Children Who Are Medically Fragile in North Carolina: Using Medicaid Data to Estimate Prevalence and Medical Care Costs in 2004

Objectives: The purpose of this paper is to demonstrate a method of using medical insurance paid claims and enrollment data to estimate the prevalence of selected health conditions in a population and to profile associated medical care costs. The examples presented here use North Carolina Medicaid data to produce estimates for children ages 0–19 who are medically fragile. These children with serious health conditions are a small subset of all children with special health care needs. Methods: The children who are medically fragile were identified through selected procedure and durable medical equipment codes. We profiled the expenditures for all medical services provided to these children during 2004. Results: 1,914 children ages 0–19 enrolled in Medicaid were identified as medically fragile (0.22 percent). The amount paid by Medicaid for these children during 2004 for all medical services was $133.8 million, or $69,906 per child. By comparison, the average expenditure by Medicaid during 2004 for a randomly selected group of children receiving well-child care visits was $3,181 per child. The $133.8 million of Medicaid expenditures for the children who are medically fragile represents 6.8 percent of the nearly $2 billion spent by Medicaid in 2004 for all medical services for all children ages 0–19. Conclusions: This study presents a standard methodology to identify children with specific health conditions and describe their medical care costs. Our example uses Medicaid claims and enrollment data to measure prevalence and costs among children who are medically fragile. This approach could be replicated for other health care payer data bases and also in other geographic areas.     

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.     

The Nebraska Medicaid managed behavioral health care initiative: Impacts on utilization,expenditures, and quality of care for mental health

This study evaluates the impact of Nebraska's Medicaid managed care program for behavioral health services on mental health service utilization, expenditures, and quality of care. Implementation of the program is correlated with progressive reductions in both total (about 13% over 3 years) and per eligible per month (20%) expenditures and a rapid, extensive decline in inpatient utilization and admissions. The percentage of enrollees receiving any type of treatment for a mental disorder actually increased modestly. Most important, several indicators of quality of care (eg, timely receipt of ambulatory care following discharge from inpatient care and readmission to inpatient care shortly following discharge) suggest that quality of care did not materially change under the carve-out. Although a thorough assessment of quality of care impacts is warranted, this study suggests implementation of a managed care program may allow states to reduce Medicaid expenditures without compromising quality of care.     

Medicaid support of alcohol, drug abuse, and mental health services

Medicaid expenditures for alcohol, drug abuse, and mental health (ADM) services in 1984 were examined for the States of California and Michigan. Persons receiving such services constituted 9 to 10 percent of the total Medicaid population in the two States and accounted for 22 to 23 percent of total Medicaid expenditures. ADM expenditures were 11 to 12 percent of the total. Although the two States had similar proportions of overall expenditures for these services, Michigan appeared to emphasize inpatient psychiatric care, while California emphasized ambulatory and nursing home care. Based on the experience of the two States, national Medicaid expenditures for ADM services exclusive of long-term care were estimated to be $3.5 to $4.9 billion in 1984, two to three times the level suggested by earlier estimates.     

Do public health activities pay for themselves? The effect of county‐level public health expenditures on county‐level public assistance medical care benefits in California

This study estimates the effect of county‐level public health expenditures in reducing county‐level public assistance medical care benefits (public assistance medical care benefits is a measure compiled by the US Bureau of Economic Analysis and includes Medicaid and other medical vendor payments). The effect is modeled using a static panel model and estimated using two‐stage limited information maximum likelihood and a valid instrumental variable. For every $1 invested in county‐level public health expenditures, public assistance medical care benefits are reduced by an average of $3.12 (95% confidence interval: ?$5.62, ?$0.94). Because Medicaid in California is financed via an approximate 50% match of federal dollars with state dollars, savings to the state are approximately one‐half of this, or $1.56 for every $1 invested in county‐level public health expenditures.     

Differences in Use of Health Services Between White and African American Children Enrolled in Medicaid in North Carolina

Objectives: Racial differences in health status and use of health services persist in the United States and are not completely explained by differences in socioeconomic status. This study examines differences in use of health services between White and African American children enrolled in Medicaid, controlling for other factors that affect service use. We make comparisons for use of primary preventive services, diagnosis and treatment of selected common childhood illnesses, and Medicaid expenditures. Methods: We linked Medicaid enrollment records, Medicaid paid claims data, and data on use of child WIC services to birth certificates for NorthCarolina children born in 1992 to measure use of health services and Medicaid expenditures by race for children ages 1, 2, 3, and 4. Logistic and Tobit regression models were used to estimate the independent effect ofrace, controlling for other variables such as low birth weight, WICparticipation, and mother's age, education, and marital status. Since allchildren enrolled in Medicaid are in families of relatively low income, racial differences in socioeconomic status are partially controlled.Results: African American children had consistently lower Medicaidexpenditures and lower use of health servicesthan did White children,after statistically controlling for other maternal and infantcharacteristics that affect health service use, including child WICparticipation. For example, total annual Medicaid expenditures were $207–303 less for African American children than for White children,controlling for other variables. African America children were significantly less likely to receive well-child and dental services than were White children. Conclusions: African American children enrolled in Medicaid use healthservices much less than White children, even when controlling forsocioeconomic status and other factors that affect service use. Linkingstate administrative databases can be a cost-effective way of addressingimportant issues such as racial disparities in health service use.     

Partially capitated managed care versus FFS for special needs children

Little research has examined whether Medicaid managed care plans (MCPs) that incorporate case management are effective in coordinating services for children with special health care needs (CSHCN). This study evaluates the effects of enrollment of special needs children into a partially capitated MCP (with ongoing case management) versus the fee-for-service (FFS) option on use of therapeutic services, specifically speech, occupational, and physical therapy by site of service (school versus health care sector). Results show that special needs children enrolled in the partially capitated MCP are significantly more likely to obtain occupational and physical therapy at school relative to their FFS counterparts. Moreover, children enrolled in FFS are significantly less likely to be either regular or frequent users of each type of therapy relative to children enrolled in managed care. We attribute much of these disparities in use of therapeutic services at school to the availability of case management and coordination that is an integral component of the partially capitated MCP.     

Variations in state-level definitions: children with special health care needs

Multiple agencies at the federal and state level provide for children with special health care needs (CSHCN), with variation in eligibility criteria. Epidemiological studies show that 3.8%-32% of children could be classified as children with special health care needs, depending on the definition and method of determination used. OBJECTIVES: To determine the extent of variation between definitions used and funding by Supplemental Security Income (SSI), Title V, and Medicaid for CSHCN. METHODS: Statistics on children receiving SSI and the amount of funding were obtained from the SSI website. This was compared to information on Title V children from the Maternal and Child Health Bureau (MCHB) website and eligibility definitions published by the Institute of Child Health Policy in Gainesville, Florida. Medicaid definitions were obtained through interviews with state Medicaid agencies and confirmed with state regulations. RESULTS: The population enrolled in SSI has varied with alterations in eligibility criteria. The number of children enrolled in SSI and the amount of funding per child in each state correlate with the state poverty rate (r=0.56, p<0.0001; r=0.44, p<0.001). Enrollment in Title V does not correlate with state poverty rates (r=0.16, p=0.25). Title V definitions vary widely among states, but there was no correlation between the number of children served or amount of funding per child and the type of definition used (Z=-0.12, p=0.91; Z=-0.59, p=0.55). State Medicaid agencies rarely define CSHCN. CONCLUSIONS: There is significant variation in definitions used by agencies serving CSHCN. Agencies need to be more explicit with eligibility criteria so the definitions are logical to those making referrals for services.     

Health-care use and expenditures for children in special education with special health-care needs: is dual classification a marker for high use?

OBJECTIVES: Children with special health-care needs are an important group for policy and research planning. Special education engages a group of children with increased utilization of services related to education. While increased service utilization in education or health-care settings is often used to classify children as having special needs, considerable heterogeneity exists within each group. The extent to which being identified in two functionally defined systems--special education and health care--relates to health-care utilization is unknown. We sought to determine health-care and mental health utilization and expenditures for children dually classified as receiving special education and having special health-care needs (SHCN) compared with those who only have SHCN, only are in special education, or don't fall into either category. METHODS: A nationally representative sample of children aged 5-17 years from the Medical Expenditure Panel Survey was used to compare mean health-care and mental health utilization and expenditures for the four groups. RESULTS: Dually classified children had significantly higher mean utilization of health-care services than the other three groups (p < 0.05). Mean 12-month total health-care expenditures were highest for dually classified children ($3,891/year) (p < 0.05) and higher for children classified only as having SHCN ($1,426/year) than for children with neither classification ($644/year, p < 0.05). CONCLUSIONS: Children dually classified as receiving special education and having SHCN represent a subgroup of children with SHCN with high levels of health-care utilization and expenditures. This information can assist policy makers in identifying characteristics that place children at risk for very high expenditures, and in allocating health-care resources.     

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.     

An evaluation of the impact of maternity care coordination on Medicaid birth outcomes in North Carolina.

BACKGROUND. Care coordination is an important component of the enhanced prenatal care services provided under the recent expansions of the Medicaid program. The effect of maternity care coordination services on birth outcomes in North Carolina was assessed by comparing women on Medicaid who did and did not receive these services. METHODS. Health program data files, including Medicaid claims paid for maternity care coordination, were linked to 1988 and 1989 live birth certificates. Simple comparisons of percentages and rates were supplemented by a logistic regression analysis. RESULTS. Among women on Medicaid who did not receive maternity care coordination services, the low birth weight rate was 21% higher, the very low birth weight rate was 62% higher, and the infant mortality rate was 23% higher than among women on Medicaid who did receive such services. It was estimated that, for each $1.00 spent on maternity care coordination, Medicaid saved $2.02 in medical costs for newborns up to 60 days of age. Among the women who did receive maternity care coordination, those receiving it for 3 or more months had better outcomes than those receiving it for less than 3 months. CONCLUSIONS: These results suggest that maternity care coordination can be effective in reducing low birth weight, infant mortality, and newborn medical care costs among babies born to women in poverty.     

Medicaid expansion under health reform may increase service use and improve access for low-income adults with diabetes

Medicaid's key role in financing diabetes care will grow when many low-income uninsured people with diabetes gain eligibility to the program in 2014 under the Affordable Care Act. Using a national data set to describe current health care use and spending among the nonelderly, low-income adult population, we found that adult Medicaid beneficiaries with diabetes had total annual per capita health expenditures more than three times higher ($14,229 versus $4,568) than those of adult beneficiaries without diabetes. At the same time, Medicaid facilitates financial protection and care access among beneficiaries with diabetes. Low-income adults with diabetes who were uninsured used fewer services, spent more out of pocket, and reported worse access than did their peers who were covered by Medicaid. Uninsured adults with diabetes who gain Medicaid coverage under health reform are likely to enter the program with unmet needs, and coverage is likely to result in both improved access and increased use of health care.     

Mental health services for youths in foster care and disabled youths.

OBJECTIVES: This study assessed whether mental health services for youths differ with respect to medical assistance aid category. METHODS: Computerized claims for 15,507 youths with Medicaid insurance in a populous county of a mid-Atlantic state were used to establish population-based prevalence estimates of mental disorders and psychotherapeutic treatments during 1996. RESULTS: An analysis of service claims revealed that the prevalence of mental disorders among youths enrolled in foster care (57%) was twice that of youths receiving Supplemental Security Income (SSI; 26%) and nearly 15 times that of other youths receiving other types of aid (4%). Rates of mental health service use were pronounced among foster care youths aged 6 to 14 years. Attention deficit/hyperactivity disorder, depression, and developmental disorders were the most prevalent disorders. Stimulants, antidepressants, and anticonvulsants were the most prevalent medications. CONCLUSIONS: Youths enrolled in foster care and youths receiving SSI use far more mental health services than do youths in other aid categories. Additional research should evaluate the complexity and outcomes of mental health services for youths in foster care.     

Modeling the determinants of Medicaid home care payments for children with special health care needs: A structural equation model approach

BackgroundThe management of children with special needs can be very challenging and expensive.ObjectiveTo examine direct and indirect cost drivers of home care expenditures for this vulnerable and expensive population.MethodsWe retrospectively assessed secondary data on children, ages 4–20, receiving Medicaid Personal Care Services (PCS) (n = 2760). A structural equation model assessed direct and indirect effects of several child characteristics, clinical conditions and functional measures on Medicaid home care payments.ResultsThe mean age of children was 12.1 years and approximately 60% were female. Almost half of all subjects reported mild, moderate or severe ID diagnosis. The mean ADL score was 5.27 and about 60% of subjects received some type of rehabilitation services. Caseworkers authorized an average of 25.5 h of PCS support per week. The SEM revealed three groups of costs drivers: indirect, direct and direct + indirect. Cognitive problems, health impairments, and age affect expenditures, but they operate completely through other variables. Other elements accumulate effects (externalizing behaviors, PCS hours, and rehabilitation) and send them on a single path to the dependent variable. A few elements exhibit a relatively complex position in the model by having both significant direct and indirect effects on home care expenditures – medical conditions, intellectual disability, region, and ADL function.ConclusionsThe most important drivers of home care expenditures are variables that have both meaningful direct and indirect effects. The only one of these factors that may be within the sphere of policy change is the difference among costs in different regions.     

Transportation brokerage services and Medicaid beneficiaries' access to care

Objective. To examine the effect of capitated transportation brokerage services on Medicaid beneficiaries' access to care and expenditures.
Data Sources/Study Setting. The study period from 1996 to 1999 corresponds to the period of a natural experiment during which Georgia and Kentucky implemented transportation brokerage services. Effects were estimated for asthmatic children and diabetic adults.
Study Design. We used difference-in-differences models to assess the effects of transportation brokerage services on access to care, measured by Medicaid expenditures and health services use. The study design is strengthened by the staggered implementation dates between states and within each state.
Principal Findings. For asthmatic children, transportation brokerage services increased nonemergency transportation expenditures and the likelihood of using any services; reductions in monthly expenditures more than offsetting the increased transportation costs. For diabetic adults, nonemergency transportation costs decreased despite increased monthly use of health services; average monthly medical expenditures and the likelihood of hospital admission for an ambulatory care-sensitive condition (ACSC) also decreased.
Conclusions. The shift to transportation brokerage services improved access to care among Medicaid beneficiaries and decreased the expenditures. The increase in access combined with reduced hospitalizations for asthmatic children and ACSC admissions for diabetic adults are suggestive of improvements in health outcomes.     

Sexually transmitted infection among adolescents receiving special education services

Background: To estimate the relative risk of sexually transmitted infections (STIs) among children identified as having learning disabilities through the special education system. Methods: This cross‐sectional study used special education data and Medicaid data from Philadelphia, Pennsylvania, for calendar year 2002. The sample comprised 51,234 Medicaid‐eligible children, aged 12‐17 years, 8015 of whom were receiving special education services. Claims associated with diagnoses of STIs were abstracted, and logistic regression was used to estimate the odds of STI among children in different special education categories. Results: There were 3% of males and 5% of females who were treated for an STI through the Medicaid system in 2002. Among females, those in the mental retardation (MR) category were at greatest risk (6.9%) and those in the emotionally disturbed or “no special education” category at lowest risk (4.9% each). Among males, STIs were most prevalent among those classified as mentally gifted (6.7%) and lowest among those in the MR category (3.0%). In adjusted analyses, males with specific learning disabilities and females with MR or who were academically gifted were at excess risk for STIs. Conclusions: The finding that children with learning disabilities are at similar or greater risk for contracting STIs as other youth suggests the need to further understand their risk behaviors and the potential need to develop prevention programs specific to their learning needs.     

Penny wise, pound wise: a comparison of Medicaid expenditures for home and community-based services versus nursing facility care for older adults

Kansas Medicaid offers home and community-based services through the Frail and Elderly (FE) program as an alternative for older adults who are eligible for nursing home (NH) care but wish to stay in the community. We determined demographic and clinical characteristics of enrollees receiving FE or NH services, examined their relative health care utilization patterns, and estimated the difference in Medicaid's expenditures for FE versus NH care. After adjusting for key demographic and clinical variables, mean monthly expenditures were $1,281 lower for the FE cohort. Since NH and FE populations are dissimilar, these care options may not be easily interchangeable at the individual level.     

Medicaid expenditures for maternity and newborn care in America

An Alan Guttmacher Institute (AGI) survey of the Medicaid programs in each state and the District of Columbia found that some 542,000 low-income women have a Medicaid-subsidized delivery each year--about 15 percent of all women who give birth. The proportion ranges from three percent in Alaska to 25 percent in Michigan. The federal and state governments spend almost $1.2 billion annually for maternity care (including prenatal, postpartum and newborn care); the average expenditure per patient is $2,200. Tennessee reports the highest expenditure per patient ($3,500) and Louisiana the lowest ($1,300). Only the highest payments under Medicaid are close to charges for maternity care in the open market, a fact that results in a significant disincentive for physicians and hospitals to accept Medicaid patients. The $1.2 billion spent for Medicaid-subsidized maternity care compares with an estimated $11.5 billion spent for such care nationwide. Thus, Medicaid pays for about 10 percent of the nation's maternity care bill, although Medicaid subsidizes deliveries for 15 percent of all women who give birth. The figures for maternity care do not include Medicaid expenditures for neonatal intensive care, which, for the 17 states reporting data, average about $11,800 per infant. Although only about six percent of all newborns whose deliveries are subsidized by Medicaid require neonatal intensive care, such care is so expensive that it adds about 30 percent to all Medicaid expenditures for maternity care. Increased Medicaid payments for maternity care, including prenatal care, could have a positive impact on health outcomes for low-income mothers and their babies, and could reduce the necessity for massive and expensive medical treatment for newborns.     

Learning your ABDs: Variation in health care utilization across Kansas Medicaid disability groups

BackgroundState Medicaid programs provide critical health care access for persons with disabilities and older adults. Aged, Blind and Disabled (ABD) programs consist of important disability subgroups that Medicaid programs are not able to readily distinguish.Objective/hypothesisThe purpose of this project was to create an algorithm based principally on eligibility and claims data to distinguish disability subgroups and characterize differences in demographic characteristics, disease burden, and health care expenditures.MethodsWe created an algorithm to distinguish Kansas Medicaid enrollees as adults with intellectual or developmental delays (IDD), physical disabilities (PD), severe mental illness (SMI), and older age.ResultsFor fiscal year 2009, our algorithm separated 101,464 ABD enrollees into the following disability subgroups: persons with IDD (19.6%), persons with PD (21.0%), older adults (19.7%), persons with SMI (32.8%), and persons not otherwise classified (6.9%). The disease burden present in the IDD, PD, and SMI subgroups was higher than for older adults. Home- and community-based services expenditures were common and highest for persons with IDD and PD. Older adults and persons with SMI had their highest expenditures for long-term care. Mean Medicaid expenditures were consistently higher for adults with IDD followed by adults with PD.ConclusionsThere are substantial differences between disability subgroups in the Kansas Medicaid ABD population with respect to demographics, disease burden, and health care expenditures. Through this algorithm, state Medicaid programs have the opportunity to collaborate with the most closely aligned service providers reflecting needed services for each disability subgroup.