Health Promotion Interventions for Low-Income Californians Through Medi-Cal Managed Care Plans, 2012.

INTRODUCTION: Prevention is the most cost-effective approach to promote population health, yet little is known about the delivery of health promotion interventions in the nation's largest Medicaid program, Medi-Cal. The purpose of this study was to inventory health promotion interventions delivered through Medi-Cal Managed Care Plans; identify attributes of the interventions that plans judged to have the greatest impact on their members; and determine the extent to which the plans refer members to community assistance programs and sponsor health-promoting community activities. METHODS: The lead health educator from each managed care plan was asked to complete a 190-item online survey in January 2013; 20 of 21 managed care plans responded. Survey data on the health promotion interventions with the greatest impact were grouped according to intervention attributes and measures of effectiveness; quantitative data were analyzed using descriptive statistics. RESULTS: Health promotion interventions judged to have the greatest impact on Medi-Cal members were delivered in various ways; educational materials, one-on-one education, and group classes were delivered most frequently. Behavior change, knowledge gain, and improved disease management were cited most often as measures of effectiveness. Across all interventions, median educational hours were limited (2.4 h), and median Medi-Cal member participation was low (265 members per intervention). Most interventions with greatest impact (120 of 137 [88%]) focused on tertiary prevention. There were mixed results in referring members to community assistance programs and investing in community activities. CONCLUSION: Managed care plans have many opportunities to more effectively deliver health promotion interventions. Establishing measurable, evidence-based, consensus standards for such programs could facilitate improved delivery of these services.

Local access to care programs (LACPs): new developments in the access to care for the uninsured.

CONTEXT: New, locally based health care access programs are emerging in response to the growing number of uninsured, providing an alternative to health insurance and traditional safety net providers. Although these programs have been largely overlooked in health services research and health policy, they are becoming an important local supplement to the historically overburdened safety net. METHODS: This article is based on a literature review, Internet search, and key actor interviews to document programs in the United States, using a typology to classify the programs and document key characteristics. FINDINGS: Local access to care programs (LACPs) fall outside traditional private and publicly subsidized insurance programs. They have a formal enrollment process, eligibility determination, and enrollment fees that give enrollees access to a network of providers that have agreed to offer free or reduced-price health care services. The forty-seven LACPs documented in this article were categorized into four general models: three-share programs, national-provider networks, county-based indigent care, and local provider-based programs. CONCLUSIONS: New, locally based health access programs are being developed to meet the health care needs of the growing number of uninsured adults. These programs offer an alternative to traditional health insurance and build on the tradition of county-based care for the indigent. It is important that these locally based, alternative paths to health care services be documented and monitored, as the number of uninsured adults is continuing to grow and these programs are becoming a larger component of the U.S. health care safety net.

Management of behavioral health provider networks in private health plans.

We explored the techniques used by private health plans or by their contracted managed behavioral healthcare organizations (MBHOs) to maintain networks of behavioral health providers. In particular, we focused on differences by health plans' product types (health maintenance organization, point-of-service plan, or preferred provider organization) and contracting arrangements (MBHO contracts, comprehensive contracts, or no contracts). More than 94% of products selected providers using credentialing standards, particular specialists, or geographic coverage. To retain providers viewed as high quality, 54% offer reduced administrative burden and 44% higher fees. Only 16% reported steerage to a core group of highest-quality providers and few reported an annual bonus or guaranteed volume of referrals. Some standard activities are common, but some health plans are adopting other approaches to retain higher-quality providers.

Effects of managed care on the proportion of inappropriate elective diagnostic coronary angiographies in non-emergency patients in Switzerland: a retrospective cross-sectional analysis.

OBJECTIVE: Guidelines recommend non-invasive ischaemia testing (NIIT) for the majority of patients with suspected ischaemic heart disease in a non-emergency setting. A substantial number of these patients undergo diagnostic coronary angiography (CA) without therapeutic intervention inappropriately due to lacking preceding NIIT. The aim of this study was to evaluate the effect of voluntary healthcare models with limited access on the proportion of patients without NIIT prior to elective purely diagnostic CA. DESIGN: Retrospective cross-sectional analysis of insurance claims data from 2012 to 2015. Data included claims of basic and voluntary healthcare models from approximately 1.2 million patients enrolled with the Helsana Insurance Group. Voluntary healthcare models with limited health access are divided into gate keeping (GK) and managed care (MC) capitation models. INCLUSION CRITERIA: patients undergoing CA. EXCLUSION CRITERIA: Patients<18 years, incomplete health insurance data coverage, acute cardiac ischaemia and emergency procedures, therapeutic CA (coronary angioplasty/stenting or coronary artery bypass grafting). The effect of voluntary healthcare models on the proportion of NIIT undertaken within 2 months before diagnostic CA was assessed by means of multiple logistic regression analysis, controlled for influencing factors. RESULTS: 9173 patients matched inclusion criteria. 33.2% (3044) did not receive NIIT before CA. Compared with basic healthcare models, MC was independently associated with a higher proportion of NIIT (p<0.001, OR 1.17, CI 1.045 to 1.312), when additionally controlled for demographics, insurance coverage, inpatient treatment, cardiovascular medication, chronic comorbidities, high-risk status (patients with therapeutic cardiac intervention 1 month after or 18 months prior to diagnostic CA). GK models showed no significant association with the rate of NIIT (p=0.07, OR 1.11, CI 0.991 to 1.253). CONCLUSIONS: In a non-GK healthcare system, voluntary MC healthcare models with capitation were associated with a reduced inappropriate use of diagnostic CA compared with GK or basic models.

Quality of care in Medicaid managed care and commercial health plans.

CONTEXT: In contrast to the commercially insured population, the proportion of Medicaid beneficiaries enrolling in health maintenance organizations continues to increase. OBJECTIVE: To compare quality of care within and between the Medicaid and commercial populations in 3 types of managed care plans: Medicaid-only plans (serving predominantly Medicaid enrollees), commercial-only plans (serving predominantly commercial enrollees), and Medicaid/commercial plans (serving substantial numbers of both types of enrollees). DESIGN, SETTING, AND PARTICIPANTS: All 383 health plans that reported quality-of-care data to the National Committee for Quality Assurance for 2002 and 2003, including 204 commercial-only plans, 142 Medicaid/commercial plans (plans reported data for the Medicaid and commercial populations separately); and 37 Medicaid-only plans. MAIN OUTCOME MEASURES: Eleven quality indicators from the Healthcare Effectiveness Data and Information Set (HEDIS) applicable to the Medicaid population. RESULTS: Among Medicaid enrollees, performance on the 11 measures observed in this study were comparable for Medicaid-only plans and Medicaid/commercial plans. Similarly, among commercial enrollees, there was virtually no difference in performance between health plans that served only the commercial population and those that also served the Medicaid population. Overall across all health plan types, the performance for the commercial population exceeded the performance for the Medicaid population on all measures except 1, ranging from a difference of 4.9% for controlling hypertension (58.4% for commercial vs 53.5% for Medicaid; P = .002) to 24.5% for rates of appropriate postpartum care (77.2% for commercial vs 52.7% for Medicaid; P = .001). Differences of similar magnitude were observed for commercial and Medicaid populations treated within the same health plan. CONCLUSIONS: Medicaid managed care enrollees receive lower-quality care than that received by commercial managed care enrollees. There were no differences in quality of care for the Medicaid population between Medicaid-only plans and commercial plans that also served the Medicaid population.

Do content and format affect older consumers' use of comparative information in a Medicare health plan choice? Results from a controlled experiment.

We assessed the efficacy of materials that integrated comparative information on cost, benefits, and quality for employer-based retiree health plans and Medicare Advantage plans in a randomized experiment to test the impact of content and format. Results indicate that older consumers who received the intervention materials found the materials easier to use, gained greater knowledge about Medicare from them, were more likely to value comparative quality information, were more likely to select higher quality plans, and were more likely to choose a plan that reflected the dimensions they found most important compared to older consumers receiving the control materials.

Managed care and gender disparities in problematic health care experiences.

OBJECTIVE: To determine whether gender differences in reports of problematic health care experiences are associated with characteristics of managed care. DATA SOURCES: The 2002 Yale Consumer Experiences Survey (N=5,000), a nationally representative sample of persons over 18 years of age with private health insurance, Interstudy Competitive Edge HMO Industry Report 2001, Area Resource File 2002, and the American Hospital Association Annual Survey of Hospitals 2002. STUDY DESIGN: Independent and interactive effects of gender and managed care on reports of problematic health care experiences were modeled using weighted multivariate logistic regression. PRINCIPAL FINDINGS: Women were significantly more likely to report problems with their health care compared with men, even after controlling for gendered differences in expectations about medical care. Gender disparities in problem reporting were larger in plans that used certain managed care techniques, but smaller in plans using other methods. Some health plan managed care practices, including closed networks of providers and gatekeepers to specialty care, were associated with greater problem reporting among women, while others, such as requirements for primary care providers, were associated with greater problem reporting among men. Markets with higher HMO competition and penetration were associated with greater problem reporting among women, but reduced problem reporting among men. Women reported more problems in states that had enacted regulations governing access to OB/GYNs, while men reported more problems in states with regulations allowing specialists to act as primary care providers in health plans. CONCLUSIONS: There are nontrivial gender disparities in reports of problematic health care experiences. The differential consequences of managed care at both the plan and market levels explain a portion of these gender disparities in problem reporting.

Comparing employee health benefits in the public and private sectors, 1997.

Data from the 1997 Robert Wood Johnson Foundation Employer Health Insurance Survey provide new information comparing public- and private-sector employee health benefits. The federal government is ahead of other employers in adopting managed competition principles using financial incentives and consumer information to promote choosing efficient plans. Federal employees experience a $200 annual compensation gap relative to those in the private sector, but it is partly explained by advantage in purchasing power. In contrast, state and local governments make higher payments toward health insurance than private-sector employers do. Their premiums are equivalent, but they pay a greater share of the total cost.

Do consumers know how their health plan works?

Expanding consumer choice of plans is beneficial only to the extent that consumers make informed choices. Using data from the 1996-97 Community Tracking Study (CTS), this study compares consumers' responses on four key attributes of their health plan with information provided directly by the plan. Plan attributes relate to choice of providers and access to specialists. Although the accuracy of reporting some individual attributes was fairly high, fewer than one-third of consumers accurately reported all four health plan attributes. In general, consumers tended to overreport plan restrictions, especially the need for approval to see specialists.

Health benefits in 2003: premiums reach thirteen-year high as employers adopt new forms of cost sharing.

This paper reports changes in job-based health insurance from spring 2002 to spring 2003. The cost of health insurance rose 13.9 percent, the highest rate of increase since 1990. Employers required larger contributions from employees for the monthly cost of health insurance. Separate copayments and deductibles for hospital services have become commonplace, and provider networks have broadened. There was no change in the percentage of employers offering health plans to their workers. Employers indicate little confidence in any future strategies for controlling health care costs.

Trends in managed care and managed competition, 1993-1997.

According to the recent literature, we are experiencing a managed care "revolution," and managed competition is increasingly being embraced by private- and public-sector policymakers. Using two large employer health insurance surveys, this paper presents new estimates that both confirm and add to our understanding of changes taking place in employment-based health plans. The dramatic shifts in enrollment from indemnity to managed care largely reflect employers' choices about the types of plans to offer. Employees are limited in the number and types of plans from which they can choose. When choice is available, it is generally not governed by managed competition principles.

Quality information and consumer health plan choices.

This paper presents an empirical analysis of the effects of providing information about plan quality on consumers' health plan choices in a private employment setting. Analysis of plan switching behavior suggests that the provision of quality information had a small, but significant effect on consumer plan choices. Employees were more likely to switch from plans with lower reported quality. Cross-sectional analyses of plan choice indicate that reported quality played a role in plan selection even after controlling for other health plan characteristics commonly associated with plan choice. The age of the policyholder and the type of policy purchased moderated the effects of plan characteristics on plan choice in ways that may be consequential for adverse selection.

Measuring consumer perceptions of quality differences among competing health benefit plans.

In this paper, we combine revealed preference and survey data on attribute importance to estimate parameters that represent average perceived differences in the quality and convenience of competing health benefit plans. We find that consumers do not perceive differences in provider quality across options. though they do perceive differences related to waiting time and access to specialists. In order to validate our approach, we estimate parameters representing perceived premiums and compare the estimates to actual premium differences. The results suggest that consumers correctly perceive the high-premium option to cost more than the low-premium option. These results increase our confidence in the use of stated importance data to identify and interpret parameters measuring the effect of otherwise unobservable attributes of choice alternatives.

Wrestling with typology: penetrating the "black box" of managed care by focusing on health care system characteristics.

The health care system has undergone a fundamental transformation undermining the usefulness of the typology of the health maintenance organization, the independent practice association, the preferred provider organization, and so forth. The authors present a new approach to studying the health care system. In matrix form, they have identified a set of organizational and delivery characteristics with the potential to influence outcomes of interest, such as access to services, quality, health status and functioning, and cost. The matrix groups the characteristics by domain--financial features, structure, care delivery and management policies, and products--and by key roles in the health care system--sponsor, plan, provider intermediary organization, and direct services provider. The matrix is a tool for researchers, administrators, clinicians, data collectors, regulators, and other policy makers. It suggests a new set of players to be studied, emphasizes the relationships among the players, and provides a checklist of independent, control, and interactive variables to be included in analyses.

Cost sharing for substance abuse and mental health services in managed care plans.

Recent initiatives to improve private insurance coverage for substance abuse and mental health in the United States have mostly focused on equalizing coverage limits to those found in general medical care. Federal law does not address cost sharing (copayments and coinsurance), which may also deter needed care or impose significant financial burdens on enrollees. This article reports on cost sharing requirements for outpatient care in a nationally representative sample of managed care plans in 1999. Levels of cost sharing are substantial, with around 40 percent of products requiring copayments of $20 or more and another 15 percent requiring coinsurance of 50 percent. Cost sharing for outpatient substance abuse treatment is very similar to that for mental health. Compared to general medical care, at least 30 percent of products impose higher cost sharing for substance abuse and mental health treatment. Future parity initiatives should be examined for how they address differences in cost sharing as well as limits.