Determinants of enrollment among applicants to PACE

During the 1970s and 1980s, a new approach to the integration of acute and long-term care (LTC) services was conceived and refined at On Lok, an organization in the Chinese community of San Francisco. Since then, On Lok and 10 Federal demonstration sites have tested this model which is today called the Program of All-Inclusive Care for the Elderly (PACE). This program has gained considerable political support and as a result, the 1997 Balanced Budget Agreement establishes PACE as a permanent provider under Medicare. The Federal demonstration of PACE was designed as a voluntary program. By exploiting its voluntary enrollment design, this study analyzes the determinants of program participation within a group of screened applicants. Findings of this study support the theory that the capitated payment structure of PACE creates incentives for program staff to avoid costly individuals. However, home ownership and provider attachment also act as important and significant barriers to enrollment.

Managing access: extending Medicaid to children through school-based HMO coverage

This study explores how a health maintenance organization's (HMO) capacity and incentives to manage care might be used to improve access. In the early 1990s, the Florida Healthy Kids (FHK) demonstration extended Medicaid-like HMO coverage to indigent children in the public schools of Volusia County, Florida. The study finds that uninsured student months in area public schools were likely reduced by one-half. Utilization and cost levels for these indigent enrollees proved to be indistinguishable from commercial clients; and measures of access, utilization, and satisfaction for enrollees were in line with (and in some cases, superior to) non-enrollees with private insurance. Overall, these results suggest the value of using schools as a medium for providing coverage, and the importance of taking deliberate steps to manage access to reduce non-financial barriers to care.