The Kansas Medicaid Buy-In: Factors influencing enrollment and health care utilization

BackgroundMedicaid Buy-Ins are optional programs states may implement to create work incentives for people with disabilities. These programs allow participants to increase earnings without losing Medicaid eligibility—potentially moving them out of poverty without risking loss of health care coverage. They also provide the opportunity for beneficiaries to offset some of their medical costs to the federal and state governments through premiums for coverage and increased taxes paid. State and federal policy makers and administrators have speculated about who might enroll, how they might use the benefits, and whether positive health outcomes for persons with disabilities would result.ObjectiveWe compared characteristics and health care utilization of 184 enrollees and 158 eligible nonenrollees in Kansas' Medicaid Buy-In.ResultsEnrollees were older and significantly more likely to have more than one disability, with mental illness being more prevalent than physical disabilities, and to have both higher Social Security and earned income. A majority of the sample was dually eligible for Medicare and Medicaid with Medicaid paying most costs. Home health service costs were the primary difference between enrollee and nonenrollee expenditures.ConclusionsIncreased Medicaid Buy-In enrollment could prevent long-term dependence on federal disability benefits.     

Does your health care depend on how your insurer pays providers? Variation in utilization and outcomes in Thailand

Hospitals in Thailand operate in a multiple insurance payment environment. This paper examines (1) access to medicines and other medical technologies, (2) treatment outcomes, and (3) efficiency in resource use, among beneficiaries of the three government health insurance schemes in Thailand. Using 2003–2005 outpatient and inpatient data for patients with three tracer diseases from three government hospitals, we find that utilization of more expensive items differs between patients whose insurers pay on a closed- or open-ended basis. Where new vs. conventional drugs are both available, patients whose insurer pays on a fee-for-service basis tend to have greater access to new drugs, compared to patients whose insurer pays on a capitated or case basis. Similar patterns were found where there are options between originator versus generic drugs, drugs in different dosage forms, and more versus less advanced diagnostic technologies. Effects of insurance payment are more pronounced where price gaps among the medical technologies are significant. Efficiency results are mixed, depending on nature of the disease conditions and type of resources required for treatment.      

Medicaid behavioral health care plan satisfaction and children's service utilization

This study examines associations between caregivers' satisfaction with children's Medicaid-funded behavioral health care plans and the likelihood that children with severe emotional disturbance receive mental health services. Data are from a multisite study of managed care versus fee-for-service (FFS) settings. In multivariate logistic regression analyses controlling for demographic, environmental, site, and clinical characteristics, plan satisfaction was associated with greater likelihood of subsequent service use regardless of managed care versus FFS setting. Children in managed care plans were less likely to use intensive residential and non-traditional outpatient services. Efforts to increase plan satisfaction may encourage service use, consequently, improving children's behavioral health outcomes.     

Integrated care models and behavioral health care utilization: Quasi‐experimental evidence from Medicaid health homes

Integration of behavioral and general medical care can improve outcomes for individuals with behavioral health conditions—serious mental illness (SMI) and substance use disorder (SUD). However, behavioral health care has historically been segregated from general medical care in many countries. We provide the first population‐level evidence on the effects of Medicaid health homes (HH) on behavioral health care service use. Medicaid, a public insurance program in the United States, HHs were created under the 2010 Affordable Care Act to coordinate behavioral and general medical care for enrollees with behavioral health conditions. As of 2016, 16 states had adopted an HH for enrollees with SMI and/or SUD. We use data from the National Survey on Drug Use and Health over the period 2010 to 2016 coupled with a two‐way fixed‐effects model to estimate HH effects on behavioral health care utilization. We find that HH adoption increases service use among enrollees, although mental health care treatment findings are sensitive to specification. Further, enrollee self‐reported health improves post‐HH.     

Medicaid managed care in Chicago: changes in utilization

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

Health care utilization patterns of Russian-speaking immigrant women across age groups

The collapse of the Soviet Union in 1989 substantially increased the numbers of refugees and immigrants to the United States from the former Soviet Union. Little research has been conducted with this population although studies found that immigrant's access to health care services are based on patterns of utilization in their countries of origin. The purpose of this study was to learn about the experiences of immigrant women from three former Soviet Republics (Belarus, Russia, and Ukraine) with women's health care services. Three focus groups of women were formed; ages 20–30, 37–46, and 60 and above. A focus-group guide was used to learn about their health care experiences. These immigrant women did access health care services based on patterns of utilization in their countries of origin. Greater understanding of immigrant populations' cultural patterns of health care utilization is needed to improve access and delivery of health care services to these populations.     

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.     

Changes in elderly disability rates and the implications for health care utilization and cost

Recent research indicates declining age-adjusted chronic disability among older Americans, which might moderate health care costs in the coming decades. This study examines the trend's underlying components using data from the 1984-1999 National Long-Term Care Surveys to better understand the reasons for the declines and potential implications for acute and long-term care. The reductions occurred primarily for activities like financial management and shopping. Assistance with personal care activities associated with greater frailty fell less, and independence with assistive devices rose. Institutional residence was stable. More needs to be known about the extent to which these declines reflect environmental improvements allowing greater independence at any level of health, rather than improvements in health, before concluding that the declines will mean lower costs.     

The effect of extension of benefit coverage for cancer patients on health care utilization across different income groups in South Korea

To provide financial protection against catastrophic illness, the Korean government expanded the National Health Insurance (NHI) benefit coverage for cancer patients in 2005. This paper examined whether the policy improved the income-related equality in health care utilization. This study analyzed the extent to which the policy improved income-related equality in outpatient visits, inpatient days, and inpatient and outpatient care expenditure based on triple difference estimator. Using nationwide claims data of the NHI from 2002 to 2004 and from 2006 to 2010, we compared cancer patients as a treatment group with liver disease as a control group and low-income group with the highest-income group. The results showed that the extension of NHI benefits coverage led to an increase in the utilization of outpatient services across all income groups, but with a greater increase for the low-income groups, among cancer patients. Moreover, the policy led to a less decrease in the utilization of inpatient services for the low-income group while it decreased across all income groups. Our finding suggests that the extension of NHI benefits coverage improved the income-related equality in health care utilization.     

Medicaid managed care and infant health

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

The effect of health insurance coverage on medical care utilization and health outcomes: Evidence from Medicaid adult vision benefits

Increasing the proportion of adults that have regular, comprehensive eye exams and reducing visual impairment due to uncorrected refractive error and other common eye health problems are federal health objectives. We examine the effect of vision insurance on eye care utilization and vision health outcomes by taking advantage of quasi-experimental variation in Medicaid coverage of adult vision care. Using a difference-in-difference-in-difference approach, we find that Medicaid beneficiaries with vision coverage are 4.4 percentage points (p < 0.01) more likely to have seen an eye doctor in the past year, 5.3 percentage points (p < 0.01) less likely to report needing but not purchasing eyeglasses or contacts due to cost, 2.0 percentage points (p < 0.05) less likely to report difficulty seeing with usual vision correction, and 1.2 percentage points (p < 0.01) less likely to have a functional limitation due to vision.     

Unmet health care and health care utilization

The objective of this study is to examine the causal effect of health care utilization on unmet health care needs. An IV approach deals with the endogeneity between the use of health care services and unmet health care, using the presence of drug insurance and the number of physicians by health region as instruments. We employ three cycles of the Canadian Community Health Survey confidential master files (2003, 2005, and 2014). We find a robustly negative relationship between health care use and unmet health care needs. One more visit to a medical doctor on average decreases the probability of reporting unmet health care needs by 0.014 points. The effect is negative for the women‐only group whereas it is statistically insignificant for men; similarly, the effect is negative for urban dwellers but insignificant for rural ones. Health care use reduces the likelihood of reporting unmet health care. Policies that encourage the use of health care services, like increasing the coverage of public drug insurance and increasing after hours accessibility of physicians, can help reduce the likelihood of unmet health care.     

Variation in health conditions among groups of adults with disabilities in primary care

The literature on the health of adults with disabilities focuses on one disability compared to a comparison group. This study allows cross disability comparisons with the hypothesis. Adults with disabilities had higher odds of having common health conditions, compared to adults without disability in the same practice. A retrospective record review of 1449 patients with disability and 2084 patients without disability included individuals with sensory impairments (n=117), developmental disabilities (n=692), trauma-related impairments (n=155) and psychiatric impairments (n=485). The only two health conditions with statistically significantly increased odds for all groups with disabilities were dementia and epilepsy. Patients with developmental disabilities were less likely to have coronary artery disease, cancer, and obesity. Those with sensory impairments had increased odds for congestive heart failure, diabetes, transient ischemic attacks and death. Patients with trauma disabilities had increased odds for chronic obstructive pulmonary disease, and depression. Finally, psychiatric patients had increased odds for most of the investigated condition. In conclusion, there were many similarities in the risk for common health conditions such as asthma, cancer, coronary artery disease, depression, hypertension, and obesity, among patients with and without disability. Some of the conditions with increased odds ratios, including depression, seizures, and dementia are secondary to the primary disability.Suzanne McDermott is Professor of Family and Preventive Medicine, Robert Moran is a Biostatistician in the Department of Epidemiology and Biostatistics, Tan Platt is Associate Professor of Family and Preventive Medicine, and Srikanth Dasari is a Computer Systems Programmer, all at the University of South Carolina, Columbia South Carolina, USA.     

Patient assessments of care and utilization in Medicaid managed care: PCCMs vs. PSOs

States are experimenting with different forms of delivery and financing to make Medicaid expenditures more predictable. Florida Medicaid is experimenting with a relatively new form of managed care, the provider-sponsored organization (PSO). Using the Donabedian structure-process-outcome (SPO) model, patient experiences and utilization in Florida PSOs and primary care case management (PCCM) were compared. The study analyzed Consumer Assessments of Healthcare Providers and Systems (CAHPS) data for 1,257 Medicaid beneficiaries in Florida in 2005. Results showed that beneficiaries in the PSOs had similar ratings and reports of care to those in the PCCM. However, PSOs had lower physician visits compared to the PCCM, indicating potential access barriers to primary care. The PSO's impact on emergency department (ED) utilization and specialist utilization was similar to that of the PCCM. The PSOs may lower costs, but the savings may be due to lower physician utilization rather than better case management. This is important since states that are experimenting with PSOs in their Medicaid programs are looking to these organizations to improve beneficiary care while lowering costs.     

Physician participation in a Medicaid managed care program, the Kansas Primary Care Network

This study was designed to identify the factors that enhance and impede physician participation in a Medicaid managed care program, the Kansas Primary Care Network (PCN). The data for the study were collected in the summer of 1993 through a mail survey of primary care physicians in the PCN service area. Logistic regression and cross tabular analytic techniques were employed for data analysis. The results indicate that physicians who are not receptive to capitation-based reimbursement practices, those who practice in the higher per capita income counties, those who do not compare the PCN reimbursement rates favorably with private insurance rates, and physicians who think that untimely payment and the requirement to document patient referrals for specialty treatment pose problems for them are less likely to participate in the PCN program. Further, the study shows that institutional physicians have larger Medicaid caseloads than solo practitioners, who have larger Medicaid caseloads than single-specialty and multi-specialty group practitioners. Since most of the variables that attain statistical significance in explaining physician participation in the PCN program have to do with money, the study reaffirms the two market theory of the United States' health care delivery system.     

Women's health services: restructuring for Medicaid managed care

New Jersey health care providers face the need to change dramatically the way health care is delivered as it enters a new era of managed care. This year, more than 24% of New Jersey's total population is enrolled in commercial managed care plans (New Jersey Department of Insurance, 1996). In addition, the state's Medicaid agency took steps to improve the delivery of health services to recipients by initiating implementation activities to transition from the traditional Medicaid program to a managed care model. Eighty-two percent of New Jersey's Aid to Families with Dependent Children (AFDC) and related populations have already been enrolled in managed care. The state plans to expand enrollment in managed care to the remaining 400,000 Medicaid beneficiaries. Communities with high Medicaid populations are challenged with the need to move through the managed care evolution at an accelerated rate.     

The case of disability in the family: impact on health care utilization and expenditures for nondisabled members

Families with a disabled member undergo heightened emotional and financial stress, which can arise from caring for the person with one or more disabilities over the life course or at the end of life. Because health care resources are strained by the needs of the disabled family member, nondisabled members are often limited in health care access and utilization when they are most in need of care. This analysis uses the National Medical Expenditure Survey to describe families with disabled members, based on multiple definitions of disability, and to examine health care utilization and expenditures by nondisabled family members. Indications of higher use of medical care by adult, nondisabled members of such families support the frequent reports in the literature of stress occurring in these situations. The signals of a household rationing effect for families near and at poverty levels should alert policy makers to consider the needs of the whole family when creating or modifying assistance programs.     

Determinants of maternity health care utilization in Tajikistan: Learning from a national living standards survey

This study examines the demographic, economic, social, and geographic factors that help explain maternity health care utilization in Tajikistan, a low-income transitional country in Central Asia, based on a newly available nationally representative living standard survey. Two regression models, namely, a binomial logit model and a zero-inflated negative binomial (ZINB) model are estimated. The estimations of the two models show strikingly consistent results—the year of last childbirth, educational attainment, and the availability of public infrastructure are important predictors of maternity health care utilization. The results also signify an urgent need to overturn the current negative trend in maternity health care utilization. The findings also suggest that many determinants of maternity health care are outside the direct sphere of health care policies, indicating the need of cross-sectional policies in addressing maternity health care utilization, for example, policies and strategies that include contributions from other sectors.