Are there differential effects of Medicaid and SCHIP managed care on children with chronic conditions?
- Presenter:
Chair: Ciaran Phibbs; Discussant: Ciaran Phibbs Wed June 7, 2006 9:45-11:15 Room 213
Rationale: Results of recent studies examining effects of Medicaid managed care have been mixed, with various studies reporting small reductions in ER use and hospitalizations, and increases in outpatient visits. The effects of managed care may be particularly strong for children with chronic health conditions, for whom managed care organizations have strong incentives to manage care and control costs. Alternatively, baseline use by these children may be appropriate, and managed care may exert its effects by disrupting established provider relationships. The use of behavioral health or specialty carveouts to capitated plans may further interfere with care coordination.
Objectives: To examine effects of different types of mandatory managed care programs, including use of carveouts, on children with and without chronic health conditions enrolled in Medicaid or SCHIP .
Methodology: Data on child characteristics, health status, and access and use of healthcare services are from pooled National Health Interview Survey data (1997-2002.) Data on Medicaid and SCHIP managed care program types, areas served, populations covered, and use of carve outs were collected from annual CMS Medicaid Managed Care Enrollment Reports, state specific SCHIP plans, and an Urban Institute survey of managed care implementation. A county and year specific database was created on type of managed care and whether enrollment was mandatory for children generally, and for SSI recipients or other children with chronic conditions. Managed care data were linked to children eligible for Medicaid or SCHIP, with program specific eligibility determined by application of state and year specific eligibility rules. Linear probability models were estimated for all publicly insured children, with a vector of managed care program types, child health status, and interactions between them, with controls for child, family, area characteristics, state and year.
Results: For children without chronic conditions, few managed care plan effects were significant relative to FFS. Mandatory capitated or mixed PCCM/capitated programs were associated with increased likelihood of using prescription medication. In contrast, for children with chronic conditions, mandatory PCCM and mixed mandatory PCCM/capitated programs without carve outs were associated with fewer physician visits, any specialist visits, ER use, hospital stays, and prescription drug use. When carveouts were present, effect sizes were smaller, and only the negative effects on physician visits, specialist visits and prescription drug use were significant.
Conclusions: Although managed care delivery systems may affect perceived access and use of preventive and acute services for generally healthy children, the results of this analysis suggest that the effects operate primarily on children with chronic health conditions. Mandatory enrollment in managed care, both PCCM and capitated plans, was associated with reductions in use of a variety of services. It is not possible to tell whether these changes resulted in more appropriate use of services. However, we did not observe a corresponding increase in reported unmet need for medical care or prescription drugs, thus, the net change may represent an improvement in care. Additional focus on quality and appropriateness effects of managed care on children with chronic conditions is warranted.
