Who pays when VA users are hospitalized in the private sector? Evidence from three data sources

BACKGROUND: Older veterans enrolled in VA healthcare receive much of their medical care in the private sector, through Medicare. Less is known about younger VA enrollees' use of the private sector, or its funding. We compare payers for younger and older enrollees' private sector use in 3 hospitalization datasets. RESEARCH DESIGN: From 1998 to 2000, using private sector discharge data for VA enrollees in New York State, we categorized hospitalizations according to payer (self/family, private insurance, Medicare, Medicaid, other sources). We compared this payer distribution to population-weighted national Medical Expenditure Panel Survey (MEPS) data from 1996-2003 for veterans in VA healthcare. We also compared Medicare utilization in either dataset to hospitalizations for New York veterans from 1998-2000 in the VA-Medicare dataset. Analyses separated patients younger than age 65 from those age 65 or older. RESULTS: VA enrollees under age 65 obtain roughly half their hospitalizations in the private sector; older enrollees use the private sector at least twice as often as the VA. Datasets generally agree on payer distributions. Although older enrollees rely heavily on Medicare, they also use commercial insurance and self/family payments substantially. Half of younger enrollees' non-VA hospitalizations are paid by private insurance, but Medicare, Medicaid, and self/family each pay for one-quarter to one-third of admissions. CONCLUSIONS: VA enrollees use the private sector for most of their inpatient care, which is funded by multiple sources. Developing a national UB-92/VA dataset would be critical to understanding veterans' use of the private sector for specific diagnoses and procedures, particularly for the fast growing population of younger veterans.     

Fragmentation of care for frequently hospitalized urban residents

BACKGROUND: Fragmentation across sites of care may impede efficient healthcare delivery. OBJECTIVES: The objectives of this study were to evaluate fragmentation of hospital care for chronically ill New York City (NYC) residents and its association with enrollment in the New York State (NYS) Medicaid program. RESEARCH DESIGN: We conducted a cross-sectional study using the NYS Department of Health's Statewide Planning and Research Cooperative System discharge database. We identified 53,031 NYC residents admitted 3 or more times to acute care hospitals between 2000 and 2002 with the same principal diagnosis of a specific chronic illness (diabetes, sickle cell anemia, psychosis, substance abuse, cancer, gastrointestinal disease, chronic obstructive pulmonary disease/asthma, coronary artery disease, or congestive heart failure). We also evaluated a larger cohort of 225,421 patients with >or=3 admissions for a specific chronic illness coded as either the principal or a secondary diagnosis. A generalized logit model was used to examine the relationship between fragmentation and each patient's primary insurance adjusted for diagnosis and demographic characteristics. MEASURES: Fragmentation was characterized as high, moderate, or low based on the number of distinct hospitals a patient visited relative to the patient's total number of hospitalizations over the 3-year interval. RESULTS: Among frequently hospitalized NYC residents with select chronic conditions, 17.1% experienced highly fragmented care. This rate was 9.9% for patients with commercial insurance, 24.4% for those with Medicaid, and 9.7% for those with Medicare. The unadjusted odds ratio describing high fragmentation of Medicaid enrollees compared with commercially insured patients was 3.82 (95% confidence interval [CI], 3.50-4.18) and, although attenuated, remained significant after adjustment for demographic characteristics (odds ratio, 1.33; 95% CI, 1.20-1.47). The strongest predictor of fragmentation was a diagnosis of psychosis (OR, 2.81; 95% CI, 2.43-3.25) or substance abuse (OR, 7.58; 95% CI, 6.55-8.77). CONCLUSIONS: In NYC, Medicaid enrollment is associated with greater fragmentation of hospital care, but this is largely attributable to the preponderance of Medicaid enrollees with diagnoses of psychosis and substance abuse. Strategies to improve the efficiency of healthcare delivery should focus on patients with mental illness who are frequently admitted to general hospitals.     

Ambulatory care sensitive hospitalizations and emergency visits: experiences of Medicaid patients using federally qualified health centers

BACKGROUND: Federally Qualified Health Centers (FQHCs) serve as regular sources of preventive and primary care for low-income families within their communities and are key parts of the health care safety net. OBJECTIVES: Compare admissions and emergency room visits for ambulatory care sensitive conditions (ACSCs) among Medicaid beneficiaries relying on FQHCs to other Medicaid beneficiaries. RESEARCH DESIGN: Retrospective analysis of 1992 Medicaid claims data for 48,738 Medicaid beneficiaries in 24 service areas across five states. SUBJECTS: Medicaid beneficiaries receiving more than 50% of their preventive and primary care services from FQHCs are compared with Medicaid beneficiaries receiving outpatient care from other providers in the same areas. Exclusions-managed care enrollees, beneficiaries more than age 65, dual eligibles (Medicaid and Medicare), and institutionalized populations. MEASURES: Admissions and emergency room (ER) visits for a set of chronic and acute conditions, known in the literature as ambulatory care sensitive conditions (ACSCs). RESULTS: Medicaid beneficiaries receiving outpatient care from FQHCs were less likely to be hospitalized (1.5% vs. 1.9%, P < 0.007) or seek ER care (14.9% vs. 15.7%, P < 0.02) for ACSCs than the comparison group. Controlling for case mix and other demographic variables, the odds ratios were, for hospitalizations, OR, 0.80; 95% CI, 0.67 to 0.95; P < 0.01, and for ER visits, OR, 0.87; 95% CI, 0.82 to 0.92; P < 0.001. CONCLUSIONS: Having a regular source of care such as FQHCs can significantly reduce the likelihood of hospitalizations and ER visits for ACSCs. If the reported differentials in ACSC admissions and ER visits were consistently achieved for all Medicaid beneficiaries, substantial savings might be realized.     

Emergency department visits for ambulatory care sensitive conditions: insights into preventable hospitalizations

OBJECTIVES: To explore whether differences in disease prevalence, disease severity, or emergency department (ED) admission thresholds explain why black persons, Medicaid, and uninsured patients have higher hospitalization rates for ambulatory care sensitive (ACS) conditions. MATERIALS AND METHODS: The National Hospital Ambulatory Care Survey was used to analyze the ED utilization, disease severity (assessed by triage category), hospitalization rates, and follow-up plans for adults with five chronic ACS conditions (asthma, chronic obstructive lung disease, congestive heart failure, diabetes mellitus, and hypertension). The National Health Interview Survey was used to estimate the prevalence of these conditions in similarly aged US adults. RESULTS: Black persons, Medicaid, and uninsured patients make up a disproportionate share of ED visits for these chronic ACS conditions. Cumulative prevalence of these conditions was higher in black persons (33%) compared with white persons (27%) and Hispanic persons (22%), but did not differ among the payment groups. All race or payment groups were assigned to similar triage categories and similar percentages of their ED visits resulted in hospitalization. Black persons and Hispanic persons (odds ratios for both = 0.7), were less likely than white persons, whereas Medicaid and uninsured patients (odds ratios for both = 0.8), were less likely than private patients to have follow-up with the physician who referred them to the ED. CONCLUSIONS: The disproportionate ED utilization for chronic ACS conditions by black persons and Medicaid patients does not appear to be explained by either differences in disease prevalence or disease severity. Follow-up arrangements for black persons, Medicaid, and uninsured patients suggest that they are less likely to have ongoing primary care. Barriers to primary care appear to contribute to the higher ED and hospital utilization rates seen in these groups.     

Process of care for Medicaid-enrolled children with asthma: served by community health centers and other providers

OBJECTIVE: To compare the process of care received by Medicaid-enrolled children with asthma served by community health centers (CHCs) and other Medicaid providers. DESIGN: Retrospective cohort study. SETTING: Five provider types serving Massachusetts Medicaid enrollees: three provider groups--CHCs, hospital outpatient departments (OPDs), and solo/group physicians--participating in the statewide Primary Care Clinician Plan; a staff model health maintenance organization (HMO); and fee-for-service (FFS) providers. STUDY POPULATION: Six thousand three hundred twenty-one Medicaid-enrolled children (age 2-18) with asthma assigned to one of the above provider types in 1994. DATA: Person-level files were constructed by linking Medicaid claims, demographic and enrollment files with HMO encounter data. METHODS: Five claims-based process of care measures reflecting aspects of care recommended in national guidelines were developed and used to analyze patterns of care across provider types, controlling for case-mix and other covariates. RESULTS: Children served by CHCs and the HMO had significantly higher asthma visit rates compared with those served by OPDs, solo/group physicians and FFS providers. CHCs emergency department (ED) visit rates for asthma were lower than those of OPDs (P <0.001) and similar to other providers. However, CHC patients averaged more asthma hospitalizations relative to solo/group physicians or the HMO (P <0.0001). In multivariate analyses, children served by CHCs were 2.2 times as likely (95% CI, 1.02-4.91) as those served by solo/group physicians to receive a follow-up visit within 5 days of an asthma ED visit and 4.3 times as likely (95% CI, 1.45-12.68) to receive a follow-up visit within 5 days of hospital discharge. CHC patients with utilization suggestive of persistent asthma were less likely (OR, 0.28; 95% CI, 0.13-0.59) than those served by solo/group physicians to be seen by an asthma specialist. There were no significant differences in measures of asthma pharmacotherapy across providers types. CONCLUSION: These data suggest that CHCs provide more timely follow-up care after an asthma ED visit or hospitalization relative to solo/group physicians, but diminished access to asthma specialists. There were no differences in asthma pharmacology across providers. Relatively low access to asthma specialists among children served by CHCs warrants further investigation.     

The effect of medicare health maintenance organizations on hospitalization rates for ambulatory care-sensitive conditions

OBJECTIVE: The objective of this study was to estimate the effect of Medicare Health Maintenance Organization (HMO) enrollment on hospitalization rates and total inpatient days for ambulatory care-sensitive conditions (ACSCs) after controlling for selection. RESEARCH DESIGN: Simultaneous equations using a discrete factor selection model are used to estimate the probability of HMO enrollment, hospitalization rates, and total inpatient days for ACSCs. SUBJECTS: Enrollment data on Medicare beneficiaries in California were linked to hospital discharge data from the California Office of Statewide Health Planning and Development for January through December 1996. The following beneficiaries were excluded: 1) end-stage renal disease, 2) under 65 years of age, 3) not covered by both Medicare Part A and Part B, 4) switched between HMOs and fee-for-service (FFS), and 5) switched between HMOs. The sample was stratified by age, gender, race, county, disability, Medicaid eligibility, HMO status, and death. A 2% random sample from the 4 California counties with the largest Medicare enrollment yielded 10,448 HMO enrollees and 11,803 FFS beneficiaries. RESULTS: Using a discrete factor selection model, we estimated the rate of ACSC hospitalizations among FFS beneficiaries would decline from 51.2 to 44.2 per 1000 if all FFS beneficiaries joined an HMO. Similarly, the mean total inpatient days for ACSC hospitalizations would be reduced from 7.5 days to 5.1 days if all FFS beneficiaries joined an HMO. CONCLUSIONS: After controlling for selection, Medicare HMO enrollees have lower hospitalization rates and fewer total inpatient days for 15 ACSCs than Medicare FFS beneficiaries. These findings suggest selection of healthier beneficiaries into HMOs does not completely explain their lower rates of ACSC hospitalization.     

A longitudinal evaluation of the effect of Medi-Cal managed care on supplemental security income and aid to families with dependent children enrollees in two California counties

OBJECTIVE: We examined the differential effect of Medicaid managed care (MMC) among Aid to Families With Dependent Children (AFDC) and Supplemental Security Income (SSI) enrollees over time by comparing the experiences of adult nonelderly enrollees in the Health Plan of San Mateo in California versus Ventura County's fee-for-service (FFS) enrollees. RESEARCH DESIGN: Four years of administrative claims data were used to construct a longitudinal data set and estimate panel data models to decompose the effect of managed care over time. RESULTS: AFDC MMC enrollees exhibited generally fewer ambulatory visits, lower expenditures, and higher monthly probabilities of a preventable hospitalization relative to comparably enrolled FFS patients. SSI MMC enrollees had more emergency department visits and higher monthly probabilities of hospitalization. However, SSI MMC enrollees had more ambulatory visits and more medications during the first year of enrollment relative to SSI FFS enrollees, although levels were similar in subsequent years. SSI MMC enrollees did not exhibit a significantly higher level of expenditures in the first year of enrollment, although in subsequent years, expenditure levels were significantly lower. CONCLUSIONS: The results for emergency department visits and preventable hospitalizations presented a decidedly downbeat picture of access to care for AFDC and SSI enrollees in MMC. However, some aspects of utilization under managed care exhibited results consistent with long-term- oriented treatment for enrollees with a greater likelihood of remaining in the system for a longer period of time (SSI enrollees). By contrast, enrollees more likely to be enrolled for shorter periods (AFDC enrollees) tended to exhibit care patterns under MMC consistent with lower levels of care relative to FFS.     

Hospital utilization by health maintenance organizations. Separating apples from oranges

The hospitalization rate of HMOs is reported to be 444 bed days per 1,000 enrollees per year. It is often forgotten that there is also out-of-plan utilization. A review of previous studies and a survey of reporting practices by three HMOs illustrate many problems with HMO utilization data. HMO rates, like those of other insurers, reflect only the hospital admissions that the plans know about and pay for, not the total hospital experience of their enrollees. While only a thorough tracking of subscriber utilization of all insurers and institutions will provide estimates of the magnitude of unreported admissions and their impact on utilization rates, this report enumerates the ways in which patients may receive inpatient care without the HMO having a record of the admissions and/or having to pay for them. It was found that admissions can be unreported when another insurer or institution pays (e.g., Medicare, No Fault, Workmen's Compensation, duplicate coverage, school health and liability insurance or VA, military, municipal, and state hospitals); when the HMO does not cover benefits (e.g., cosmetic and oral surgery, experimental procedures, long-term psychiatric, chronic, or rehabilitation stays); and when HMO coverage is denied for procedural reasons (e.g., catastrophic stays covered by reinsurance, newborns, voluntary "leakage," or improper following of HMO procedures). True HMO rates are unknown but are estimated by some authors to be 7-37% higher than the reported figure, depending on which types of unreported use are estimated. There is a need for future analyses to quantify true hospitalization rates of enrollees of HMOs and other insurers.     

Accuracy of Medicaid payer coding in hospital patient discharge data: implications for Medicaid policy evaluation

BACKGROUND: Ambulatory care-sensitive hospitalization rates derived from hospital discharge data have been used to compare ambulatory care across insurance and delivery system groups. OBJECTIVE: We sought to quantify the impact of coding inaccuracies in hospital discharge data on counts of hospitalizations for ambulatory care-sensitive conditions among Medicaid beneficiaries. METHODS: This was a cross-sectional comparison of administrative databases of all California Medicaid beneficiaries younger than 65 years of age. We compared the number of hospitalizations that were attributed to Medicaid beneficiaries in California's hospital discharge data for 1994 to 1999 with the number derived from a file that linked hospital discharge data with the Medicaid eligibility file. RESULTS: Hospital discharge data undercounted 28.2% of hospitalizations for ambulatory care-sensitive conditions among Medicaid beneficiaries and overcounted 13.4% of such admissions among non-Medicaid beneficiaries. Approximately 5% of hospitalizations for ambulatory care-sensitive conditions captured as Medicaid admissions in routine hospital discharge data were among patients who gained Medicaid coverage as a result of the hospitalization. Patients who acquire Medicaid coverage as a result of a hospitalization are much more likely to be placed into Medicaid fee for service rather than Medicaid managed care which biases comparisons of these 2 delivery models. CONCLUSION: Caution should be used in the interpretation of Medicaid hospitalization rates as calculated from routine hospital discharge data. State agencies that provide hospital discharge data should consider the opportunity to improve the evaluation of Medicaid services by linking hospital discharge data with Medicaid enrollment files.     

Effect of managed care on preventable hospitalization rates in California

BACKGROUND: Hospitalization rates for ambulatory care-sensitive (ACS) conditions have emerged as a potential indicator of health care access and quality. The effect of managed care on reducing these potentially preventable hospitalizations is unknown. OBJECTIVE: To ascertain whether increases in managed care penetration were associated with changes in hospitalization rates for ACS conditions. DESIGN AND SETTING: Longitudinal analysis between 1990 and 1997 of all California hospitalizations for ACS conditions aggregated to 394 small areas. MEASURES: Association of change in ACS hospitalization rate with change in managed care penetration. RESULTS: In unadjusted analysis there was no association between the change in managed care penetration and the change in hospitalization rates for ACS conditions over time. However, in a multivariate model that controlled for changes in area demographics and hospitalization rates for marker conditions that were assumed to be stable over time, the change in managed care penetration was negatively associated with a small but statistically significant change in the ACS hospitalization rate. Each 10-point increase in percentage private managed care penetration was associated with a 3.1% decrease in the ACS hospitalization rate (95% CI, -5.4% to -0.8%) CONCLUSIONS: Overall, in California, an increase in the penetration of private managed care in a community was associated with a decrease in ACS admission rates. Additional research is needed to determine if the observed association is causal, the mechanism of the effect and whether it represents an improvement in patients' health outcomes.     

Satisfaction with managed care

This article reports the findings of 1996, 1997, and 1998 patient satisfaction surveys administered to managed care enrollees in Utah. More than 14,000 managed care enrollees (both Medicaid and commercial) were selected randomly and contacted by telephone. The 38-question survey was based on Health Plan Employer Data and Information Set (HEDIS) and the National Committee for Quality Assurance (NCQA) measures. Demographic differences between the commercial and Medicaid population were identified. Medicaid enrollees were found to be higher users of health care services. Individuals reporting the greatest health plan satisfaction tended to be healthier. However, Medicaid enrollees reported greater overall health plan satisfaction than commercial enrollees.     

The impact of primary care organization on avoidable hospital admissions for diabetes in 23 countries

Objective: Diabetes is a so-called ambulatory care sensitive condition. It is assumed that by appropriate and timely primary care, hospital admissions for complications of such conditions can be avoided. This study examines whether differences between countries in diabetes-related hospitalization rates can be attributed to differences in the organization of primary care in these countries. Design: Data on characteristics of primary care systems were obtained from the QUALICOPC study that includes surveys held among general practitioners and their patients in 34 countries. Data on avoidable hospitalizations were obtained from the OECD Health Care Quality Indicator project. Negative binomial regressions were carried out to investigate the association between characteristics of primary care and diabetes-related hospitalizations. Setting: A total of 23 countries. Subjects: General practitioners and patients. Main outcome measures: Diabetes-related avoidable hospitalizations. Results: Continuity of care was associated with lower rates of diabetes-related hospitalization. Broader task profiles for general practitioners and more medical equipment in general practice were associated with higher rates of admissions for uncontrolled diabetes. Countries where patients perceive better access to care had higher rates of hospital admissions for long-term diabetes complications. There was no association between disease management programmes and rates of diabetes-related hospitalization. Hospital bed supply was strongly associated with admission rates for uncontrolled diabetes and long-term complications. Conclusions: Countries with elements of strong primary care do not necessarily have lower rates of diabetes-related hospitalizations. Hospital bed supply appeared to be a very important factor in this relationship. Apparently, it takes more than strong primary care to avoid hospitalizations.

• Key points

• Countries with elements of strong primary care do not necessarily have lower rates of diabetes-related avoidable hospitalization.

• Hospital bed supply is strongly associated with admission rates for uncontrolled diabetes and long-term complications.

• Continuity of care was associated with lower rates of diabetes-related hospitalization.

• Better access to care, broader task profiles for general practitioners, and more medical equipment in general practice was associated with higher rates of admissions for diabetes.

     

Do Medicaid and commercial CAHPS scores correlate within plans?: a New Jersey case study

BACKGROUND: The Consumer Assessment of Health Plans Study (CAHPS) health plan survey is currently administered to large independent samples of Medicaid beneficiaries and commercial enrollees for managed care organizations that serve both populations. There is interest in reducing survey administration costs and sample size requirements by sampling these 2 groups together for health plan comparisons. Plan managers may also be interested in understanding variability within plans. OBJECTIVE: The objective of this study was to assess whether the within plan correlation of CAHPS scores for the 2 populations are sufficiently large to warrant inferences about one from the other, reducing the total sample sizes needed. RESEARCH DESIGN: This study consisted of an observational cross-sectional study. SUBJECTS: Subjects were 3939 Medicaid beneficiaries and 3027 commercial enrollees in 6 New Jersey managed care plans serving both populations. MEASURES: Outcomes are 4 global ratings and 6 report composites from the CAHPS 1.0 survey. RESULTS: Medicaid beneficiaries reported poorer care than commercial beneficiaries for 6 composites, but none of the 4 global ratings. Controlling for these main effects, variability between commercial enrollees and Medicaid beneficiaries within plans exceeded variability by plans for commercial enrollees for 4 of the 10 measures (2 composites, 2 global ratings). CONCLUSIONS: Within-plan variability in evaluations of care by Medicaid and commercial health plan member evaluations is too great to permit meaningful inference about plan performance for one population from the other for many important outcomes; separate surveys should still be fielded.     

National estimates of the effects of mandatory Medicaid managed care programs on health care access and use, 1997-1999

OBJECTIVE: We sought to explore how mandatory Medicaid managed care programs affect access to care and use among full-year Medicaid beneficiaries not receiving SSI or Medicare. RESEARCH DESIGN: We used data from the 1997 and 1999 National Survey of America's Families. To establish what Medicaid beneficiaries' access and use would have been in the absence of Medicaid managed care (MMC) and to control for unobserved county differences, we estimated difference-in-difference models using a comparison group of privately insured individuals who we would not expect to be affected by MMC. RESULTS: We found weaker effects of MMC programs for children than adults. The strongest result is that mandatory HMO programs lower the probability of Medicaid adults using emergency rooms, when implemented alone or in combination with Primary Care Case Management (PCCM) programs. PCCM programs reduced the number of visits among adults but had little effect on other measures of access and use. There was less preventive care in mandatory HMO counties for women, suggesting that the federally required external quality review may be appropriate. CONCLUSION: The effects of Medicaid managed care vary with the type of program, and policy makers should not expect programs that rely on PCCMs to have the same effects as those that incorporate mandatory HMO enrollment. Moreover, none of the program models had strong and consistent effects across the indicators of access and use that we considered.     

Moving to mandatory Medicaid managed care in Ohio: impacts on pregnant women and infants

BACKGROUND: Understanding the impacts of Medicaid managed care on pregnant women is critical because Medicaid covers more than a third of all births nationally, many under managed care arrangements. OBJECTIVES: We sought to examine the impacts of mandatory Health Maintenance Organization (HMO) enrollment on prenatal care use, smoking, and birth weight for Medicaid-covered pregnant women in Ohio. RESEARCH DESIGN: Impact estimates are derived from a pre-post design with a comparison group, using Ohio birth certificate data linked to Medicaid enrollment files. Between April 1993 and April 1995 is the baseline period and October 1997 to June 1998 is the post-period. The treatment group consists of deliveries in 6 counties that implemented mandatory HMO enrollment in the mid 1990s; the comparison group consists of deliveries in 4 counties with voluntary HMO enrollment. SUBJECTS: Medicaid-covered deliveries to 24,799 non-Hispanic white women with no college education living in Ohio. MEASURES: Seven outcomes are analyzed: first trimester care; last trimester or no care; adequate prenatal care; inadequate prenatal care; smoking during pregnancy; and birth weight. RESULTS: Our findings indicate that mandatory HMO enrollment in Ohio's Medicaid program had positive effects on prenatal care and led to reductions in maternal smoking. No effects were found on birth weight. CONCLUSIONS: Even with the improvements related to Medicaid managed care, rates of inadequate prenatal care and maternal smoking remain relatively high. Addressing the underlying risk factors that are facing poor women and further expanding public programs may be critical to achieving further progress.     

Medicaid families under managed care. Anticipated behavior

This study reports the results of a household survey of 495 Medicaid clients eligible under the Aid to Families with Dependent Children program in Monroe County, New York. The purpose of the study has been to examine the views and to anticipate the health care choices/decisions of Medicaid clients prior to their enrollment in a new, county-wide Medicaid-managed care program. The findings indicate significant ethnic differentials among the Medicaid poor, both in the choice of care source and in the reasons offered for that choice. Forty percent of those interviewed would like to change to a new source of care, but less than 13% can actually be expected to change. Private practice arrangements were the preferred source of care, yet distance to such sources appears to represent a major stumbling block to access. This study suggests that the managed-care approach being offered in Monroe County may offer the Medicaid eligibles a new stigma-free way of affiliating with a health care provider. This is being recognized by those surveyed as an important element. The study demonstrates that the choices made by the Medicaid recipients are perfectly rational given the recipients' knowledge of Medicaid and the health care system, and the general conditions in which they find themselves. These findings have important implications for the move of Medicaid programs from the fee-for-service to the managed-care/HMO system.     

Health plan responses to Medicaid managed care policy in New York City

Nearly all states in the United States have instituted managed care programs to serve Medicaid recipients and are developing policies to increase program participation. State practices regarding managed care contracting, premiums, and enrollment have implications for whether managed care plans will respond in a manner consistent with overall state policy objectives for the Medicaid managed care program. The experience of expanding the Medicaid managed care program in New York City, where the number of Medicaid beneficiaries exceeds the number in all but three states, has provided an interesting opportunity to look at the relationship between Medicaid managed care policy and plan enrollment. This paper analyzes trends in Medicaid managed care enrollment in New York City from January 1991 to September 1998, a period of critical changes in Medicaid managed care policy in New York.     

Community-based care and risk of nursing home placement

OBJECTIVE: To test the substitution hypothesis, that community-based care reduces the probability of institutional placement for at-risk elderly. RESEARCH DESIGN: The closure of the Social Health Maintenance Organization (Social HMO) at HealthPartners (HP) in Minnesota in 1994 and the continuation of the Social HMO at Kaiser Permanente Northwest (KPNW) in Oregon/Washington comprised a "natural experiment." Using multinomial logistic regression analyses, we followed cohorts of Social HMO enrollees for up to 5 years, 1995 to 1999. To adjust for site effects and secular trends, we also followed age- and gender-matched Medicare-Tax Equity and Fiscal Responsibility Act (TEFRA) cohorts, enrolled in the same HMOs but not in the Social HMOs. SUBJECTS: All enrollees in the Social HMO for at least 4 months in 1993 and an age-gender matched sample of Medicare-TEFRA enrollees. To be included, individuals had to be alive and have a period out of an institution after January 1, 1995 (total n = 18,143). MEASURES: The primary data sources were the electronic databases at HP and KPNW. The main outcomes were long-term nursing home placement (90+ days) or mortality. Covariates were age, gender, a comorbidity index, and geographic site effect. RESULTS: Adjusting for variations in the 2 sites, we found no difference in probability of mortality between the 2 cohorts, but approximately a 40% increase in long-term institutional placement associated with the termination of the Social HMO at HealthPartners (odds ratio, 1.43; 95% confidence interval, 1.15-1.79). CONCLUSIONS: The Social HMO appears to help at-risk elderly postpone long-term nursing home placement.