Access to infant immunizations for poor, inner-city families: what is the impact of managed care?

Changes in childhood immunization disparities between central cities and their respective states, 2000 versus 2006

Central cities have lower childhood immunization coverage rates than states in which they are located. We conducted a secondary analysis of the National Immunization Survey (NIS) 2000 and 2006 of children 19-35 months old for 26 NIS-defined central cities and the rest of their respective states in order to examine patterns in early childhood immunization disparities between central cities and their respective states and the contextual factors associated with these disparities. We examined three measures of immunization disparities (absolute, difference, and ratio of change) and the patterns of disparity change with regard to selected contextual factors derived from the census. In 2000, immunization coverage in central cities was 68.3% and 74.7% in the rest of their states, a 6.4% disparity (t = 3.82, p < 0.000). Between 2000 and 2006, the overall city/state disparity narrowed to 3.5%, with the central city coverage up to 78.7% vs. 82.5% for the rest of state (t = 2.48, p = 0.017). However, changes in immunization disparities were not uniform: six cities narrowed, 14 had minimal change, and six widened. Central cities with a larger share of Hispanics experienced less reduction in disparities than other cities (beta = -4.2, t = -2.11, p = 0.047). Despite overall progress in childhood immunization coverage, most central cities still show significant disparities with respect to the rest of their states. Cities with larger Hispanic populations may need extra help in narrowing their disparities.

The impact of changing medicaid enrollments on New Mexico's Immunization Program

BACKGROUND

Immunizations are an important component to pediatric primary care. New Mexico is a relatively poor and rural state which has sometimes struggled to achieve and maintain its childhood immunization rates. We evaluated New Mexico's immunization rates between 1996 and 2006. Specifically, we examined the increase in immunization rates between 2002 and 2004, and how this increase may have been associated with Medicaid enrollment levels, as opposed to changes in government policies concerning immunization practices.

METHODS AND FINDINGS

This study examines trends in childhood immunization coverage rates relative to Medicaid enrollment among those receiving Temporary Assistance for Needy Families (TANF) in New Mexico. Information on health policy changes and immunization coverage was obtained from state governmental sources and the National Immunization Survey. We found statistically significant correlations varying from 0.86 to 0.93 between immunization rates and Medicaid enrollment.

CONCLUSIONS

New Mexico's improvement and subsequent deterioration in immunization rates corresponded with changing Medicaid coverage, rather than the state's efforts to change immunization practices. Maintaining high Medicaid enrollment levels may be important for achieving high childhood immunization levels.

Impact of a decline in Colorado Medicaid managed care enrollment on access and quality of preventive primary care services

BACKGROUND

Beginning in 1997 the Colorado Medicaid program de-emphasized managed care and shifted children from enrollment in a health maintenance organization (HMO), which required an enrollee to have an assigned primary care physician, to either the unassigned fee-for-service (UFFS) program in which the enrollee was not required to have a primary care physician (PCP) or to the primary care physician program (PCPP) in which the enrollee was required to select a participating PCP if one was available. The proportion of Medicaid enrollee-months in HMOs dropped from 75.4% in 1997 to 29% in 2003, whereas the proportion of enrollee-months in UFFS programs during this time period increased from 18.6% to 45.6%, and the proportion in the PCPP increased from 5.5% to 25.3%. This shift of children from HMO managed care to the UFFS program provided a natural experiment to assess the impact of not having an assigned PCP on pediatric primary care services.

OBJECTIVE

We sought to assess whether an elective shift of children from Medicaid HMO managed care plans with an assigned PCP to the UFFS program without an assigned PCP restricted access to a primary care medical home, recommended health supervision visits, and age-appropriate immunizations.

METHODS

Published Colorado Health Plan Employer Data and Information Set (HEDIS) data for 1999-2003 were reviewed to determine if Colorado children enrolled in Medicaid managed care programs with an assigned PCP (HMO and PCPP) compared with the UFFS program were more likely to have any type of visit with a PCP, to have recommended health supervision visits, and to be fully immunized. In the analysis, "HMO total" refers to the average of all children participating in HMO plans. Kaiser Permanente was considered a benchmark because it had the highest immunization rates of all HMOs. "Total Colorado" refers to the average of all children enrolled in Medicaid including the managed care and UFFS options. For 2-year-olds, the 4:3:2:1:1 combination immunization included 4 diphtheria-tetanus-acellular pertussis vaccines, 3 oral poliovirus vaccines or inactivated polio vaccines, 2 hepatitis B vaccines, 1 Haemophilus influenzae type b vaccine, and 1 measles-mumps-rubella vaccine.

RESULTS

In 1999 the percentages of children 12 to 24 months of age having any type of visit with a PCP were >80% for the PCPP, Kaiser Permanente, and UFFS programs. However, although the proportion with any visit remained >85% in 2001 for children enrolled in the PCPP and Kaiser Permanente program, the percentage dropped 13.9% to 66.2% for children in the UFFS program. In 2001 the percentage of children with any type of PCP visit enrolled in the UFFS program (66.2%) was significantly lower than the total Colorado (73.6%) as well as the PCPP (85.7%) and Kaiser Permanente program (97.7%). Children 12 to 24 months of age enrolled in the PCPP in 2001 were 1.3 times more likely to have any type of visit with a PCP compared with those enrolled in the UFFS program. Children in the PCPP in 2001, 2002, and 2003 were 1.4, 1.9, and 2.6 times more likely, respectively, to have all 6 of the recommended health supervision visits compared with children enrolled in the UFFS program. Children 3 to 6 years old in the PCPP in 2001, 2002, and 2003 were 1.3, 1.5, and 1.4 times more likely, respectively, to have an annual health supervision visit compared with children enrolled in the UFFS program. In 1999, 2001, 2002, and 2003 2-year-old children enrolled in the PCPP were 2.0, 1.4, 1.5, and 1.8 times more likely, respectively, to be up-to-date with 4:3:2:1:1 vaccines compared with children enrolled in the UFFS program. In 1999, 2001, 2002, and 2003 adolescents enrolled in the PCPP were 1.8, 1.6, 1.3, and 1.6 times more likely, respectively, to be up-to-date with 2 measles-mumps-rubella vaccines compared with children enrolled in the UFFS program.

CONCLUSIONS

This study documents the diminishing ability of the Colorado Medicaid program to provide children access to the benefits of a medical home, including visits with PCPs, recommended health supervision visits, and immunizations as care was shifted to the UFFS program from HMO managed care. The high up-to-date immunization rates achieved by Kaiser Permanente suggest that differences in immunization rates reflect the effectiveness of the care processes rather than the characteristics of the Medicaid population.

Effectiveness of individually tailored calendars in promoting childhood immunization in urban public health centers

OBJECTIVES

We examined the effectiveness of tailored calendars in increasing childhood immunization rates.

METHODS

Parents of babies aged birth to 1 year (n = 321) received individually tailored calendars promoting immunization from 2 urban public health centers. For each baby, an age- and sex-matched control was selected from the same center. Immunization status was tracked through age 24 months.

RESULTS

A higher proportion of intervention than of control babies were up to date at the end of a 9-month enrollment period (82% vs 65%, P <.001) and at age 24 months (66% vs 47%, P <.001). The younger the baby's age at enrollment in the program, the greater was the intervention effect.

CONCLUSIONS

Tailored immunization calendars can help increase child immunization rates.

Immunization coverage and Medicaid managed care in New Mexico: a multimethod assessment

BACKGROUND

We wanted to examine the association between Medicaid managed care (MMC) and changing immunization coverage in New Mexico, a predominantly rural, poor, and multiethnic state.

METHODS

As part of a multimethod assessment of MMC, we studied trends in quantitative data from the National Immunization Survey (NIS) using temporal plots, Fisher's exact test, and the Cochran-Armitage trend test. To help explain changes in immunization rates in relation to MMC, we analyzed qualitative data gathered through ethnographic observations at safety net institutions: income support (welfare) offices, community health centers, hospital emergency departments, private physicians' offices, mental health institutions, managed care organizations, and agencies of state government.

RESULTS

Immunization coverage decreased significantly after implementation of MMC, from 80% in 1996 to 73% in 2001 for the 4:3:1 vaccination series (Fisher's exact test, P = .031). New Mexico dropped in rank among states from 30th for this vaccination series in 1996 to 50th in 2001. A significant decreasing trend (Cochran-Armitage P = .025) in coverage occurred between 1996 and 2001. Findings from the ethnographic study revealed conditions that might have contributed to decreased immunization coverage: (1) reduced funding for immunizations at public health clinics, and difficulties in gaining access to MMC providers; (2) informal referrals from managed care organizations and contracting physicians to community health centers and state-run public health clinics; and (3) increased workloads and delays at community health centers, linked partly to these informal referrals for immunizations.

CONCLUSIONS

Medicaid reform in New Mexico did not improve immunization coverage, which declined significantly to among the lowest in the nation. Reduced funding for public health clinics and informal referrals may have contributed to this decline. These observations show how unanticipated and adverse consequences can result from policy interventions in complex insurance systems.

Effects of medicaid managed care on quality: childhood immunizations

BACKGROUND

Underimmunization is distributed unevenly across populations, concentrated among the impoverished. Managed care has stimulated the development of quality indicators such as immunization rates to assess health status of populations.

OBJECTIVE

To determine if enrollment in Medicaid managed care (MMC) improves quality of health care as reflected by immunization rates when compared with fee-for-service Medicaid (FFSM). DESIGN. Prospective cohort study of infants born between May 1994 and April 1995 with a 24-month follow-up period.

SETTING

Urban teaching hospital and surrounding ambulatory settings.

PARTICIPANTS

Consecutive sample of infants (n = 644) enrolled in MMC or FFSM. Ninety-two percent of eligible patients were enrolled, and 87% completed follow-up.

MAIN OUTCOME MEASURE

Up-to-date immunization status.

RESULTS

Seventy-three percent of the MMC and 72.4% of the FFSM patients were up-to-date on their immunizations: relative risk 1.01, (95% confidence interval [CI] 0.87, 1.17). No differences were found in age at immunization between the MMC and FFSM groups. After adjusting for other factors in multivariate analysis, insurance status remained unassociated with immunization status: adjusted odds ratio (OR) 1.04, (95% CI: 0.90, 1.10). Factors associated with up-to-date immunization included firstborn child, OR 2.28 (95% CI: 1.45, 3.60) and adequate maternal prenatal care, OR 2.24 (95% CI: 1.44, 3.48). Variables characterizing children less likely to be adequately immunized included father living in home with child, OR 0.53 (95% CI: 0.33, 0.85) and using private office-based primary care, OR 0.39 (95% CI: 0.23, 0.63).

CONCLUSIONS

Enrollment in MMC did not improve rates of immunizations when compared with FFSM.

Perceived access to pediatric primary care by insurance status and race

The Nemours system of children's clinics in Delaware was designed to offer comprehensive primary care (medical homes), to children regardless of families' abilities to pay for services. Racial and insurance status differences in perceptions of access to the provisions of medical home and differences by the Short Medical Home Index are assessed. A probabilities proportionate to size sampling method was used to randomly select families in nine clinics. A total of 323 caregivers of children ages 6 to 48 months were surveyed. Results suggest that there are minimal differences in perceptions of access to provisions of the medical home concept by insurance status and race in the clinics studied. However, when using a composite measure of medical home, differences in perceptions were found. The results suggest that insurance status and racial differences in perceptions of access remain even when the system is specifically designed to provide medical homes without regard to demographic factors. Future studies should focus on improving patient interactions with clinic personnel to ensure that access to provisions of care are understood by all consumers.

Effect of different types of Medicaid managed care on childhood immunization rates

Medicaid managed care can improve access to prevention services, such as immunization, for low-income children. The authors studied immunization rates for 7,356 children on Medicaid in three managed care programs: primary care case management (PCCM; n = 4,605), a voluntary HMO program (n = 851), and a mandatory HMO program (n = 1,900). Immunization rates (3:3:1 series) in PCCM (78%) exceeded rates in the voluntary HMO program (71%), which in turn exceeded those in the mandatory HMO program (67%). Adjusting for race, urban residence, and gender, compared to children in PCCM, children in the voluntary HMO program were less likely to complete the 3:3:1 series (OR = 0.75, CI = 0.63, 0.90), and children in the mandatory HMO program were even less likely to complete the series (OR = 0.59, CI = 0.51, 0.68). Results differed by individual HMOs. Monitoring of outcomes for all types of managed care by Medicaid agencies is imperative to assure better disease prevention for low-income children.

Exposure to immunization media messages among African American parents

BACKGROUND

African Americans have low immunization rates, yet little is known about their immunization knowledge, attitudes, and practices or about the effect of outreach to this audience. In Spring 1997, the California Department of Health Services (CDHS) launched a statewide culturally sensitive and ethnically specific media campaign directed toward African Americans. This campaign was preceded by a major Los Angeles County Department of Health Services media campaign.

OBJECTIVES

The objectives of this study were to (a) estimate exposure to immunization media messages among African Americans; (b) determine sources of immunization information; and (c) assess various immunization attitudes and beliefs in order to refine future outreach efforts.

METHODS

Following the CDHS media campaign, a random digit dial survey was conducted with 801 African American families with children under age 10. The sample was drawn from the four California regions with the highest African American birth rates. It included all zip codes in these regions with greater than 150 African American births per year. Lower bound response rates ranged from 62.5 to 76.1%. Higher income and education levels were overrepresented. Results were weighted to adjust for this.

RESULTS

Over 88% remembered seeing or hearing some form of immunization information. Exposure to television ads was reported by 63% followed by billboards (51%) and radio (42%). Sixty-two percent thought mild disease was possible after shots; 27% feared HIV from needles and 19% thought pain was a barrier. Respondents who cited money as a barrier (26%) were less likely to believe that shots were available for free (P = 0.02).

CONCLUSIONS

Media advertising is an effective tool for reaching African Americans. Addressing specific concerns (e.g., clarification of the circumstances and likelihood of getting a mild case of the disease following an immunization, availability of free shots, and risk of HIV) may contribute to increased immunization rates for this population.

The impact of a pediatric medical home on immunization coverage

This study assessed whether having access to provisions in the American Academy of Pediatrics "medical home" concept was associated with being age-appropriately immunized at 3, 12, and 24 months. Cross-sectional data on 495 Delaware children were collected from June 1994 to June 1995. Immunization status was determined with the Delaware immunization registry. The medical home was not significantly associated with immunization coverage. This study confirms that race, insurance status, maternal education, and family incomes are predictive of having poor immunization outcomes. Simply providing medical homes may not be an effective strategy to improve use of preventive services.

Immunization status of children enrolled in a hospital-based medicaid managed care practice: the importance of the timing of vaccine administration

OBJECTIVES

To evaluate the immunization status of children enrolled in a hospital-based Medicaid managed care practice and to assess the impact of the timing of vaccine administration on measured immunization rates.

DESIGN AND METHODS

The medical records of all children between the ages of 19 and 35 months who were continuously enrolled in the Medicaid managed care practice for the last 6 months of 1996 were reviewed. Immunization status was determined for the following vaccines: diphtheria-tetanus-pertussis/diphtheria-tetanus-acellular pertussis (4 doses); Haemophilus influenzae type b (3 doses); poliovirus (3 doses); hepatitis B (3 doses); measles-mumps-rubella (1 dose); and overall for the basic series. Two assessment methods were used to determine the immunization status of the study children: (1) a count of all documented vaccines ("count"); and (2) only including vaccines that met minimal age and spacing intervals based on American Academy of Pediatrics and CDC recommendations ("interval assessment").

RESULTS

With the count method vaccine-specific immunization rates ranged from 88 to 95%, with overall coverage of 80% for the basic series. With the interval assessment method vaccine-specific immunization rates ranged from 74 to 92%, with overall coverage of 53% for the basic series.

CONCLUSIONS

When all documented vaccines were included in the assessment, vaccine-specific immunization rates approached national goals, although overall coverage remained below 90% in this Medicaid managed care practice. The substantially lower immunization rates obtained by the interval assessment method demonstrate the importance of considering the issue of vaccine timing when interpreting immunization rates and the need for policies for revaccinating children who were immunized at less than recommended intervals. The results also have implications for provider education regarding the early administration of vaccines.

Use of social services by pregnant Medicaid eligible women in Baltimore

OBJECTIVES

To use linked health and social service databases to determine differences in the use of social services by pregnant women in different managed care systems.

METHODS

Comparison of service use by women enrolled in a fee-for-service primary care case management program (Maryland Access to Care or MAC), in a capitated health maintenance organization (HMO), or not assigned to managed care using six state databases. Participants included 5181 women receiving Medical Assistance (MA) and delivering in Baltimore City in 1993. Outcome measures were receipt of WIC, AFDC, and Food Stamps.

RESULTS

The overall proportions of women receiving WIC, AFDC, and Food Stamps at delivery were 52.7%, 89.2%, and 62.7%, respectively. Women enrolled in an HMO at delivery were less likely to be receiving WIC (adjusted odds ratios, 0.8, 95% CI, 0.69 to 0.93), AFDC (OR, 0.20; CI, 0.03 to 0.43 for women with prior children and OR 0.13; CI, 0.09 to 0.20 for women without prior children), and Food Stamps (OR 0.77; CI, 0.59 to 0.95 for women with prior children and OR, 0.49; CI, 0.35 to 0.67 for women without prior children) than their MAC counterparts. Women not assigned to managed care also generally were less likely than their MAC counterparts to receive WIC (OR 0.55; CI, 0.46, 0.66), AFDC (OR 1.07; CI 0.83, 1.30 for women with prior children and OR 0.24; CI 0.18, 0.34 for women without prior children), and Food Stamps (OR 0.31; CI 0.08, 0.55 for women with prior children and OR 0.31; CI 0.23, 0.41 for women without prior children).

CONCLUSIONS

Although many low-income pregnant women qualify for select social services, receipt of WIC and Food Stamps was low. Increasing efforts are needed by managed care systems and public health agencies to ensure delivery of appropriate services for women.

The role of state policies and programs in buffering the effects of poverty on children's immunization receipt

OBJECTIVES

This study assessed the influence of public policies on the immunization status of 2-year old children in the United States.

METHODS

Up-to-dateness for the primary immunization series was assessed in a national sample of 8100 children from the 1988 National Maternal and Infant Health Survey and its 1991 Longitudinal Follow-Up.

RESULTS

Documented immunization rates of this sample were 33% for poor children and 44% for others. More widespread Medicated coverage was associated with greater likelihood of up-to-dateness among poor children. Up-to-dateness was more likely for poor children with public rather than private sources of routine pediatric care, but all children living in states where most immunizations were delivered in the public sector were less likely to be up to date. Poor children in state with partial vaccine replacement programs were less likely to be up to date than those in free-market purchase states.

CONCLUSIONS

While state policies can enhance immunization delivery for poor children, heavy reliance on public sector immunization does not ensure timely receipt of vaccines. Public- and private-sector collaboration is necessary to protect children from vaccine-preventable diseases.

Early and periodic screening, diagnosis, and treatment and managed care

This paper presents evidence on the performance of Medicaid managed care organizations (MCOs) in providing Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services to children under age 21. States face considerable challenges in integrating EPSDT into managed care. For example, MCOs rarely offer all services required under federal law. Also, MCOs often are unable to meet state reporting requirements. On the other hand, MCOs offer children a medical home, often for the first time, that may encourage timely preventive care. The literature generally shows no differences in the performance of MCOs relative to traditional FFS providers in the EPSDT participation rate. Future needs include improving the specificity of contract language, more precisely defining the EPSDT benefit package, evaluating the adequacy of EPSDT payments, monitoring the capacity of MCO provider networks, establishing the effectiveness of outreach and enabling services, developing standardized MCO reporting requirements, documenting program outcomes, and assessing benchmarks for accountability.

Managed care and public health departments: who is responsible for the health of the population?

This review examines changes over the past decade in the delivery of health care in the United States, specifically the move toward managed care and capitation. Over 77 million Americans are now enrolled in health maintenance organizations, and the health care delivery system is reorganizing into large group practices and integrated health systems. Examined here are the implications of this shift on the interaction between managed care and public health agencies. How will a population-based system of health care be achieved in light of managed care organizations' responsibility only for their enrolled population, in contrast to the responsibility of the public health service for the entire population? Where does the responsibility of MCOs end and that of public health begin? Should certain public health functions be absorbed by managed care organizations? What are the prospects for partnership between these two systems?

The transition from Medicaid fee-for-service to managed care among private practitioners in New York City: effect on immunization and screening rates

OBJECTIVES

This study examined the association between participation in Medicaid managed care and up-to-date coverage for childhood immunizations and screenings among private practice physicians serving New York City's poorest neighborhoods.

METHOD

A random sample of 2174 children 3-35 months of age was drawn from 60 physician practices in 1995, and a cross-sectional analysis was used to compare up-to-date status for immunizations, and lead and anemia screening tests, for children cared for by managed care and nonmanaged care physicians. In 1996, an independent sample of 2380 children from the same practices was used to compare up-to-date status for individual children enrolled in Medicaid managed care and children predominantly enrolled in traditional fee-for-service Medicaid. Information from physician interviews augmented chart review data. Chi-square analysis and logistic regression were used.

RESULTS

Physicians who participate in Medicaid managed care and those who do not had equal up-to-date coverage for immunizations (41.0 vs. 36.9%, p = .527), and lead (46.8 vs. 38.7%, p = .199) and anemia screening (63.2 vs. 56.5%, p = .272). Measures of the process of care were also similar for the two groups of physicians. Children themselves enrolled in Medicaid managed care appeared significantly more likely to be up-to-date than their nonmanaged care counterparts for immunizations (OR = 1.53, p = .027) and anemia screening (OR = 2.95, p = .000).

CONCLUSIONS

Participation in managed care does not seem to change physicians' overall preventive care practice behavior. Available data did not reveal major differences in demographics or health status between individual children enrolled in managed care and those not enrolled. That children enrolled in managed care were better immunized and screened than those in fee-for-service Medicaid suggests that physicians receiving compensation under two payment systems may treat children differently depending on each child's mode of reimbursement.

Increasing immunization: a Medicaid managed care model

OBJECTIVE

To evaluate the impact of an immunization outreach program on immunization rates.

SETTING

A Pennsylvania independent practice association model managed care organization (100% Medicaid).

DESIGN

Retrospective cohort study (N = 2511) of children 30 to 35 months of age from two age cohorts that compared immunization rates for Advisory Committee on Immunization Practices schedules for diphtheria-tetanus-pertussis, oral polio vaccine, measles-mumps-rubella, and Haemophilus influenza type b. An evaluation of the outreach component of the program compared treatment and nontreatment subgroups of one age cohort (N = 1002).

INTERVENTION

The immunization program targeted approximately 19 000 members from birth to 6 years of age. The program components included computerized tracking and reminders, member and provider education, provider incentives, member incentives, and home visiting outreach.

RESULTS

Data indicate that the treatment group has higher completed immunization rates at 35 months of age than does the control group. Furthermore, data show that members with home visits have significantly higher completed immunization rates than do other members. The corresponding comparisons for age-appropriate immunizations by 24 months indicate a nonsignificant trend of increased rates.

CONCLUSION

The data provide evidence supporting a correlation between comprehensive strategies (computerized tracking, member and provider education and incentives, and home visiting) and increased immunization rates. Those individuals who received home visits were more likely to complete an immunization series by 35 months of age than those who did not. However, within the Mercy Health Plan program, age-appropriate immunizations are not significantly affected by home-visiting outreach.

Financial performance of safety-net hospitals in a changing health care environment

Safety-net hospitals serving the poor and indigent in inner-cities have received inadequate research attention regarding the determinants of their financial performance in the changing health care environment. We analyze how the 1990-92 financial performance of 275 such hospitals is related to exogenous and endogenous factors such as payer mix, service mix, staffing and ownership. Models of hospital financial performance are developed using operating margin, cost per discharge and revenue per discharge as measures of performance. Stepwise regression is used to test the model with data from the American Hospital Association (AHA) and Health Care Investment Analysts (HCIA). Results suggest that: 1) The profitability of inner-city hospitals appears positively related with technical complexity of care; 2) High interest and low operating surplus may constrain the addition of technically sophisticated services to enhance profitability; 3) There is some evidence that new governmental programs, e.g. Medicaid managed care and Medicaid Diagnosis Related Groups (DRGs), may not have improved operating margins, though Medicaid DRGs appear to have contained costs. Follow-up research is needed on this issue; 4) Given external fiscal realities, internal management strategies for inner-city hospitals require research, e.g. developing appropriate managed care systems and timely expansion of sub-acute services and; 5) Services such as AIDS treatment and community health education represent opportunities to respond to community needs, especially since unit cost of such services will decline with high volume.