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.     

Where the action really is: Medicaid and the disabled

Discussions of Medicaid tend to focus on low-income children and their mothers and the institutionalized elderly as the principal beneficiaries, but Medicaid spends more on the nonelderly disabled than on any other group. In the past two decades Medicaid has helped finance the deinstitutionalization of the mentally retarded and a growing proportion of the mentally ill, but implementation of the Olmstead decision has deflected advocates' attention from the more important issue of how managed care plans treat disabled Medicaid beneficiaries.     

Impact of Medicare managed care market withdrawal on beneficiaries

The 2001 Survey of Involuntary Disenrollees was conducted to investigate the impact of Medicare+Choice (M+C) plan withdrawals on Medicare beneficiaries. Eighty-four percent of a total of 4,732 beneficiaries whose Medicare managed care (MMC) plan stopped serving them at the end of 2000 responded to the survey. Their responses indicated that the withdrawal of plans from Medicare affected beneficiaries in terms of concerns about getting and paying for care, increased payments for premiums and out-of-pocket costs, and changes in health care arrangements. Of particular concern were the impacts on those in vulnerable subgroups such as the disabled, less educated, and minorities.     

Estimating Medicare advantage lock-in provisions impact on vulnerable Medicare beneficiaries

Beginning January 2006, Medicare beneficiaries will have limited ability to change health plans. We examine the Medicare managed care enrollment and disenrollment behavior of traditionally vulnerable beneficiaries from 1999-2001 to estimate the potential impact of the new enrollment restrictions. Findings that several such groups were more likely to make multiple health plan elections, leave their managed care plan midyear, and/or have higher voluntary disenrollment rates and transfers to original fee-for-service (FFS) Medicare suggest that the lock-in provisions may have greater negative impacts on vulnerable beneficiaries. This article identifies several recommendations that CMS might consider to lessen the detrimental effects on at-risk groups.     

Disabled Medicare beneficiaries by dual eligible status: California, 1996-2001

This highlight describes the characteristics and inpatient utilization of under age 65 disabled California Medicare beneficiaries by dual eligible status (i.e., Medicaid State buy-in coverage or not). More disabled dually eligible beneficiaries are younger, non-White, and in fee-for-service (FFS) than non-dually eligible beneficiaries. Disabled dually eligible beneficiaries experienced consistently higher hospitalization rates and average length of stay (LOS) than nondually eligible beneficiaries from 1996 to 2001. Inpatient days remain higher among dually eligible beneficiaries when stratified by the system of care, age, sex, or race. In addition, the hospitalization rate of disabled dually eligible beneficiaries was higher for most diagnoses, but how much higher varied by condition.     

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.     

The impact of Medicaid managed care on hospitalizations for ambulatory care sensitive conditions

OBJECTIVE: To determine whether Medicaid managed care is associated with lower hospitalization rates for ambulatory care sensitive conditions than Medicaid fee-for-service. We also explored whether there was a differential effect of Medicaid managed care by patient's race or ethnicity on the hospitalization rates for ambulatory care sensitive conditions. DATA SOURCES/STUDY SETTING: Electronic hospital discharge abstracts for all California temporary assistance to needy families (TANF)-eligible Medicaid beneficiaries less than age 65 who were admitted to acute care hospitals in California between 1994 and 1999. STUDY DESIGN: We performed a cross-sectional comparison of average monthly rates of admission for ambulatory care-sensitive conditions among TANF-eligible Medicaid beneficiaries in fee-for-service, voluntary managed care, and mandatory managed care. DATA COLLECTION/EXTRACTION METHODS: We calculated monthly rates of ambulatory care-sensitive condition admission rates by counting admissions for specified conditions in hospital discharge files and dividing the monthly count of admissions by the size of the at-risk population derived from a separate monthly Medicaid eligibility file. We used multivariate Poisson regression to model monthly hospital admission rates for ambulatory care-sensitive conditions as a function of the Medicaid delivery model controlling for admission month, admission year, patient age, sex, race/ethnicity, and county of residence. PRINCIPAL FINDINGS: The adjusted average monthly hospitalization rate for ambulatory care-sensitive conditions per 10,000 was 9.36 in fee-for-service, 6.40 in mandatory managed care, and 5.25 in voluntary managed care (p<.0001 for all pairwise comparisons). The difference in hospitalization rates for ambulatory care sensitive conditions in Medicaid fee-for-service versus managed care was significantly larger for patients from minority groups than for whites. CONCLUSIONS: Selection bias in voluntary Medicaid managed care programs exaggerates the differences between managed care and fee-for-service, but the 33 percent lower rate of hospitalizations for ambulatory care sensitive conditions found in mandatory managed care compared with fee-for-service suggests that Medicaid managed care is associated with a large reduction in hospital utilization, which likely reflects health benefits. The greater effect of Medicaid managed care for minority compared with white beneficiaries is consistent with other findings that suggest that managed care is associated with improvements in access to ambulatory care for those patients who have traditionally faced the greatest barriers to health care.     

Access and satisfaction within the disabled Medicare population

Little is known about variations in the levels of access and satisfaction within the disabled Medicare population. Based on the Medicare Current Beneficiary Survey (MCBS), beneficiaries under 65 years of age were classified by original reason for disability (mental versus physical). Those with a mental disability were less likely to have a private physician as a usual source; were less satisfied with the overall quality of care, availability of after-hours care, followup care, and coordination of care; and were more likely to report unmet need, owing in large part to supply barriers. Implications for the current delivery system and for design of managed care programs are discussed.     

A Randomized Controlled Trial of Intensive Care Management for Disabled Medicaid Beneficiaries with High Health Care Costs

ObjectiveTo evaluate outcomes of a registered nurse–led care management intervention for disabled Medicaid beneficiaries with high health care costs.ConclusionsWe found no health care cost savings for disabled Medicaid beneficiaries randomized to intensive care management. Among participants, care management may have the potential to increase access to needed care, slow growth in the number and therefore cost of unplanned hospitalizations, and prevent homelessness. These findings apply to start-up care management programs targeted at high-cost, high-risk Medicaid populations.     

Medicaid confronts a changing managed care marketplace

After two decades of concerted efforts, more than one-half of all Medicaid beneficiaries are now enrolled in managed care arrangements. Most States appear strongly committed to continued reliance on managed care, but the contemporary managed care marketplace is undergoing a number of significant changes. We describe how several of these developments are being revealed in commercial managed care and discuss implications for Medicaid purchasers and beneficiaries. State Medicaid agencies will have to adapt managed care strategies to respond to the evolving products and practices of managed care plans and their interest in public sector product lines.     

Favorable selection in the Medicare+Choice program: new evidence

Historically, studying the Medicare managed care favorable-selection issue has been difficult because direct data on managed care enrollees have been unavailable. In this study, we analyzed the first year of Balanced Budget Act (BBA)-mandated inpatient encounter data. Based on this comparison of actual managed care and fee-for-service (FFS) beneficiaries, it appears that there are significant differences between these populations. The most striking differences are found in the comparison of average risk factors, indicating a clear bias in the managed care populations toward beneficiaries predicted to be less costly.     

Access to care and satisfaction with care among fee-for-service Medicare beneficiaries by level of care need

BackgroundVariation among fee-for-service (FFS) Medicare beneficiaries by level of care need for access to care and satisfaction with care is unknown.ObjectiveWe examined access to care and satisfaction with care among FFS Medicare beneficiaries by level of care need.MethodsWe employed a cross-sectional study design. Using the Medicare Current Beneficiary Survey, we categorized 17,967 FFS Medicare beneficiaries into six groups based on level of care need: the relatively healthy (11.0%), those with simple chronic conditions (26.1%), those with minor complex chronic conditions (28.6%), those with major complex chronic conditions (14.2%), the frail (6.2%), and the non-elderly disabled or end-stage renal disease (ESRD) (13.9%). Outcome measures included multiple indicators for access to care and satisfaction with care. For each outcome, we conducted a linear probability model while adjusting for individual-level and county-level characteristics and estimated the adjusted value of the outcome by level of care need.ResultsThe non-elderly disabled or ESRD were more likely to experience limited access to care and poor satisfaction with care than other five care need groups. Particularly, the rates of reporting trouble accessing needed medical care were the highest among the non-elderly disabled or ESRD (12.4% [95% CI: 9.6–15.3] vs. 2.1 [95% CI: 1.5–2.8] to 2.5 [95% CI: 1.6–3.5]). The leading reason for trouble accessing needed care among the non-elderly disabled or ESRD was attributable to affordability (59.6%).ConclusionsPolicymakers need to develop targeted approaches to improve access to care and satisfaction with care for the non-elderly with a disability or ESRD.     

The evolution of quality management in Medicaid managed care

Since the early 1990s almost all states have moved some or all of their Medicaid beneficiaries to Medicaid managed care (MMC). Critics have worried about quality since MMC's inception. Proponents argued that state Medicaid agencies, as large-scale purchasers of care, would pursue "value-based purchasing" and other strategies to stimulate quality improvements. In this paper we extend and update previous evaluations of the use of managed care for the Medicaid population, the extent to which beneficiaries receive care from Medicaid only and from commercial health plans, and the quality management programs that state Medicaid agencies supported during 2001.     

What does voluntary disenrollment from Medicare+Choice plans mean to beneficiaries?

The Balanced Budget Act (BBA) of 1997 required CMS to report publicly Medicare managed care (MMC) plan voluntary disenrollment rates. To ensure disenrollment rates would be meaningful to beneficiaries in health plan choice, CMS funded the development of surveys and reporting formats to identify and present the reasons that beneficiaries voluntarily leave plans. Public reporting of reasons on the Medicare Web site began in 2002. We discuss results from extensive audience testing of disenrollment rates and reasons materials. Medicare beneficiaries do not easily understand disenrollment. We also discuss challenges in presenting useful disenrollment information and policy implications for public reporting.     

There is little experience and limited data to support policy making on integrated care for dual eligibles

Coordinating care for the nine million elderly or disabled and low-income people who are dually eligible for Medicare and Medicaid is a pressing policy issue. To support the debate over this issue, we synthesized public data on how services are provided to dual eligibles receiving covered benefits in both programs. Our analysis confirmed that most dual-eligible beneficiaries receive benefits separately for each program through fee-for-service arrangements. Their enrollment in Medicare and Medicaid managed care is growing but still low, with highly uneven experiences across states. Few states or health plans have experience with coordinating care for dual eligibles within an integrated plan. These findings reinforce the need for caution in considering policies that would rapidly give states the responsibility for coordinating dual eligibles' care and coverage. We also found data gaps that warrant prompt attention in order to provide national-level oversight and improve the evidence base for debating and tracking policy changes.     

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.     

Racial and ethnic differences in receipt of primary care services between medicaid fee-for-service and managed care plans

We used a cross-sectional, population-based sample of Medicaid beneficiaries aged 18-64 to determine whether managed care enrollment was associated with reduced racial/ethnic disparities in self-reported access to primary care services compared with fee-for-service. Managed care beneficiaries reported greater access in each racial/ethnic category and for each outcome than did fee-for-service beneficiaries, although associations were not always statistically significant. Racial/ethnic minorities enrolled in managed care plans reported as much benefit from managed care enrollment as did whites. Within Medicaid, interventions aimed at the health insurance delivery model can facilitate increased access to primary care services without enhancing racial/ethnic disparities.     

Unhealthy Competition: Consequences of Health Plan Choice in California Medicaid

Objectives. We compared the quality of care received by managed care Medicaid beneficiaries in counties with a choice of health plans and counties with no choice.Methods. This cross-sectional study among California Medicaid beneficiaries was conducted during 2002. We used a multivariate Poisson model to calculate adjusted rates of hospital admissions for ambulatory care–sensitive conditions by duration of plan enrollment.Results. Among beneficiaries with continuous Medicaid coverage, the percentage with 12 months of continuous enrollment in a health plan was significantly lower in counties with a choice of plans than in counties with no choice (79.2% vs 95.2%; P < .001). Annual ambulatory care–sensitive admission rates adjusted for age, gender, and race/ethnicity were significantly higher among beneficiaries living in counties with a choice of plans (6.58 admissions per 1000 beneficiaries; 95% confidence interval [CI] = 6.57, 6.58) than among those in counties with no choice (6.27 per 1000; 95% CI = 6.27, 6.28).Conclusions. Potential benefits of health plan choice may be undermined by transaction costs of delayed enrollment, which may increase the probability of hospitalization for ambulatory care–sensitive conditions.Extending consumer choice in health care is an important policy objective in a growing number of countries, reflecting recent developments in the United Kingdom¹ and the Netherlands.² This trend is occurring because choice and associated market-like competition are seen by many as an essential component of strategies to improve quality and efficiency and to increase the responsiveness of health care systems.^3,4Choice and competition are highly embedded features of the financing and delivery of health care in the United States. Many consumers of US health care are afforded a choice of health plans, medical groups, and providers as well as the ability to directly access specialist care and seek a second opinion. During the Clinton era,⁵ the concepts of competition and choice became synonymous with, rather than simply enablers of, efficient, high-quality health care. However, concern is increasing among health care analysts that the potential benefits of competition and choice are not being realized in practice.⁶ Furthermore, popular concerns about loss of choice have undermined key efforts to reform the US health care system. For example, arguments from those who opposed the expansion of managed care in the 1990s were often framed around how managed delivery systems would restrict choice of doctors and access to care.⁷ Similarly, opponents of recent proposals for a government-run, public plan option argued that the public option would limit, rather than expand, health plan choice by undermining the viability of commercial plans.⁸The availability of choice is not uniform across the US health care system, and the poor and uninsured frequently have either no choice or limited choices. For example, Medicaid beneficiaries typically have fewer providers to choose from than do patients with commercial insurance because of low participation rates by physicians in the Medicaid program.^9,10 Although approximately 60% of Medicaid beneficiaries nationwide are in managed care, the extent to which beneficiaries are able to choose a health plan varies considerably both between and within states.^11,12In California, managed care is mandatory for Temporary Assistance for Needy Families (TANF) Medicaid beneficiaries in 21 counties where approximately 90% of the state''s beneficiaries reside. This group of California Medicaid beneficiaries consists mainly of children (67% are aged 18 years or younger) and younger women (66% of adult beneficiaries are women younger than 50 years). Although California beneficiaries do not have a choice about being in managed care, they may have a choice of health plans, depending on the county in which they reside. California has 3 county models of mandatory managed care: (1) County Organized Health Systems (COHS), with a single, nonprofit, county-run health plan (8 counties); (2) Two Plan counties, in which a nonprofit, county-run plan competes with a commercial plan (11 counties); and (3) Geographic Managed Care, in which multiple commercial plans compete (2 counties). In counties in which TANF beneficiaries have a choice of health plans, the beneficiaries have up to 45 days after gaining Medicaid eligibility to choose a plan. Furthermore, beneficiaries can change plans at any time while they are enrolled in California Medicaid. The difference between counties in the availability of health plan choice provides a natural experiment in which to compare differences in the quality of care delivered to the target population. In the present study, we examined the hypothesis that Medicaid beneficiaries living in counties that offer a choice of health plans receive a higher quality of care and have better health outcomes than do beneficiaries living in counties with a single health plan.