Evaluating medicaid managed care programs for children

Impact of managed care on publicly insured children with special health care needs

OBJECTIVE

The aim of this review was to evaluate the impact of managed care on publicly insured children with special health care needs (CSHCN).

METHODS

We conducted a review of the extant literature. Using a formal computerized search, with search terms reflecting 7 specific outcome categories, we summarized study findings and study quality.

RESULTS

We identified 13 peer-reviewed articles that evaluated the impact of Medicaid and State Children's Health Insurance program (SCHIP) Managed Care (MSMC) on health services delivery to populations of CSHCN, with all studies observational in design. Considered in total, the available scientific evidence is varied. Findings concerning care access demonstrate a positive effect of MSMC; findings concerning care utilization were mixed. Little information was identified concerning health care quality, satisfaction, costs, or health status, whereas no study yielded evidence on family impact.

CONCLUSION

The available studies suggest that the evaluated record of MSMC for CSHCN has been mixed, with considerable heterogeneity in the definition of CSHCN, program design, and measured outcomes. These findings suggest caution should be exercised in implementing MSMC for CSHCN and that greater emphasis on health outcomes and cost evaluations is warranted.

Health plan notification and feedback to providers is associated with increased filling of preventer medications for children with asthma enrolled in Medicaid

OBJECTIVE

To test the hypothesis that children enrolled in Medicaid managed care health plans that provide asthma-specific communication to providers would be more likely to have adequate asthma medication filling.

STUDY DESIGN

We conducted a historical cohort study of 4498 children (2-17 years old) with moderate-severe asthma in Washington State and Tennessee Medicaid managed care programs from 2000 to 2002. Interviews with health plans were conducted to identify communication strategies health plans used to improve asthma care by providers in the plan. The main outcome measure was guideline-recommended filling of asthma preventer medications.

RESULTS

Children in plans that provided specific feedback to providers about asthma quality and notified providers when children had an asthma-related event had the highest mean days plus or minus SE of filling in the 365-day follow-up period (164.6 +/- 13 days) compared with children in plans with neither (135.3 +/- 10.8 days; P < .05). In children with the greatest asthma severity, enrollment in a plan with both features was associated with 27.1 additional days of filling (95% CI, 0.7-53.4 days) during the follow-up period.

CONCLUSION

Health plan communication to providers was associated with increased preventer filling in children with moderate-severe asthma in 2 state Medicaid programs.

Measuring community-based case management performance: strategies for evaluation

Case management services are not implemented uniformly or with the same levels of intensity. Case managers serve in diverse settings, have varied training and experiences, and individualize care at the patient level. The flexible characteristics of case management services pose challenges to, and accentuate the need for, successful ongoing evaluation. The purpose of this article is to describe a multimodal evaluation planning strategy that was applied to case management services delivered to pediatric Medicaid recipients within an enhanced primary care case management delivery system. The evaluation planning steps included describing the organization and case management program, identifying barriers to evaluation, outlining evaluation questions, specifying data needs, identifying sources of data, and selecting evaluation methods. The evaluation plan utilized a combination of case studies, monitoring, surveys, and trend analysis. The approaches outlined in this article are likely to be applicable to evaluating diverse case management programs and services.

Variability in asthma care and services for low-income populations among practice sites in managed Medicaid systems

OBJECTIVE

To characterize and describe variability in processes of asthma care and services tailored for low-income populations in practice sites participating in Medicaid managed care (MMC).

STUDY SETTING

Eighty-five practice sites affiliated with five not-for-profit organizations participating in managed Medicaid (three group-model health maintenance organizations [HMOs] and two Medicaid managed care organizations [MCOs]).

STUDY DESIGN/DATA COLLECTION

We conducted a mail survey of managed care practice site informants using a conceptual model that included chronic illness care and services targeting low-income populations. The survey asked how frequently a number of processes related to asthma care occurred at the practice sites (on a scale from "never" to "always"). We report mean and standard deviations of item scores and rankings relative to other items. We used within-MCO intraclass correlations to assess how consistent responses were among practice sites in the same MCO.

PRINCIPAL FINDINGS

Processes of care related to asthma varied gready in how often practice sites reported doing them, with information systems and self-management support services ranking lowest. There was also significant variation in the availability of services targeting low-income populations, specifically relating to cultural diversity, communication, and enrollee empowerment. Very little of the site-to-site variation was attributable to the MCO.

CONCLUSIONS

Our conceptual framework provides a means of assessing the provision of chronic illness care for vulnerable populations. There is room for improvement in provision of chronic asthma care for children in managed Medicaid, particularly in the areas of self-management support and information systems. The lack of consistency within MCOs on many processes of care suggests that care may be driven more at the practice site level than the MCO level, which has implications for quality improvement efforts.

Comparing asthma care provided to Medicaid-enrolled children in a Primary Care Case Manager plan and a staff model HMO

OBJECTIVE

To examine differences in selected processes of asthma care provided to Medicaid-enrolled children in a state-administered Primary Care Case Manager (PCCM) plan and a staff model health maintenance organization (HMO).

METHODS

Retrospective cohort study assessing performance on 6 claims-based processes of care measures that reflect aspects of pediatric asthma care recommended in national guidelines. Analyzed Medicaid and HMO claims and encounter data for 2365 children with asthma in the Massachusetts Medicaid program in 1994.

RESULTS

There were no plan differences in asthma primary care visits, asthma pharmacotherapy or follow-up care after asthma hospitalization. Children in the HMO were only 54% as likely (confidence interval [CI]: 0.37-0.80; P<.01) as those in the PCCM plan to experience an asthma emergency department (ED) visit or hospitalization. HMO-enrolled children were only half as likely (CI: 0.38-0.64; P<.001) to meet the National Committee for Quality Assurance (NCQA) definition for persistent asthma and only 32% as likely (CI: 0.19-0.56; P<.001) to have prior asthma ED visits or hospitalizations relative to children in the PCCM plan. Controlling for case mix and other covariates, children in the HMO were 2.9 times as likely (CI: 1.09-7.78; P<.05) as children in the PCCM plan to receive timely follow-up care (within 5 days) after an asthma ED visit and 1.8 times as likely (CI: 1.05-3.01; P<.05) as those in the PCCM plan to receive a specialist visit during the year.

CONCLUSIONS

In this study, the HMO served a less sick pediatric asthma population. After controlling for case mix, the staff model HMO provided greater access to asthma specialists and more timely follow-up care after asthma ED visits relative to providers in the state-administered PCCM plan. Further understanding of the impact of these differences on clinical outcomes could guide asthma improvement efforts.

Generalist and subspecialist care for children with chronic conditions

OBJECTIVE

To determine, among Medicaid-enrolled children with chronic conditions, associations of indicators of morbidity and expenditures with different patterns of generalist, subspecialist, and pediatric subspecialist use.

DESIGN AND SETTING

Cross-sectional analysis of Medicaid claims, enrollment, and provider data from 4 states (California, Georgia, Michigan, and Tennessee).

SAMPLE

All children enrolled in Supplemental Security Income (aged 0-21 years) and a sample of other Medicaid-enrolled children matched for age and gender. We included 11 chronic conditions, including both uncommon conditions (eg, spina bifida, hemophilia) and common ones (eg, asthma, attention deficit hyperactivity disorder).

MAIN OUTCOME MEASURES

We determined the number of visits per year to generalists and subspecialists (pediatric and other), using only subspecialists relevant to that condition. We categorized patterns of care as generalist only, predominantly generalist, or predominantly subspecialist, and examined patterns by condition and an indicator of morbidity. Among children seeing subspecialists, we also compared morbidity by pediatric and other subspecialists. We used linear regression to determine per-year total expenditures, controlling for demographic characteristics and morbidity.

RESULTS

Most children (60.7%) saw generalists only. Twenty-eight percent were in predominantly generalist arrangements, and 11% were in predominantly subspecialist arrangements. Children in predominantly generalist arrangements had higher morbidity than children in generalist-only or predominantly subspecialist arrangements. Among children seeing subspecialists, those seeing pediatric subspecialists had generally higher morbidity than those seeing other subspecialists. Mean yearly expenditures varied from 1306 dollars (attention deficit hyperactivity disorder) to 11,633 dollars (acquired immunodeficiency syndrome). Children who saw only generalists had significantly lower expenditures for 6 of the 11 conditions, after adjusting for morbidity.

CONCLUSIONS

Medicaid-enrolled children in predominantly generalist arrangements appear to have more complicated conditions than children in generalist-only or predominantly subspecialist arrangements, engendering also higher expenditures. Although children who saw generalists only had lower expenditures than those seeing subspecialists, this finding may reflect unmeasured variations in morbidity.

Health services research for children with disabilities

Growing numbers of children and adolescents have long-term disabilities. Research on the epidemiology, clinical care and its improvement, organization, and financing of care for children with disabilities is very limited. Given the cost burden of the nation's chronic diseases and disabilities, the lack of investigation into necessary clinical activities seems remarkable. This article reviews recent research on health services relating to children and adolescents with disabilities and outlines a research agenda in clinical and health services for this population in these study areas.