Honesty as good policy: evaluating Maryland's Medicaid managed care program

A systematic review of stakeholder engagement in comparative effectiveness and patient-centered outcomes research

OBJECTIVES

We conducted a review of the peer-reviewed literature since 2003 to catalogue reported methods of stakeholder engagement in comparative effectiveness research and patient-centered outcomes research.

METHODS AND RESULTS

We worked with stakeholders before, during and after the review was conducted to: define the primary and key research questions; conduct the literature search; screen titles, abstracts and articles; abstract data from the articles; and analyze the data. The literature search yielded 2,062 abstracts. The review was conducted on 70 articles that reported on stakeholder engagement in individual research projects or programs.

FINDINGS

Reports of stakeholder engagement are highly variable in content and quality. We found frequent engagement with patients, modestly frequent engagement with clinicians, and infrequent engagement with stakeholders in other key decision-making groups across the healthcare system. Stakeholder engagement was more common in earlier (prioritization) than in later (implementation and dissemination) stages of research. The roles and activities of stakeholders were highly variable across research and program reports.

RECOMMENDATIONS

To improve on the quality and content of reporting, we developed a 7-Item Stakeholder Engagement Reporting Questionnaire. We recommend three directions for future research: 1) descriptive research on stakeholder-engagement in research; 2) evaluative research on the impact of stakeholder engagement on the relevance, transparency and adoption of research; and 3) development and validation of tools that can be used to support stakeholder engagement in future work.

Searching for a business case for quality in Medicaid managed care

BACKGROUND

Despite the prevalence of evidence-based interventions to improve quality in health care systems, there is a paucity of documented evidence of a financial return on investment (ROI) for these interventions from the perspective of the investing entity.

PURPOSES

To report on a demonstration project designed to measure the business case for selected quality interventions in high-risk high-cost patient populations in 10 Medicaid managed care organizations across the United States.

METHODOLOGY/APPROACH

Using claims and enrollment data gathered over a 3-year period and data on the costs of designing, implementing, and operating the interventions, ROIs were computed for 11 discrete evidence-based quality-enhancing interventions.

FINDINGS

A complex case management program to treat adults with multiple comorbidities achieved the largest ROI of 12.21:1. This was followed by an ROI of 6.35:1 for a program which treated children with asthma with a history of high emergency room (ER) use and/or inpatient admissions for their disease. An intervention for high-risk pregnant mothers produced a 1.26:1 ROI, and a program for adult patients with diabetes resulted in a 1.16:1 return. The remaining seven interventions failed to show positive returns, although four sites came close to realizing sufficient savings to offset investment costs.

PRACTICE IMPLICATIONS

Evidence-based interventions designed to improve the quality of patient care may have the best opportunity to yield a positive financial return if it is focused on high-risk high-cost populations and conditions associated with avoidable emergency and inpatient utilization. Developing the necessary tracking systems for the claims and financial investments is critical to perform accurate financial ROI analyses.

State responses to new flexibility in medicaid

CONTEXT

States have long lobbied to be given more flexibility in designing their Medicaid programs, the nation's health insurance program for the low-income, the elderly, and individuals with disabilities. The Bush administration and the Deficit Reduction Act of 2005 have put in place policies to make it easier to grant states this flexibility.

METHODS

This article explores trends in states' Medicaid flexibility and discusses some of the implications for the program and its beneficiaries. The article uses government databases to identify the policy changes that have been implemented through waivers and state plan amendments.

FINDINGS

Since 2001, more than half the states have changed their Medicaid programs, through either Medicaid waivers or provisions in the Deficit Reduction Act of 2005. These changes are in benefit flexibility, cost sharing, enrollment expansions and caps, privatization, and program financing.

CONCLUSIONS

With a few important exceptions, these changes have been fairly circumscribed, but despite their expressed interest, states have not yet fully used this flexibility for their Medicaid programs. However, states may exercise this newly available flexibility if, for example, the nation's health care system is not reformed or an economic downturn creates fiscal pressures on states that must be addressed. If this happens, the policies implemented during the Bush administration could lead to profound changes in Medicaid and could be carried out relatively easily.

Multimethod evaluation of health policy change: an application to Medicaid managed care in a rural state

OBJECTIVE

To answer questions about the impacts of Medicaid managed care (MMC) at the individual, organizational/community, and population levels of analysis.

DATA SOURCES/STUDY SETTING

Multimethod approach to study MMC in New Mexico, a rural state with challenging access barriers.

STUDY DESIGN

Individual level: surveys to assess barriers to care, access, utilization, and satisfaction. Organizational/community level: ethnography to determine changes experienced by safety net institutions and local communities. Population level: analysis of secondary databases to examine trends in preventable adverse sentinel events.

DATA COLLECTION/EXTRACTION METHODS

SURVEY

multivariate statistical methods, including factor analysis and logistic regression. Ethnography: iterative coding and triangulation to assess documents, field observations, and in-depth interviews. Secondary databases: plots of sentinel events over time.

PRINCIPAL FINDINGS

The survey component revealed no consistent changes after MMC, relatively favorable experiences for Medicaid patients, and persisting access barriers for the uninsured. In the ethnographic component, safety net institutions experienced increased workload and financial stress; mental health services declined sharply. Immunization rate, as an important sentinel event, deteriorated.

CONCLUSIONS

MMC exerted greater effects on safety net providers than on individuals and did not address problems of the uninsured. A multimethod approach can facilitate evaluation of change in health policy.