National and state trends in enrollment and spending for dual eligibles under age 65 in Medicaid managed care

BackgroundTo reduce costs and improve care, states are increasingly enrolling individuals with disabilities in Medicaid managed care. Many states allow or require adults who are dually eligible for Medicaid and Medicare to enroll in these plans.ObjectiveThis study (1) quantifies changes in enrollment by managed care arrangement for duals under age 65, between 2005 and 2008 and (2) compares enrollment and spending between dual eligibles and Medicaid-only beneficiaries.MethodsWe used Medicaid Analytic eXtract data to compare the Medicaid enrollment and spending for all-year, full-benefit dual eligibles ages 21–64 with that of Medicaid-only Supplemental Security Income (SSI) and disabled beneficiaries. The study population was classified into 9 types of managed care to quantify enrollment and calculate expenditures by year.ResultsNationwide, the proportion of adult duals in managed care increased from 2005 to 2008, with the expansion of prepaid health plans (PHPs) (31.0%–46.6%), particularly behavioral health PHPs, driving the increase. In 2008, Medicaid-only disabled adults were three times as likely as dual adults to enroll in comprehensive managed care (CMC) (35.1% versus 11.7%). Average Medicaid expenditures per enrollee differed markedly by managed care arrangement and state.ConclusionsFrom 2005 to 2008, there was little expansion of CMC among adult duals, while the use of PHPs to cover carved out services increased greatly. New federal initiatives aim to reduce barriers to enrolling duals into comprehensive, integrated managed care. With expanded enrollment, it will be important to monitor enrollment and evaluate whether integration improves care.     

Midwifery and Birth Centers Under State Medicaid Programs: Current Limits to Beneficiary Access to a High-Value Model of Care

Policy Points

• Birth center services must be covered under Medicaid per federal mandate, but reimbursement and other policy barriers prevent birth centers from serving more Medicaid patients.
• Midwifery care provided through birth centers improves maternal and infant outcomes and lowers costs for Medicaid beneficiaries. Birth centers offer an array of birth options and have resources to care for patients with medical and psychosocial risks.
• Addressing the barriers identified in this study would promote birth centers’ participation in Medicaid, leading to better outcomes for Medicaid‐covered mothers and newborns and significant savings for the Medicaid program.

ContextMidwifery care, particularly when offered through birth centers, has shown promise in both improving pregnancy outcomes and containing costs. The national evaluation of Strong Start for Mothers and Newborns II, an initiative that tested enhanced prenatal care models for Medicaid beneficiaries, found that women receiving prenatal care at Strong Start birth centers experienced superior birth outcomes compared to matched and adjusted counterparts in typical Medicaid care. We use qualitative evaluation data to investigate birth centers’ experiences participating in Medicaid, and identify policies that influence Medicaid beneficiaries’ access to midwives and birth centers.MethodsWe analyzed data from more than 200 key informant interviews and 40 focus groups conducted during four case study rounds; a phone‐based survey of Medicaid officials in Strong Start states; and an Internet‐based survey of birth center sites. We identified themes related to access to midwives and birth centers, focusing on influential Medicaid policies.FindingsMedicaid beneficiaries chose birth center care because they preferred midwife providers, wanted a more natural birth experience, or in some cases sought certain pain relief methods or birth procedures not available at hospitals. However, Medicaid enrollees currently have less access to birth centers than privately insured women. Many birth centers have difficulty contracting with managed care organizations and participating in Medicaid value‐based delivery system reforms, and birth center reimbursement rates are sometimes too low to cover the actual cost of care. Some birth centers significantly limit Medicaid business because of low reimbursement rates and threats to facility sustainability.ConclusionsMedicaid beneficiaries do not have the same access to maternity care providers and birth settings as their privately insured counterparts. Medicaid policy barriers prevent some birth centers from serving more Medicaid patients, or threaten the financial sustainability of centers. By addressing these barriers, more Medicaid beneficiaries could access care that is associated with positive birth outcomes for mothers and newborns, and the Medicaid program could reap significant savings.     

Medicaid managed care in Iowa: Experiences of older adults and people with disabilities

BackgroundA growing number of states are turning to managed care arrangements to provide care to senior and disabled Medicaid beneficiaries. Despite their complex care needs, very little is known about the experience of these individuals in managed care.ObjectiveTo document experiences of a sample of aged and disabled Medicaid beneficiaries receiving long-term services and supports through managed care in Iowa and to assess whether these experiences changed over time.MethodsA purposive sample of 49 aged and disabled beneficiaries enrolled in one of seven HCBS waivers in Iowa was recruited in 2017. Telephone surveys were conducted in 2017 and 2019. A conventional content analysis was used to generate themes, which were then ranked by frequency proportions. Thematic frequencies were compared across waves among repeat respondents.ResultsContent analysis yielded seven themes in the following areas: system navigation; service approvals; provider relations; customer service; case management; perception of Iowa’s transition to managed care; and oversight. Concerns with service approvals was the most frequently reported theme and within this, issues related to changes in approved services or hours and quality of newly approved services comprised the largest number of references. Beneficiary concerns appeared to grow over time among respondents participating in both survey interview waves.ConclusionThe results of this study point to serious and persistent concerns related to access and quality of care under managed care for at least some HCBS waiver participants in Iowa, underscoring the need for a comprehensive evaluation of the program.     

Cost of Cervical Cancer Treatment: Implications for Providing Coverage to Low-Income Women under the Medicaid Expansion for Cancer Care

BackgroundTo date, no study has reported on the cost of treating cervical cancer among Medicaid beneficiaries younger than 65 years of age. This information is essential for assessing the cost effectiveness of screening interventions for low-income women and the funding required for treatment programs established by the Breast and Cervical Cancer Prevention and Treatment Act of 2000.MethodsAdministrative data from the North Carolina Medicaid program linked with cancer registry data were used to analyze total Medicaid costs for these patients and the incremental costs of cervical cancer care at 6 and 12 months from diagnosis. We compared 207 beneficiaries diagnosed with cancer during the years 2002 to 2004 with 414 controls.FindingsTotal Medicaid costs at 6 months after diagnosis were $3,807, $23,187, $35,853, and $45,028 for in situ, local, regional, and distant cancers, respectively. The incremental cost of cancer treatment for local and regional cancers was $13,935 and $26,174 and by 12 months increased to $15,868 and $30,917, respectively.ConclusionMedicaid coverage may be required for many months after diagnosis to ensure the provision of comprehensive care, especially for women with late-stage cancers. Given the great differences in cost of early versus late-stage cancers, interventions aimed at increasing screening among low-income women are likely to be cost effective.     

Health Care Utilization among Children Enrolled in Medicaid and CHIP via Express Lane Eligibility

ObjectiveTo assess health care utilization among children enrolled in Medicaid and CHIP via Express Lane Eligibility (ELE).ConclusionsHealth care use patterns suggest that ELE enrollees are aware of their coverage; enrollees accessed and repeatedly used services covered by public health insurance. However, states considering this policy may expect that remaining eligible but uninsured children may be less expensive to cover than existing beneficiaries.     

Telephone Care Management's Effectiveness in Coordinating Care for Medicaid Beneficiaries in Managed Care: A Randomized Controlled Study

Objective

To test the effectiveness of a telephone care management intervention to increase the use of primary and preventive care, reduce hospital admissions, and reduce emergency department visits for Medicaid beneficiaries with disabilities in a managed care setting.

Data Source

Four years (2007–2011) of Medicaid claims data on blind and/or disabled beneficiaries, aged 20–64.

Study Design

Randomized control trial with an intervention group (n = 3,540) that was enrolled in managed care with telephone care management and a control group (n = 1,524) who remained in fee-for-service system without care management services. Multi-disciplinary care coordination teams provided telephone services to the intervention group to address patients'' medical and social needs.

Data Collection/Extraction

Medicaid claims and encounter data for all participants were obtained from the state and the managed care organization.

Principal Findings

There was no significant difference in use of primary care, specialist visits, hospital admissions, and emergency department between the intervention and the control group. Care managers experienced challenges in keeping members engaged in the intervention and maintaining contact by telephone.

Conclusions

The lack of success for Medicaid beneficiaries, along with other recent studies, suggests that more intensive and more targeted interventions may be more effective for the high-needs population.Only about 7 percent of Medicaid beneficiaries are blind and/or disabled, but they account for 40 percent of Medicaid spending (Vladeck 2003). Because they are low income as well, they are likely to be a vulnerable and hard-to-reach group that experiences greater difficulty navigating the health care system (Agency for Healthcare Research and Quality 2008; Kaiser Family Foundation 2010). Many states are looking for cost-effective strategies to provide medical services to this population. One such strategy is care management.Care management describes programs that are intended to increase appropriate use of medical care while reducing unnecessary services, such as emergency department (ED) visits and hospitalizations (Wagner et al. 2001; Mattke, Seid, and Ma 2007). In care management programs, to meet patients'' needs, care managers (who are usually nurses or Master''s level clinicians) encourage patients to seek appropriate treatment, help them find and make appointments with health care professionals, make sure they are keeping appointments and taking prescribed medications, educate them about treatment effectiveness, and identify other needs that patients might have (Wagner et al. 2001; Rittenhouse and Robinson 2006). Care managers also often work with primary care physicians (PCPs), providing them with information designed to help them monitor a patient''s overall health care use and communicate with other health care providers.Care management programs have traditionally focused on patients with chronic conditions such as diabetes mellitus, asthma, depression, coronary artery disease, and congestive heart failure (Wagner et al. 2001; Mattke, Seid, and Ma 2007). Studies have shown that care management can improve health outcomes for patients with particular chronic health conditions, such as diabetes (Sidorov et al. 2002; Dorr et al. 2005; Glazier et al. 2006; Chin et al. 2007), cardiovascular disease (Harris et al. 2003; Sequist et al. 2006), and congestive heart failure (Gorski and Johnson 2003; DeWalt et al. 2006). For patients with depression, care management has encouraged patients to talk to mental health specialists, increased their use of antidepressants, reduced their depression, improved their health, and improved their work performance and job retention (Wang et al. 2007; Mohr et al. 2008; Kroenke et al. 2010). In addition, care management has been found to reduce the costs of care in some settings (Handley, Shumway, and Schillinger 2008), although this might not be the norm (Peikes et al. 2009).Despite the success of care management in some settings, there has not been a rigorous evaluation of this approach in a diverse set of Medicaid beneficiaries with multiple chronic conditions. For example, studies of Medicaid care management in Florida (Afifi et al. 2007; Kominski et al. 2008) and Virginia (Zhang et al. 2008) have found improvements such as fewer hospital stays and ED visits. However, those studies used nonrandomly chosen comparison groups, and the results may have confounded the effects of the programs with other unobserved differences between the groups (Rosenbaum and Rubin 1983; Bell et al. 1995; Michalopoulos, Bloom, and Hill 2004). This is an important gap in the research as more than 20 states operate some form of care management for this population (Rosenman et al. 2006; Arora et al. 2008). This article begins to fill this gap in knowledge by presenting results from a randomized study of a telephone care management program for blind and/or disabled Medicaid beneficiaries in Colorado, many of whom often have multiple chronic conditions.     

End-of-Life Medical Costs of Medicaid Cancer Patients

ObjectivesTo quantify end-of-life (EOL) medical costs for adult Medicaid beneficiaries diagnosed with cancer.ConclusionsMedicaid cancer patients incur substantially higher EOL costs than noncancer patients. This increased cost may reflect the cost of palliative care. Future studies should assess the types and timing of services provided to Medicaid cancer patients at the EOL.     

The Opportunity for Health Plans to Improve Quality and Reduce Costs by Embracing Primary Care Medical Homes

Background

The large and growing costs of healthcare will continue to burden all payers in the nation''s healthcare system—not only the states that are struggling to meet Medicaid costs and the federal government, but also the private health plans that serve commercial, Medicare Advantage, and Medicaid beneficiaries. Cost will increasingly become a concern as millions more people become newly insured as a result of the Patient Protection and Affordable Care Act (ACA). Primary care delivery through patient-centered medical homes (PCMHs) and other coordinated-care models have improved care and reduced costs. Health plans have a strategic opportunity to promote better care at a lower cost by embracing medical homes and encouraging their growth. Health plans can play an important role in transforming the US healthcare system, as well as better position themselves for long-term corporate success.

Objectives

To discuss several examples of organizations that serve a variety of beneficiaries and have been successful in promoting medical homes and coordinated primary care, and to suggest steps that health plans can take to improve the quality of care and reduce costs.

Discussion

The models discussed in this article take a number of different approaches to create incentives for high-quality, cost-effective, coordinated primary care. Several health plans and groups use enhanced fee-for-service or per-member per-month payment models for primary care physician (PCP) practices that reach a specified level of medical home or electronic health record certification. Most of the examples addressed in this article also include an additional payment to encourage care management and coordination. The results showed a significant decline in costs and in the use of expensive medical services. One Medicaid coordinated-care program we reviewed saved almost $1 billion in reduced spending over 4 years, and achieves savings of approximately 15% within 6 months of the beneficiaries'' enrollment into their program. Another PCMH payer program led to an approximate 28% reduction in acute care hospital admissions among Medicare beneficiaries and an approximate 38% reduction in admissions among commercial beneficiaries.

Conclusion

Based on the review of real-world examples, we recommend 6 steps that health plans can use to take advantage of the opportunity to embrace medical homes as a means to improve healthcare quality and to reduce costs. These recommendations include getting feedback from PCPs to improve plan provider networks, creating value-based primary care reimbursement systems, encouraging biannual visits with high-risk patients, funding case managers for high-risk patients, considering Medicaid coordinated-care models, and promoting ACA policies that support primary care.The large and growing cost of healthcare, which amounted to 17.9% of the gross domestic product in 2011,1 will continue to be a burden for all payers in the US healthcare system, not only for states that are struggling to meet Medicaid costs and the federal government''s requirements, but also for private health plans that serve commercial, Medicare Advantage, and Medicaid beneficiaries.2,3 Costs will continue to grow as millions more people become newly insured because of the Patient Protection and Affordable Care Act (ACA).Primary care that is delivered through patient-centered medical homes (PCMHs) and other coordinated-care models has served as a means to improve care and to reduce costs.4,5 Health plans, therefore, have a strategic opportunity to promote better care at a lower cost by embracing medical homes and encouraging their growth. Using this strategy would enable health plans to play an important role in transforming the US healthcare system, and to be better positioned for long-term corporate success.Large business groups already have taken note of the potential for primary care and medical homes to reduce their healthcare costs. The National Business Group on Health (NBGH), which has more than 300 large corporate members that provide health insurance for 50 million Americans, has made primary care, and more recently the PCMH model, a priority “for years,” said NBGH Vice President Veronica Goff in an April 18, 2012, telephone interview. Several large employers are conducting PCMH pilot programs, including IBM, Boeing, Whirlpool, Dow Chemical, and Perdue Farms. Some state Medicaid programs and private health plans have also launched efforts to establish medical homes.In this article, we discuss several examples of organizations that serve a variety of beneficiaries and that have been successful in promoting medical homes and coordinated primary care. We review their results and make recommendations to health plans that are interested in seizing this opportunity.     

Medicaid's role in ambulatory health care

Medicaid plays an enormously important role in ambulatory care financing, both primary and specialized, for patients with routine health needs, as well as individuals with chronic illness and disability. Nearly all Medicaid beneficiaries receive the vast bulk of their health care in ambulatory settings. Medicaid plays a critical role for low-income persons, including children, pregnant women and families, and elderly and disabled Medicare beneficiaries. The Bush administration's proposal to subject federal Medicaid spending to annual aggregate limits could be expected to have especially severe effects on states' capacity to support ambulatory services and achieve innovations in community-based care.     

Assessing the Barriers to Engaging Challenging Populations in Disease Management Programs

Disease management has gained popularity as a way to improve health status and control of chronic illness through the use of risk stratification, targeted nurse outreach, telephonic nurse advice, and evidence-based guidelines in managing illness. Disease management programs have been successfully implemented by commercial insurers and managed care plans, as well as in Medicare and state Medicaid programs. Although evidence regarding cost savings is inconsistent, it appears that disease management programs do impact health status and quality of care, and improve self-management among the chronically ill.Disease management programs can be customized to meet the needs of vulnerable subpopulations. This article explores the barriers to dealing with chronic illness and other factors faced by disease management programs for Medicaid populations. Barriers to participation and success in disease management for Medicaid beneficiaries are apparent due to lack of access to translation and interpretation services; difficulty with community outreach; achieving buy in from providers and beneficiaries; problems with housing; difficulties accessing primary and specialty care; problems with the availability of pharmacy, durable medical equipment, and other support services; as well as difficulties with Medicaid eligibility and ‘churn’.In order to create a successful disease management program that positively impacts health status, utilization, and cost, it is necessary to consider all of these barriers when designing an intervention for Medicaid beneficiaries. Some of the innovative ways to handle the difficulties of dealing with Medicaid or other low-income populations with special healthcare needs include expanded interpretation and translation activities, extensive community outreach to patients and safety net providers such as clinics and public hospitals, providing support services related to non-medical problems experienced by enrollees, providing understandable written and verbal instructions and training related to health education and medication adherence, as well as efforts to track and maintain contact with eligible and enrolled individuals. Disease management programs can be successful in saving money and improving health in Medicaid populations. However, they must be carefully designed with the specific state Medicaid program and should target the needs of the state’s beneficiaries.     

Access to care among disabled adults on Medicaid

Although disabled individuals account for a disproportionate share of Medicaid expenditures, little is known about their health care needs and experiences. This article explores differences in access and use among key disability subgroups--adults with physical disabilities, mental illness, and mental retardation/development disabilities (MR/DD). We find that disabled Medicaid beneficiaries with mental illness and those with greater health and functional limitations face more difficulties in obtaining care. This suggests a need for changes in the system of care under Medicaid, including targeting efforts to improve access to individuals with specific types of disabilities.     

Return to work: A critical aspect of care coordination for younger dual eligibles

BackgroundAnnual health care costs for dual eligibles now top $300 billion. Many dual eligibles are under age 65 and their needs differ significantly from retired elderly dual eligibles. For younger dual eligibles, successful return to work is an important objective for coordinated care.ObjectivesTo assess relative rates of dual eligibility by age group and program enrollment (SSDI or OASI), and to identify the prevalence among these subgroups of factors associated with return to work.MethodsPopulation estimates and logistic regression analysis of the 2010 Medicare Current Beneficiary Survey (MCBS).ResultsAlthough they make up only 16% of the total Medicare beneficiary population, disabled workers under age 65 constitute 42% of all dual eligibles. SSDI beneficiaries under age 45 have 20 times greater odds of receiving Medicaid benefits compared to retirees (AOR = 19.8, 95% CI = 16.2–24.2). The youngest dual eligible adults are more likely to work, have fewer chronic conditions, and report better health status than other dual eligibles. However, they are more likely to report problems with obtaining health care and be dissatisfied with the quality of the care they receive.ConclusionsDual eligible workers with disabilities are an important target population for coordinated services because of their high lifetime program costs – many will receive SSDI, SSI, Medicare, and Medicaid benefits for decades. Return to work and continued employment are important policy objectives for younger dual eligibles and should provide the greatest return in terms of reduced dependence on federal disability programs.     

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.     

Health care access,use, and satisfaction among disabled Medicaid beneficiaries

Despite being a vulnerable and costly population, little is known about disabled Medicaid beneficiaries. Using data from a 1999-2000 survey, we describe the population and their health care experiences in terms of access, use, and satisfaction with care. Results indicate that disabled beneficiaries are a unique population with wide-ranging circumstances and health conditions. Our results on access to care were indeterminate: by some measures, they had good access, but by others they did not. Beneficiaries' assessments of their health care were more clear: The bulk of the sample rated one or more area of care as being fair or poor.     

Reconsidering the effect of Medicaid on health care services use.

OBJECTIVE: Our research compares health care use by Medicaid beneficiaries with that of the uninsured and the privately insured to measure the program's effect on access to care. DATA SOURCES/STUDY SETTING: Data include the 1987 National Medical Expenditure Survey and the Survey of Income and Program Participation for 1984-1988. STUDY DESIGN: We predict annual use of ambulatory care and inpatient hospital care for Medicaid beneficiaries receiving AFDC cash assistance and compare it to what their use would be if uninsured or if covered by private insurance. Comparisons are based on multivariate models of health care use that control for demographic and economic characteristics and for health status. Our model distinguishes among Medicaid beneficiaries on the basis of eligibility to account for the poor health of beneficiaries in some eligibility groups. PRINCIPAL FINDINGS: AFDC Medicaid beneficiaries use considerably more ambulatory care and inpatient care than they would if they remained uninsured. Use among the AFDC Medicaid population is about the same as use among otherwise similar, privately insured persons. Use rates differ substantially among different Medicaid beneficiary groups, supporting the expectation that some beneficiary groups are in poor health. CONCLUSIONS: Although Medicaid has increased access to health care services for beneficiaries to rates now comparable to those for the privately insured population, because of lower cost sharing in Medicaid we would expect higher service use than we are finding. This suggests possible barriers to Medicaid patients in receiving the care they demand. Enrollment of less healthy individuals into some Medicaid beneficiary groups suggests that pooled purchasing arrangements that include Medicaid populations must be designed to ensure adequate access for the at-risk populations and, at the same time, to ensure that private employers do not opt out because of high community-rated premiums.     

Incomplete Home Health Care Referral After Hospitalization Among Medicare Beneficiaries

ObjectivesPatients who are referred to home health care after an acute care hospitalization may not receive home health care, resulting in incomplete home health referrals. This study examines the prevalence of incomplete referrals to home health, defined as not receiving home health care within 7 days after an initial hospital discharge, and investigates the relationship between home health referral completion and patient outcomes.DesignRetrospective cohort study.Setting and ParticipantsMedicare beneficiaries who are discharged from short-term acute care hospitals between October 2015 and December 2016 with a discharge status code on the hospital claim indicating home health care.MethodsPatient characteristics and outcomes were compared between Medicare beneficiaries with complete and incomplete home health referrals after hospital discharge. The outcomes included mortality, readmission rate, and total spending over a 1-year episode following hospitalization. These outcomes were risk-adjusted using patient demographic, socioeconomic, clinical characteristic, hospital characteristic, and state fixed effects.ResultsApproximately 29% of the 724,700 hospitalizations in the analytic dataset had incomplete home health referrals after discharge. The rate of incomplete home health referrals varied among clinical conditions, ranging from 17% among joint/musculoskeletal patients and 38% among digestive/endocrine patients. Risk-adjusted 1-year mortality and readmission rates were 1.4 and 2.4 percentage points lower and total spending was $1053 higher among patients with complete home health referrals as compared with those with incomplete home health referrals after hospital discharge.Conclusions and ImplicationsThe analysis revealed that almost 1 in 3 patients discharged from a hospital with a discharge status of home health does not receive home health care. In addition, complete home health referrals are associated with lower mortality and readmission rates and higher spending. As home health care utilization increases, policymakers should pay attention to the tradeoff between quality and cost when implementing alternative policies and payment models.     

Potential Adult Medicaid Beneficiaries Under the Patient Protection and Affordable Care Act Compared With Current Adult Medicaid Beneficiaries

PURPOSE

Under health care reform, states will have the opportunity to expand Medicaid to millions of uninsured US adults. Information regarding this population is vital to physicians as they prepare for more patients with coverage. Our objective was to describe demographic and health characteristics of potentially eligible Medicaid beneficiaries.

METHODS

We performed a cross-sectional study using data from the National Health and Nutrition Examination Survey (2007–2010) to identify and compare adult US citizens potentially eligible for Medicaid under provisions of the Patient Protection and Affordable Care Act (ACA) with current adult Medicaid beneficiaries. We compared demographic characteristics (age, sex, race/ethnicity, education) and health measures (self-reported health status; measured body mass index, hemoglobin A_1c level, systolic and diastolic blood pressure, depression screen [9-item Patient Health Questionnaire], tobacco smoking, and alcohol use).

RESULTS

Analyses were based on an estimated 13.8 million current adult non-elderly Medicaid beneficiaries and 13.6 million nonelderly adults potentially eligible for Medicaid. Potentially eligible individuals are expected to be more likely male (49.2% potentially eligible vs 33.3% current beneficiaries; P <.001), to be more likely white and less likely black (58.8% white, 20.0% black vs 49.9% white, 25.2% black; P = .02), and to be statistically indistinguishable in terms of educational attainment. Overall, potentially eligible adults are expected to have better health status (34.8% “excellent” or “very good,” 40.4% “good”) than current beneficiaries (33.5% “excellent” or “very good,” 31.6% “good”; P <.001). The proportions obese (34.5% vs 42.9%; P = .008) and with depression (15.5% vs 22.3%; P = .003) among potentially eligible individuals are significantly lower than those for current beneficiaries, while there are no significant differences in the expected prevalence of diabetes or hypertension. Current tobacco smoking (49.2% vs 38.0%; P = .002), and moderate and heavier alcohol use (21.6% vs 16.0% and 16.5% vs 9.8%; P <.001, respectively) are more common among the potentially eligible population than among current beneficiaries.

CONCLUSIONS

Under the ACA, physicians can anticipate a potentially eligible Medicaid population with equal if not better current health status and lower prevalence of obesity and depression than current Medicaid beneficiaries. Federal Medicaid expenditures for newly covered beneficiaries therefore may not be as high as anticipated in the short term. Given the higher prevalence of tobacco smoking and alcohol use, however, broad enrollment and engagement of this potentially eligible population is needed to address their higher prevalence of modifiable risk factors for future chronic disease.     

Are Dual Eligibles Admitted to Poorer Quality Skilled Nursing Facilities?

BackgroundDual eligibles, persons who qualify for both Medicare and Medicaid coverage, often receive poorer quality care relative to other Medicare beneficiaries.ObjectivesTo determine whether dual eligibles are discharged to lower quality post-acute skilled nursing facilities (SNFs) compared with Medicare-only beneficiaries.SubjectsA total of 692,875 Medicare fee-for-service patients (22% duals) who were discharged for Medicare paid SNF care between July 2004 and June 2005.MeasuresMedicare enrollment and the Medicaid Analytic Extract files were used to determine dual eligibility. The proportion of Medicaid patients and nursing staff characteristics provided measures of SNF quality.ResultsDuals are more likely to be discharged to SNFs with a higher share of Medicaid patients and fewer nurses. These results are robust to estimation with an alternative subsample of patients based on primary diagnoses, propensity of being dual eligible, and likelihood of remaining in the nursing home.ConclusionsDisparities exist in access to quality SNF care for duals. Strategies to improve discharge planning processes are required to redirect patients to higher quality providers, regardless of Medicaid eligibility.     

Ambulatory Care Sensitive Hospitalizations among Medicaid Beneficiaries with Chronic Conditions

Objectives: This study examined the relationship between ambulatory care sensitive hospitalizations (ACSH) and patient-level and county-level variables. Methods: Utilizing a retrospective cohort approach, multi-state Medicaid claims data from 2007-2008 was used to examine ACSH at baseline and follow-up periods. The study cohort consisted of adult, non-elderly Medicaid beneficiaries with chronic physical conditions, who were continuously enrolled in fee-for-service programs, not enrolled in Medicare, and did not die during the study period (N=7,021). The dependent variable, ACSH, was calculated in the follow-up year using an algorithm from the Agency for Healthcare Research and Quality algorithm. Patient-level (demographic, health status, continuity of care) and county-level (density of healthcare providers and facilities, socio-economic characteristics, local economic conditions) factors were included as independent variables. Multivariable logistic regression models were used to examine the relationship between ACSH and independent variables. Results: In this study population, 8.2% had an ACSH. African-Americans were more likely to have an ACSH [AOR=1.55, 95% CI 1.16, 2.07] than Caucasians. Adults with schizophrenia were more likely to have an ACSH, compared to those without schizophrenia [AOR=1.54, 95% CI 1.16, 2.04]. Residents in counties with a higher number of community mental health centers [AOR=0.88, 95% CI 0.80, 0.97] and rural health centers [AOR=0.98, 95% CI 0.95, 0.99] were less likely to have an ASCH. Conclusions: Programs and interventions designed to reduce the risk of ACSH may be needed to target specific population subgroups and improve healthcare infrastructure.