Effects of Managed Care Enrollment
on Publicly Insured Children with
Chronic Health Conditions
Amy J. Davidoff, Ph.D.
University of Maryland Baltimore County
University of Maryland School of Pharmacy
Presented at the Annual AcademyHealth Meeting,
Seattle, WA
June 25, 2006
Funded by a grant from the Maternal and Child Health
Bureau
Setting the stage
• Managed care (MC) dominant financing, delivery
mechanism in Medicaid, SCHIP
• Incentives in MC => improved access, use for
primary, preventive care
• Concerns about impacts for children with chronic
conditions
–
–
–
–
Disrupt existing provider relationships
Inadequate expertise
Hoops
Skimping?
• Need to understand MC impacts, by program type,
on children with chronic conditions
Previous studies provide limited
information on managed care for children
with chronic conditions
• Most studies evaluate state specific programs
for SSI recipients
– Often lack control or comparison groups
– Don’t permit comparisons across program types
– Results mixed
• National cross-plan estimates - don’t address
differential effects by health status
Study by Hill et al. (2002) provides
useful framework, hypotheses
• Qualitative study of Medicaid programs, 8
states
• FFS – lacks coordination
• Mainstream PCCM, capitated plans
– Adequate primary, specialty care
– Poor ID of children, lacked non-medical
wraparound
• Mainstream plans with carveouts – create
confusion
• Special programs for children with chronic
conditions perceived positively
Analytic Approach
• Estimate linear probability models, DD interpretation
Access/Use = a0 + a1 CC + a2 MCtype
+ a3 CC*MCtype + a4 X + e
• CC = indicator for child w/ chronic condition
• MCType = vector MC program types
– PCCM, capitated w/ & w/o carveout, special programs
– reference is FFS
– focus on mandatory
Data
• Household survey data:
– National Health Interview Survey (NHIS),
1997 - 2002
• Data on managed care plan type abstracted
from multiple sources
– CMS Medicaid Managed Care Enrollment
Reports
– SCHIP state plans
– Urban Institute, NASHP surveys
Data on Managed Care Plan Type
(cont.)
Captured information on
• Type of MC program, service carve outs
• Counties operational
• Inclusion of SSI recipients, others with special
needs
• => Medicaid/SCHIP, county, year, health
status specific database of MC program types
• Linked to NHIS along multiple dimensions
Study population
• Children w/ & w/o chronic conditions
– children w/ chronic conditions identified
through
• Condition checklist
• Activity limitation, caused by condition lasting
>= 1 year
• Reported sad or unhappy most of time, past 6
months
• Eligible & Enrolled in Medicaid or SCHIP
• Used detailed algorithm that applies state specific
eligibility rules to ID likely eligibles
Effects of Mandatory Capitated Programs without
Carveouts, Children w/ CC
0.010
Specialist
MH Visit
Eye Care
>= 10 visits
Regular Rx
ER Visit
Hospital Stay
0.000
-0.009
0.001
-0.010
-0.020
-0.031*
-0.032
-0.030
-0.042*
-0.040
-0.050
-0.060
-0.072*
-0.076*
-0.070
-0.080
Source: Davidoff et al. analysis of 1997-2002 NHIS
Effects of Mandatory Capitated Programs with Carveouts,
Children w/ CC
0.000
-0.020
-0.043
-0.039*
-0.040
-0.053*
-0.064*
-0.079*
-0.060
-0.078*
-0.080
-0.096*
Hospital Stay
Specialist
MH Visit
Eye Care
>= 10 visits
Regular Rx
-0.100
ER Visit
-0.120
Source: Davidoff et al. analysis of 1997-2002 NHIS
Effects of Mandatory Special Programs, Children w/ CC
0.050
Specialist
MH Visit
Eye Care
>= 10 visits
Regular Rx
0.043
ER Visit
Hospital Stay
0.040
0.042
0.035
0.030
0.021
0.024
0.020
0.010
0.000
-0.009
-0.010
-0.018
-0.020
-0.030
Source: Davidoff et al. analysis of 1997-2002 NHIS
Magnitude of reductions large
relative to FFS reference group
E.g. for capitated plans w/ carveout:
• 7.9 percentage point reduction in
probability of specialist visit = 27%
reduction
• 3.9 percentage point reduction in
probability of hospital stay = 30%
reduction
• Study Limitations
Study limitations
• Managed care policy assigned, not reported
– Gap between enrollment, assignment =>
downward bias
– Eliminates selection bias related to voluntary
enrollment, exceptions, transitions
• Does not address selection into public
insurance
• Limitations of self reported HH survey data
Conclusions
• Mandatory enrollment in capitated programs
– reduced ER visits, hospital stays
– suggests improved outpatient management
• Also reduced specialist, mental health,
prescription drug use
• Failure to find increased access problems
suggests appropriate reductions
Conclusions (cont.)
• Reductions in use more pronounced with
carveouts
– Consistent with expectations
– Additional research to probe incentives, systems
• Effects of special programs difficult to
interpret
– Not different from FFS
– Affected sample small