The Impact of SCHIP Enrollment and Managed Care
Organizational Characteristics on Preventive Care
Background
„
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)
„
„
„
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 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)
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
„
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)
Health and Sociodemographic Characteristics
70%
60%
50%
40%
30%
20%
10%
0%
Special Needs
White nonHispanic
Black nonHispanic
Time 1
Hispanic
Other
Time 2
1
Risky Behaviors
Health Care Experiences: Time 1 and Time 2
60%
50%
40%
30%
20%
10%
0%
Depressed
Smoking
Sexual Activity
Time 1
CHIP
Enrollment
Alcohol Use
Seat Belt Use
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
% Usual Source of Care
% Preventive Care
T ime 2
Time 1
% Private Visit
% Counseling
Time 2
Odds Ratio = 1.8-1.9
SCHIP Enrollment Influences:
Physician
Visit?
Odds Ratio = 0.65
Risk
Behaviors
„
Usual Source of Care
„
Private Visit
„
Counseling
Privacy |
Visit
Our Recursive
Statistical Model
„
Odds Ratio = 2.85
Odds Ratio = 1.66
„
Counseling
Usual Source
of Care
„
Teens
who
Enrollees
Enrollees
arehave
are
35%
Enrollees
are 66%
privacy during
their
80-90%
less likely
moretolike
get to
visits are
almost
threea
more
likely
to have
have
counseling
privacy
during
during
times
as
likely
to
usual source of care.
their
a counseling.
visit.
visits.
receive
MCO
Characteristics
66% greater odds of a usual source of care
1.9 times more likely to have a private visit
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.
SCHIP ENROLLMENT
CHIP
Enrollment
MCO Characteristics Influence:
Physician
Visit?
„
Risk
Behaviors
-
Privacy |
Visit
Odds Ratio = 1.74
Usual Source of Care
„
„
Receipt of Counseling During Visit
„
Counseling
Usual Source
of Care
Odds Ratio = 2.4
Profiling
Odds Ratio = 2.0
1.6
No Prior Authorization
MCO
Characteristics
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
usual
tosource
receiveof
fewercounseling.
risky behaviors.
counseling.
care.
„
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
MCO CHARACTERISTICS
2
Hispanic
Odds Ratio = 0.58
CHIP
Enrollment
Physician
Visit?
Black Non-Hispanic
Odds Ratio = 0.60
Sociodemographic Characteristics
Influence:
„
Risk
Behaviors
Privacy |
Visit
„
„
Age
Hispanic
Odds Ratio = 0.34
„
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
to report
having
aa
report
report
having
having
a preventive
a usual
private
visit.
preventive
care
visit.
source
care of
visit.
care.
MCO
Characteristics
CHIP
Enrollment
„
Odds Ratio = 2.3
Physician
Visit?
ASHCN
Odds Ratio = 2.0
Other Influences:
„
Privacy |
Visit
Odds Ratio = 1.74
„
„
„
Odds Ratio = 2.85
Preventive Care Visits
„
Counseling
„
„
Usual Source
of Care
MCO
Characteristics
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
health
needs,
she
isis
additional
careteen
needs
are
behavior
more
than
twice
1.7
times
as
likely
more
to
likely
have
a
2.6
times aaspreventive
likely
to
having
times
likely
to to
preventive
receive
counseling.
care visit.
receive
counseling.
receive
care
counseling.
visit.
Depression – 2 times more likely to have a visit
If ASHCN – 2 times more likely to have visit
Counseling
Odds Ratio = 2.57
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
OTHER FACTORS
Summary
„
Odds increase with age
SOCIODEMOGRAPHIC
CHARACTERISTICS
Risk
Behaviors
„
Hispanics – 42% less likely
Black non
- Hispanics – 40% less likely
Privacy During Visit
„
Depression
„
Hispanics – 66% less likely than White
non
- Hispanic children
Preventive Care Visits
„
Counseling
Usual Source
of Care
Usual Source of Care
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
3