Managed care for the Medicaid disabled: effect on utilization and costs

From hospital to home after cardiac surgery: evaluation of a community nursing care management model

PURPOSE/OBJECTIVES

This quasi-experimental research aims to (1) evaluate the implementation process of a community nursing care management model and (2) assess the effects of this model on patients followed at home.

PRIMARY PRACTICE SETTING

Two community healthcare centers had introduced a community nursing care management model in their practice (experimental groups), whereas another health community care center with no experience with such a model served as a control group. The community nursing care management model included clinical pathways designed for a clientele who had been hospitalized for cardiac surgery.

FINDINGS/CONCLUSIONS

Even though the implementation process was challenging, the community nursing care management model was found useful enough to be integrated into routine nursing home care practice after cardiac surgery. Although the effects produced by this systematic home care program on the clientele did not differ significantly from those produced by usual nursing care, there was a positive effect for the clientele recorded on all measurement indicators used.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The introduction of the nursing care management model enabled nurses to structure the care provided and reduced interindividual variation. The application of this program also proved to be an opportunity to initiate and assimilate new professional roles. Additional studies should be conducted to assess its effectiveness in home care for other health problems.

Medicaid managed care and cost containment in the adult disabled population

BACKGROUND

Despite the increasing enrollment of adult disabled beneficiaries into Medicaid managed care organizations (MCOs), there is little evidence of its (hoped for) effectiveness at reducing Medicaid expenditures.

OBJECTIVE

: To evaluate the impact of Medicaid MCOs on health care expenditures for adults with disabilities.

RESEARCH DESIGN

I employ a repeated observations design comparing individual monthly Medicaid expenditures across beneficiaries who reside in counties with mandatory, voluntary, and no MCOs. County-level Medicaid MCO program status for adults with disabilities was merged with the Medical Expenditure Panel Survey and the Area Resource File for 1996-2004. Two-part regression models are used to estimate the probability and level of Medicaid expenditure.

SUBJECTS

Working age Medicaid beneficiaries who receive Supplement Security Income for disability comprise the sample of 1613 individuals.

MEASURES

Outcome measures include total and service-specific Medicaid expenditures.

RESULTS

On average, total monthly Medicaid expenditures per beneficiary do not differ between FFS and MCO counties although some service-specific spending differs. Relative to FFS counties, average monthly Medicaid spending per beneficiary is higher for prescription medications in voluntary ($24) and mandatory ($25) MCO counties. Average Medicaid monthly spending for other medical care and dental care is $4 to $11 higher per beneficiary in MCO relative to FFS counties.

CONCLUSIONS

Medicaid MCO programs as implemented are not associated with lower Medicaid spending; thus, state Medicaid programs should consider additional policy tools to contain health care expenditures in this population.

The future of health insurance for children with special health care needs

CONTEXT

Because of their elevated need for services, health insurance is particularly important for children with special health care needs. In this article we assess how well the current system is meeting the insurance needs of children with special health care needs and how emerging trends in health insurance may affect their well-being.

METHODS

We begin with a review of the evidence on the impact of health insurance on the health care experiences of children with special health care needs based on the peer-reviewed literature. We then assess how well the current system meets the needs of these children by using data from 2 editions of the National Survey of Children With Special Health Care Needs. Finally, we present an analysis of recent developments and emerging trends in the health insurance marketplace that may affect this population.

RESULTS

Although a high proportion of children with special health care needs have insurance at any point in time, nearly 40% are either uninsured at least part of the year or have coverage that is inadequate. Recent expansions in public coverage, although offset in part by a contraction in employer-based coverage, have led to modest but significant reductions in the number of uninsured children with special health care needs. Emerging insurance products, including consumer-directed health plans, may expose children with special health care needs and their families to greater financial risks.

CONCLUSIONS

Health insurance coverage has the potential to secure access to needed care and improve the quality of life for these children while protecting their families from financially burdensome health care expenses. Continued vigilance and advocacy for children and youth with special health care needs are needed to ensure that these children have access to adequate coverage and that they fare well under health care reform.

Does managed care improve access to care for Medicaid beneficiaries with disabilities? A national study

States increasingly are shifting Medicaid beneficiaries with disabilities from the fee-for-service (FFS) delivery system to managed care in an effort to control program costs and address long-standing problems with access to care under the program. Using a county-based measure of managed care enrollment and pooled data from the 1997 to 2004 National Health Interview Surveys, we investigate whether Medicaid managed care (MMC), relative to FFS Medicaid, improves access to care. We find some evidence of improved access to care under MMC; however, the gains appear to be largely limited to beneficiaries in urban areas with fully capitated managed care. There is little evidence of improved access under primary care case management or, regardless of MMC type, in rural areas.

Effects of managed care on service use and access for publicly insured children with chronic health conditions

OBJECTIVE

Our goal was to estimate the effects of managed care program type on service use and access for publicly insured children with chronic health conditions.

METHODS

Data on Medicaid and State Children's Health Insurance Program managed care programs were linked by county and year to pooled data from the 1997-2002 National Health Interview Survey. We used multivariate techniques to examine the effects of managed care program type, relative to fee-for-service, on a broad array of service use and access outcomes.

RESULTS

Relative to fee-for-service, managed care program assignment was associated with selected reductions in service use but not with deterioration in reported access. Capitated managed care plans with mental health or specialty carve-outs were associated with a 7.4-percentage-point reduction in the probability of a specialist visit, a 6.3-percentage-point reduction in the probability of a mental health specialty visit, and a 5.9-percentage-point decrease in the probability of regular prescription drug use. Reductions in use associated with primary care case management and integrated capitated programs (without carve-outs) were more limited, and integrated capitated plans were associated with a reduction in unmet medical care need. We failed to find significant effects of special managed care programs for children with chronic health conditions.

CONCLUSIONS

Managed care is associated with reduced service use, particularly when capitated programs carve out services. This finding is of key policy importance, as the proportion of children enrolled in plans with carve-out arrangements has been increasing over time. It is not possible to determine whether reductions in services represent better care management or skimping. However, despite the reductions in use, we did not observe a corresponding increase in perceived unmet need; thus, the net change may represent improved care management.

Methods to estimate and compare VA expenditures for assistive devices to Medicare payments

OBJECTIVE

To describe the methods used to estimate and compare Veterans Health Administration (VA) annual expenditures for assistive devices and their repair at six VA hospitals with payments for those same devices in the private sector.

METHODS

Information about dispensed assistive devices and their costs was extracted from (1) the VA's National Prosthetic Patient Database, (2) each site's listing of the VA's Denver Distribution Center cost center in the Cost Distribution Jurisdictional Report, and (3) review of invoices for implanted prosthetics at each study site. We estimated private sector payments by applying Medicare geographically adjusted rates for purchases or rentals, where rates existed, or by inflating VA costs by 30%.

RESULTS

The VA spent a total of $30.6 million for prosthetics at the six sites in fiscal year 1999, of which $14.2 million was for items captured in the National Prosthetic Patient Database, $3.4 million for the Denver Distribution Center, and more than $8.1 million for implants. Indirect VA costs were estimated at $4.8 million. Hypothetical private sector payments were estimated at $49.8 million.

CONCLUSIONS

Unlike Medicare, VA both contracts to provide assistive devices (through a competitive bidding process) and dispenses devices it has purchased. This approach results in significantly lower expenditures, consistent with other reports. Generalizing these cost savings to other private or federal programs covering assistive devices requires further study.