Medicaid Managed Care and Health Care Access for Adult Beneficiaries with Disabilities

Objective. To evaluate the impact of Medicaid managed care organizations (MCO) on health care access for adults with disabilities (AWDs).
Data Sources. Mandatory and voluntary enrollment data for AWDs in Medicaid MCOs in each county were merged with the Medical Expenditure Panel Survey and the Area Resource File for 1996–2004.
Study Design. I use logit regression and two evaluation perspectives to compare access and preventive care for AWDs in Medicaid MCOs with FFS. From the state's perspective, I compare AWDs in counties with mandatory, voluntary, and no MCOs. From the enrollee's perspective, I compare AWDs who must enroll in an MCO or FFS to those who may choose between them.
Principal Findings. Mandatory MCO enrollees are 24.9 percent more likely to wait >30 minutes to see a provider, 32 percent more likely to report a problem accessing a specialist, and 10 percent less likely to receive a flu shot within the past year. These differences persist from the state evaluation perspective.
Conclusions. States should not expect a dramatic change in health care access when they implement Medicaid MCOs to deliver care to the adult disabled population. However, continued attention to specialty care access is warranted for mandatory MCO enrollees.     

Managed care and preventable hospitalization among Medicaid adults

OBJECTIVE: The study examines the association between managed care enrollment and preventable hospitalization patterns of adult Medicaid enrollees hospitalized in four states. DATA SOURCES/STUDY SETTING: Hospital discharge data from the Healthcare Cost and Utilization Project (HCUP) database of the Agency for Healthcare Research and Quality (AHRQ) for New York (NY), Pennsylvania (PA), Wisconsin (WI), and Tennessee (TN) residents in the age group 20-64 hospitalized in those states, linked to the Area Resource File (ARF) and American Hospital Association (AHA) survey files for 1997. STUDY DESIGN: The study uses separate logistic models for each state comparing preventable admissions with marker admissions (urgent, insensitive to primary care). The model controls for socioeconomic and demographic variables, and severity of illness. PRINCIPAL FINDINGS: Consistently in different states, private health maintenance organization (HMO) enrollment was associated with fewer preventable admissions than marker admissions, compared to private fee-for-service (FFS). However, Medicaid managed care enrollment was not associated with a reduction in preventable admissions, compared to Medicaid FFS. CONCLUSIONS: Our analysis suggests that the preventable hospitalization pattern for private HMO enrollees differs significantly from that for commercial FFS enrollees. However, little difference is found between Medicaid HMO enrollees and Medicaid FFS patients. The findings did not vary by the level of Medicaid managed care penetration in the study states.     

Medicaid Primary Care Physician Fees and the Use of Preventive Services among Medicaid Enrollees

Objective

The Patient Protection and Affordable Care Act (ACA) increases Medicaid physician fees for preventive care up to Medicare rates for 2013 and 2014. The purpose of this paper was to model the relationship between Medicaid preventive care payment rates and the use of U.S. Preventive Services Task Force (USPSTF)–recommended preventive care use among Medicaid enrollees.

Data Sources/Study Session

We used data from the 2003 and 2008 Medical Expenditure Panel Survey (MEPS), a national probability sample of the U.S. civilian, noninstitutionalized population, linked to Kaiser state Medicaid benefits data, including the state Medicaid-to-Medicare physician fee ratio in 2003 and 2008.

Study Design

Probit models were used to estimate the probability that eligible individuals received one of five USPSF-recommended preventive services. A difference-in-difference model was used to separate out the effect of changes in the Medicaid payment rate and other factors.

Data Collection/Extraction Methods

Data were linked using state identifiers.

Principal Findings

Although Medicaid enrollees had a lower rate of use of the five preventive services in univariate analysis, neither Medicaid enrollment nor changes in Medicaid payment rates had statistically significant effects on meeting screening recommendations for the five screenings. The results were robust to a number of different sensitivity tests. Individual and state characteristics were significant.

Conclusions

Our results suggest that although temporary changes in primary care provider payments for preventive services for Medicaid enrollees may have other desirable effects, they are unlikely to substantially increase the use of these selected USPSTF-recommended preventive care services among Medicaid enrollees.     

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.     

The Association between Long-Term Care Setting and Potentially Preventable Hospitalizations among Older Dual Eligibles

ObjectiveTo compare the probability of experiencing a potentially preventable hospitalization (PPH) between older dual eligible Medicaid home and community-based service (HCBS) users and nursing home residents.ConclusionsHCBS users’ increased probability for potentially and non-PPHs suggests a need for more proactive integration of medical and long-term care.     

Meeting the Need for Personal Care among the Elderly: Does Medicaid Home Care Spending Matter?

Objective. To determine whether Medicaid home care spending reduces the proportion of the disabled elderly population who do not get help with personal care.
Data Sources. Data on Medicaid home care spending per poor elderly person in each state is merged with data from the Medicare Current Beneficiary Survey for 1992, 1996, and 2000. The sample ( n =6,067) includes elderly persons living in the community who have at least one limitation in activities of daily living (ADLs).
Study Design. Using a repeated cross-section analysis, the probability of not getting help with an ADL is estimated as a function of Medicaid home care spending, individual income, interactions between income and spending, and a set of individual characteristics. Because Medicaid home care spending is targeted at the low-income population, it is not expected to affect the population with higher incomes. We exploit this difference by using higher-income groups as comparison groups to assess whether unobserved state characteristics bias the estimates.
Principal Findings. Among the low-income disabled elderly, the probability of not receiving help with an ADL limitation is about 10 percentage points lower in states in the top quartile of per capita Medicaid home care spending than in other states. No such association is observed in higher-income groups. These results are robust to a set of sensitivity analyses of the methods.
Conclusion. These findings should reassure state and federal policymakers considering expanding Medicaid home care programs that they do deliver services to low-income people with long-term care needs and reduce the percent of those who are not getting help.     

Variability in Asthma Care and Services for Low-Income Populations among Practice Sites in Managed Medicaid Systems

Objective. To characterize and describe variability in processes of asthma care and services tailored for low–income populations in practice sites participating in Medicaid managed care (MMC).
Study Setting. Eighty-five practice sites affiliated with five not-for-profit organizations participating in managed Medicaid (three group-model health maintenance organizations [HMOs] and two Medicaid managed care organizations [MCOs]).
Study Design/Data Collection. We conducted a mail survey of managed care practice site informants using a conceptual model that included chronic illness care and services targeting low-income populations. The survey asked how frequently a number of processes related to asthma care occurred at the practice sites (on a scale from "never" to "always"). We report mean and standard deviations of item scores and rankings relative to other items. We used within-MCO intraclass correlations to assess how consistent responses were among practice sites in the same MCO.
Principal Findings. Processes of care related to asthma varied greatly in how often practice sites reported doing them, with information systems and self-management support services ranking lowest. There was also significant variation in the availability of services targeting low-income populations, specifically relating to cultural diversity, communication, and enrollee empowerment. Very little of the site-to-site variation was attributable to the MCO.
Conclusions. Our conceptual framework provides a means of assessing the provision of chronic illness care for vulnerable populations. There is room for improvement in provision of chronic asthma care for children in managed Medicaid, particularly in the areas of self-management support and information systems. The lack of consistency within MCOs on many processes of care suggests that care may be driven more at the practice site level than the MCO level, which has implications for quality improvement efforts.     

The relationship between formal and informal care among adult Medicaid Personal Care Services recipients

Objectives

To test hypotheses concerning the relationship between formal and informal care and to estimate the impact of hours of formal care authorized for Medicaid Personal Care Services (PCS) on the utilization of informal care.

Data Sources/Study Setting

Data included home care use and adult Medicaid beneficiary characteristics from assessments of PCS need in four Medicaid administrative areas in Texas.

Study Design

Cross-sectional design using ordinary least-squares (OLS) and instrumental variable (IV) methods.

Data Collection/Extraction Methods

The study database consisted of assessment data on 471 adults receiving Medicaid PCS from 2004 to 2006.

Principal Findings

Both OLS and IV estimates of the impact of formal care on informal care indicated no statistically significant relationship. The impact of formal care authorized on informal care utilization was less important than the influence of beneficiary need and caregiver availability. Living with a potential informal caregiver dramatically increased the hours of informal care utilized by Medicaid PCS beneficiaries.

Conclusions

More formal home care hours were not associated with fewer informal home care hours. These results imply that policies that decrease the availability of formal home care for Medicaid PCS beneficiaries will not be offset by an increase in the provision of informal care and may result in unmet care needs.     

Does Ambulatory Process of Care Predict Health-Related Quality of Life Outcomes for Patients with Chronic Disease?

Objective. The validity of quality of care measurement has important implications for practicing clinicians, their patients, and all involved with health care delivery. We used empirical data from managed care patients enrolled in west coast physician organizations to test the hypothesis that observed changes in health-related quality of life across a 2.5-year window reflecting process of care.
Data Sources/Study Setting. Patient self-report data as well as clinically detailed medical record review regarding 963 patients with chronic disease associated with managed care from three west coast states.
Study Design. Prospective cohort study of change in health-related quality of life scores across 30 months as measured by change in SF-12 physical component scores.
Data Collection/Extraction Methods. Patient self-report and medical record abstraction.
Principal Findings. We found a positive relationship between better process scores and higher burden of illness ( p <.05). After adjustment for burden of illness, using an instrumental variables approach revealed better process is associated with smaller declines in SF-12 scores across a 30-month observation window ( p =.014). The application of the best quartile of process of care to patients currently receiving poor process is associated with a 4.24 increment in δ SF-12-physical component summary scores.
Conclusions. The use of instrumental variables allowed us to demonstrate a significant relationship between better ambulatory process of care and better health-related quality of life. This finding underscores the importance of efforts to improve the process of care.     

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.     

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.