The Impact of SCHIP Enrollment and Managed Care Organizational Characteristics on Preventive Care Elizabeth Shenkman, PhD Bruce Vogel, PhD Lise Youngblade, PhD The University of Florida June 2004 Funded by the Agency for Healthcare Research and Quality (AHRQ) with co-funding from the David and Lucile Packard Foundation, and the Health Resources and Services Administration (AHRQ No. HS10463) Background Adolescents at risk for morbidity and mortality – risky behaviors Preventive care visits Privacy Counseling SCHIP contract with managed care organizations (MCOs) to form provider network and deliver services Does SCHIP and the MCOs’ organizational characteristics influence preventive care, privacy, and counseling? Study Design Longitudinal follow-up of 11.5 to 17 year olds newly enrolled in SCHIP and one year postenrollment Adolescent interviews Demographic characteristics Risky behaviors – drinking, sexual activity, depression, seat belt use Preventive care visits Counseling during visits Study Design MCO Characteristics For profit, not-for-profit Percentage of providers reimbursed fee-for-service (FFS) Adolescents with special health care needs (ASHCN) exempt from prior authorizations Provider profiling for quality standards Prior authorization required for referrals Allows specialists to function as primary care providers (PCPs) Study Sample 918 SCHIP enrollees Time 1 502 at Time 2 No significant differences in age, presence of special needs, family income, or gender Mean age 14.2(1.6) Mean income $22,794($8,811) Health and Sociodemographic Characteristics 70% 60% 50% 40% 30% 20% 10% 0% Special Needs White nonHispanic Black nonHispanic Time 1 Time 2 Hispanic Other Risky Behaviors 60% 50% 40% 30% 20% 10% 0% Depressed Smoking Sexual Activity Time 1 Time 2 Alcohol Use Seat Belt Use Health Care Experiences: Time 1 and Time 2 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% % Usual Source of Care % Preventive Care Time 1 % Private Visit Time 2 % Counseling CHIP Enrollment Odds Ratio = 1.8-1.9 Physician Visit? Odds Ratio = 0.65 Risk Behaviors Odds Ratio = 1.66 Privacy | Visit Our Recursive Statistical Model Odds Ratio = 2.85 Counseling Usual Source of Care MCO Characteristics Teens who have privacy Enrollees Enrollees areare 35% Enrollees 66% during theirare visits are 80-90% less likely moretolike get to almost threeto times more likely haveasa have counseling privacy during during likely to receive usual source of care. their a visit. visits. counseling. SCHIP ENROLLMENT SCHIP Enrollment Influences: Usual Source of Care Private Visit 66% greater odds of a usual source of care 1.9 times more likely to have a private visit Counseling SCHIP directly reduces the likelihood of counseling BUT increases the likelihood of privacy, which increases the likelihood of counseling. The effects seem to offset each other. CHIP Enrollment Physician Visit? Risk Behaviors - Privacy | Visit Odds Ratio = 1.74 Counseling Usual Source of Care Odds Ratio = 2.4 Profiling Odds Ratio = 2.0 1.6 No Prior Authorization MCO Odds Ratio = 2.0 For Profit Teens Teens plans plans that where use Teensinin for-profit Teens ininplans where CSHCNs provider quality are exempt profiling from plans areare twice as likely CSHCNs exempt from are prior 2.4authoriziation times more likely are prior utilization have to report receiving totwice report as alikely usualtosource receiveof fewercounseling. risky behaviors. counseling. care. Characteristics MCO CHARACTERISTICS MCO Characteristics Influence: Usual Source of Care Receipt of Counseling During Visit Provider quality profiles – 2.4 times more likely For-profit – 2 times more likely CSHCN exempt from prior authorization – 1.6 times more likely No other MCO influences seen Hispanic Odds Ratio = 0.58 CHIP Enrollment Physician Visit? Risk Behaviors Black Non-Hispanic Odds Ratio = 0.60 Privacy | Visit Age Counseling Usual Source of Care Hispanic Odds Ratio = 0.34 MCO Characteristics Black non-Hispanics teens Hispanic teens are 42% 66% Older teens are more are less likely than less40%, likely than White likely than younger teens White non-Hispanic non-Hispanic teensteens to to report having a to report having a report report having having a preventive a usual private visit. preventive care visit. source care of visit. care. SOCIODEMOGRAPHIC CHARACTERISTICS Sociodemographic Characteristics Influence: Usual Source of Care Preventive Care Visits Hispanics – 66% less likely than White non-Hispanic children Hispanics – 42% less likely Black non-Hispanics – 40% less likely Privacy During Visit Odds increase with age CHIP Enrollment Odds Ratio = 2.3 Physician Visit? ASHCN Depression Odds Ratio = 2.0 Risk Behaviors Privacy | Visit Odds Ratio = 1.74 Odds Ratio = 2.85 Odds Ratio = 2.57 Counseling Usual Source of Care MCO If Depressed the visit isteens private, are teen has special Teens A teen with having special one health twice the ascare likely isrisk almost to report three additional careteen needs are behavior more than health needs, she isis twice 1.7 times as likely tolikely have a 2.6 times more likely to having times aas preventive likely to to preventive receive counseling. care visit. receive counseling. receive care counseling. visit. Characteristics OTHER FACTORS Other Influences: Preventive Care Visits Depression – 2 times more likely to have a visit If ASHCN – 2 times more likely to have visit Counseling If the visit is private – 3 times more likely to get counseling If ASHCN – 2.5 times more likely to get counseling One reported risk behaviors 1.7 times more likely to get counseling than those with none. See increasing odds with increasing numbers of risk behaviors Summary SCHIP improves access to usual source of care and private visits Limited number of MCO characteristics important for usual source of care and counseling Black non-Hispanic and Hispanic children remain at risk after enrollment for not having a usual source of care or receiving a preventive care visit Summary Health status – presence of special needs, reporting feelings of depression important for visits Physicians targeting counseling towards those with risky behaviors and not all adolescents Ensuring privacy during visits very important Strongest effects on preventive care, privacy and counseling related to individual adolescent characteristics