The health care experiences of rural Medicaid beneficiaries

Medicaid plays a vital role in rural America, yet, because of data limitations, little research exists on the health care experiences of low-income rural adults. We use data from the National Survey of America's Families, with its oversample of low-income populations, to examine differences in access to and use of care between urban and rural Medicaid beneficiaries, and between Medicaid beneficiaries and low-income privately insured adults in urban and rural areas. We find evidence that access to care under Medicaid is worse than under private insurance in both urban and rural areas; however, Medicaid beneficiaries have a more consistent level of access across urban and rural areas than do low-income privately insured people.     

Risk adjustment for health plans disproportionately enrolling frail Medicare beneficiaries

There is concern about the adequacy of diagnosis-based risk adjusters for paying health plans that disproportionately enroll frail Medicare beneficiaries. The Medicare Current Beneficiary Survey (MCBS) was used to examine the ability of two risk-adjustment models to predict Medicare costs for groups defined by institutional status and difficulty with activities of daily living (ADLs). Both models underpredicted average costs for non-institutionalized frail beneficiaries; however, the models slightly overpredicted expenses for most frail individuals and severely underpredicted for a minority. Further refinements are needed if diagnosis-based models are used to pay plans that disproportionately enroll frail beneficiaries.     

Overcoming problems with dental care for Medicaid beneficiaries

Lack of access to dental care means more than dirty teeth to many vulnerable consumers. It also is related to pain, poor nutrition, and the inability to accomplish tasks of daily living. This issue of States of Health examines the nature of the problem and the variety of ways advocates are addressing it.     

Evaluating government health and substance abuse programs for indigenous peoples: a comparative review

Most health and substance abuse programs for indigenous peoples in Australia are funded by government. Over the past decade there have been calls for greater accountability in the conduct of these programs. Initial attempts focused on the development of standardised performance indicators, an approach that has been criticised on both political and methodological grounds. Recently, some government agencies have sought to identify culturally appropriate models for the evaluation of programs for indigenous peoples. In a comparative review of the evaluation of indigenous programs in Australia and Canada, conducted for the Western Australian Aboriginal Affairs Department, the authors were not able to identify any generally applicable models. However, this literature review and our own research and experience in working with Aboriginal community organisations have identified some principles that should be an essential part of any attempts to evaluate health and substance abuse programs for indigenous peoples. Underlying these principles is the realisation that evaluation is not a politically or ideologically neutral activity. Theoretical and mediodological considerations of the evaluation process must take into account the very real differences between the agendas of indigenous peoples and those who seek to evaluate programs for them.     

Access of rural AFDC Medicaid beneficiaries to mental health services

This article examines geographic differences in the use of mental health services among Aid to Families with Dependent Children (AFDC)-eligible Medicaid beneficiaries in Maine. Findings indicate that rural AFDC beneficiaries have significantly lower utilization of mental health services than urban beneficiaries. Specialty mental health providers account for the majority of ambulatory visits for both rural and urban beneficiaries. However, rural beneficiaries rely more on primary-care providers than do urban beneficiaries. Differences in use are largely explained by variations in the supply of specialty mental health providers. This finding supports the long-held assumption that lower supply is a barrier to access to mental health services in rural areas.     

For-profit and not-for-profit health plans participating in Medicaid

The proliferation of for-profit health plans has heightened concerns about quality of care, particularly with respect to Medicaid. We undertook this study to compare for-profit and not-for-profit health plans that participate in Medicaid, examining processes of care and the organizational characteristics related to utilization management, financial incentives, and quality of care. Our findings demonstrate that for-profit and not-for-profit plans appear to be more similar than dissimilar in many areas of management, although for-profit plans are more likely to use aggressive utilization review and have slightly less developed quality management systems. On balance, these findings should reassure critics of for-profit health care.     

Public reporting of quality information on Medicaid health plans

Transparency through public reporting of quality data is key to achieving the Institute of Medicine's (IOM) vision for 21st century health care. This article reviews the status of States' voluntary public reporting of Medicaid managed care (MMC) quality data, and analyzes these data. Twenty-one States, including 17 of the 20 largest managed care States, have made plan-level data publicly available online, although the data are sometimes thin, with few measures reported, hard-to-access, and old. We conclude that CMS could better leverage the power of public reporting for quality improvement (QI) by increasing the visibility of health plan employer data and information set (HEDISV) data that States already collect.     

Impact of the 1115 behavioral health Medicaid waiver on adult Medicaid beneficiaries in New York State

ObjectiveTo evaluate the impact of the Health and Recovery Plan (HARP), a capitated special needs Medicaid managed care product that fully integrates physical and behavioral health delivery systems in New York State.Data Sources2013‐2019 claims and encounters data on continuously enrolled individuals from the New York State Medicaid data system.Study DesignWe used a difference‐in‐difference approach with inverse probability of exposure weights to compare service use outcomes in individuals enrolled in the HARP versus HARP eligible comparison group in two regions, New York City (NYC) pre‐ (2013‐2015) versus post‐ (2016‐2018) intervention periods, and rest of the state (ROS) pre‐ (2014‐2016) versus post‐ (2017‐2019) intervention periods.Data Collection/Extraction MethodsNot applicable.Principal FindingsHARPs were associated with a relative decrease in all‐cause (RR = 0.78, 95% CI 0.68‐0.90), behavioral health‐related (RR = 0.76, 95% CI 0.60‐0.96), and nonbehavioral‐related (RR = 0.87, 95% CI 0.78‐0.97) stays in the NYC region. In the ROS region, HARPs were associated with a relative decrease in all‐cause (RR = 0.87, 95% CI 0.80‐0.94) and behavioral health‐related (RR = 0.80, 95% CI 0.70‐0.91) stays. Regarding outpatient visits, the HARPs benefit package were associated with a relative increase in behavioral health (RR = 1.21, 95% CI 1.13‐1.28) and nonbehavioral health (RR = 1.08, 95% CI 1.01‐1.15) clinic visits in the NYC region. In the ROS region, the HARPs were associated with relative increases in behavioral health (RR = 1.47, 95% CI 1.32‐1.64) and nonbehavioral health (RR = 1.17, 95% CI 1.11‐1.25) clinic visits.ConclusionsCompared to patients with similar clinical needs, HARPs were associated with a relative increase in services used and led to a better engagement in the HARPs group regardless of the overall decline in services used pre‐ to postperiod.     

Access and use of health services by chronically mentally ill Medicaid beneficiaries

This article has two objectives: to quantify the access and utilization of services received by chronically mentally ill Medicaid recipients, and to compare service utilization and access under prepayment and fee-for-service (FFS) payment. The study setting is Hennepin County (Minneapolis), Minnesota, where 35 percent of Medicaid recipients were randomly assigned to receive services from prepaid plans. An algorithm was developed to identify recipients with chronic mental illness, resulting in 739 study participants, split approximately evenly between prepayment and FFS Medicaid. Data were collected through in-person surveys at baseline, and after 1 year. We found slight improvements in the majority of access measures studied and no significant decreases in the use of inpatient or outpatient services for enrollees in prepaid health plans. The results support efforts to expand the use of prepaid health plans to meet the needs of non-institutionalized chronically mentally ill Medicaid beneficiaries.     

Improving health-based payment for Medicaid beneficiaries: CDPS

This article describes the Chronic Illness and Disability Payment System (CDPS), a diagnostic classification system that Medicaid programs can use to make health-based capitated payments for TANF and disabled Medicaid beneficiaries. The authors describe the diversity of diagnoses and different burdens of illness among disabled and AFDC Medicaid beneficiaries. Claims from seven States are analyzed, and payment weights are provided that States can use when adjusting HMO payments. The authors also compare the taxonomy and statistical performance of CDPS to other leading diagnostic classification systems and find that the new model performs better in a number of respects.     

When plans opt out: family planning access in Medicaid managed care

The state of New York is attempting to ensure access to family planning (FP) services for Medicaid recipients enrolled in managed care (MC) plans administered by institutions affiliated with the Roman Catholic Church, which will not provide FP services or referrals. When the US Congress allowed states to lock Medicaid recipients into MC plans, they prohibited states from abrogating recipients' freedom of choice in FP services. In 1996, New York became one of 16 states that mandates MC for Medicaid recipients and has tried to ensure that patients and MC plans understand patient rights to free access to FP services. MC plans must inform members and prospective enrollees that FP services are available from any provider who accepts Medicaid without the need for a referral and at no cost. Additional information must be given to potential enrollees. The plan physicians, however, have no obligation to answer patient questions about the provision. Studies indicate that enrollees generally are confused and uninformed about their rights. Physicians working in Roman Catholic MC plans are also unaware that patients can go outside of the plan to obtain FP services. It will be difficult to get the information out to the estimated 1.4 million new enrollees in New York City, especially because the Medicaid population generally has a 6th-grade reading level. Planned Parenthood is working with state health officials to inform the public, and officials are especially concerned about adolescents.     

Residential adolescent substance abuse treatment: recommendations for collaboration between school health and substance abuse treatment personnel

Thousands of youth participate in residential substance abuse treatment each year. After completing treatment, many of these youth return to school. This study analyzed the process of substance abuse treatment at the Generations Youth Program, and identified opportunities for collaboration with school health personnel. A qualitative case study design was employed. Analysis of the treatment process revealed the primary goal of treatment was to assist youth in developing a belief in their ability to remain sober. This goal was achieved through a peer support network, development of self-control, and acquisition of treatment knowledge. Youth who develop these skills are successfully discharged from treatment and return to home and school. Opportunities exist for collaboration between school health and substance abuse treatment personnel to enable discharged youth to remain drug free.     

Benefit policy and disenrollment of adult Medicaid beneficiaries from the Oregon health plan

Oregon's Medicaid program experienced a dramatic decrease in its non-categorically eligible adult members after implementing a new benefit policy in February 2003 for these beneficiaries. The policy included four main elements: premium increases for some enrollees; a more stringent premium payment policy; elimination of some benefits, including mental health and substance abuse treatment; and, the imposition of co-payments. The study compared monthly disenrollment rates eight months before and after the policy change. The new premium payment policy was found to be the main driver of disenrollment, followed by benefit elimination. Premium increases and co-payments had limited impact. Disenrollment was particularly high among vulnerable beneficiary groups, including people with no reported income, those previously obtaining premium waivers, methadone users, and other enrollees with substance abuse conditions. Better understanding of the relationship between benefit design and retention in public health insurance programs could help avoid the unintended policy effects experienced in Oregon.