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Studies examine the impact of Medicaid managed care programs on access to and use of care

During the past two decades, nearly all States have implemented managed care for their Medicaid health insurance programs for the poor, including mental health services. Three new studies, supported in part by the Agency for Healthcare Research and Quality (AHRQ), recently examined the impact of Medicaid managed care (MMC) on access to care and use of care.

The first study (AHRQ grant HS10925) concluded that concerns of reduced access to care for the uninsured through MMC programs appear to be unwarranted. According to the second study (AHRQ grant HS09703), the advantages of MMC for mental health care may be diminished in rural, medically underserved States like New Mexico. The third study (AHRQ grants HS10249 and HS10384) unexpectedly found that lapses in enrollment in an MMC program did not affect emergency department visits and hospitalizations for children with asthma. The studies are briefly summarized here.

Haberer, J.E., Garrett, B.M. and Baker, L.C. (2005, July). "Does Medicaid managed care affect access to care for the uninsured?" Health Affairs 24(4), pp. 1095-1105.

Some have been concerned that the prevalence of MMC patients at safety-net providers, such as community health centers, would reduce available care for the uninsured, and that less Medicaid funding to cross-subsidize care for the uninsured would also reduce their access to care. However, these concerns appear to be unwarranted, concludes this study. Researchers examined the relationship between MMC and care access for the uninsured, using county-level data from the National Health Interview Survey on a nationwide sample over an 8-year period (1994-2001) during which MMC enrollment increased dramatically. After controlling for other factors that typically affect care access (such as race/ethnicity and income), the researchers found that MMC had no consistent effect on care access for the uninsured.

The findings suggest that safety-net providers are coping with the changes associated with MMC. However, it is not known if MMC has affected quality of care for the uninsured or how MMC will evolve in the future.

Willging, C., Waitzkin, H., and Wagner, W. (August, 2005). "Medicaid managed care for mental health services in a rural state." Journal of Health Care for the Poor and Underserved 16, pp. 497-514.

In 1997, the rural State of New Mexico, in which one of every five people holds Medicaid coverage, implemented Medicaid managed care for both physical and mental health services. The reform led to administrative burdens, payment problems, stress, and high turnover among providers. In addition, restrictions on inpatient and residential treatment worsened access problems for Medicaid-insured individuals with mental health problems, according to this study. These findings suggest that for rural, medically underserved States, the advantages of managed care for mental health care may be diminished.

The investigators conducted interviews, made field observations, and reviewed legal documents and State monitoring data to examine the impact of Medicaid reform on mental health safety net institutions and on the patients they served in an urban and rural county in New Mexico. MMC made it increasingly difficult for safety net institutions to maintain their tradition of service to the poor. Patients also faced greater barriers in obtaining inpatient care and community-based services such as outpatient therapy and case management.

Continuity of care for some patients became compromised when their providers ceased participation in Medicaid because of work-related stress and low reimbursements. Reduced case management, due to large caseloads and low wages, decreased coordination of mental health. Social services tasks fell to clinicians or were neglected entirely. Sixty child and adolescent mental health programs closed between 1998 and 2001, and one hospital ended its adolescent residential treatment program to conserve financial resources.

Cooper, W.O., Arbogast, P.G., Hickson, G.B., and others (2005, July). "Gaps in enrollment from a Medicaid managed care program." Medical Care 43(7), pp. 718-725.

This study found that children with asthma, whose enrollment in the Tennessee Medicaid managed care program (TennCare) lapsed, had no more asthma-related emergency department visits and hospitalizations than children without gaps in enrollment. Also, children with gaps in coverage were less likely to have emergency department visits and hospitalizations for nonrespiratory conditions. Several factors may have contributed to the first unexpected finding. For example, private coverage may have been present before the gap began or families might have sought private insurance coverage once the child's TennCare coverage lapsed. Also, coverage gaps may have been too short to have impeded access to medications sufficiently to cause poorer asthma outcomes. In other cases, families may have paid for the prescription out of pocket for a child with worsening asthma symptoms. On the other hand, providers may have avoided hospitalizing children with gaps in enrollment because of the families' inability to pay.

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