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.     

What to demand of your managed care network

Employers can get more for their money by tying managed care plans' fees to specific performance standards. Consultants share strategies for controlling costs and for judging the financial performance of an HMO.     

A blue streak for managed care

The nation;s Blue Cross and Blue Shield organizations have taken the lead in managed care. Enrollment in their 76 HMOs recently reached 7.6 million. By exploring the opportunity to go public and other options, the plans are looking for even more growth in the field.     

Improving HEDIS measurement: linking managed care organization and health system ambulatory care data

This article describes one health system's efforts to improve HEDIS measurement by integrating claims information from its managed care organization with data from its medical center's automated billing, scheduling, and clinical information systems. The authors discuss problems encountered while establishing an integrated measurement process and offer suggestions for others considering such an approach.     

A model for regulating managed competition

Adapting proven regulatory mechanisms from the Federal Reserve System and the Clean Air Act to a managed-competition-based health care system may provide a consistent nationwide framework for health care delivery and financing that takes into account the role of the states.     

Merging managed care with the German model

Since public officials in the United States may lack the courage and political will to significantly raise payroll taxes or the contain Social Security, Medicare and Medicaid benefits, Americans can anticipate that; (a) future generations increasingly will pay for these entitlements; (b) additional cutbacks to providers in Medicare, Medicaid and health maintenance organization reimbursement will hasten the current thrust of hospitals, physicians and insurers in forming huge health networks with their powerful managed care plans; and, (c) many of these new alliances will function as virtual monopolies--eventually resulting in the public proposing that state health services commissions be established. This article then suggests that future modifications in how the United States health delivery system be organized and financed preferably should be along the lines of the German multi-player, multi-tier, self-governing, decentralized, quasi-private, quasi-public model; and, also patterned after experiences of the State of Arizona's Medicaid program. It concludes that what America needs most is a hybrid of the European global budgetary targets to constrain total health expenditures, and the competitive managed care concept to curtail use patterns and to enhance quality.     

The hospital-health center collaborative: a model for ambulatory care

In summary, the staff and administration of the Muhlenberg-health center project feel it has thus far been successful in meeting its original goals of reducing duplication, ensuring access, controlling costs, and maintaining quality care. We believe that this model of cooperation benefits both organizations and provides the patients served with an ambulatory care program that is superior to either of its predecessors.     

Complex chronic care patients managed using hospice model

Some patients just defy the traditional disease management model. Many are elderly, have complex medical needs, and find comfort in their frequent visits to the hospital emergency department. Find out how a pilot DM program is using hospice and home health care providers as partners to help manage CHF and COPD among the high-cost elderly, and how the DM approach maintains its effectiveness even in the patients' final days.     

The Canadian health care system as a managed care model for the United States

After discussing the evolution of the Canadian health care system and its current cost trends, the authors address the degree to which the Canadian system provides direction for reform in the United States. Accessibility, quality, and cultural acceptability provide the focus of their approach.