PEDIATRICS Vol. 119 No. 5 May 2007, pp. 956-964 (doi:10.1542/peds.2006-2222)
ARTICLE |
Effects of Managed Care on Service Use and Access for Publicly Insured Children With Chronic Health Conditions
a Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland
b Urban Institute, Washington, DC
c Department of Demography, University of California, Berkeley, California
 |
ABSTRACT |
|---|
 TOP ABSTRACT BACKGROUND AND PREVIOUS...DATA AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
OBJECTIVE. Our goal was to estimate the effects of managed care program type on service use and access for publicly insured children with chronic health conditions.
METHODS. Data on Medicaid and State Children's Health Insurance Program managed care programs were linked by county and year to pooled data from the 1997–2002 National Health Interview Survey. We used multivariate techniques to examine the effects of managed care program type, relative to fee-for-service, on a broad array of service use and access outcomes.
RESULTS. Relative to fee-for-service, managed care program assignment was associated with selected reductions in service use but not with deterioration in reported access. Capitated managed care plans with mental health or specialty carve-outs were associated with a 7.4-percentage-point reduction in the probability of a specialist visit, a 6.3-percentage-point reduction in the probability of a mental health specialty visit, and a 5.9-percentage-point decrease in the probability of regular prescription drug use. Reductions in use associated with primary care case management and integrated capitated programs (without carve-outs) were more limited, and integrated capitated plans were associated with a reduction in unmet medical care need. We failed to find significant effects of special managed care programs for children with chronic health conditions.
CONCLUSIONS. Managed care is associated with reduced service use, particularly when capitated programs carve out services. This finding is of key policy importance, as the proportion of children enrolled in plans with carve-out arrangements has been increasing over time. It is not possible to determine whether reductions in services represent better care management or skimping. However, despite the reductions in use, we did not observe a corresponding increase in perceived unmet need; thus, the net change may represent improved care management.
Key Words: health insurance • managed care • chronic conditions • access to care
Abbreviations: CWCHC—children with chronic health conditions • MCO—managed care organization • SCHIP—State Children's Health Insurance Program • SSI—Supplemental Security Income • PCCM—primary care case management • FFS—fee-for-service • ED—emergency department • NHIS—National Health Interview Survey
Experts are mixed in their expectations of how well managed care programs meet the needs of children with chronic health conditions (CWCHC).1–4 Although managed care holds promise for improved organization and accountability, questions have been raised about the capacity of managed care organizations (MCOs) to provide appropriate access to high-quality care. In particular, concerns have been raised about the breadth and adequacy of provider networks, and health plans’ lack of experience delivering care to CWCHC. Financial incentives to limit access to necessary but expensive services may be particularly problematic for children who have elevated service needs. Furthermore, enrollment of CWCHC in closed panel managed care systems could disrupt preexisting provider relationships.
The question of how Medicaid and State Children's Health Insurance Program (SCHIP)–enrolled CWCHC fare under managed care is particularly important. CWCHC rely disproportionately on public insurance,5 and managed care is now the predominant financing and delivery mechanism for Medicaid and SCHIP enrollees, with an estimated 60% penetration in Medicaid by 2003.6 Most separate SCHIP programs have adopted managed care, further emphasizing its importance.7,8 Historically, children receiving Supplemental Security Income (SSI), a subgroup of CWCHC, were exempted from some mandatory managed care arrangements used in Medicaid programs, but the broader group of Medicaid- and SCHIP-enrolled CWCHC has been mainstreamed into managed care in most states. In recent years, SSI recipients in many states have also been enrolled on a mandatory basis in managed care plans.9,10
Assessing the impact of managed care on CWCHC is complicated by the fact there is no single model of managed care. Rather, federal Medicaid policy has permitted a variety of program designs to emerge within Medicaid, and the advent of freestanding SCHIP plans resulted in the incorporation of an array of mainstream private MCOs into public programs. The experience of CWCHC may vary depending on how the delivery of care is organized and the nature of financial incentives to providers. Thus, to assess the extent to which the needs of CWCHC are being met, it is important to compare across different managed care program types.
In this article, we provide the first national estimates of the effects of different types of managed care programs on access to and use of health care services for publicly insured CWCHC. We examine not only the mainstream managed care programs, both those that integrate and those that exclude or "carve-out" mental health or specialty services, but also consider programs designed specifically for CWCHC. The results of our analyses provide important new information to state and federal policy makers concerned about access to high-quality care for this group of vulnerable children.
|
BACKGROUND AND PREVIOUS LITERATURE |
|---|
|
TOPABSTRACTBACKGROUND AND PREVIOUS...DATA AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
Within the Medicaid and SCHIP programs, managed care programs generally fall into 1 of 2 major categories. Primary care case management (PCCM) programs designate a primary care physician who is paid a small monthly management fee and serves as the gatekeeper or manager of specialty referrals and other health care services.11 Capitated risk models pay a predetermined monthly fee to an MCO to arrange for provision of the full range of necessary services. The MCO may be a private health maintenance organization, or a risk-bearing provider group, often organized around traditional safety net hospitals and/or clinics. In a number of states, prescription drugs, dental care, mental health, substance abuse, and/or other specialty services are excluded from the principal MCO contracts, with services provided through a separate capitated network or on a fee-for-service (FFS) basis. In recent years, Medicaid and SCHIP programs in a small number of states and localities have designed managed care systems specifically for CWCHC. These systems are typically built around networks of primary and specialty providers that possess particular expertise serving CWCHC and are often paid risk-adjusted rates to account for the higher cost of serving this population. Enrollment in any of these programs may be mandatory or voluntary. Some programs may be mandatory for selected populations, whereas others may be included on a voluntary basis or excluded completely.
There is limited literature on managed care for publicly enrolled CWCHC. Previous research examined Medicaid programs in single states or counties by using pre-post designs or comparisons between SSI recipients, CWCHC not receiving SSI, and children without reported health problems. Results concerning access effects are mixed, with some studies finding that MCO enrollment reduces unmet needs,12 whereas other studies find the reverse.13 MCO enrollment in 2 studies was associated with reduced use of services and costs.14,15 However, the use of different study populations and relatively little information concerning the design of each program make it difficult to generalize from these studies or to compare the impact of different models of managed care.
In an effort to move beyond isolated state-specific studies and to explore the role of managed care program design on access and satisfaction, Hill et al16 used qualitative methods to compare the experiences of CWCHC served under FFS and 4 Medicaid managed care models in 8 states. Findings indicate that mainstream managed care systems provide high-quality primary and specialty medical care but often fall short in their ability to identify CWCHC and address their nonmedical needs. Mainstream capitated plans that carve out selected services caused considerable fragmentation in service delivery and were often confusing to families. Specialized managed care systems seemed to be the most successful in meeting the diverse and complex needs of CWCHC. This study suggests mechanisms through which managed care plan design can affect access and use, and highlights the importance of carve-outs as a focus for additional analysis.
Variation in managed care program type across states and over time was used in several studies to compare effects of different types of Medicaid managed care plans, although not specific to CWCHC.17–19 For example, Garrett et al17 found that mandatory capitated programs reduced emergency department (ED) use and increased specialist visits for children. Mandatory programs where the family must choose either an MCO or PCCM increase the probability of having a usual source of care, reduce ED use, increase immunization completeness, and increase the probability of having a physician visit. Few effects were found for PCCM programs. However, the study did not examine outcomes separately for CWCHC; in fact, to achieve a more homogeneous population, children with SSI were dropped from the analytic sample. In our study, we extend the work of Garrett and colleagues but focus specifically on the effects of managed care plan types on access to care and use of services for CWCHC.
|
DATA AND METHODS |
|---|
|
TOPABSTRACTBACKGROUND AND PREVIOUS...DATA AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
The primary source of data was the National Health Interview Survey (NHIS), an ongoing household survey that collects data on demographic characteristics, health status, insurance coverage, access to care, and use of health care services.20 Additional detail was captured for a sample child from each family, with an annual sample of
13000. A knowledgeable parent or other adult reported on behalf of minor children. We pooled data from the person level and sample child files from 1997–2002, selecting children eligible for and enrolled in either Medicaid or SCHIP. We used the NHIS data to construct a series of child, parent, and family measures; identify CWCHC; and measure access and service use outcomes.
Identifying CWCHC on the NHIS
The definition of CWCHC is primarily diagnosis-based. We included children reported to have been diagnosed as having 1 of several common chronic conditions that appeared on a checklist on the NHIS. These conditions include attention-deficit/hyperactivity disorder, mental retardation, Down syndrome, asthma, cerebral palsy, sickle cell anemia, muscular dystrophy, autism, congenital or other heart disease, and diabetes. We also included children reported to have an activity limitation caused by a health condition lasting at least 12 months, to capture children with a condition not included on the checklist. We used information from a mental health scale to identify children reported to be unhappy or sad most of the time over the previous 6 months as a proxy measure for child depression. This definition is broader than the consequence-based definition of children with special health care needs adopted by the Maternal and Child Health Bureau.21 We chose not to use that definition because some of the factors used to identify affected children,22 for example, elevated service use, are outcomes for our study; thus, interpretation of the results might be confounded by changes in the population of interest. The final analytic sample included 13550 children eligible for and enrolled in Medicaid or SCHIP, with one fifth of those identified as CWCHC.
Outcome Measures: Use of Services and Access to Care
We selected a variety of use and access measures from topics addressed in the NHIS. Indicators were created for any ED use; any inpatient stay; 
10 health professional visits (designated as "elevated outpatient use"); any visit with a medical specialist, mental health specialist, or vision care provider, all during the past 12 months; and regular prescription drug use during the past 3 months. Indicators of access included the presence of a usual source of care other than a hospital ED and unmet needs for medical, dental, prescription drug, and mental health services.
Child, Parent, and Family Characteristics
In the multivariate models, we controlled for demographic characteristics of the child, parent, and family. Child characteristics included age, gender, race, ethnicity, and immigration status. We controlled for parents’ education, earnings relative to the federal poverty level, marital and health status, as well as family size, sibling health, and age. Because managed care program type may be correlated with local area characteristics, we also controlled for metropolitan statistical area size and county-level measures of primary and specialty physician supply as reported in the Area Resource File, the presence of an academic medical center as reported by the American Hospital Association, and private health maintenance organization penetration as reported by Interstudy. Fixed state effects were included to capture aspects of state policy that might affect outcomes but did not change over time, and year indicators were included to capture temporal trends that were independent of changes in managed care.
Data on Managed Care Plan Type
The NHIS collects information on managed care restrictions for persons enrolled in Medicaid, such as the need to get approval for referrals, but this information is inadequate to distinguish between different types of managed care. Instead of using the self-reported information on managed care enrollment, for each year of the NHIS we assigned information on the type of managed care implemented in the county of residence, specific to Medicaid and separate SCHIP programs, by CWCHC status. Although many states have implemented programs statewide, there are others where implementation is partial; thus, it is important to assign county-specific plan types. These measures and the process of linking managed care plan types to children are described in the following sections.
Information on managed care program type was abstracted from annual Medicaid managed care enrollment reports,23–25 special surveys of state Medicaid programs and SCHIP,17,26 and SCHIP state plans. The Enrollment Reports are submitted annually by states to Centers for Medicare and Medicaid Services, and describe the different types of managed care programs operating in the state, the covered services, the included and excluded populations, and for each plan, the counties in which it is operational. A county- and year-specific database was created on managed care type and whether enrollment was mandatory for children generally, and for SSI recipients enrolled in Medicaid or other CWCHC in SCHIP. Given the variety of plan types available, we grouped plans to make the analysis tractable. We split capitated programs based on the presence of mental health or specialty care carve-outs. The final managed care categories are FFS, voluntary plans, mandatory PCCM, mandatory "integrated" capitated plans (inclusive of mental health or specialty services), mandatory capitated plans with mental health or specialty service carve-outs, and specialized managed care systems for Medicaid-enrolled children with SSI or SCHIP-enrolled CWCHC. The latter group includes some programs that were optional for CWCHC, but the default program was a mandatory capitated plan.
Managed care data were linked to children eligible for Medicaid or SCHIP. Because many states had different managed care programs for Medicaid and separate SCHIP, we distinguished between children eligible for each program. We used a detailed algorithm that replicates the eligibility determination process, incorporating federal- and state-specific Medicaid and SCHIP eligibility rules. The algorithm models the application of most categorical, income, and resource tests, using data from the NHIS to create child or family level measures for each relevant eligibility comparison.
Specification of Access and Use Models
We estimated multivariate linear probability regressions for each dichotomous outcome measure. Because of the large number of control variables, we estimated models by using the full sample of eligible and enrolled children. The models included indicators for the types of managed care plans, with FFS as the reference category, an indicator for CWCHC, and interaction terms between them. The full effects for CWCHC, which we present in this article, are based on the sum of the main and interaction effects for which we test the significance by using Wald tests.26
The estimates should be interpreted as managed care program effects, reflecting the program reported by the state as being implemented in each county for each population group. This program effect may differ from the individual effect of being enrolled in a managed care plan, to the extent that not all the Medicaid or SCHIP enrollees are enrolled.17 With voluntary programs, there may be partial and disproportionate enrollment of selected groups, and even in counties with mandatory programs, some individuals may be exempted from the program and will opt out, whereas others may have difficulty enrolling in their managed care plan. In the results we present, program and individual enrollment effects should be reasonably close, because we limit our focus to the mandatory programs.
The public-use NHIS data do not include the state or county identifiers needed to link state Medicaid and SCHIP eligibility rules, or to link county-level measures of managed care type to individual observations. To access data files with these state and county indicators, we conducted all analyses at the National Center for Health Statistics’ Research Data Center in Hyattsville, Maryland.
All analyses were performed by using Stata 8 software. Sample proportions presented were weighted to national totals. Standard errors were adjusted to reflect the complex sample design of the NHIS. All results discussed are significant with P 
.05, unless otherwise indicated.
|
RESULTS |
|---|
|
TOPABSTRACTBACKGROUND AND PREVIOUS...DATA AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
CWCHC are enrolled in a variety of managed care programs, and the distribution has shifted over time away from FFS to various mandatory programs. The most prevalent types of managed care in the analytic sample are mandatory capitated programs with mental health or specialty carve-outs, affecting 25% of Medicaid- and SCHIP-enrolled CWCHC (Table 1). Integrated capitated programs are the next most common managed care type, affecting almost 22% of children. Only 6% of CWCHC were in counties with mandatory special programs, whereas almost one third (32%) were in counties with either FFS or voluntary managed care programs. The small representation of CWCHC in special programs is consistent with the small number of states and populations for whom these plans are relevant. In 1997, almost one quarter (24.5%) of CWCHC were enrolled in FFS programs. This proportion decreased to 11.1% by 2002. This shift was balanced by a dramatic increase in the proportion of CWCHC enrolled in capitated programs with carve-outs.
|
Consistent with their elevated needs, publicly insured CWCHC tend to have high levels of health care service use (Table 2). For example, almost one quarter had medical specialist (23%) and mental health specialist (24%) visits, 31% reported a vision care visit, and 38% reported regular use of prescription medications. Two in 5 reported at least 1 visit to a hospital ED, and more than half of those (22%) reported multiple visits (data not shown). One in 10 was hospitalized in the past year. Almost all (95%) had a usual source provider when sick. Among children 2 to 17 years old, 15% were reported to have foregone needed medical, dental, prescription drug, or mental health services; unmet need for dental care services was reported by almost 10%.
|
Comparison across managed care program types indicates that use levels for specific services, such as
10 health care provider visits and any specialist were lower in the 2 capitated programs compared with FFS enrollees. Children enrolled in integrated capitated programs had lower hospitalization rates (8.4% vs 12.8% in FFS), and CWCHC in capitated programs with carve-outs had lower rates of regular prescription drug use (33.6% vs 38.4% for FFS). These comparisons do not control for differences in characteristics across managed care plan types.
Estimated Effects of Mandatory Managed Care Plans
Figures 1 through 4 summarize the effects on use of services associated with the 4 groups of mandatory managed care plans, relative to FFS, after adjustment for child, family, and area characteristics, state, and year. Mandatory PCCM programs were associated with reductions in the probability of any specialist visit (–5.8 percentage points), mental health specialty visit (–5.0 percentage points), and hospital stay (–3.0 percentage points) and a reduction in reported unmet need for mental health services, but none of these estimates reached standard levels of significance.
|
|
|
|
Integrated capitated programs were associated with reductions in the probability of any specialist visits (–5.3 percentage points) and any ED visit (–5.8 percentage points), but only the estimated reduction in unmet need for medical care (–2.3 percentage points) reached the standard level of significance. When managed care plans carved out mental health or specialty services, there was a reduced probability of specialist visits (–7.4 percentage points), mental health specialty visits (–6.3 percentage points), vision care visits (–8.2 percentage points), and regular prescription drug use (–5.9 percentage points). The negative effects on mental health visits and prescription drug use are significantly larger for plans with carve-outs relative to plans where these services are integrated. It should be noted that there is a high correlation between use of mental health and other types of service carve-outs, which may explain what seems to be a spillover effect on vision care and prescription drug services. Alternatively, differences in mental health specialty use may result in reduced use of prescription drugs.
In contrast to the other models, special managed care programs for CWCHC were not found to have significant effects on service use; small positive trends were observed but they do not meet standards of significance. Special managed care programs for CWCHC were associated with an upward shift in physician visits, although it is not reflected in the measure of elevated outpatient use we report.
Magnitude of Managed Care Plan Effects
The findings reported reflect the marginal change in the probability of service use associated with each managed care model relative to FFS plans. Although some of these changes are relatively small, they represent substantial changes relative to the FFS base. For example, the 7.4-percentage-point reduction in specialist visits associated with capitated plans with carve-outs represents a 26% reduction relative to the 29% of children in FFS counties who visit a specialist.
|
DISCUSSION |
|---|
|
TOPABSTRACTBACKGROUND AND PREVIOUS...DATA AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
Our results suggest that when CWCHC enrolled in Medicaid or SCHIP are assigned to managed care plans, they experience lower use rates of commonly needed services, relative to CWCHC enrolled in FFS. Consistent with the findings of Hill et al,16 the effects of managed care plans differed across type, with capitated programs with carve-outs presenting profiles that differed from integrated capitated programs, PCCM, and special programs for CWCHC. Although all PCCM and capitated programs reduced the likelihood of specialist visits to some extent, only capitated programs with carve-outs were associated with significant declines in the probability of any mental health provider use and reduced prescription drug use. The effects associated with PCCM enrollment, albeit weaker, were somewhat unexpected, because PCCM providers lack the strong financial incentives present in capitated plans to manage services. It is likely that PCCM providers also participate in capitated networks, and that practice patterns carry over from patients in one form of managed care to another. It is also possible that PCCM programs create barriers to specialty referral that may be similar to a capitated plan with carve-outs.
Mandatory special programs for CWCHC are designed with goal of facilitating access and improving care management. However, because we fail to find positive effects on perceived access or reductions in ED or hospital use, it is not possible to draw conclusions about how well these programs work. It may be that only the most severely affected children (ie, those with SSI) are assigned to these plans, or that small numbers in the study sample limit statistical power.
The difference in effects of capitated plans with and without carve-outs are fully consistent with other research addressing this issue.16 Service carve-outs are intended to steer children to more specialized provider networks, but if those networks are at financial risk for services, there is a discentive to accept referrals. State-specific studies of mental health carve-outs suggest that carve-outs encourage substitution of outpatient for inpatient care, medical for specialty mental health visits, and increased use of psychotropic medications.28–30 The findings from this study are consistent with the second mechanism, but the observed reduction in regular use of prescription drugs is inconsistent with the reported pattern of substituting medication use for specialty care.
The increasing reliance on capitated managed care programs with carve-outs may or may not be problematic, depending on whether the reductions in specialist, mental health, and vision care visits represent appropriate substitution of primary care providers and judicious use of specialists, or whether plans are providing inadequate service to CWCHC. If the latter situation were true, then we would expect to observe an increase in reported unmet need for services. Because such increases were not observed, these results do not support an interpretation that managed care plans were skimping on specialty services. More research is clearly needed to explore the incentives that plans establish for both primary care and specialty providers when carve-outs are present and how those incentives affect referrals for care between systems.
A few caveats related to this study should be noted. This analysis uses household survey data, which relies on parent report of child health status, use of services and access problems, along with child and family characteristics. Self-reported data are subject to reporting error, which may have affected selection of children into the sample of Medicaid- or SCHIP-eligible and -enrolled, assignment by chronic condition status, and reported outcomes. These errors in measurement, particularly for child health status, may result in downward bias of estimated effects. The study is also limited in that the NHIS access to care and service use measures are applicable to children generally. If managed care programs affect access to truly specialized services that are of particular value to CWCHC, this analysis would not capture those effects.
Although the study provides critical new information on managed-care effects for CWCHC, there is substantial heterogeneity within the group of children, and managed care may have differential effects on children depending on the nature of their condition and its severity and stability. Although it would be ideal to stratify children along those dimensions in this analysis, the NHIS health status measures are not likely to capture such nuances adequately.
It is important to note that the estimated effects represent national averages. Plans likely vary in how they are implemented across and even within states. This study opens the black box of managed care by exploring effects associated with carve-outs and special programs. Future research is ongoing to address whether explicit policy choices within capitated care plans are associated with different outcomes.
Much debate still surrounds the issue of whether managed care can work for CWCHC. This study does not resolve the debate, but does suggest that managed care is associated with changes in outpatient management for CWCHC without jeopardizing access. However, the large differential effects associated with carve-outs suggest a need for additional study, involving data with sufficient clinical detail to more clearly assess the adequacy and appropriateness of care delivered to CWCHC under managed care.
|
ACKNOWLEDGMENTS |
|---|
This research was funded by Maternal and Child Health Bureau grant R40 MC 02495-01.
|
FOOTNOTES |
|---|
Accepted Dec 29, 2006.
Address correspondence to Amy J. Davidoff, PhD, Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch St, 12th Floor, Baltimore, MD 21201. E-mail: adavidof{at}rx.umaryland.edu
|
REFERENCES |
|---|
|
TOPABSTRACTBACKGROUND AND PREVIOUS...DATA AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
- Curtis D, Kaye N, Riley T. Transitioning to Medicaid managed care: children with special health care needs. Portland, ME: National Academy for State Health Policy; 1999
- Hill I, Westphal Lutzky A, Schwalberg R. Are We Responding to Their Needs? States’ Early Experiences Serving Children With Special Health Care Needs Under SCHIP. Washington, DC: Urban Institute; 2001. Available at: www.urban.org/url.cfm?ID=310286. Accessed March 12, 2007
- Newacheck PW, Stein RE, Walker DK, Gortmaker SL, Kuhlthau K, Perrin JM. Monitoring and evaluating managed care for children with chronic illnesses and disabilities.
Pediatrics. 1996;98
:952
–958
[Abstract/Free Full Text] - Szilagyi PG. Managed care for children: effect on access to care and utilization of health services. Future Child. 1998;8 :39 –59[Web of Science][Medline]
- Davidoff AJ. Insurance for children with special health care needs: patterns of coverage and burden on families to provide adequate insurance.
Pediatrics. 2004;114
:394
–403
[Abstract/Free Full Text] - Centers for Medicare and Medicaid Services. National summary of Medicaid managed care programs and enrollment. Available at: www.cms.hhs.gov/MedicaidDataSourcesGenInfo/Downloads/mmcer03.pdf. Accessed March 12, 2007
- Hill I, Hawkes C, Harrington M. Final Cross-cutting Report on the Findings From Ten State Site Visits: Congressionally Mandated Evaluation of the State Children's Health Insurance Program. Princeton, NJ: Mathematica Policy Research, Inc; 2003
- Hill I. Charting new courses for children's health insurance. Policy Pract. 2000;58 :30 –38
- Fox HB, McManus MA, Almeida RA, Lesser C. Medicaid managed care policies affecting children with disabilities: 1995 and 1996. Health Care Financ Rev. 1997;18 :23 –36[Web of Science][Medline]
- Kenesson M. Medicaid Managed Care: Outreach and Enrollment for Special Populations. Working Paper. Hamilton, NJ: Center for Health Care Strategies; 1998
- Hurley R, Freund D, Paul J. Managed Care in Medicaid: Lessons for Policy Design. Ann Arbor, MI: Health Administration Press; 1993
- Mitchell JM, Gaskin DJ. Do children receiving Supplemental Security Income who are enrolled in Medicaid fare better under a fee-for-service or comprehensive capitation model.
Pediatrics. 2004;114
:196
–204
[Abstract/Free Full Text] - Mitchell JB, Khatutsky G, Swigonski NL. Impact of the Oregon Health Plan on children with special health care needs.
Pediatrics. 2001;107
:736
–743
[Abstract/Free Full Text] - Cebul RD, Solti I, Gordon NH, Singer ME, Payne SM, Gharrity KA. Managed care for the Medicaid disabled: effect on utilization and costs. J Urban Health. 2000;77 :603 –624[CrossRef][Web of Science][Medline]
- Grossman LK, Rich LN, Michelson S, Hagerty G. Managed care of children with special health care needs: the ABC Program.
Clin Pediatr (Phila). 1999;38
:153
–160
[Abstract/Free Full Text] - Hill I, Schwalberg R, Zimmerman B, Tilson W, Ireys H. Achieving service integration for children with special health care needs: an assessment of alternative Medicaid managed care models. J Health Care Policy Law. 2002;5 :208 –232
- Garrett B, Davidoff AJ, Yemane A. Effects of Medicaid managed care programs on health services access and use. Health Serv Res. 2003;38 :575 –594[CrossRef][Web of Science][Medline]
- Garrett B, Zuckerman S. National estimates of the effects of mandatory Medicaid managed care programs on health care access and use, 1997–1999. Med Care. 2005;43 :649 –657[CrossRef][Web of Science][Medline]
- Zuckerman S, Brennan N, Yemane A. Medicaid managed care and beneficiary access and use. Inquiry. 2002;39 :221 –242[Web of Science][Medline]
- Botman SL, Moore TF, Moriarty LL, Parsons VL. Design and estimation for the National Health Interview Survey, 1995–2004. Vital Health Stat 2. 2000;(130) :1 –31
- McPherson M, Arango P, Fox H, et al. A new definition of children with special health care needs.
Pediatrics. 1998;102
:137
–140
[Free Full Text] - Davidoff AJ. Identifying children with special health care needs in the National Health Interview Survey: a new resource for policy analysis. Health Serv Res. 2004;39 :53 –71[CrossRef][Web of Science][Medline]
- Centers for Medicare and Medicaid Services. Description of state Medicaid programs, for 2000–2002. Available at: www.cms.hhs.gov/MedicaidDataSourcesGenInfo/06_DescStateProg.asp. Accessed March 12, 2007
- Centers for Medicare and Medicaid Services, Finance, Systems, and Budget Group. Description of State Medicaid Programs, for 1997–1999. Baltimore, MD: Centers for Medicare and Medicaid Services; 2000
- National summary of state Medicaid managed care programs, reports for 1997–2002. Available at: www.cms.hhs.gov/MedicaidDataSourcesGenInfo/04_MdManCrEnrllRep.asp. Accessed March 12, 2007
- Holahan J, Suzuki S. Medicaid managed care payment methods and capitation rates in 2001.
Health Aff (Millwood). 2003;22
:204
–218
[Abstract/Free Full Text] - Greene WH. Econometric Analysis. 4th ed. New Jersey: Prentice-Hall, Inc; 2000
- Burns BJ, Teagle SE, Schwartz M, Angold A, Holtzman A. Managed behavioral health care: a Medicaid carve-out for youth. Health Aff (Millwood). 1999;18 :214 –225[Medline]
- Busch AB, Frank RG, Lehman AF. The effect of a managed behavioral health carve-out on quality of care for Medicaid patients diagnosed as having schizophrenia.
Arch Gen Psychiatry. 2004;61
:442
–448
[Abstract/Free Full Text] - Liu CF, Manning WG, Christianson JB, et al. Patterns of outpatient use of mental health services for Medicaid beneficiaries under a prepaid mental health carve-out. Adm Policy Ment Health. 1999;26 :401 –415[CrossRef][Web of Science][Medline]
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
CiteULike 
Connotea 
Del.icio.us 
Digg 
Facebook 
Reddit 
Technorati 
Twitter What's this?
This article has been cited by other articles:
|
|
 |
|
  A. Davidoff, I. Hill, B. Courtot, and E. Adams Are There Differential Effects of Managed Care on Publicly Insured Children With Chronic Health Conditions? Med Care Res Rev, June 1, 2008; 65(3): 356 - 372. [Abstract] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
