Children's health services in a "system of care": patterns of mental health, primary and specialty use

OBJECTIVES: This study was designed to investigate demonstrable impacts of the Mental Health Services Program for Youth (MHSPY), a highly coordinated, intentionally integrated "system of care," on patterns of health service utilization for youth with multiple needs. METHODS: The MHSPY intervention is available to a target population of urban youth who face barriers to health care and are at risk for out-of-home placement. These youth are enrolled in a non-profit managed care organization (MCO). Patterns of medical, pharmacy, and mental health and substance abuse service use were compared for children aged 3 to 19 across insurance categories. RESULTS: Despite risks for access and engagement barriers to care, and for greater medical expense due to greater morbidity, MHSPY enrollees received significantly more ambulatory care per person-year than either the privately insured population or the Medicaid Standard population, and medical expense for MHSPY members was significantly lower than expected. During the four years studied, individuals in the privately insured and Medicaid Standard populations were less likely than MHSPY enrollees to have had an ambulatory pediatric visit (odds ratio [OR] 0.833, 95% confidence interval [CI] 0.765, 0.908 and OR 0.823, 95% CI 0.775, 0.897, respectively). Medical expenses per member per month for MHSPY enrollees were significantly less than that for the similarly impaired Medicaid Disabled population with any medical claim (p < 0.001) or with any outpatient mental health claim (p < 0.01). CONCLUSIONS: Patterns of health care for subpopulations with known risk are important to identify to evaluate system-of-care effectiveness. The service utilization patterns for youth enrolled in the MHSYP system of care vs. those for similar MCO youth suggest health care access for individuals can be affected by delivery system design variables.     

Acutely injured patients with trauma in Massachusetts: differences in care and mortality, by insurance status.

OBJECTIVES. This study was designed to determine whether resource use and mortality differed by insurance status for patients with acute trauma. METHODS. All adults emergently hospitalized in Massachusetts during 1990 with acute trauma (n = 15,008) were examined. RESULTS. After adjustment for confounders, uninsured patients were as likely to receive care in an intensive care unit as were patients with private insurance (odds ratio [OR] = 0.97, 95% confidence interval [CI] = 0.85, 1.11) but were less likely to undergo an operative procedure (OR = 0.68, 95% CI = 0.63, 0.74) or physical therapy (OR = 0.61, 95% CI = 0.57,0.67) and were more likely to die in a hospital (OR = 2.15, 95% CI = 1.44, 3.19). Compared with patients with private insurance, those with Medicaid were less likely to receive an operative procedure (0.85, 0.75-0.97), were equally likely to receive care in an intensive care unit (OR = 1.05, 95% CI = 0.86, 1.30) or physical therapy (OR = 0.90, 95% CI = 0.79, 1.02), and were no more likely to die (OR = 1.28, 95% CI = 0.69,2.39). CONCLUSIONS. These results suggest that the uninsured receive less trauma-related care and have a higher mortality rate. The excess mortality in uninsured patients may be avoided if their resource use is increased to that of insured patients.     

Children’s Receipt of Health Care Services and Family Health Insurance Patterns

PURPOSE Insured children in the United States have better access to health care services; less is known about how parental coverage affects children’s access to care. We examined the association between parent-child health insurance coverage patterns and children’s access to health care and preventive counseling services.METHODS We conducted secondary analyses of nationally representative, cross-sectional, pooled 2002–2006 data from children (n = 43,509), aged 2 to 17 years, in households responding to the Medical Expenditure Panel Survey (MEPS). We assessed 9 outcome measures pertaining to children’s unmet health care and preventive counseling needs.RESULTS Cross-sectionally, among US children (aged 2 to 17 years) living with at least 1 parent, 73.6% were insured with insured parents, 8.0% were uninsured with uninsured parents, and the remaining 18.4% had discordant family insurance coverage patterns. In multivariable analyses, insured children with uninsured parents had higher odds of an insurance coverage gap (odds ratio [OR] = 2.45; 95% confidence interval [CI], 2.02–2.97), no usual source of care (OR = 1.31; 95% CI, 1.10–1.56), unmet health care needs (OR = 1.11; 95% CI, 1.01–1.22), and having never received at least 1 preventive counseling service (OR = 1.20; 95% CI, 1.04–1.39) when compared with insured children with insured parents. Insured children with mixed parental insurance coverage had similar vulnerabilities.CONCLUSIONS Uninsured children had the highest rates of unmet needs overall, with fewer differences based on parental insurance status. For insured children, having uninsured parents was associated with higher odds of going without necessary services when compared with having insured parents.     

Delayed and Forgone Care for Children with Special Health Care Needs in New York State

Objective: To identify characteristics associated with delayed/forgone care for children with special health care needs (CSHCN) in New York State (NYS) as reported by their parents. Methods: Data come from NYS participants in the 2000–2002 National Survey of Children with Special Health Care Needs. Data were analyzed using weighted bivariate and multivariate regression models. The dependent variable was report of delayed/forgone routine health care. Independent variables included illness characteristics, potential and actual access to care, and provider care characteristics. Results: In NYS, 8.4% reported delayed/forgone health care for their child. Parents of children with delayed/forgone care were more likely to report that their child was uninsured (adjusted odds ratio [aOR] 3.8, 95% confidence interval[CI] 1.3–11.8), had experienced interrupted health insurance (aOR 3.9, 95% CI 1.5–9.7), or their child’s insurance was not adequate for CSHCN (aOR 3.6, 95% CI 1.4–9.1). Further, these parents were more likely to report that providers never spend adequate time (aOR 6.3, 95% CI 1.2–34.4), provide sufficient information (aOR 8.0, 95% CI 2.5–25.0), act as partners in care (aOR 6.7, 95% CI 2.3–19.7), or display cultural sensitivity (aOR 5.4, 95% CI 1.2–24.3). Conclusions: An estimated 40,771 NYS CSHCN experience delayed/forgone routine health care. Their families report two noteworthy barriers: inadequate or discontinuous insurance coverage and poor communication with health-care providers. Access to care for CSHCN can be improved by increasing consistent comprehensive insurance coverage and increasing sensitivity in relationships between health care providers and families of CSHCN.     

Changes in health insurance coverage and health care access as teens with disabilities transition to adulthood

BackgroundPre-ACA, less than 6% of children with disabilities were uninsured, compared with more than 42% of young adults with disabilities ages 19–25. Individuals with disabilities face greater barriers to health care access upon transition into adulthood.ObjectivesWe examined whether the ACA dependent coverage provision and Medicaid expansion improved the transition from pediatric to adult healthcare systems by reducing the gap in insurance coverage and access to care between teens and young adults with disabilities.MethodsUsing cross-sectional data from the 2006–2009 and 2011–2015 National Health Interview Survey (n = 10,136), we estimate the change in insurance coverage and access to care from pre-to post-ACA time periods for teens (ages 13–18) and young adults (ages 19–25) with disabilities in a difference-in-differences model. We completed the same analyses for these groups in Medicaid expansion and non-expansion states.ResultsBoth teens and young adults with disabilities made significant gains in insurance coverage (4.55 and 8.96% point gains respectively, p < .001) and access to care (4.01 and 3.14% points decline in delayed care due to cost, p < .05) under the dependent coverage provision and Medicaid expansion.ConclusionsMedicaid expansion had a greater impact on both insurance coverage and on access to care than did the dependent coverage provision. The benefits of these changes flowed primarily to young adults with disabilities, reducing the gaps in insurance coverage between teens and young adults, and expanding access to care for both groups, providing a more seamless transition from pediatric to adult health care systems, post-ACA.     

Multimethod evaluation of health policy change: an application to Medicaid managed care in a rural state

Objective. To answer questions about the impacts of Medicaid managed care (MMC) at the individual, organizational/community, and population levels of analysis.
Data Sources/Study Setting. Multimethod approach to study MMC in New Mexico, a rural state with challenging access barriers.
Study Design. Individual level: surveys to assess barriers to care, access, utilization, and satisfaction. Organizational/community level: ethnography to determine changes experienced by safety net institutions and local communities. Population level: analysis of secondary databases to examine trends in preventable adverse sentinel events.
Data Collection/Extraction Methods. Survey: multivariate statistical methods, including factor analysis and logistic regression. Ethnography: iterative coding and triangulation to assess documents, field observations, and in-depth interviews. Secondary databases: plots of sentinel events over time.
Principal Findings. The survey component revealed no consistent changes after MMC, relatively favorable experiences for Medicaid patients, and persisting access barriers for the uninsured. In the ethnographic component, safety net institutions experienced increased workload and financial stress; mental health services declined sharply. Immunization rate, as an important sentinel event, deteriorated.
Conclusions. MMC exerted greater effects on safety net providers than on individuals and did not address problems of the uninsured. A multimethod approach can facilitate evaluation of change in health policy.     

Decreased attendance at cystic fibrosis centers by children covered by managed care insurance

OBJECTIVE: The evolution of managed care has raised concerns about differential access to care for children with cystic fibrosis (CF). We tested the hypothesis that children with CF with managed care attended CF centers less frequently compared with children with non-managed care. METHODS: We conducted a prospective cohort study by telephone every 4 months to measure access to care at CF centers among 630 randomly selected patients aged 6-18 years from 15 US CF centers. We analyzed data with unconditional logistic regression and generalized estimating equations. RESULTS: Attendance at CF centers was significantly reduced among children with managed care (odds ratio [OR] = 0.74; 95% confidence interval [CI] = 0.57, 0.98; P=0.03) and among girls (OR=0.68; 95% CI=0.48, 0.97; P=0.04). CONCLUSIONS: Children with CF with managed care attended CF centers significantly less frequently than those with non-managed care. These findings suggest that children with CF with managed care may not have equal access to experts in CF as children with non-managed care. Families should consider this when selecting their medical insurance plan. These findings may apply to other children with special health care needs.     

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.     

Public insurance substituting for private insurance: new evidence regarding public hospitals, uncompensated care funds, and Medicaid

This paper examines the impact of public health insurance programs, whether structured as subsidies to health care providers (public hospitals and uncompensated care reimbursement funds) or as direct insurance (Medicaid), on the purchase of private health insurance. The presence of a public hospital is associated with a lower likelihood of private insurance for those with incomes between 100-200% and 200-400% of the poverty level. Uncompensated care reimbursement funds were associated with less purchase of private health insurance and a higher likelihood of being uninsured across all income groups. More generous Medicaid programs showed both safety-net and crowd out effects.     

Parental employment and health insurance coverage among school-aged children with special health care needs

OBJECTIVES: This study examined parental employment and health insurance coverage among children with and without special health care needs. Special needs were defined as conditions likely to require a high amount of parental care, potentially affecting parental employment. METHODS: Data from the 1994 National Health Interview Survey were analyzed for 21,415 children aged 5 to 17 years, including 1604 children with special needs. Logistic regression was used to estimate the effect of special needs on the odds of full-time parental employment and on the odds of a child's being uninsured, having Medicaid, or having employer-sponsored insurance. RESULTS: Parents of children with special needs had less full-time employment. Their children had lower odds of having employer-sponsored insurance (adjusted odds ratio [OR] = 0.7) than other children. Children with special needs had greater odds of Medicaid coverage (adjusted OR = 2.3-5.1, depending on family income). Children with and without special needs were equally likely to be uninsured. CONCLUSIONS: Lower full-time employment among parents of children with special needs contributes to the children's being less likely to have employer-sponsored health insurance. Medicaid covers many children with special needs, but many others remain uninsured.     

Alcohol,drug abuse,and mental health care for uninsured and insured adults

OBJECTIVE: To compare adults with different insurance coverage in care for alcohol, drug abuse, and mental health (ADM) problems. DATA SOURCES/STUDY SETTING: From a national telephone survey of 9,585 respondents. DESIGN: Follow-up of adult participants in the Community Tracking Study. DATA COLLECTION: Self-report survey of insurance plan (Medicare, Medicaid, unmanaged, fully, or partially managed private, or uninsured), ADM need, use of ADM services and treatments, and satisfaction with care in the last 12 months. PRINCIPAL METHODS: Logistic and linear regressions were used to compare persons by insurance type in ADM use. PRINCIPAL FINDINGS: The likelihood of ADM care was highest under Medicaid and lowest for the uninsured and those under Medicare. Perceived unmet need was highest for the uninsured and lowest under Medicare. Persons in fully rather than partially managed private plans tend to be more likely to have ADM care and ADM treatments given need. Satisfaction with care was high in public plans and low for the uninsured. CONCLUSIONS: The uninsured have the most problems with access to and quality of ADM care, relative to the somewhat comparable Medicaid population. Persons in fully managed plans had better rather than worse access and quality compared to partially managed plans, but findings are exploratory. Despite low ADM use, those with Medicare tend to be satisfied. Across plans, unmet need for ADM care was high, suggesting changes are needed in policy and practice.     

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.     

Insurance or a regular physician: which is the most powerful predictor of health care?

OBJECTIVES: This study compared the relative effects on access to health care of relationship with a regular physician and insurance status. METHODS: The subjects were 1952 nonretired, non-Medicare patients aged 18 to 64 years who presented with 1 of 6 chief complaints to 5 academic hospital emergency departments in Boston and Cambridge, Mass, during a 1-month study period in 1995. Access to care was evaluated by 3 measures: delay in seeking care for the current complaint, no physician visit in the previous year, and no emergency department visit in the previous year. RESULTS: After clinical and socioeconomic characteristics were controlled, lacking a regular physician was a stronger, more consistent predictor than insurance status of delay in seeking care (odds ratio [OR] = 1.6, 95% confidence interval [CI] = 1.2, 2.1), no physician visit [OR] = 4.5%, 95% CI = 3.3, 6.1), and no emergency department visit (OR = 1.8, 95% CI = 1.4, 2.4). For patients with a regular physician, access was no different between the uninsured and the privately insured. For privately insured patients, those with no regular physician had worse access than those with a regular physician. CONCLUSIONS: Among patients presenting to emergency departments, relationship with a regular physician is a stronger predictor than insurance status of access to care.     

Covering the uninsured through TennCare: does it make a difference?

Tennessee created TennCare in 1994 to address the needs of "poor and uninsured citizens ... excluded from the health care system." Under TennCare, Tennessee implemented managed care in its Medicaid program and used savings anticipated from the switch to expand insurance coverage to uninsured and uninsurable adults and children. Our analysis of the expansion suggests that it improved access to care, reduced unmet need, and encouraged use of preventive services, particularly for children. These changes coincided with higher levels of satisfaction with care among TennCare beneficiaries.     

Pennsylvania's medically uninsured population: findings from a statewide survey

Pennsylvania is currently considering legislative options to expand coverage and improve access to medical care for state residents who lack health insurance. Relevant data are presented from a telephone survey of 10,809 Pennsylvania households. Almost nine percent (8.5%) of the state's population lacks health insurance, representing over one million people. Those most likely to be uninsured are children and young adults, non-whites and the poor. A substantial number of poor people are not covered by the state's Medicaid program. The uninsured report poorer health status, more obstacled to receiving care and greater use of hospital services for primary care.     

Healthcare Providers’ Satisfaction with a State Children’s Health Insurance Program (SCHIP)

Purpose This study’s purpose was to understand how experiences with and perceptions of the health care plan characteristics influence provider satisfaction with a State Children’s Health Insurance Program (SCHIP). Methods Physicians and other health care providers participating in one program (ALL Kids) were mailed a survey (n = 500). Pediatricians were the most likely to return the survey. We used frequencies, chi-square and logistic regression analysis to explore relationships. Results The odds of being less satisfied with the program among providers who perceived that reimbursement in the ALL Kids program was less compared to private insurance were almost 7 times (OR = 6.81; 95% CI = (1.88–24.73)) greater than for those who perceived that reimbursement was more or the same in ALL Kids. Likewise, respondents who perceived that All Kids families were less likely than families with private insurance to return for follow-up visits were less satisfied with ALL Kids (OR = 17.42; 95% CI = (1.85–164.70)). Conclusions The stigma of SCHIP may be less than that often associated with Medicaid; however, this investigation should be considered with others that have identified barriers for provider’s participation. This study indicates that provider satisfaction is related to their perceptions of SCHIP policies and families, though it does not tell us what factors might contribute to this perception, such as, previous experience with public insurance (Medicaid) and publicly insured patients. Increasing reimbursement rates may not address perceptions that affect provider views of publicly-supported health plans and the participating families.     

Variations in healthcare measures by insurance status for patients receiving ventilator support

OBJECTIVE: To examine differences in healthcare delivery by expected health insurance status for hospitalized patients in diagnosis-related group (DRG) 475, respiratory system diagnoses requiring intubation and continuous ventilator support. DESIGN: A survey, derived from the Healthcare Cost and Utilization Project interstate database, of the care delivered to 21,149 adult patients in DRG 475 and hospitalized in one of 718 acute-care hospitals in nine states. Multivariate analysis was performed, controlling for demographic and hospital factors. RESULTS: Patients insured by health maintenance organizations (HMOs) had significantly lower rates of inpatient mortality (odds ratio [OR], 0.84; 95% confidence interval [CI95], 0.73-0.96), 14.3 more procedures performed (CI95, 11.5-17.2), 7.0% shorter hospitalizations (CI95, 12.5-1.6), and 5.2% higher charges (CI95, 0.4-10.0) than those with traditional private insurance. In addition, patients insured by Medicaid had 3.5% more procedures performed (CI95, 1.6-5.4), 10.4% longer lengths of hospitalization (CI95, 6.7-14.0), and 13.8% higher charges (CI95, 10.6-17.0) than those with traditional private insurance. Finally, the uninsured had significantly lower rates of inpatient mortality (OR, 0.87; CI95, 0.77-0.99), 8.5% more procedures performed (CI95, 6.0-11.1), 16.5% shorter hospitalizations (CI95, 21.5-11.6), and 13.4% lower charges (CI95, 17.8-9.0) than those with traditional private insurance. CONCLUSION: Variations in healthcare measures by insurance status for this DRG emphasize the importance of more careful analyses of insurance categories as a determinant of healthcare access and outcomes. Expected insurance status was an independent predictor of cost. Private insurance and HMO populations differed significantly in outcome and cannot be considered equivalent.     

Children's Access to Dental Care in Connecticut's Medicaid Managed Care Program

Objective: To describe dental care utilization and access problems in Connecticut's Medicaid managed care program, using quantitative and qualitative research methods. Methods: Using Medicaid managed care enrollment and encounter data from Connecticut, utilization rates for preventive care and treatment services are determined for 87,181 children who were continuously enrolled in Medicaid managed care for 1 year in 1996–97. Sociodemographic and enrollment factors associated with utilization are identified using bivariate and multivariate methods. Dental providers and practices where children received services are described. Qualitative methods are used to characterize problems experienced by families seeking dental care during the study period. Results: Only 30.5% of children continuously enrolled in Medicaid managed care for 1 year received any preventive dental services; 17.8% received any treatment services. Children who received preventive care were eight times more likely to have received treatment services. Utilization was higher among (a) younger children, (b) children who lived in Hartford and in other counties served by public dental clinics, and (c) children enrolled in health plans that did not subcontract for administration of dental services. Just 5% of providers, primarily those in public dental clinics, performed 50% of the services. Families whose children needed care encountered significant administrative and logistical problems when trying to find willing providers and obtain appointments. Conclusions: Access to dental care is a problem for children in Connecticut's Medicaid managed care program. Several features of managed care have negatively affected access. Public dental clinics served many children across the state and contributed to higher utilization of preventive care and treatment services among children living in Hartford.     

The effect of a Medicaid managed care program on the adequacy of prenatal care utilization in Rhode Island

OBJECTIVES: The purpose of this study was to determine whether adequacy of prenatal care utilization improved after the implementation of a Medicaid managed care program in Rhode Island. METHODS: Rhode Island birth certificate data (1993-1995; n = 37021) were used to analyze pre- and post-program implementation changes in adequacy of prenatal care utilization. Logistic regression models were used to characterize the variation in prenatal care adequacy as a function of both time and the various covariates. RESULTS: Adequacy of prenatal care utilization for Medicaid patients improved significantly after implementation of the program, from 57.1% to 62.1% (odds ratio [OR] = 1.2, 95% confidence interval [CI] = 1.1, 1.3). After the program was implemented, Medicaid patients who went to private physicians' offices for prenatal care were 1.4 times as likely as before to receive adequate prenatal care (OR = 1.4, 95% CI = 1.2, 1.7). CONCLUSIONS: Unlike many other Medicaid expansions for pregnant women, the RIte Care program in Rhode Island has resulted in significant improvement in adequacy of prenatal care utilization for its enrollees. This improvement was due to specific program interventions that addressed and changed organizational and delivery system barriers to care.     

The role of community health centers in delivering primary care to the underserved: experiences of the uninsured and Medicaid insured

Community health centers (CHCs) have long served an important safety-net healthcare delivery role for vulnerable populations. Federal efforts to expand CHCs, while potentially reducing the Federal budget for Medicaid, raise concern about how Medicaid and uninsured patients of CHCs will continue to fare. To examine the primary care experiences of uninsured and Medicaid CHC patients and compare their experiences with those of similar patients nationally, cross-sectional analyses of the 2002 CHC User Survey with comparison data from the 1998 and 2002 National Health Interview surveys were done. Self-reported measures of primary care access, longitudinality, and comprehensiveness of care among adults aged 18 to 64 years were used. Despite poorer health, CHCs were positively associated with better primary care experiences in comparison with similar patients nationally. Uninsured CHC patients were more likely than similar patients nationally to report a generalist physician visit in the past year (82% vs 68%, P < .001), having a regular source of care (96% vs 60%, P < .001), receiving a mammogram in the past 2 years (69% vs 49%, P < .001), and receiving counseling on exercise (68% vs 48%, P < .001). Similar results were found for CHC Medicaid patients versus Medicaid patients nationally. Even within CHCs, however, Medicaid patients tended to report better primary care experiences than the uninsured. Health centers appear to fill an important gap in primary care for Medicaid and uninsured patients. Nonetheless, this study suggests that Medicaid insurance remains fundamental to accessing high-quality primary care, even within CHCs.