beneficiaries with AIDS. No direct medical care will be provided, but the program will provide education, support services, and information to patients and providers.     

Florida's medicaid reform: informed consumer choice?

Florida is among the first states to implement Medicaid reform using a competitive consumer choice model. Using data from a 2006-07 Kaiser Family Foundation survey of Medicaid recipients newly enrolled in Florida's reform program, we examine how well they understood the changes taking place and their experiences in selecting a health plan. We find important gaps in people's understanding of major components of the reform: About 30 percent were not aware that they were enrolled in reform, and more than half had trouble understanding plan information. These problems were not particular to any group but instead were experienced broadly across the full Medicaid population.     

Incentives in a Medicaid carve-out: impact on children with special health care needs

Objective. To evaluate whether a specialty care payment "carve-out" from Medicaid managed care affects caseloads and expenditures for children with chronic conditions.
Data Source. Paid Medicaid claims in California with service dates between 1994 and 1997 that were authorized by the Title V Children with Special Health Needs program for children under age 21.
Study Design. A natural experiment design evaluated the impact of California's Medicaid managed care expansion during the 1990s, which preserved fee-for-service payment for certain complex medical diagnoses. Outcomes in time series regression include Title V program participation and expenditures. Multiple comparison groups include children in managed care counties who were not mandated to enroll, and children in nonmanaged care counties.
Data Collection/Extraction Methods. Data on the study population were obtained from the state health department claims files and from administrative files on enrollment and managed care participation.
Principal Findings. The carve-out policy increased the number of children receiving Title V-authorized services. Recipients and expenditures for some ambulatory services increased, although overall expenditures (driven by inpatient services) did not increase significantly. Cost intensity per Title V recipient generally declined.
Conclusions. The carve-out policy increased identification of children with special health care needs. The policy may have improved children's access to prevailing standards of care by motivating health plans and providers to identify and refer children to an important national program.     

An Examination of the Medicaid Undercount in the Current Population Survey: Preliminary Results from Record Linking

Objective. To assess reasons why survey estimates of Medicaid enrollment are 43 percent lower than raw Medicaid program enrollment counts (i.e., "Medicaid undercount").
Data Sources. Linked 2000–2002 Medicaid Statistical Information System (MSIS) and the 2001–2002 Current Population Survey (CPS).
Data Collection Methods. Centers for Medicare and Medicaid Services provided the Census Bureau with its MSIS file. The Census Bureau linked the MSIS to the CPS data within its secure data analysis facilities.
Study Design. We analyzed how often Medicaid enrollees incorrectly answer the CPS health insurance item and imperfect concept alignment (e.g., inclusion in the MSIS of people who are not included in the CPS sample frame and people who were enrolled in Medicaid in more than one state during the year).
Principal Findings. The extent to which the Medicaid enrollee data were adjusted for imperfect concept alignment reduces the raw Medicaid undercount considerably (by 12 percentage points). However, survey response errors play an even larger role with 43 percent of Medicaid enrollees answering the CPS as though they were not enrolled and 17 percent reported being uninsured.
Conclusions. The CPS is widely used for health policy analysis but is a poor measure of Medicaid enrollment at any time during the year because many people who are enrolled in Medicaid fail to report it and may be incorrectly coded as being uninsured. This discrepancy should be considered when using the CPS for policy research.     

A Cost Analysis of the Iowa Medicaid Primary Care Case Management Program

Objective. To determine the cost savings attributable to the implementation and expansion of a primary care case management (PCCM) program on Medicaid costs per member in Iowa from 1989 to 1997.
Data Sources. Medicaid administrative data from Iowa aggregated at the county level.
Study Design. Longitudinal analysis of costs per member per month, analyzed by category of medical expense using weighted least squares. We compared the actual costs with the expected costs (in the absence of the PCCM program) to estimate cost savings attributable to the PCCM program.
Principal Findings. We estimated that the PCCM program was associated with a savings of $66 million to the state of Iowa over the study period. Medicaid expenses were 3.8 percent less than what they would have been in the absence of the PCCM program. Effects of the PCCM program appeared to grow stronger over time. Use of the PCCM program was associated with increases in outpatient care and pharmaceutical expenses, but a decrease in hospital and physician expenses.
Conclusions. Use of a Medicaid PCCM program was associated with substantial aggregate cost savings over an 8-year period, and this effect became stronger over time. Cost reductions appear to have been mediated by substituting outpatient care for inpatient care.     

Factors related to Medicaid payment acceptance at outpatient substance abuse treatment programs

Objective. To examine factors associated with Medicaid acceptance for substance abuse (SA) services by outpatient SA treatment programs. Data Sources. Secondary analysis of 2003–2006 National Survey of Substance Abuse Treatment Services data combined with state Medicaid policy and usage measures and other publicly available data. Study Design. We used cross‐sectional analyses, including state fixed effects, to assess relationships between SA treatment program Medicaid acceptance and (1) program‐level factors, (2) county‐level sociodemographics and treatment program density, and (3) state‐level population characteristics, SA treatment‐related factors, and Medicaid policy and usage. Data Extraction Methods. State Medicaid policy data were compiled based on reviews of state Medicaid‐related statutes/regulations and Medicaid plans. Other data were publicly available. Principal Findings. Medicaid acceptance was significantly higher for programs: (a) that were publicly funded and in states with Medicaid policy allowing SA treatment coverage; (b) with accreditation/licensure and nonprofit/government ownership, as well as mental‐ and general‐health focused programs; and (c) in counties with lower household income. Conclusions. SA treatment program Medicaid acceptance related to program‐, county, and state‐level factors. The data suggest the importance of state policy and licensure/accreditation requirements in increasing SA program Medicaid access.     

The Utility of the State Buy-In Variable in the Medicare Denominator File to Identify Dually Eligible Medicare-Medicaid Beneficiaries: A Validation Study

Objective. To compare the adequacy of the state buy-in variable (SBI) in the Medicare denominator file to identify dually eligible patients.
Data Source/Study Settings. We used linked Medicare and Medicaid data from Michigan and Ohio for elders diagnosed with incident breast, prostate, or colorectal cancer between 1996 and 2001.
Study Design. Using the Medicaid enrollment file as the "gold standard," we assessed the number of duals from Medicare files in cross-sectional and longitudinal analyses.
Data Collection/Extraction Methods. Data for the study population were linked with Medicare and Medicaid files using patient identifiers.
Principal Findings. Sensitivity was low (74.2 percent, 95 percent confidence interval [CI]: 72.7, 75.6 and 80.8 percent, 79.7, 81.9, in Michigan and Ohio, respectively). PPV was above 95 percent in Michigan and 88.8 percent in Ohio. Both sensitivity and PPV varied between and within the states. Both in Michigan and in Ohio, we observed limited agreement on the length of enrollment in Medicaid between the two data sources.
Conclusions. Except to examine disparities by dual status at a very broad level, the SBI variable alone may be inadequate to identify duals. The findings call for improvements in Medicare and Medicaid information management systems and for uniformity in database linking strategies.     

Assessing the association between environmental impacts and health outcomes: a case study from Florida

The Centers for Disease Control and Prevention (CDC) created the Environmental Public Health Tracking (EPHT) program to integrate hazard monitoring, exposure, and health effects surveillance into a cohesive tracking network. Part of Florida's effort to move toward implementation of EPHT is to develop models of the spatial and temporal association between myocardial infarctions (MIs) and ambient ozone levels in Florida. Existing data were obtained from Florida's Agency for Health Care Administration, Florida's Department of Environmental Protection, the U.S. Census Bureau, and CDC's Behavioral Risk Factor Surveillance System. These data were linked by both ignoring spatial support and using block kriging, a support-adjusted approach. The MI data were indirectly standardized by age, race/ethnicity, and sex. The state of Florida was used as the comparison standard to compute the MI standardized event ratio (SER) for each county and each month. After the data were linked, global models were used initially to relate MIs to ambient ozone levels, adjusting for covariates. The global models provide an estimated relative MI SER for the state. Realizing that the association in MIs and ozone might change across locations, local models were used to estimate the relative MI SER for each county, again adjusting for covariates. Results differed, depending on whether the spatial support was ignored or accounted for in the models. The opportunities and challenges associated with EPHT analyses are discussed and future directions highlighted.     

Implications of the Medicaid Undercount in a High-Penetration Medicaid State

Research Objective. This study investigates the impact of misreporting by Medicaid recipients on estimates of the uninsured in Louisiana, and is based on similar work by Call et al. in Minnesota and Klerman, Ringel, and Roth in California. With its unique charity hospital system, culture, and high poverty, Louisiana provides an interesting and unique context for examining Medicaid underreporting.
Study Design. Results are based on a random sample of 2,985 Medicaid households. Respondents received a standard questionnaire to identify health insurance status, and individual records were matched to Medicaid enrollment data to identify misreporting.
Data Sources. Data were collected by the Public Policy Research Lab at Louisiana State University using computer-assisted telephone interviewing. Using Medicaid enrollment data to obtain contact information, the Louisiana Health Insurance Survey was administered to 2,985 households containing Medicaid recipients. Matching responses on individuals from these households to Medicaid enrollment data yielded responses for 3,199 individuals.
Conclusions. Results suggest relatively high rates of underreporting among Medicaid recipients in Louisiana for both children and adults. Given the very high proportion of Medicaid recipients in the population, this may translate up to a 3 percent bias in estimates of uninsured populations.
Implications. Medicaid bias may be particularly pronounced in areas with high Medicaid enrollments. Misreporting rates and thus the bias in estimates of the uninsured may differ across areas of the United States with important consequences for Medicaid funding.
Funding Source. Louisiana Department of Health and Hospitals.     

Nurse Staffing Levels and Medicaid Reimbursement Rates in Nursing Facilities

Objective. To examine the relationship between nursing staffing levels in U.S. nursing homes and state Medicaid reimbursement rates.
Data Sources. Facility staffing, characteristics, and case-mix data were from the federal On-Line Survey Certification and Reporting (OSCAR) system and other data were from public sources.
Study Design. Ordinary least squares and two-stage least squares regression analyses were used to separately examine the relationship between registered nurse (RN) and total nursing hours in all U.S. nursing homes in 2002, with two endogenous variables: Medicaid reimbursement rates and resident case mix.
Principal Findings. RN hours and total nursing hours were endogenous with Medicaid reimbursement rates and resident case mix. As expected, Medicaid nursing home reimbursement rates were positively related to both RN and total nursing hours. Resident case mix was a positive predictor of RN hours and a negative predictor of total nursing hours. Higher state minimum RN staffing standards was a positive predictor of RN and total nursing hours while for-profit facilities and the percent of Medicaid residents were negative predictors.
Conclusions. To increase staffing levels, average Medicaid reimbursement rates would need to be substantially increased while higher state minimum RN staffing standards is a stronger positive predictor of RN and total nursing hours.     

Medicaid and Long-Term Care for the Elderly: Implications of Restructuring

Because it absorbs about a third of Medicaid spending, long-term care would be affected by any major changes in the financing or structure of this federal–state program. Analysis of the implications for long-term care of the Medicaid restructuring proposals that Congress considered in the 1995–96 federal budget debate leads to this conclusion: the fiscal pressure and incentives that would be created by fixed dollar or block grants, or by limits on federal spending per beneficiary (per capita caps), when combined with enhanced state flexibility in program design, could significantly hinder service choice and quality, reduce access to care, and increase out-of-pocket payments by Medicaid beneficiaries or their families.     

Meeting the Need for Personal Care among the Elderly: Does Medicaid Home Care Spending Matter?

Objective. To determine whether Medicaid home care spending reduces the proportion of the disabled elderly population who do not get help with personal care.
Data Sources. Data on Medicaid home care spending per poor elderly person in each state is merged with data from the Medicare Current Beneficiary Survey for 1992, 1996, and 2000. The sample ( n =6,067) includes elderly persons living in the community who have at least one limitation in activities of daily living (ADLs).
Study Design. Using a repeated cross-section analysis, the probability of not getting help with an ADL is estimated as a function of Medicaid home care spending, individual income, interactions between income and spending, and a set of individual characteristics. Because Medicaid home care spending is targeted at the low-income population, it is not expected to affect the population with higher incomes. We exploit this difference by using higher-income groups as comparison groups to assess whether unobserved state characteristics bias the estimates.
Principal Findings. Among the low-income disabled elderly, the probability of not receiving help with an ADL limitation is about 10 percentage points lower in states in the top quartile of per capita Medicaid home care spending than in other states. No such association is observed in higher-income groups. These results are robust to a set of sensitivity analyses of the methods.
Conclusion. These findings should reassure state and federal policymakers considering expanding Medicaid home care programs that they do deliver services to low-income people with long-term care needs and reduce the percent of those who are not getting help.     

Do Provider Service Networks Result in Lower Expenditures Compared with HMOs or Primary Care Case Management in Florida's Medicaid Program?

ObjectiveTo determine the impact of Florida''s Medicaid Demonstration 4 years post-implementation on per member per month (PMPM) Medicaid expenditures and whether receiving care through HMOs versus provider service networks (PSNs) in the Demonstration was associated with PMPM expenditures.DataFlorida Medicaid claims from two fiscal years prior to implementation of the Demonstration (FY0405, FY0506) and the first four fiscal years after implementation (FY0607-FY0910) from two urban Demonstration counties and two urban non-Demonstration counties.ConclusionsThe Medicaid Demonstration in Florida appears to result in lower PMPM expenditures. Demonstration PSNs generated slightly greater reductions in expenditures compared to Demonstration HMOs. PSNs appear to be a promising model for delivering care to Medicaid enrollees.