Estimating pediatric primary care provider visits in a capitated environment: encounter vs. claims databases.
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PURPOSE: To evaluate the accuracy of insurance claims data indicating underutilization of primary care visits by children with special health care needs (CSHCN). DESIGN: The study was a retrospective comparison of primary care provider (PCP) utilization by 1,131 CSHCN, using secondary data from electronic claims-and-encounters databases in a Medicaid health maintenance organization (HMO) and a commercial HMO. METHODOLOGY: The study was conducted at the Children's Clinics for Rehabilitative Services (Children's Clinics) in Tucson, Ariz., a provider of specialty care to CSHCN. All the children in the study were eligible for specialty services under Arizona's statewide program for CSHCN and were simultaneously enrolled, from Oct. 1, 1995 through Sept. 30, 1996, in either one or both of the managed care plans for their primary care. Identical PCP-visit information for the same 1-year period was collected from the plans' claims-and-encounters databases, and the number of primary care visits as computed from both databases was compared. PRINCIPAL FINDINGS: Health plan claims data show that only 14 percent of the patients visited a PCP during the course of a year. The encounter data indicate that 59 percent of the same cohort had PCP visits. CONCLUSIONS: Encounter databases capture more information about PCP visits than insurance claims databases in capitated environments. (+info)
Tracking Medicaid managed care in rural communities: a fifty-state follow-up.
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This study updates a 1997 study examining implementation of rural Medicaid managed care programs. Most states operate Medicaid managed care programs for their beneficiaries, but the types of programs vary across urban and rural settings. Over the past four years the number of rural counties covered by Medicaid managed care, including fully capitated programs, has grown, although primary care case management (PCCM) remains the predominant program type in rural areas. Health plan withdrawals from rural areas have led some states with rural capitated programs to provide financial incentives or develop alternative approaches, such as enhanced PCCM programs. (+info)
Integration and its discontents: substance abuse treatment in the Oregon Health Plan.
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With the creation of the Oregon Health Plan (OHP) in 1994, Oregon placed its Medicaid program under a managed care system. This paper examines the managed care practices of seven health plans serving OHP enrollees between 1996 and 1998. Results indicated that the original vision of integrating substance abuse treatment services with physical care for OHP enrollees evolved into a multilayered, carved-out approach. Factors working against integration included changes in the administration and management of the chemical dependency benefit, financial losses by health plans, and lack of training and incentives for physicians to refer clients to substance abuse treatment. (+info)
Managed care for uninsured adults: the rise and fall of a university-based program.
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OBJECTIVE: To assess the impact of CU CARE, a managed care program for medically indigent adults developed by University Hospital (UH) in Denver and Kaiser Permanente, on outpatient and inpatient utilization. STUDY DESIGN: Pre-post study with concurrent comparison groups. PATIENTS AND METHODS: Administrative claims from 1994-1996 were analyzed for all enrollees in a state-funded medically indigent program (intervention group) compared with Medicaid patients and uninsured adults rated as "self-pay" who were ineligible for the medically indigent program. RESULTS: In 1994, before initiation of CU CARE, UH provided care to 10,118 medically indigent, 5330 Medicaid, and 7626 self-pay patients; similar numbers received care in 1995-1996, but only 12% of medically indigent patients received care in both time periods. The proportion of medically indigent patients with 1 or more primary care visits increased by 185% (from 10.9% in 1994 to 31.1% in 1995-1996). Medically indigent patients had relative declines of 36% in specialty clinic visits, 25% in emergency department visits, 40% in hospital visits, and 31% in visit costs between 1994 and 1995-1996. All these changes were significant compared with Medicaid and self-pay patients. The impact on acute care utilization was greater for medically indigent patients who used UH in both 1994 and 1995-1996. CONCLUSIONS: This managed care program increased utilization of primary care and reduced specialty and acute care utilization. However, the program was scaled back in 1997 and terminated in 2000 because of problems with care coordination across institutions, increasing costs (particularly pharmacy costs), and competitive pressures. (+info)
AIDS Drug Assistance Programs: highlighting inequities in human immunodeficiency virus-infection health care in the United States.
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The AIDS Drug Assistance Programs (ADAPs) were founded in 1987 to pay for human immunodeficiency virus (HIV)-related medications in the United States and to help provide prescriptions for HIV-infected patients ineligible for Medicaid who have no private health insurance. As HIV care has shifted from the inpatient to the outpatient arena and as patients live longer because of more-effective antiretroviral therapy, medication costs have increased, and ADAPs have increasingly been operating under emergency measures, with coverage limitations and eligibility restrictions. Because these programs operate at the state level, inequalities in resource distribution to those in need are manifest and appear to contribute to differences in disease outcomes that are based solely on patients' place of residence. Cost-effectiveness analysis would offer a more informed basis for distribution of ADAP resources in an efficient and equitable manner, leading to a standardized national structure. (+info)
Minimum nurse-to-patient ratios in acute care hospitals in California.
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Many registered nurses believe that nurse staffing in acute care hospitals is inadequate. In 1999 California became the first state to mandate minimum nurse-to-patient ratios in hospitals. State officials announced draft ratios in January 2002 and expect to implement the legislation by July 2003. We estimate that the direct costs of compliance will be small. However, mandatory ratios could generate opportunity costs that are not easily measured and that may outweigh their benefits. Policymakers elsewhere should consider other strategies to address nurses' concerns, because other approaches may be less costly and produce greater benefits to nurses and patients. (+info)
Effects of CAHPS health plan performance information on plan choices by New Jersey Medicaid beneficiaries.
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OBJECTIVE: To assess the effects of CAHPS health plan performance information on plan choices and decision processes by New Jersey Medicaid beneficiaries. DATA SOURCES/STUDY SETTING: The study sample was a statewide sample of all new Medicaid cases that chose Medicaid health plans during April 1998. The study used state data on health maintenance organization (HMO) enrollments and survey data for a subset of these cases. STUDY DESIGN: An experimental design was used, with new Medicaid cases randomly assigned to experimental or control groups. The experimental group received a CAHPS report along with the standard enrollment materials, and the control group did not. DATA COLLECTION: The HMO enrollment data were obtained from the state in June 1998, and evaluation survey data were collected from July to October 1998. PRINCIPAL FINDINGS: No effects of CAHPS information on HMO choices were found for the total sample. Further examination revealed that only about half the Medicaid cases said they received and read the plan report and there was an HMO with dominant Medicaid market share but low CAHPS performance scores. The subset of cases who read the report and did not choose this dominant HMO chose HMOs with higher CAHPS scores, on average, than did those in an equivalent control group. CONCLUSIONS: Health plan performance information can influence plan choices by Medicaid beneficiaries, but will do so only if they actually read it. These findings suggest a need for enhancing dissemination of the information as well as further education to encourage informed choices. (+info)
Provision of sexual health services to adolescent enrollees in Medicaid managed care.
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OBJECTIVES: This Seattle project measured sexual health services provided to 1112 Medicaid managed care enrollees aged 14 to 18 years. METHODS: Three health maintenance organizations (HMOs) that provide Medicaid services for a capitated rate agreed to participate. These included a non-profit staff-model HMO, a for-profit independent practice association (IPA), and a non-profit alliance of community clinics. Analyses used health maintenance organizations' administrative data, chart reviews, and Medicaid encounter data. RESULTS: Health maintenance organizations provided primary care to 54% and well care to 20% of Medicaid enrollees. Girls were more likely than boys to have their sexual history taken or to be given condom counseling. Only 27% of sexually active girls were tested for chlamydia, with significantly lower rates of testing among those who spoke English as a second language. The nonprofit staff-model plan outperformed the for-profit independent practice association on most measures. CONCLUSIONS: Substantial room for improvement exists in sexual health services delivery to adolescent Medicaid managed care enrollees. (+info)