Effect of different types of Medicaid managed care on childhood immunization rates

Medicaid managed care can improve access to prevention services, such as immunization, for low-income children. The authors studied immunization rates for 7,356 children on Medicaid in three managed care programs: primary care case management (PCCM; n = 4,605), a voluntary HMO program (n = 851), and a mandatory HMO program (n = 1,900). Immunization rates (3:3:1 series) in PCCM (78%) exceeded rates in the voluntary HMO program (71%), which in turn exceeded those in the mandatory HMO program (67%). Adjusting for race, urban residence, and gender, compared to children in PCCM, children in the voluntary HMO program were less likely to complete the 3:3:1 series (OR = 0.75, CI = 0.63, 0.90), and children in the mandatory HMO program were even less likely to complete the series (OR = 0.59, CI = 0.51, 0.68). Results differed by individual HMOs. Monitoring of outcomes for all types of managed care by Medicaid agencies is imperative to assure better disease prevention for low-income children.     

Medicaid Managed Care and Health Care Access for Adult Beneficiaries with Disabilities

Objective. To evaluate the impact of Medicaid managed care organizations (MCO) on health care access for adults with disabilities (AWDs).
Data Sources. Mandatory and voluntary enrollment data for AWDs in Medicaid MCOs in each county were merged with the Medical Expenditure Panel Survey and the Area Resource File for 1996–2004.
Study Design. I use logit regression and two evaluation perspectives to compare access and preventive care for AWDs in Medicaid MCOs with FFS. From the state's perspective, I compare AWDs in counties with mandatory, voluntary, and no MCOs. From the enrollee's perspective, I compare AWDs who must enroll in an MCO or FFS to those who may choose between them.
Principal Findings. Mandatory MCO enrollees are 24.9 percent more likely to wait >30 minutes to see a provider, 32 percent more likely to report a problem accessing a specialist, and 10 percent less likely to receive a flu shot within the past year. These differences persist from the state evaluation perspective.
Conclusions. States should not expect a dramatic change in health care access when they implement Medicaid MCOs to deliver care to the adult disabled population. However, continued attention to specialty care access is warranted for mandatory MCO enrollees.     

Medicaid Managed Care and Health Care for Children

Objective. Many states expanded their Medicaid managed care programs during the 1990s, causing concern about impacts on health care for affected populations. We investigate the relationship between Medicaid managed care enrollment and health care for children.
Data Sources and Measures. Repeated cross-sections of Medicaid-covered children under 18 years of age from the 1996/1997 and 1998/1999 Community Tracking Study Household Surveys ( n =2,602) matched to state-year CMS Medicaid managed care enrollment data. For each individual, we constructed measures of health care utilization (provider and emergency department visits, hospitalizations, surgeries); health care access (usual source of care, unmet medical needs, put-off needed care); and satisfaction (satisfaction overall, with doctor choice, and with last visit).
Study Design. Regression analysis of the relationship between within-state changes in Medicaid managed care enrollment rates and changes in mean utilization, access, and satisfaction measures for children covered by Medicaid, controlling for a range of potentially confounding factors.
Principal Findings. Increases in Medicaid health maintenance organization (HMO) enrollment are associated with less emergency room use, more outpatient visits, fewer hospitalizations, higher rates of reporting having put off care, and lower satisfaction with the most recent visit. Medicaid primary care case management (PCCM) plans are associated with increases in outpatient visits, but also with higher rates of reporting unmet medical needs, putting off care, and having no usual source of care.
Conclusions. Both Medicaid HMO and PCCM plans can have important impacts on health care utilization, access, and satisfaction. Some impacts may be positive (e.g., less ED use and more outpatient provider use), although concern about increasing challenges in access to care and satisfaction is also warranted.     

Managed care and preventable hospitalization among Medicaid adults

OBJECTIVE: The study examines the association between managed care enrollment and preventable hospitalization patterns of adult Medicaid enrollees hospitalized in four states. DATA SOURCES/STUDY SETTING: Hospital discharge data from the Healthcare Cost and Utilization Project (HCUP) database of the Agency for Healthcare Research and Quality (AHRQ) for New York (NY), Pennsylvania (PA), Wisconsin (WI), and Tennessee (TN) residents in the age group 20-64 hospitalized in those states, linked to the Area Resource File (ARF) and American Hospital Association (AHA) survey files for 1997. STUDY DESIGN: The study uses separate logistic models for each state comparing preventable admissions with marker admissions (urgent, insensitive to primary care). The model controls for socioeconomic and demographic variables, and severity of illness. PRINCIPAL FINDINGS: Consistently in different states, private health maintenance organization (HMO) enrollment was associated with fewer preventable admissions than marker admissions, compared to private fee-for-service (FFS). However, Medicaid managed care enrollment was not associated with a reduction in preventable admissions, compared to Medicaid FFS. CONCLUSIONS: Our analysis suggests that the preventable hospitalization pattern for private HMO enrollees differs significantly from that for commercial FFS enrollees. However, little difference is found between Medicaid HMO enrollees and Medicaid FFS patients. The findings did not vary by the level of Medicaid managed care penetration in the study states.     

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.     

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.     

Capitated Medicaid Managed Care in a Rural Area: The Impact of Minnesota''s PMAP Program

CONTEXT: Although states have had difficulty extending Medicaid managed care (MMC) to rural areas, rural models of capitated MMC are expected to grow in response to new federal regulations and the serious budget problems facing nearly all states. As such, understanding the effects of capitated MMC in rural settings is important for policy considerations. PURPOSE: To evaluate the effects of capitated MMC on beneficiary access and use in rural Minnesota. METHODS: We took advantage of delays in the timing of the introduction of MMC across rural counties in Minnesota to estimate the effects of managed care on adults and children under Medicaid using a difference-in-differences framework. FINDINGS: We found that Minnesota's shift from fee-for-service Medicaid to MMC in its rural counties had little effect on access to health care for either adults or children. CONCLUSIONS: Because Minnesota reports that Medicaid costs under MMC are below expected costs under FFS Medicaid, it appears that the primary accomplishment of Minnesota's rural MMC initiative is one of cost savings: MMC provides the same access to care as FFS Medicaid, but at lower cost. With steep budget deficits in nearly all states, other states may want to consider Minnesota's rural MMC model as a mechanism for reducing their Medicaid costs.     

Quality oversight in medicaid primary care case management programs

As health maintenance organizations (HMOs) have curtailed participation in Medicaid, enrollment in primary care case management (PCCM) programs has grown. To examine state Medicaid agencies' monitoring of PCCM and HMO programs, we surveyed Medicaid agency directors of forty-six states and the District of Columbia. Agencies were less likely to collect performance data in PCCM programs than in HMO programs. Few PCCM programs reported performance results for the public or providers. Reporting states tended to emphasize utilization results over quality-measure results. Despite growing enrollment, PCCM programs appear less likely to use the quality-oversight strategies employed by Medicaid health plans.     

Primary care case management and birth outcomes in the Iowa Medicaid program.

OBJECTIVES: This study compares prenatal care utilization and birth outcomes between Iowa Medicaid recipients receiving care in a primary care case management (PCCM) system and those receiving care in a fee-for-service (FFS) system. METHODS: Birth certificates linked with Medicaid hospitalization claims were analyzed for seven PCCM and seven FFS counties. RESULTS: From 1989 through 1992, there was (1) a 20% increase in the number of women who received adequate prenatal care in the FFS counties, vs a 5% increase in the PCCM counties; (2) a 17% increase in the number of women who initiated care within the first trimester in the FFS counties, vs a 6% increase in the PCCM counties; and (3) a 442% increase in the number of women who received enhanced prenatal services in the FFS counties, vs a 278% increase in the PCCM counties. There were no significant differences between groups in mean gestational age or birthweight; however, there was an increase of very-low-birthweight babies in both groups. CONCLUSIONS: PCCM, as implemented by the Iowa Medicaid program, has not appreciably improved prenatal care utilization or birth outcomes.     

Access, satisfaction, and utilization in two forms of Medicaid managed care

We determined access and satisfaction of 2,598 recipients of Virginia's Medicaid program, comparing its health maintenance organizations (HMOs) to its primary care case management (PCCM) program. Positive responses were summed as sub-domains either of access, satisfaction, or of utilization, and adjusted odds ratios were calculated for HMO (vs. PCCM) sub-domain scores. The response rate was 47 per cent. We found few significant differences in perceived access, satisfaction, and utilization. Both HMO adults and children more often perceived good geographic access (adults, OR, [CI] = 1.50, [1.04-2.16]; children, OR, [CI] = 1.773 [1.158, 2.716]). But HMO patients less often reported good after-hours access (adults, OR, [CI] = 0.527 [0.335, 0.830]; children, OR, [CI] = 0.583 [0.380, 0.894]). Among all patients reporting poorer function, HMO patients more often reported good general and preventive care (OR, [CI] = 2.735 [1.138, 6.575]). We found some differences between Medicaid HMO versus PCCM recipients' reported access, satisfaction, and utilization, but were unable to validate concerns about access and quality under more restrictive forms of Medicaid managed care.     

The Effect of Medicaid Managed Care on Prenatal Care: The Case of Puerto Rico

Objectives From 1994 to the year 2000 the government of Puerto Rico implemented a health care reform which included the mandatory enrollment of the entire Medicaid eligible population under Medicaid managed care (MMC) plans. This study assessed the effect of MMC on the use, initiation, utilization, and adequacy of prenatal care services over the reform period. Methods Using the vital records of all infants born alive in Puerto Rico from the year 1995–2000, a series of bivariate and multivariate analyses were conducted to assess the effect of insurance status (traditional Medicaid, MMC, private insurance and uninsured) on prenatal care utilization patterns. In order to assess the potential influence of selection bias in generating the health insurance assignments, propensity scores (PS) were estimated and entered into the multivariate regressions. Results MMC had a generally positive effect on the frequency and adequacy of prenatal care when compared with the experience of women covered by traditional Medicaid. However, the PS analyses suggested that self-selection may have generated part of the observed beneficial effects. Also, MMC reduced but did not eliminate the gap in the amount and adequacy of prenatal care received by pregnant women covered by Medicaid when compared to their counterparts covered by private insurance. Conclusions The Puerto Rico Health Reform to implement MMC for pregnant women was associated with a general improvement in prenatal care utilization. However, continued progress will be necessary for women covered by Medicaid to reach prenatal care utilization levels experienced by privately insured women.     

Tracking Medicaid managed care in rural communities: a fifty-state follow-up

This study updates a 1997 study examining implementation of rural Medicaid managed care programs. Most states operate Medicaid managed care programs for their beneficiaries, but the types of programs vary across urban and rural settings. Over the past four years the number of rural counties covered by Medicaid managed care, including fully capitated programs, has grown, although primary care case management (PCCM) remains the predominant program type in rural areas. Health plan withdrawals from rural areas have led some states with rural capitated programs to provide financial incentives or develop alternative approaches, such as enhanced PCCM programs.     

The long-term effects of Medicaid managed care on obstetrics care in three California counties

OBJECTIVE: To evaluate the long-term effects of Medicaid managed care (MMC) on obstetric service use and program costs in California. DATA SOURCES/STUDY SETTING: Longitudinal administrative data on Medi-Cal enrollment and claims and encounters related to pregnancy and delivery services were gathered from three counties--two long-standing MMC counties and one traditional fee-for-service Medicaid county--in California between 1987 and 1992. STUDY DESIGN: We studied Aid to Families with Dependent Children (AFDC) beneficiaries with live singleton vaginal deliveries with associated hospital stays of 14 days or less. Effects of managed care were examined with respect to prenatal visits, length of stay for delivery, maternal postpartum readmission rates, and total program expenditures. Multivariate analyses examined how the relative effect of managed care on service use and program expenditures in each MMC county evolves over time in comparison to fee-for-service. We controlled for length of Medi-Cal enrollment prior to delivery, data censoring, and individual characteristics such as race and age. PRINCIPAL FINDINGS: Prenatal care use is consistently lower in the MMC counties, although all three counties' prenatal care provision is well below the national standard. Drastic increases in one-day-stay deliveries were found: up to almost 50 percent of deliveries in MMC counties were one-day stays. Program cost savings associated with MMC enrollment are unambiguous. CONCLUSIONS: MMC cost savings might have come at the expense of reduced provision of prenatal care and shorter delivery length of stay. Future studies should verify any possible causal link and the effects on maternal and infant health outcomes.     

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.     

A randomized trial to evaluate the effectiveness of a Medicaid HMO

The value of health-care services used by AFDC Medicaid patients receiving care in a voluntary enrollment HMO is contrasted with that of health care services used by Medicaid patients receiving fee-for-service (FFS) care. The randomized assignment of Medicaid recipients to the HMO or to FFS allows the authors to conclude that the apparent lower use of HMO enrollees results from the HMO's selection of patients with lower needs for care rather than from technical efficiency. Patients had lower use while in the HMO, but disenrollees and those who refused enrollment had significantly higher use than FFS participants. In contrast to the effect of HMOs on non-Medicaid populations, the Medicaid HMO studied provided significantly fewer outpatient services, but the same level of inpatient services as the FFS sector. Overall, voluntary enrollment of Medicaid eligibles into the HMO resulted in higher state expenditures for Medicaid because of favorable selection.     

Factors Associated with Continued Participation in Mammography Screening

BACKGROUND: Relatively little is known about factors that predict ongoing participation in mammography screening at regular intervals. Members of managed care plans have access to this preventive service; yet, many still do not receive it routinely. METHODS: Using administrative data from HIP Health Plan of New York, a group model HMO, 24,215 women ages 50-80 years identified as having a screening mammogram during the baseline period were followed for 2 years to determine demographic and utilization factors that might be related to having a subsequent mammogram within the recommended time interval. RESULTS: Of the 24,215 women with an index mammogram, 71.8;pc had a subsequent screening mammogram within 2 years. Women ages 65-74 years and those with Medicare coverage had the highest mammogram rates among the age and coverage categories. Number of primary care and gynecology physician visits was strongly related to having a subsequent mammogram. The average (mean) time between index and subsequent mammogram was 14.4 months. CONCLUSION: The significance of health plan visits in subsequent mammography underscores the importance of physician-patient communication in a managed care plan and the integration of health plan members into the HMO delivery system. Even in this environment with equal access for all types of coverage, Medicaid members were less likely to receive this preventive service.     

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.     

Price elasticity and pharmaceutical selection: the influence of managed care

State Medicaid programs are turning increasingly to managed care to control expenditures, although the types of managed care programs in use have changed dramatically. Little is known about the influence of the shifting Medicaid managed care arena on treatment decisions. This paper investigates factors affecting the selection of treatments for depression by providers participating in either of two Medicaid managed care programs. Of particular interest is the influence of medication price on the choice of treatment, since one vehicle through which managed care organizations can reduce total expenditures is by increasing the price sensitivity of participating providers. We take a new approach by phrasing the problem as a discrete choice, using a nested multinomial logit model for the analyses. Contrary to earlier literature, we find some evidence that physicians in both programs do take price into consideration when selecting among treatment options. HMO providers in particular demonstrate increased price sensitivity in the two most commonly prescribed categories of antidepressants.