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APHA Scientific Session and Event Listing

Recorded presentation

Amy J. Davidoff, PhD¹, Ian T. Hill, MPA, MSW², Brigette M. Courtot, BA², and Emerald Adams². (1) Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, 14th floor, Baltimore, MD 21201, (2) Health Policy Center, The Urban Institute, 2100 M Street, NW, Washington, DC 20037, 202/261-5374, ihill@ui.urban.org

Children with chronic health conditions (CWCHC) are increasingly enrolled in mandatory Medicaid or SCHIP managed care (MC) programs. The effects of MC may be particularly strong for CWCHC, as they have extensive service needs, while capitated MC plans have strong financial incentives to both coordinate and limit care. The addition of behavioral health or specialty “carve-outs,” while intended to direct children to appropriate systems of care, may create fragmentation and access barriers. MC programs designed specifically for CWCHC may ameliorate negative effects. The objective of this study is to examine the effect of different types of mandatory MC programs on CWCHC. Pooled data from the National Health Interview Survey (1997-2002) were supplemented with county, year, and population specific data on Medicaid and SCHIP MC program types. CWCHC were identified based on parent report of diagnosed conditions or activity limitations. Linear probability models estimated the effects of MC program types relative to FFS on access and use for publicly insured children, with and without CHC. Relative to FFS, mandatory capitated programs without carve-outs are associated with decreased physician visits, reduced likelihood of a specialist visit (-7.2%), ER visits (-7.6%) and hospital stays (-3.1%). When MC programs include carve-outs we also observe reduced probability of mental health specialty visits (-7.8%), vision care visits (-6.4%) and prescription drug use (-9.6%). Special MC programs for CWCHC are associated with increased physician visits. Few significant effects are identified for children without CHC. Our results suggest that the effects of MC in Medicaid and SCHIP operate primarily on CWCHC. Relative to FFS, mandatory MC programs are associated with reduced use of services commonly used by CWCHC. The addition of behavioral health or specialty carve-outs is associated with even greater reductions in use. Reductions in ER and hospital use are suggestive of improved outpatient management; it is not possible to determine whether reductions in other 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. Much debate surrounds the issue of whether MC improves coordination and integration of care for CWCHC or whether incentives to control costs lead plans to under-serve these vulnerable children. This study suggests that MC is associated with improved outpatient management without increases in unmet need, and that specialty managed care models can facilitate access to physician care.

Learning Objectives: At the conclusion of the session the learner will be able to

• identify the various types of managed care programs used in Medicaid and SCHIP programs
• articulate potential mechanisms through which managed care can affect access to care and use of services for children with chronic conditions
• identify key effects of managed care plans on access and use that were supported by study findings

Keywords: Health Care Managed Care, Access to Care

Presenting author's disclosure statement:

Any relevant financial relationships? No

Recorded presentation