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