Outcomes of Risk-Based Medicaid Managed Care Programs: a Review of the Literature

Appendix A

Outcomes of Risk-based Medicaid Managed Care Programs: A Review of the Literature

By Katie Rosingana, Paul Saucier and Karen Pearson

Muskie School of Public Service, University of Southern Maine

Purpose and Approach

In the fall of 2009, we were commissioned by the Maine Department of Health and Human Services to conduct a review of the literature on Medicaid managed care nationally. Specifically, we were asked to identify and summarize studies addressing the impact of risk-based Medicaid managed care on quality of care and health outcomes. We were asked to specify impact by major population group.

We searched electronic databases for peer-reviewed articles on Medicaid managed care since the mid-1990’s. We also identified national organizations known to conduct policy analyses, quality activities and technical assistance in Medicaid managed care and searched their websites for relevant publications. These included the National Committee for Quality Assurance (NCQA), the Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare and Medicaid Services (CMS), the Institute of Medicine (IOM), and the Center for Health Care Strategies (CHCS).

To be included in our review, an article or publication met the following criteria: 1) it addressed risk-based Medicaid managed care; and 2) it reported on outcomes. We found very few studies addressing member health outcomes, such as morbidity or mortality. Most of the Medicaid managed care literature addressesutilization outcomes. In some instances, a change in utilization is considered an indicator of good quality. Examples are increases in childhood immunization and decreases in preventable admissions to hospitals. Other changes in utilization are desired because they promote cost-effectiveness and are generally preferred by consumers. Examples are decreases in institutional care and increases in home- and community-based care. Because studies addressing direct health outcomes are rare, most of the articles included in this review address impact on utilization.

Summary: Impact of Risk-based Medicaid Managed Care

The literature assessing the impact of risk-based Medicaid managed care is mixed to favorable. Actual health outcome studies are scarce, but the preponderance of access and utilization studies are favorable. Risk-based Medicaid managed care increases the likelihood of having a usual source of care, and reduces the use of emergency departments and admissions to hospitals. It has been associated with smoking cessation among pregnant women, and with greater likelihood of receiving prenatal care, well-child care and childhood immunizations. Among those who use long term services and supports, risk-based managed care has been associated with reduced use of nursing home care, and increased use of home- and community-based services.

A smaller number of studies report adverse outcomes, including increases in emergency department use and fewer pre-natal visits in the early stages of pregnancy. At least one study associated negative impact with program implementation problems that included difficulties transferring member information from the Medicaid agency to contractors, resulting in service delays.

Several studies noted significant data challenges or unique local conditions that limit the generalizability of their findings. Most Medicaid managed care studies are limited to one state, and like Medicaid programs in general, Medicaid managed care programs vary significantly from state to state.

Impact of Medicaid Managed Care on Children and Parents

Prenatal Care and Newborns

Because Medicaid covers pregnant women at higher income levels than other eligibility groups, and finances a growing number of births nationally, a number of studies have looked specifically at the impact of MMC on pregnant women and infants. A study of the impact of mandatory HMO enrollment for expectant mothers in Ohio found positive effects on prenatal care and reductions in smoking (Kenney et al., 2005). A New York study found that MMC performed statistically higher than a fee-for-service comparison group on most HEDIS measures, including prenatal care in the first trimester (Roohan et al, 2006). Another New York state study found a marked decrease in neonatal intensive care unit admissions in the five years following mandatory enrollment into MMC for pregnant TANF-eligible women, a positive outcome associated with implementation of a quality improvement program intended to improve birth outcomes (Stankaitis et al, 2005).

Sommers et al. (2005) compared the outcomes of pregnant women in MMC and fee-for-service counties in Missouri between 1995 and 2000 and found mixed results. The authors found improvements over the time period for both groups, but concluded that gains were greater in the fee-for-service counties. The authors did find that managed care reduced smoking among mothers and increased enrollment in WIC (the Women, Infants and Children nutrition program), but it did not reduce the incidence of low-birth rate. The authors note that the study period included the initial implementation of MMC, and that administrative challenges with program start-up made it difficult for managed care organizations to identify pregnant women in the first trimester.

Finally, a longitudinal study of California women concluded that the implementation of managed care had a negative effect. Studying a group of women who were in fee-for-service Medicaid for one birth, then in managed care for a subsequent birth, the authors found a negative impact associated with managed care that included decreased utilization of prenatal care and increased likelihood of low birth weight (Aizer et al., 2007).

Other Children and Parents

Several studies have found enrollment in a MMC program associated with greater likelihood of maintaining a usual source of care, and less likelihood of emergency room (ER) use among adults and children. (Garrett et al., 2003; Baker et al., 2005, Garrett and Zuckerman, 2005; Verdier et al., 2009). MMC has been associated with shorter travel times to one’s usual source of care and shorter wait times once there. (Sisk et al., 1996; Coughlin and Long, 2000).

Colorado’s move away from managed care in the late 1990s offered a natural opportunity to study what happens when people move out of MMC and back to fee-for-service Medicaid. Berman et al. (2005) assessed the impact of the change on pediatric primary care services and found that the return to fee-for-service diminished access to a medical home, including reduction in well-child check-ups and immunizations.

Bindman et al. (2005) studied TANF adults admitted into California hospitals between 1994 and 1999. Comparing those in fee-for-service with those in MMC, the authors found that those in managed care had 33% fewer admissions for ambulatory care-sensitive conditions, suggesting greater effectiveness at avoiding preventable admissions.

Health and Quality Outcomes For Persons with Disabilities

Because many states enrolled SSI-related population groups in risk-based MMC later in the evolution of their programs, fewer outcome studies have been conducted regarding MMC impact on persons with disabilities. Persons with disabilities have more specialized needs than parents and adults, and political resistance to including them in MMC has been greater. The small but growing body of evidence on managed care’s effect on Medicaid beneficiaries with disabilities has focused primarily on access and utilization.

Schuster et al. (2007) studied the effects of enrolling children with special needs into a partial-risk MMC program v. fee-for-service (FFS) and found that the MMC children were more likely to obtain occupational and physical therapy at school relative to their FFS counterparts. They also found that children in FFS were significantly less likely to be frequent or regular users of each type of therapy relative to children enrolled in MMC.

Hutchinson and Foster (2003) conducted a synthesis of eight studies that involved evaluations of MMC, included children with mental health or substance abuse disorders, and had non-MMC comparison groups. The use of inpatient care for children using mental health services was reduced under managed care, with MMC children having lower admission rates, length of stay, and expenditures on inpatient care. The reductions in inpatient care were often accompanied by an increase in outpatient care and services used in less restrictive settings. The authors note that, although this utilization trend away from inpatient and toward less restrictive treatment options appears favorable, they were not able to find any quality outcomes reported in the literature.

The findings for adults with disabilities are more mixed. Lo Sasso and Freund (2000) assessed the relative effects of mandatory enrollment in MMC in two California counties and found a higher probability of emergency department use and hospital admissions among SSI-eligible MMC enrollees v. SSI-eligible adults in fee-for-service. The authors also found SSI-eligibles in MMC had more ambulatory care visits and prescription drugs in their first year, after which utilization was similar to those in FFS.

Coughlin et al. (2009) used pooled data from National Health Interview Surveys from 1997 to 2004 to conduct a national study of the how MMC impacts access for persons with disabilities. They found evidence that MMC improved access to care, including a greater likelihood of having a usual source of care for preventive health, but only for beneficiaries enrolled in full-risk MMC in urban areas. They did not find any positive effect for persons in PCCM programs, or for persons in any type of MMC in rural areas.

In another national study, Burns (2009) merged enrollment data for adults with disabilities in MMC with the Medical Expenditure Panel Survey and the Area Resource File for 1996–2004. Like Coughlin et al., Burns found that MMC beneficiaries with disabilities are more likely to have a usual source of care, but she also found they are more likely to wait more than 30 minutes to see the regular provider, and are more likely to report a problem accessing a specialist, and less likely to have received a flu shot in the past year than those in FFS.

Palsbo and Mastal (2006) examined an emerging type of service delivery model that integrates health, social, and life services for people with disabilities, which the report calls DCCOs- Disability Care Coordination Organizations. Most of the DCCOs were partially capitated. Preliminary evidence indicates that care coordination reduces hospitalizations and ER use as it improves access to primary, preventive and specialty care. Satisfaction with Medicaid and quality of life improved, according to self-reported data, as well as DCCO internal data on clinical outcomes.

Health and Quality Outcomes for Persons Using Long Term Services and Supports

Although a majority of states include older persons and persons with disabilities in MMC, relatively few include long term services and supports (LTSS) in their MMC programs. Among the few of these programs that have been evaluated, modest to positive benefits for members were found. (Saucier and Fox-Grage, 2005) In a CMS-sponsored evaluation of the Minnesota Senior Health Options program, Kane et al. (2003) found few significant differences between MMC members and members of a control group. MMC members living in the community did become less likely to report moderate to severe pain over time than control group members, but comparative measures of functioning (ADL and IADL scores) over time showed no significant differences. Functioning of MMC members in nursing homes (ADL scores) was not significantly different from functioning of nursing home comparison group members. The authors concluded that, in general, MSHO resulted in modest benefit for enrollees compared with control groups.

A CMS-sponsored evaluation of outcomes in the Program of All-inclusive Care for the Elderly (PACE) was positive, finding improved quality of life, satisfaction, and functional status. (Chatterji et al., 1998) The study also found that PACE enrollees lived longer and spent more days in the community thanmembers of a comparison group.

A two-part independent assessment of the Wisconsin Family Care managed care program found that waiting lists for long-term services in Family Care counties were eliminated, while waiting lists in comparison counties continued to increase. (APS Healthcare, 2003) The program was also associated with reductions in institutionalization, illness burden and functional impairment among participants. (APS Healthcare, 2005)

Conclusion

The literature assessing the impact of risk-based Medicaid managed care is mixed to favorable and addresses changes in utilization primarily. The changes most often reported—increases in preventive and ambulatory care, and decreases in institutional care—are consistent with what policy makers want Medicaid managed care to achieve. Because most Medicaid managed care initiatives reflect the unique characteristics of the programs in which they operate, caution must be taken in projecting those outcomes in Maine. Nonetheless, the preponderance of studies from other states suggests that risk-based Medicaid managed care can improve access and quality, particularly when implementation is planned carefully, and a strong quality management program is in place.

References

Aizer, A., Currie, J., & Moretti, E. (2007, August). Does managed care hurt health? Evidence from Medicaid mothers. Review of Economics & Statistics, 89(3), 385-399.

APS Healthcare, Inc. 2003. Family Care Independent Assessment: An Evaluation of Access, Quality and Cost-Effectiveness for Calendar Year 2002.” Washington, DC: APS Healthcare, Inc.

APS Healthcare, Inc. 2005. “Family Care Independent Assessment: An Evaluation of Access, Quality and Cost Effectiveness for Calendar Year 2003 – 2004.” Washington, DC: APS Healthcare, Inc.

Baker, L.C., & Afendulis, C. (2005 Oct). Medicaid managed care and health care for children. Health Services Research, 40(5 Pt 1), 1466-88.

Berman, S., Armon, C., & Todd, J. (2005, December). Impact of a decline in Colorado Medicaid managed care enrollment on access and quality of preventive primary care services. Pediatrics , 116(6), 1474-1479.

Bindman, A.B., Chattopadhyay, A., Osmond, D.H., Huen, W., & Bacchetti, P. (2005 Feb). The impact of Medicaid managed care on hospitalizations for ambulatory care sensitive conditions. Health Services Research, 40(1), 19-38.

Burns, M.E. (2009). Medicaid managed care and health care access for adult beneficiaries with disabilities. Health Services Research, 44(5, part 1), 1521-1541.

Chatterji, P., et al. (1998, July 13). The impact of PACE on participant outcomes: Evaluation of the Program of All-Inclusive Care for the Elderly (PACE) Demonstration. Cambridge, MA: Abt Associates, Inc.

Coughlin, T.A. & Long, S.K. (2000). Effects of Medicaid managed care on adults. Medical Care, 38, 433-46.

Coughlin, T.A., Long, S.K., & Graves, J.A. (2009). Does managed care improve access to care for Medicaid beneficiaries with disabilities? A national study. Inquiry, 45(4), 395-407.

Garrett, B., Davidoff, A.J., & Yemane, A. (2003 Apr). Effects of Medicaid managed care programs on health services access and use. Health Services Research, 38(2), 575-94.

Garrett, B., & Zuckerman, S. (2005 July). National estimates of the effects of mandatory Medicaid managed care programs on health care access and use, 1997-1999. Medical Care, 43(7), 649-57.

Hutchinson, A.B., & Foster, E.M. (2003). The effect of Medicaid managed care on mental health care for children: a review of the literature. Mental Health Services Research, 5(1), 39-54.

Kane, R.L. et al. (2003 Apr). Outcomes of managed care of dually eligible older persons. Gerontologist, 43(2), 165-74.

Kenney, G., Sommers, A.S., & Dubay, L. (2005, July). Moving to mandatory Medicaid managed care in Ohio: Impacts on pregnant women and infants. Medical Care, 43(7), 683-90.

Lo Sasso, A.T., & Freund, D.A. (2000, Sept). A longitudinal evaluation of the effect of Medi-Cal managed care on supplemental security income and aid to families with dependent children enrollees in two California counties. Medical Care, 38(9), 937-47.

Palsbo, S.E., & Mastal, M.F. (2006). Disability Care Coordination Organizations--The experience of Medicaid managed care programs for people with disabilities. (Resource Paper). Hamilton, NJ: Center for Health Care Strategies.

Roohan, P.J., Butch, J.M., Anarella, J.P., Gesten, F., & Shure, K. (2006). Quality measurement in Medicaid managed care and fee-for-service: The New York State experience. American Journal of Medical Quality, 21(3), 185-191.

Saucier, P., & Fox-Grage, W. (2005, Nov). Medicaid managed long-term care. (Issue Brief Number 79). Washington, DC: AARP Public Policy Institute.

Schuster, C.R., Mitchell, J.M., & Gaskin, D.J. (2007). Partially capitated managed care versus FFS for special needs children. Health Care Financing Review, 28(4), 109-23.

Sisk, J.E. et al. (1996). Evaluation of Medicaid managed care: Satisfaction, access, and use. JAMA, 276(1), 50-5.

Sommers, A.S., Kenney, G. M. & Dubay, L. (2005). Implementation of mandatory Medicaid managed care in Missouri: impacts for pregnant women. American Journal of Managed Care, 11, 433-442.

Stankaitis, J.A., Brill, H.R., & Walker, D.M. (2005, March). Reduction in neonatal intensive care unit admission rates in a Medicaid managed care program. American Journal of Managed Care, 11(3), 166-72.

Verdier, J., Colby, M., et al. (2009, Jan). SoonerCare 1115 Waiver evaluation: Final report. (MPR No. 6492-005 ). Washington, DC: Mathematica Policy Research, Inc.

APPENDIX A DHHS Report: Feasibility of Risk-Based Contracting in MaineCare April 2010 A-1