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 = 0 + 1 CC + 2 MCtype + 3 CC*MCtype + 4 X +

• 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

-0.009

-0.032

0.001

-0.072*

-0.042*

-0.031*

-0.076*

-0.080

-0.070

-0.060

-0.050

-0.040

-0.030

-0.020

-0.010

0.000

0.010

Specialist MH Visit Eye Care >= 10 visits Regular Rx ER Visit Hospital Stay

Source: Davidoff et al. analysis of 1997-2002 NHIS

Effects of Mandatory Capitated Programs with Carveouts, Children w/ CC

-0.043-0.039*

-0.096*

-0.053*

-0.064*

-0.078*-0.079*

-0.120

-0.100

-0.080

-0.060

-0.040

-0.020

0.000

Specialist MH Visit Eye Care >= 10 visits Regular Rx ER VisitHospital Stay

Source: Davidoff et al. analysis of 1997-2002 NHIS

Effects of Mandatory Special Programs, Children w/ CC

0.0240.021

-0.009

0.0420.043

-0.018

0.035

-0.030

-0.020

-0.010

0.000

0.010

0.020

0.030

0.040

0.050

Specialist MH Visit Eye Care >= 10 visitsRegular Rx ER Visit Hospital Stay

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