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* Georgetown Public Policy Institute, Georgetown University, Washington, District of Columbia
Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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ABSTRACT |
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 TOP ABSTRACT BACKGROUNDMETHODSRESULTSDISCUSSIONREFERENCES |
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Objective. To examine how enrollment of children with SHCN with SSI into a Medicaid capitated managed care plan differs from regular FFS with respect to unmet needs and access to care in the District of Columbia.
Design, Setting, and Participants. We conducted telephone interviews with a random sample of 1088 caregivers of children with SHCN who resided in the District of Columbia during the summer and fall of 2002.
Main Outcome Measures. 1) Usual source of care; 2) unmet need for the following services during the 6-month period prior to the interview: physician/hospital, mental health, therapy services, dental care, durable medical equipment and supplies, prescription drugs, and home health services; and 3) caregivers' ratings of dimensions of access to services.
Results. The percentage of FFS children who did not receive needed dental care, durable medical equipment/supplies, or prescription drugs was significantly larger than the percentage of children enrolled in the capitated managed care plan. We found no significant differences by plan type in unmet need for physician/hospital care, mental health services, home health service, or therapy services.
The most problematic areas of access seem to be "wait time between making an appointment and the actual visit," "waiting time in the doctor's office," "office hours for appointments," "getting medical advice by phone," and "getting specialist's care if needed." For each of these dimensions of access, children in the FFS system experienced significantly more of such access problems, compared with children in Health Services for Children With Special Needs (HSCSN). These 4 dimensions of access cause problems for 18% to 29% of FFS parents but only 13.6% to 22.3% of caregivers with a child in HSCSN. Three other dimensions of access, "convenience of doctor's office," "getting emergency care if needed," and "getting hospital care if needed," also seemed to pose significantly more problems for caregivers with children in FFS plans, compared with those in HSCSN. These dimensions of access were only problematic for 9% to 14% of FFS caregivers and 5.9% to 7.7% of caregivers with children enrolled in HSCSN.
Conclusions. Children in the managed care option have lower levels of unmet need than children in FFS plans. Caregivers of children in FFS plans encountered more difficulties in navigating the health care system, compared with those with children in managed care. We conclude that a combination of factors that characterize the capitated managed care plan are responsible for improving access to care and mitigating the level of unmet need among children with SHCN. These include the comprehensive care plan assessment, ongoing case management, primary care providers' gatekeeping role, and higher physician reimbursement.
Key Words: Medicaid • managed care
Abbreviations: MC, managed care • FFS, fee-for-service • SHCN, special health care needs • BBA, Balanced Budget Act • SSI, Supplemental Security Income • PCP, primary care provider • ABC, Access to Better Care • MAA, Medical Assistance Administration • HSCSN, Health Services for Children With Special Needs
Enrollment in Medicaid managed care (MC) has grown rapidly in recent years, as most states have replaced their fee-for-service (FFS) approach with some form of MC. In 2002, 57.6% of Medicaid beneficiaries were enrolled in MC plans, ie, either capitation or primary care case management.1 Relatively few states have required that children with special health care needs (SHCN) enroll in capitated MC plans, because the financial incentives to control costs that are inherent in such plans may elicit undertreatment, restrict access to specific procedures, services, and specialty providers, disrupt established relationships with providers, and have adverse effects on quality.2,3 Moreover, the utilization controls that characterize capitated plans may generate onerous paperwork and administrative requirements. Although the Balanced Budget Act (BBA) of 1997 permitted states to enroll their Medicaid populations into MC plans without a waiver, federal policy-makers were so concerned about the potentially deleterious effects that MC might have for certain vulnerable populations that they specifically excluded most children with SHCN.4
Despite these concerns, enrolling all children with SHCN in a capitated MC plan has some advantages over the FFS approach.5,6 These advantages include 1) the system capacity to better coordinate services important to children with SHCN, 2) an ongoing relationship of each child with a primary care provider (PCP), 3) easy access to needed specialists (although the PCP is able to monitor referrals to specialists), 4) ease of record sharing, and 5) potential cost savings from coordination of care and elimination of duplicate or unnecessary services.
There are also advantages to serving all children with SHCN in the FFS system. These include 1) access to a larger pool of specialists and other providers, 2) increased choices available to the child and family, and 3) the ability to continue to receive services from the same providers without seeking prior approval.5,6 The FFS approach has some disadvantages, however. For example, often there is no one available to help the family coordinate and obtain all needed services. This may result in a duplication of services among providers. This tends to make children's care more expensive with FFS approaches than with capitated MC plans. Moreover, if children routinely obtain services from a large clinic, they may not be treated by the same providers each time.
As of October 1999, 35 states and the District of Columbia had requested permission to enroll children with SHCN into capitated Medicaid MC plans.7 Because there is considerable uncertainty regarding whether the capitation approach can work for children with SHCN, it is critical to evaluate the performance of such programs. Assessing the effects of capitation on children with SHCN is difficult, however, because of the lack of specific criteria for identifying this vulnerable population of children. The BBA provided some assistance to states in this matter. Under the BBA, children with SHCN include those who qualify for at least 1 of 5 federally funded programs, namely, Title V, Supplemental Security Income (SSI), federal foster care or adoption assistance under Title IV-E of the Social Security Act, foster care or out-of-home placement funded from other sources, or the Katie Beckett waiver program.
Because states are not required to keep track of all children who satisfy the criteria for the 5 categories outlined in the BBA, researchers frequently lack data on whether children are enrolled in such programs. As an alternative approach, researchers have relied on a variety of criteria to identify children with SHCN, such as functional status,8 limitations in activities of daily living,9 use of services,10 type of health condition,11 or some combination of these criteria. By using multiple criteria to define children with SHCN, researchers and policy-makers are able to overcome the inherent limitations of relying on a single measure to identify such children.
Although children with SHCN are particularly vulnerable to any limitation or disruption of service, little research has addressed how children with SHCN fare in Medicaid MC plans.6 Given the widespread growth of MC, research examining the effects of Medicaid MC on the use of services, access to care, and quality of care for children with SHCN is clearly warranted.6 In this study, we address this gap in knowledge. Specifically, we examined how enrollment in a Medicaid capitated MC plan versus the traditional FFS approach affected unmet needs for services and dimensions of access for children with SHCN in the District of Columbia. The District of Columbia defines children with SHCN as those who qualify for SSI because of a disability. The Social Security Administration considers a child disabled if he or she has a physical or mental condition or conditions that can be medically proven and that results in marked severe functional limitations; the condition must have lasted or be expected to last 
12 months or to end in death. In addition, the household income must not exceed a threshold amount.
Our research represents an important contribution to the sparse literature on this subject for at least 2 reasons. First, nearly all previous research on children enrolled in Medicaid MC plans has attempted to address questions regarding unmet needs and dimensions of access with claims data. Evaluation of unmet needs and access to care by using claims data is problematic, because the claims data indicate only utilization. Medicaid service use reflects the availability and accessibility of services, outreach efforts, and medical needs. Claims or encounter data provide no information on children who needed care but were unable to obtain services. We could evaluate unmet needs and access to care because the data we analyzed were collected via telephone interviews with random samples of parents/guardians of children with SHCN who actually received care, as well as parents/guardians who wanted to obtain care for their children but for some reason were unable to do so.
Second, the Medicaid MC plan for children with SHCN in the District of Columbia, known as Health Services for Children With Special Needs (HSCSN), is responsible for administering and providing a comprehensive set of services to its enrollees. Although a few other states have implemented either a capitated MC plan or a primary care case management option for children with SHCN, those plans typically include carve-outs for major categories of services, such as mental health and dental care. Because this is not the case with HSCSN, our analyses can provide important insights regarding the implications of including a comprehensive array of services in the administration of the MC plan.
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BACKGROUND |
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TOPABSTRACTBACKGROUNDMETHODSRESULTSDISCUSSIONREFERENCES |
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14% did not receive needed home health services, and almost 10% did not receive mental health services. More recent data from the 2001–2002 National Survey of Children with Special Health Care Needs, conducted by the Maternal and Child Health Bureau and the National Center for Health Statistics,13 demonstrated much lower rates of unmet needs. Approximately 11.6% of children with SHCN experienced unmet needs for health care services during a 12-month period. Unmet needs for dental care were the most common, affecting 8% of children. Less than 5% of children experienced unmet needs for mental health services, and even smaller percentages experienced unmet needs for specialty care, therapy services, or preventive care. Although this recent evidence documents the prevalence of unmet needs among children with SHCN, the studies did not evaluate whether unmet needs varied according to type of insurance coverage. Policy-makers recognize that the shift to Medicaid MC is likely to have the most profound effects on poor children with chronic or disabling conditions, because this group of children must rely on a wide array of physicians and specialty care providers.2 Although children with SHCN are particularly vulnerable to any limitation or disruption in service, little research has addressed how children with SHCN fare in Medicaid MC plans.6 We provide a brief review of this sparse literature below.
The Ohio Medicaid program developed the Access to Better Care (ABC) program as a 1915-B waiver demonstration, in which children with SHCN who received SSI were permitted to voluntarily enroll in MC plans. Grossman et al14 reported that, after the first 1 year of operation, only 46 of 3000 eligible children with SHCN were enrolled. Although the number of hospitalizations decreased significantly between the pre-ABC and ABC periods, there was no difference in the costs per month for outpatient, inpatient, urgent emergency department, or nonurgent emergency department care between the 2 periods. High users of care in the pre-ABC period were found to be high users during the ABC period. These results cannot be generalized, because the enrollment rate was extremely low; only 1% of eligible children enrolled in the program. The state of Ohio recently eliminated this program.
Abt Associates15 conducted an evaluation of the District of Columbia Medicaid initiative for children with SHCN after the program had been operational for 3 years. The Abt Associates researchers conducted a survey with caregivers during a 17-month period (June 1998 through October 1999). Because Abt Associates evaluated this MC initiative during the demonstration period, their results indicate short-term rather than long-term effects. Moreover, the demonstration period can be regarded as a time of transition, during which the capitated MC plan was evolving and workers were learning how to best meet the needs of this population of disabled children. The Abt Associates researchers found that, among all children, the proportions experiencing unmet needs ranged from 1.1% for hospital services to 13.4% for dental care. Almost 9% of all caregivers reported that the child experienced >1 unmet need. The Abt Associates researchers compared unmet needs for specific services according to plan choice (HSCSN versus FFS). Although FFS enrollees were more likely to report unmet needs than were HSCSN participants for 8 of the 12 services in question, the differences in unmet needs for 11 of the 12 services examined were not statistically significant. The 1 exception was the need for therapy services, which was significantly higher for FFS enrollees (14.9%), compared with HSCSN participants (10.0%). Moreover, the Abt Associates findings indicated that, except for dental and therapy services, <10% of children in either plan experienced unmet needs for the services in question.
The only other recent study comparing how children with SHCN fare in Medicaid MC versus Medicaid FFS plans was based on 1999 survey data from Oregon. Mitchell et al16 examined the frequency of unmet needs among children with disabilities in MC versus FFS plans and found no differences between the 2 groups of children with respect to the ability to see a specialist, obtain dental care, or obtain prescription drugs. Moreover, those authors reported that MC and FFS enrollees experienced similar 12-month utilization rates for hospital, physician, dentist, and prescription drug services.
Overview of HSCSN
Between 1996 and 2002, Medicaid MC penetration in the District of Columbia increased from 55% to 63%. As part of this expansion, the District of Columbia created a special MC program for children who qualify for Medicaid because they receive SSI because of a disability. (As noted above, defining children with SHCN as those who qualify for SSI because of a disability is only 1 approach for identifying this group of children.) The primary goal of the District of Columbia Medical Assistance Administration (MAA) was to improve both the delivery and cost-effectiveness of services for this high-cost group of enrollees. These children are not eligible for regular Medicaid MC plans in the District of Columbia. Medicaid officials, with the Hospital for Sick Children, decided to implement a MC plan (HSCSN) to serve exclusively children who qualify for Medicaid because they receive SSI. HSCSN is a nonprofit organization that coordinates care for children and youths with disabilities and complex medical needs. Its mission is to provide access to comprehensive, high-quality health care for these children, through a network of community-based services.
HSCSN began enrolling children in February 1996; by November 1997, 1900 children were participating. Enrollment continued to increase, and there were 3150 participants by the end of 2003. HSCSN was formed initially as a capitated health maintenance organization. Under that financial structure, HSCSN was reimbursed on a per-member/per-month basis. During 1999, HSCSN recognized that it was not financially feasible to provide services to this small but high-risk and costly population of children on a fully capitated basis. Abt Associates reported that HSCSN had incurred large losses in 3 of its first 4 years of operation. Effective December 1999, District of Columbia Medicaid revised its reimbursement methods for HSCSN. Under the revised system, HSCSN receives a monthly capitation payment for each enrolled child. HSCSN uses 20% of total capitation payments to cover administrative expenses, including case management services and outreach. The other 80% of total capitation payments are used to reimburse providers for services rendered and to pay transportation expenses for enrollees. If the total costs of medical and transportation services rendered exceed the total amount of capitation payments set aside to cover such services, then Medicaid and HSCSN agree on a settlement payment to partially cover the difference between capitation payments received and provider reimbursements and transportation expenses. Therefore, whereas HSCSN is at full risk for the administrative expenses, it is at partial risk for the direct costs of medical and transportation services.
For the most part, provider reimbursement is greater under HSCSN than under the Medicaid FFS program. Under HSCSN, PCPs, specialists, and dentists are reimbursed at rates that are approximately twice the amounts paid by the Medicaid FFS program. For example, the payment rate for an office visit with a PCP/specialist for the evaluation and treatment of an established patient is $20 under FFS and $40 under HSCSN, whereas an individual 50-minute psychotherapy visit with a psychiatrist is reimbursed $42 under FFS and $80 under HSCSN. HSCSN and the Medicaid FFS program have similar and sometimes identical rates for home health care services, therapy services, and durable medical equipment. Similar to the Medicaid FFS program, HSCSN does not use bonuses, withholds, or other financial incentives to influence the delivery of services.
The HSCSN provider network includes only a small proportion of the providers who participate in the Medicaid program. Of the 3266 physicians who participate in the Medicaid FFS program, only 107 are part of the HSCSN provider network. Forty-one dentists participate in the Medicaid FFS program, compared with 8 in the HSCSN provider network. However, HSCSN will include any providers in its network who are willing to accept its contract. For example, HSCSN encourages new enrollees to remain with their current PCPs. To receive a higher reimbursement rate, a nonparticipating provider is asked to sign a provider agreement. If the provider does not, then the PCP is reimbursed at the Medicaid FFS rate. The higher reimbursement rates serve as a strong incentive for PCPs to participate in HSCSN.
HSCSN provides a comprehensive array of services for enrolled children, including primary and specialty medical care, mental health care, and an array of ancillary and support services. Table 1 lists the services available to children receiving SSI under the traditional FFS system and under HSCSN, the MC option. As indicated in Table 1, the MC option offers a number of benefits to participants that are not available to children who are enrolled in the FFS system. Prior approval by the child's PCP or the HSCSN medical director is required for all health services except primary care, routine dental care, family planning, routine laboratory testing, and most diagnostic testing. Services may be preauthorized once the PCP has approved the enrollee's plan of treatment. HSCSN pays for emergency department services if its is notified within 1 business day of the visits and the patient's condition meets specific criteria with respect to observed symptoms, medical diagnoses, and severity of condition. Emergency department visits are subject to utilization review. This differs from the Medicaid FFS program, which does not use utilization controls for emergency department care, nonelective inpatient care, and physician care. However, prior approval from the MAA Office of Quality Assurance is required for elective inpatient care, transplant services, eyeglasses, and durable medical equipment. Patients need prior approval for mental health care visits, home health care, and personal care services only if they exceed certain limits. The Office of Quality Assurance makes prior approval decisions in consultation with the MAA medical director.
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Each child enrolled in HSCSN has a plan of treatment. This falls under the purview of the case manager. The child's PCP, caregiver, and case manager are the core participants in developing the plan of treatment. The PCP has the responsibility of assessing member needs and authorizing health care and health-related services. Each plan of treatment takes into consideration 1) the child's age, 2) the child's medical history, and 3) available family and community resources. The PCP and caregiver jointly sign the plan of treatment. The case manager monitors the plan of treatment, to ensure that recommended services are performed as specified. The case manager formally reviews, updates, and revises the plan of treatment at specified intervals, according to HSCSN policy, in conjunction with the multidisciplinary team and caregiver.
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METHODS |
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TOPABSTRACTBACKGROUNDMETHODSRESULTSDISCUSSIONREFERENCES |
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Sampling
Using the enrollment files for the District of Columbia MMA and the MC plan (HSCSN), 2 samples were designated, 1 including children enrolled in the capitated MC plan (HSCSN) and the other including children enrolled in the FFS plan. We included only children born between 1986 and 1998 (4–16 years of age). Only 1 child per family was selected, and children in group foster homes were excluded from the study. The final samples contained 1296 children from the capitated MC plan roster and 1251 children enrolled in the FFS plan, a total of 2547 cases. After the samples were released, another 197 children were discovered to be ineligible for reasons of age, duplication, sibling enrollment, discontinuation of enrollment in Medicaid, or death.
Data Collection
Six telephone interviewers received 10 hours of project training. Data collection began at the end of June 2002 and continued until late November 2002. Respondents were sent an advance letter, which described the study and listed a toll-free telephone number that respondents could call to schedule an appointment for an interview. Different versions of the letter were sent to HSCSN and FFS sample members. The letters mentioned that those who completed interviews would be sent a supermarket gift card worth $25 (for HSCSN cases) or $35 (for FFS cases). The MMA FFS enrollment files often did not contain enrollees' telephone numbers. Therefore, FFS respondents were asked to call and supply the survey firm with a telephone number so that they could participate. We did not encounter this problem with the HSCSN enrollment files, because telephone numbers were available for a large percentage of enrollees.
Response Rates
We completed interviews with 644 caregivers whose children were enrolled in the capitated MC plan and 444 caregivers whose children were enrolled in the FFS plan. Because of the large number of nonlocatable subjects, we calculated a response rate and a cooperation rate. The response rate was defined as the number of completed cases (1088 cases) divided by the total sample (2547 cases) minus the number of ineligible cases (197 cases). The cooperation rate removed subjects who were nonlocatable; it was defined as the number of completed cases (1088 cases) divided by the total sample (2547 cases) minus both ineligible cases (197 cases) and nonlocatable cases (1008 cases). The overall response rate for the study was 46%, with a 50.8% rate for the capitated MC sample and a 41% rate for the FFS sample. Removal of the subjects we were not able to locate from the denominator yielded an overall cooperation rate of 81% for the entire sample, with cooperation rates of 75% for the capitated MC sample and 92% for the FFS sample.
Outcome Variables
Access
We measured access in 2 ways. First, we examined whether each child had a usual source of care. This indicator was a combination of the responses to 2 questions, ie, "Is there a regular or main doctor the child usually goes to for medical care?" and "Is there a place where the child usually goes for medical care?" We constructed 3 possible outcomes from these questions, ie, 1) no usual source of care, 2) the usual source of care is a regular doctor, and 3) the usual source of care is a clinic or hospital.
Second, we measured access in terms of unmet needs, because this indicator allowed us to examine the effect of plan choice on children who needed services but were not able to obtain them. Unmet needs for health services reflect the extent to which existing health problems are not addressed.17 Unmet needs are of particular concern among children with SHCN, given the high demands for medical care for this population. Caregivers were asked if there was a time in the past 6 months when the child needed a specific type of service but was not able to get it. Questions were asked regarding the following list of services: 1) emergency department care, 2) overnight hospital stay, 3) shot, immunization, or checkup, 4) visit with a PCP or physician assistant, 5) visit with a physician specialist, 6) visit with a physical, occupational, or speech therapist, 7) dental care, 8) mental health, behavioral, or psychiatric counseling, 9) home health services, 10) medical equipment, supplies, or eyeglasses, and 11) prescribed medications. For purposes of analysis, we aggregated the responses to questions 1 to 5 and labeled this category "unmet needs for physician or hospital care." We used the responses to the other 6 questions to create indicators measuring unmet needs for the following types of care: therapy services (physical, occupational, or speech), mental health services, dental care, home health services, medical equipment/supplies, and prescribed medications.
Caregivers' Ratings of Dimensions of Access
Caregivers were asked to rate dimensions of access on a traditional 5-point scale (poor = 1, fair = 2, good = 3, very good = 4, excellent = 5). Caregivers were asked to evaluate the following dimensions of access: 1) convenience of the physician's office/clinic, 2) hours when office visits can be scheduled, 3) getting a specialist's care if the child needs it, 4) getting hospital care if the child needs it, 5) getting emergency care if the child needs it, 6) making appointments for medical care by telephone, 7) length of time between making an appointment and the actual medical care visit, 8) waiting time in the office, 9) getting medical information or advice by telephone, 10) getting medical care whenever the child needs it, and 11) getting prescriptions filled. For each dimension of access, we constructed a dichotomous indicator equal to 1 if the caregiver's rating was fair or poor or 0 if the caregiver's rating was good, very good, or excellent.
Statistical Analyses
The null hypothesis underlying our comparisons was that no relationship exists either between the indicators of unmet needs and plan type or between caregivers' ratings of the various dimensions of access and plan type. We used contingency table analysis to evaluate whether there was a systematic relationship between each indicator of an unmet need (or dimension of access) and plan type. If the 
2 test statistic from each contingency table analysis was statistically significant at P < .05, then we rejected the null hypothesis of no relationship between the indicator of an unmet need (dimension of access) and plan type.
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RESULTS |
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TOPABSTRACTBACKGROUNDMETHODSRESULTSDISCUSSIONREFERENCES |
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63% of capitated MC enrollees were 10 to 16 years of age, compared with 58% of children enrolled in the FFS plan. Boys accounted for 68% of the total sample. Almost 33% of the children enrolled in the capitated MC plan were girls, compared with 30% of those in the FFS option. Children enrolled in the capitated MC plan were more likely to be in fair or poor health. Caregivers reported that close to 18% of those in the capitated plan were in fair/poor health, compared with 12.6% of those with FFS coverage.
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It is important to recognize that the primary caregivers for these children were not exclusively biologic mothers or fathers. Almost 79% of children with FFS coverage and 75% of children in the capitated MC plan had their biologic mothers as the primary caregiver. Approximately 10% of FFS enrollees and >13% of capitated MC enrollees were cared for primarily by their grandmothers. One-fifth of both MC and FFS enrollees had a primary caregiver <30 years of age.
Usual Source of Care
Table 3 contains the contingency table analyses of whether children receiving SSI had a usual source of care, controlling for plan type. The 2 statistic of 13.2 (P < .001) was highly significant and indicated that plan choice was associated with having a usual source of care. Approximately 3.4% of FFS enrollees had no usual source of care, compared with 1.4% of children enrolled in the capitated MC plan. FFS enrollees were much less likely to have a regular doctor as the usual source of care. Approximately 83% of FFS enrollees had a regular physician, compared with 90% of capitated MC plan enrollees. Caregivers of FFS enrollees were significantly more likely to report that the usual source of care was a clinic, hospital, or community health center (14% for children in the FFS plan versus 8.6% for children enrolled in the capitated MC plan).
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1 of these services, compared with almost 40% of children enrolled in the capitated MC plan (P < .002). For each of the other categories of services (physician/hospital care, mental health care, therapy services, and home health care), differences in the percentages of FFS and capitated MC enrollees who experienced an unmet need for such services were not statistically significant.
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Regardless of plan type, between 10 and 20% of caregivers interviewed gave a fair/poor rating to the following components of access: office hours for appointments, getting a specialist's care if needed, and making appointments by telephone. Two of these components of access, ie, office hours for appointments and getting a specialist's care if needed, seemed to be significantly more problematic for caregivers of FFS enrollees than for caregivers of capitated MC enrollees; >21% of parents with children in the FFS option assigned a fair/poor rating to getting a specialist's care when needed, compared with 13% of caregivers with children in the MC plan (P < .01). With respect to office hours available for appointments, 18% of caregivers of FFS enrollees rated this dimension as fair/poor, compared with <14% of caregivers of children enrolled in the MC plan (P < .01). Although a high percentage of caregivers in both plans encountered difficulties in making appointments by telephone (18.2% of capitated MC enrollees and 19.8% of FFS enrollees), the difference between plan types was not statistically significant. Making appointments by telephone seemed to be equally problematic for caregivers of FFS and capitated MC enrollees.
Three other dimensions of access seemed to pose significantly greater problems for caregivers of FFS enrollees than for caregivers of capitated MC participants. These were convenience of doctor's office, getting emergency care if needed, and getting hospital care if needed. Less than 8% of caregivers of children enrolled in the capitated MC plan assigned a fair or poor rating to convenience of doctor's office, compared with >14% of caregivers of FFS enrollees (P < .001). Close to 12% of caregivers of FFS enrollees indicated that getting emergency care if needed was problematic, compared with <8% of caregivers of children enrolled in the capitated MC plan (P < .02). Finally, getting hospital care if needed posed problems for >9% of caregivers of children enrolled in the FFS option but <6% of caregivers of children enrolled in the capitation plan (P < .05).
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DISCUSSION |
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TOPABSTRACTBACKGROUNDMETHODSRESULTSDISCUSSIONREFERENCES |
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Results from our telephone interviews with a random sample of caregivers of children who were receiving SSI and were enrolled in Medicaid indicated that only 2% of all children had no usual source of care. However, caregivers of children enrolled in the FFS plan were significantly more likely to report that the child's usual source of care was either a clinic or a hospital, rather than a regular physician. This finding may be attributable to the fact that fees paid to physicians under the FFS option were lower than those paid under the capitated MC plan. Another reason why children in the capitated MC plan were more likely to have a regular doctor is that the case managers work with each family to ensure that the child consistently sees the same physician. Access to the same physician is important because this ensures continuity of care.
Our analyses also revealed that children enrolled in the capitated MC plan had better access then children enrolled in the FFS option. Caregivers of children enrolled in the capitated MC plan were less likely to report unmet needs than were caregivers of children enrolled in the FFS plan. Although both FFS and capitated MC enrollees experienced moderately high levels of unmet needs, children enrolled in the FFS plan were more likely to experience unmet needs for dental care, durable medical equipment/supplies, and prescription drugs. Moreover, caregivers of children enrolled in the FFS plan were more likely to rate the child's access as fair/poor. For 8 of the 11 dimensions of access we examined, the percentage of caregivers who rated the child's access as fair/poor was significantly higher for FFS enrollees than for capitated MC enrollees.
We offer 3 possible explanations for why caregivers of children enrolled in the capitated MC plan reported significantly fewer difficulties, compared with caregivers of children enrolled in the FFS plan. First, it seems that the case management component of the capitated MC plan has been successful in assisting caregivers in navigating the health care system and obtaining needed services for their children. Second, children enrolled in the capitated MC plan were more likely to have a physician as their usual source of care. This potentially can improve continuity of care across provider settings and facilitate access to needed services. Under the capitated MC plan, PCPs must approve the care management plan and authorize the use of specific services. However, because the MC plan does not place the PCP at risk for the services delivered to the patients, the PCPs may act more like advocates for their patients. The PCPs may see their role as that of a guardian, ensuring that their patients obtain needed services, rather than that of a gatekeeper. Third, the capitated MC plan reimbursed participating physicians at higher rates than did the FFS plan. In theory, this payment differential should give physicians the financial incentives to treat children enrolled in the capitated MC plan, rather than those enrolled in the FFS option. However, we did not observe any differences in unmet needs for physician services between the FFS and capitated MC groups. Therefore, it seems reasonable to conclude that the overall differences in access between capitated MC and FFS enrollees cannot be attributed to differences in payment rates. However, we did observe differences for dental care and durable medical equipment/supplies. Rates differ for dental care, but rates are similar for durable medical equipment. It could be argued that the additional reimbursement might encourage physicians to better coordinate care for their patients.
An alternative explanation is that the observed differences are attributable to selection bias. We contend that selection bias alone would not produce the results we observed. Irrespective of plan choice, these children, because of their disabilities, need and use many medical services. Caregivers elect to keep their children in the FFS system or to enroll the children in the capitated MC plan on the basis of whether they think the plan will improve their children's access to care. Caregivers make the enrollment choice with the objective of minimizing access problems.
Our results suggest that the capitated MC plan has improved access to care for children with SHCN who qualify for the District of Columbia Medicaid program. Given the paucity of evidence documenting how children with SHCN fare under Medicaid MC plans versus Medicaid FFS plans, the findings reported here should be of considerable value to state policymakers who are charged with designing and implementing cost-effective programs to provide health care services to children with SHCN.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Reprint requests to (J.M.M.) Georgetown Public Policy Institute, Georgetown University, 3600 N St NW, Suite 200, Washington, DC 20007. E-mail: mitchejm{at}georgetown.edu
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REFERENCES |
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TOPABSTRACTBACKGROUNDMETHODSRESULTSDISCUSSIONREFERENCES |
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A. E. Jeffrey and P. W. Newacheck Role of Insurance for Children With Special Health Care Needs: A Synthesis of the Evidence Pediatrics, October 1, 2006; 118(4): e1027 - e1038. [Abstract] [Full Text] [PDF]
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M. L. Ganz and S. A. Tendulkar Mental health care services for children with special health care needs and their family members: prevalence and correlates of unmet needs. Pediatrics, June 1, 2006; 117(6): 2138 - 2148. [Abstract] [Full Text] [PDF]
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D. Obrinsky, L. Girling Jr, M. Kieschnick, P. M. Miller, P. A. Steinman, F. Wilson, M. J. Wilson, and J. Young Children With Special Health Care Needs and Managed Care Pediatrics, August 1, 2005; 116(2): 520 - 521. [Full Text] [PDF]
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S. Berman, M. Rannie, L. Moore, E. Elias, L. J. Dryer, and M. D. Jones Jr Utilization and Costs for Children Who Have Special Health Care Needs and Are Enrolled in a Hospital-Based Comprehensive Primary Care Clinic Pediatrics, June 1, 2005; 115(6): e637 - e642. [Abstract] [Full Text] [PDF]
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