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.     

Effects of Medicaid managed care programs on health services access and use

OBJECTIVE: To estimate the effects of Medicaid managed care (MMC) programs on Medicaid enrollees' access to and use of health care services at the national level. DATA SOURCES/STUDY SETTING: 1991-1995 National Health Interview Surveys (NHIS) and a 1998 Urban Institute survey on state Medicaid managed care programs. STUDY DESIGN: Using multivariate regression models, we estimated the effect of living in a county with an MMC program on several access and use measures for nonelderly women who receive Medicaid through AFDC and child Medicaid recipients. We focus on mandatory programs and estimate separate effects for primary care case management (PCCM) programs, health maintenance organization (HMO) programs, and mixed PCCM/HMO programs, relative to fee-for-service (FFS) Medicaid. We control for individual and county characteristics, and state and year effects. DATA COLLECTION/EXTRACTION METHOD: This study uses pooled individual-level data from up to five years of the NHIS (1991-1995), linked to information on Medicaid managed care characteristics at the county level from the 1998 MMC survey. PRINCIPAL FINDINGS: We find virtually no effects of mandatory PCCM programs. For women, mandatory HMO programs reduce some types of non-emergency room (ER) use, and increase reported unmet need for medical care. The PCCM/HMO programs increase access, but had no effects on use. For children, mandatory HMO programs reduce ER visits, and increase the use of specialists. The PCCM/HMO programs reduce ER visits, while increasing other types of use and access. CONCLUSIONS: Mandatory PCCM/HMO programs improved access and utilization relative to traditional FFS Medicaid, primarily for children. Mandatory HMO programs caused some access problems for women.     

Safety-net institutions buffer the impact of Medicaid managed care: a multi-method assessment in a rural state

OBJECTIVES: This project used a long-term, multi-method approach to study the impact of Medicaid managed care. METHODS: Survey techniques measured impacts on individuals, and ethnographic methods assessed effects on safety-net providers in New Mexico. RESULTS: After the first year of Medicaid managed care, uninsured adults reported less access and use (odds ratio [OR] = 0.46; 95% confidence interval [CI] = 0.34, 0.64) and worse barriers to care (OR = 6.60; 95% CI = 3.95, 11.54) than adults in other insurance categories. Medicaid children experienced greater access and use (OR = 2.11; 95% CI = 1.21, 3.72) and greater communication and satisfaction (OR = 3.64; 95% CI = 1.13, 12.54) than children in other insurance categories; uninsured children encountered greater barriers to care (OR = 6.29; 95% CI = 1.58, 42.21). There were no consistent changes in the major outcome variables over the period of transition to Medicaid managed care. Safety-net institutions experienced marked increases in workload and financial stress, especially in rural areas. Availability of mental health services declined sharply. Providers worked to buffer the impact of Medicaid managed care for patients. CONCLUSIONS: In its first year, Medicaid managed care exerted major effects on safety-net providers but relatively few measurable effects on individuals. This reform did not address the problems of the uninsured.     

Medicaid Managed Care and Health Care for Children

Objective. Many states expanded their Medicaid managed care programs during the 1990s, causing concern about impacts on health care for affected populations. We investigate the relationship between Medicaid managed care enrollment and health care for children.
Data Sources and Measures. Repeated cross-sections of Medicaid-covered children under 18 years of age from the 1996/1997 and 1998/1999 Community Tracking Study Household Surveys ( n =2,602) matched to state-year CMS Medicaid managed care enrollment data. For each individual, we constructed measures of health care utilization (provider and emergency department visits, hospitalizations, surgeries); health care access (usual source of care, unmet medical needs, put-off needed care); and satisfaction (satisfaction overall, with doctor choice, and with last visit).
Study Design. Regression analysis of the relationship between within-state changes in Medicaid managed care enrollment rates and changes in mean utilization, access, and satisfaction measures for children covered by Medicaid, controlling for a range of potentially confounding factors.
Principal Findings. Increases in Medicaid health maintenance organization (HMO) enrollment are associated with less emergency room use, more outpatient visits, fewer hospitalizations, higher rates of reporting having put off care, and lower satisfaction with the most recent visit. Medicaid primary care case management (PCCM) plans are associated with increases in outpatient visits, but also with higher rates of reporting unmet medical needs, putting off care, and having no usual source of care.
Conclusions. Both Medicaid HMO and PCCM plans can have important impacts on health care utilization, access, and satisfaction. Some impacts may be positive (e.g., less ED use and more outpatient provider use), although concern about increasing challenges in access to care and satisfaction is also warranted.     

Quality oversight in medicaid primary care case management programs

As health maintenance organizations (HMOs) have curtailed participation in Medicaid, enrollment in primary care case management (PCCM) programs has grown. To examine state Medicaid agencies' monitoring of PCCM and HMO programs, we surveyed Medicaid agency directors of forty-six states and the District of Columbia. Agencies were less likely to collect performance data in PCCM programs than in HMO programs. Few PCCM programs reported performance results for the public or providers. Reporting states tended to emphasize utilization results over quality-measure results. Despite growing enrollment, PCCM programs appear less likely to use the quality-oversight strategies employed by Medicaid health plans.     

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.     

Effective Contraception Use by Usual Source of Care: An Opportunity for Prevention

Introduction

Women using emergency departments (ED) or urgent care facilities for their usual care may lack access to contraception. This study examined the relationship between effectiveness of current contraception use (highly effective/effective methods vs. less effective/no method) and usual source of care in the clinic (referent group), urgent care, ED, or none among U.S. reproductive-aged females at risk for unintended pregnancy.

Assessing Medicaid recipient access and satisfaction. Fee-for-service, case management, and capitation

Medicaid increasingly requires enrollment in managed care programs. This study assessed access to care, satisfaction with care, and appointment wait times during the transition from fee for service to managed care using three annual Medicaid recipient surveys. There was little evidence of dissatisfaction or poorer access among managed care recipients. Fee-for-service recipients, compared to primary care case management, reported greater general (91 vs. 78%, p < .01) and specialty care access (92 vs. 80%, p < .01). When appointments were required, adult HMO enrollees, compared to case management, had longer waits for routine care in the second (5.8 +/- 8.2 days vs. 4.0 +/- 6.6) and third surveys (5.5 +/- 6.9 days vs. 3.8 +/- 7.3); waits for other appointments did not consistently differ by program. There were no significant program differences in overall satisfaction. Findings are tempered by the potential for response bias and geographic confounding. Continued monitoring is crucial to assure that access and satisfaction remain high in Medicaid managed 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.     

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.     

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.     

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.     

Outsourcing administrative functions: service organization demonstrations and Florida Medicaid PCCM program costs

This study examines the cost implications of outsourcing Medicaid functions to the private sector. We examine the expenditures for enrollees in three Medicaid primary care case management (PCCM) demonstration projects compared to Florida's PCCM program from February 2002-February 2003. The RAND two-part model was used to analyze the medica expenditures for enrollees in each program. After adjusting for sociodemographic factors and the probability of service use, we found that all three demonstration projects reduced expenditures compared to the PCCM program. The implications from the study are that Medicaid programs may want to consider outsourcing PCCM functions after further studies examine the utilization experience for enrollees in these programs.     

Help-seeking for insomnia among adult patients in primary care

OBJECTIVE: To clarify the patient characteristics associated with seeking medical help for insomnia. METHODS: A consecutive sample (n = 700) of adults attending a non-urgent primary care appointment was screened for sleep problems. A follow-up mailed survey then assessed insomnia symptoms, daytime impairment, beliefs about sleep, medication use, sleepiness and fatigue, and medical help-seeking. RESULTS: Fifty-two percent of patients with probable insomnia reported discussing this with a physician. Multivariate logistic regression analyses indicated that discussing one's probable insomnia with a physician was independently associated with having a greater number of medical conditions (OR, 2.19 [95% CI, 1.13 to 4.22]), being more highly educated (1.67 [95% CI, 1.11 to 2.51]), sleeping less per night (OR, 0.71 [95% CI, 0.52 to 0.96]), and greater perceived daytime impairment due to insomnia (OR, 2.07 [95% CI, 1.06 to 4.03]). CONCLUSIONS: Primary care patients often seek medical help when they experience insomnia. Clinical treatment ought to especially target poor sleepers presenting with significant insomnia-related impairment, medical morbidity, or both. Future research should further clarify the role of medical and psychiatric comorbidities and determine whether resolution of insomnia and its consequences improves the outcomes of common medical conditions.     

Medicaid beneficiaries' experiences in HMO and fee-for-service health care

How do HMO-enrolled Medicaid beneficiaries' ratings of access to, and satisfaction with, their health care compare with the ratings of those beneficiaries receiving care in fee-for-service settings? Do poor single mothers report differences in access to, and satisfaction with, their HMO health care compared with those living in other family structures? These questions were examined with survey data from 961 California Medicaid recipients in 1991. Medicaid recipients enrolled in HMOs reported more difficulty gaining access to, and less satisfaction with, various aspects of the health care system. HMO-enrolled single mothers reported particularly negative experiences with their health care. The findings suggest a potential lack of fit between the health needs of the poor and the aims of managed health care.