Prepaid capitation versus fee-for-service reimbursement in a Medicaid population. (1/77)

Utilization of health resources by 37,444 Medicaid recipients enrolled in a capitated health maintenance organization was compared with that of 227,242 Medicaid recipients enrolled in a traditional fee-for-service system over a 1-year period (1983-1984) in the state of Kentucky. Primary care providers in the capitated program had financial incentives to reduce downstream costs like specialist referral, emergency room use, and hospitalizations. The average number of physician visits was similar for both groups (4.47/year in the capitated program; 5.09/year in the fee-for-service system). However, the average number of prescriptions (1.9 versus 4.9 per year), average number of hospital admissions per recipient (0.11 versus 0.22 per year), and average number of hospital days per 1,000 recipients (461 versus 909 per year) were 5% to 60% lower in the capitated group than in the fee-for-service group. The Citicare capitated program resulted in a dramatic reduction in healthcare resource utilization compared with the concurrent fee-for-service system for statewide Medicaid recipients.  (+info)

Subspecialist referrals in an academic, pediatric setting: rationale, rates, and compliance. (2/77)

Appropriate referrals reduce healthcare costs and enhance patient satisfaction. We evaluated the subspecialty referral pattern of a managed care general pediatric office over a 4-month period. Three-hundred-forty-six referrals (267 meeting inclusion criteria) to 24 subspecialties were generated during 4,219 office visits, with five subspecialties receiving 59% of the referrals. The main objective of each referral was management (100), diagnostic assistance (75), special procedure (63), or a combination (29). Patients kept less than half of the referral appointments, with the highest (80%) and lowest (28%) compliance rates observed in cardiology and ophthalmology, respectively. Appointments made within four weeks of the referral were more likely to be kept than those with greater lag time (P = 0.001). The subspecialists prepared written, post-consultation responses to the referring physician in 73% of cases. Presumptive and post-consultation diagnoses were congruent in 78% of those cases in which both diagnoses were noted. Overall, the managed care format enabled our practice to track referral outcomes. The subspecialists' written responses also allowed for an educational exchange between physicians. Compliance with referral appointments is a substantial problem that needs to be addressed.  (+info)

The impact of welfare reform on parents' ability to care for their children's health. (3/77)

OBJECTIVES: Most of the national policy debate regarding welfare assumed that if middle-income mothers could balance work while caring for their children's health and development, mothers leaving welfare for work should be able to do so as well. Yet, previous research has not examined the conditions faced by mothers leaving welfare for work. METHODS: Using data from the National Longitudinal Survey of Youth, this study examined the availability of benefits that working parents commonly use to meet the health and developmental needs of their children; paid sick leave, vacation leave, and flexible hours. RESULTS: In comparison with mothers who had never received welfare, mothers who had been on Aid to Families with Dependent Children were more likely to be caring for at least 1 child with a chronic condition (37% vs 21%, respectively). Yet, they were more likely to lack sick leave for the entire time they worked (36% vs 20%) and less likely to receive other paid leave or flexibility. CONCLUSIONS: If current welfare recipients face similar conditions when they return to work, many will face working conditions that make it difficult or impossible to succeed in the labor force at the same time as meeting their children's health and developmental needs.  (+info)

Medicaid recipients' experiences under mandatory managed care. (4/77)

OBJECTIVE: To describe Medicaid recipients' experiences with the outcomes of access, quality, and satisfaction in a mandatory managed care (MC) program. STUDY DESIGN: A qualitative case study design with content analysis of narrative focus group (FG) data, which was part of a comprehensive program evaluation that also involved pre- and postsurveys and analyses of cost and utilization data. PATIENTS AND METHODS: Six FG interviews were conducted in the autumn of 1997 with 31 women on the Aid to Families with Dependent Children program. Participants were recruited from a randomly ordered list of women who had responded to a 1996 premanaged care survey regarding their or their child's healthcare experiences under traditional Medicaid. RESULTS: There was general consensus across all focus groups on a range of issues, including improvements in access to primary care and continuity of care. Overall, few participants expressed discontent with restriction of choice of provider and on MC policies regarding use of the emergency room. There was no consensus on what factors influenced choice of MC plan, although convenience of location was named most frequently. An unanticipated outcome was the recurrent theme across all focus groups of disrespectful treatment by healthcare personnel, especially under traditional Medicaid, which had declined somewhat under managed care. CONCLUSIONS: These contextual accounts identify specific features of a mandatory Medicaid MC program that are viewed as improvements over traditional Medicaid. Specific features that were dissatisfying can be addressed to improve both enrollee satisfaction and the transition to managed care for Medicaid recipients.  (+info)

Medicaid managed care payment rates in 1998. (5/77)

This paper reports on a new survey of state Medicaid managed care payment rates. We collected rate data for Medicaid's Aid to Families with Dependent Children (AFDC)/Temporary Assistance for Needy Families (TANF) and poverty-related populations and made adjustments to make the data comparable across states. The results show a slightly more than twofold variation in capitation rates among states, caused primarily by fee-for-service spending levels and demographics. There is a very low correlation between the variation in Medicaid capitation rates among states and the variations in Medicare's adjusted average per capita cost. The data are not sufficient to answer questions about the adequacy of rates but should help to further policy discussions and research.  (+info)

Health insurance coverage after welfare. (6/77)

This DataWatch examines the health insurance coverage of former welfare recipients who left welfare between January 1995 and mid-1997, using data from the 1997 National Survey of America's Families. Although the majority of women who left welfare were working, only 33 percent of these women obtained health coverage through their jobs. Rates of uninsurance increase with the number of months since leaving welfare and with declines in Medicaid coverage. A year or more after leaving welfare, 49 percent of women and 30 percent of children were uninsured.  (+info)

Mandated managed care for blind and disabled Medicaid beneficiaries in a county-organized health system: implementation challenges and access issues. (7/77)

OBJECTIVES: The challenges of Medicaid managed care organizations that serve blind and disabled members are reviewed. Beneficiary satisfaction and access to care are assessed, and access problems are identified and resolved or minimized to the greatest degree possible. STUDY DESIGN: Formative evaluation consisting of a mailed survey and follow-up telephone outreach contacts. PATIENTS AND METHODS: A written survey was sent to more than 18,000 Supplemental Security Income (SSI) beneficiary members who were blind or disabled, with 5574 recipients responding. Of these, 1981 members identified issues that warranted 2106 follow-up telephone calls. RESULTS: Survey responses showed that beneficiaries had limited experience with managed care and were generally satisfied with access to primary care. The healthcare system used the study findings to develop focused training programs and materials, to initiate a special needs liaison program, and to revise guidelines to simplify and standardize authorization procedures for obtaining medical supplies and repairing equipment. CONCLUSIONS: Factors found to be associated with the success of a Medicaid managed care program serving blind and disabled beneficiaries include educating the members and providers for better understanding of managed care, incorporating collaborative service improvement activities, and documenting trends.  (+info)

Employment outcomes among AFDC recipients treated for substance abuse in Washington State. (8/77)

In 1996, Congress passed sweeping welfare reform, abolishing the Aid to Families with Dependent Children (AFDC) program. Each state now administers its own welfare-to-work program under broad federal guidelines, which require eligible adult recipients to work or perform community service. High-risk welfare recipients, especially those with chemical dependency problems, face significant obstacles in their efforts to achieve greater self-sufficiency under the new welfare-to-work programs. State databases were used to track employment outcomes for AFDC clients admitted to treatment for chemical dependency in Washington State during a two-year period. Exposure to treatment was associated with a greater likelihood of becoming employed and with increased earnings for those who became employed. Ensuring that welfare recipients with substance abuse problems have access to appropriate treatment and vocational services is critical if welfare-to-work programs are to promote greater economic self-sufficiency.  (+info)

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