Persistent spatial structuring of coastal ocean acidification in the California Current System.

The near-term progression of ocean acidification (OA) is projected to bring about sharp changes in the chemistry of coastal upwelling ecosystems. The distribution of OA exposure across these early-impact systems, however, is highly uncertain and limits our understanding of whether and how spatial management actions can be deployed to ameliorate future impacts. Through a novel coastal OA observing network, we have uncovered a remarkably persistent spatial mosaic in the penetration of acidified waters into ecologically-important nearshore habitats across 1,000 km of the California Current Large Marine Ecosystem. In the most severe exposure hotspots, suboptimal conditions for calcifying organisms encompassed up to 56% of the summer season, and were accompanied by some of the lowest and most variable pH environments known for the surface ocean. Persistent refuge areas were also found, highlighting new opportunities for local adaptation to address the global challenge of OA in productive coastal systems.

A national study of commercial health insurance and medicaid definitions of medical necessity: what do they mean for children?

OBJECTIVE: To analyze medical necessity standards used by state Medicaid agencies and the largest commercial insurers in the United States on the basis of criteria related to scope of health problems covered and requirements for effectiveness and cost. METHODS: Information was obtained from managed care contract documents used by the 45 state Medicaid agencies enrolling children into managed care organizations and from certificates of coverage used by the largest health maintenance and preferred provider organization insurers in each state. RESULTS: Commercial insurers are more likely than Medicaid agencies to articulate medical necessity standards that limit coverage to treatment for illnesses and injuries and to include stringent requirements for cost and evidence of effectiveness. CONCLUSION: To reduce the discretion retained by insurers in determining medical necessity, particularly around the scope of health problems covered, much greater clarity and uniformity in medical necessity language will be required in the future.

An examination of state Medicaid financing arrangements for early childhood development services.

OBJECTIVE: To determine the extent to which Medicaid finances early childhood development services, either on a capitated or fee-for-service basis, and to gauge future interest in financing such services. METHODS: We analyzed state Medicaid managed care contracts in effect in April 1998 in 45 states using capitated arrangements for children at the end of 1997 to ascertain whether state Medicaid agencies financed any of six types of early childhood development services, including parent counseling, home visiting, comprehensive assessments, telephone advice lines, parent education classes, and case management. We also conducted structured telephone surveys with the same 45 states' Medicaid managed care directors. RESULTS: Overall, state Medicaid agencies finance few early childhood development services on a capitated or fee-for-service basis. Case management was the most popular service to be paid for fee-for-service. Parent education was the most popular service required in managed care contracts. Parent counseling and telephone advice lines for information on child development or parenting issues were the services least likely to be reimbursed through either Medicaid financing mechanism. CONCLUSION: To date, Medicaid agencies generally have not required managed care plans to cover early childhood development services, nor have they paid for such services on a fee-for-service basis. However, 17 states expressed an interest in expanding early childhood development services, particularly home visiting, parent education, and telephone advice lines. Nonetheless, several challenges exist in expanding Medicaid financing, including the need for more evidence on cost-effectiveness and greater political support for promoting early childhood development.

How far have state Medicaid agencies advanced in performance measurement for children?

BACKGROUND: While children represent the largest population group enrolled in Medicaid managed care, little is known about the pediatric performance measures used by state Medicaid agencies. OBJECTIVE: To identify Medicaid managed care requirements for using Health Plan Employer Data and Information Set and other performance measures for children (defined as those aged 0-21 years in this study). DESIGN: A structured telephone survey of pediatric performance measures. PARTICIPANTS: Survey respondents were state Medicaid officials responsible for managed care quality oversight in 39 states. MAIN OUTCOME MEASURES: Percentage of states in 1998 with effectiveness-of-care measures on health promotion and disease prevention, early detection and screening, and acute and chronic illness; with use measures on preventive care, ambulatory care, pharmacy, inpatient hospital care, and mental health and chemical dependency services; and with access measures on primary care, low-birth-weight neonates delivered at appropriate facilities, and dental care. RESULTS: In 1998, state Medicaid agencies placed most of their emphasis on monitoring preventive care for children, with immunization rates being the primary focus. Far less attention was directed at assessing the treatment of acute illness. Although more than half of states monitored the treatment of chronic childhood conditions, they focused exclusively on asthma and selected mental health diagnoses. CONCLUSIONS: States are still in the initial phases of designing and implementing quality oversight systems for Medicaid-insured children. Additional quality reporting requirements are clearly needed to assess the treatment of acute and chronic illness among children along with more age-specific reporting requirements.

Improving state Medicaid contracts and plan practices for children with special needs.

The rapid transition of state Medicaid beneficiaries into fully capitated managed care plans requires a special focus on children with chronic or disabling conditions, who often depend on numerous pediatric physicians and other specialty services for health care and related services. Because managed care arrangements for this population are growing in popularity nationwide, it is important that states craft managed care contracts to address the unique needs of children with complex physical, developmental, and mental health problems. Based on the research reported in this article, in-depth interviews with state Medicaid agency staff, interviews with medical directors and administrators of managed care plans serving Medicaid recipients, and input from experts in pediatrics and managed care, a set of recommendations is made for tailoring managed care contracts to meet the needs of this vulnerable group of children. Six contracting elements that should be adopted by state Medicaid agencies include (1) clarifying the specificity of pediatric benefits, (2) defining appropriate pediatric provider capacity requirements, (3) developing a medical necessity standard specific to children, (4) identifying pediatric quality-of-care measures, (5) setting appropriate pediatric capitation rates, and (6) creating incentives for high-quality pediatric care. Nine approaches that should be adopted by managed care practices interested in providing high-quality care for children with special needs also are identified. These include (1) ensuring that assigned primary care providers have appropriate training and experience, (2) offering support systems for primary care practices, (3) providing specialty consultation for primary care providers, (4) establishing arrangements for the comanagement of primary and specialty pediatric services, (5) arranging for comprehensive care coordination, (6) establishing flexible service authorization policies, (7) implementing provider profiling systems that adjust for pediatric case mix, (8) creating financial incentives for serving children with special needs, and (9) encouraging family involvement in plan operations. Implementing these changes to managed care contracting could have a major impact on the quality and comprehensiveness of health care received by children with special needs. Successful implementation, however, requires strong support from both state Medicaid agencies and the managed care plans dedicated to serving this population.

Managed care's impact on Medicaid financing for early intervention services.

Medicaid has been a major source of financing for early intervention services since the inception of the Infants and Toddlers with Disabilities Program in 1986. In this article, the authors analyze Medicaid financing of early intervention services in 39 States before and after the introduction of managed care. The association between level of Medicaid financing and program characteristics, provider arrangements, managed care carve-out policies, and managed care contract requirements is assessed. The authors discuss the reduction of Medicaid financing after managed care and its implications for State Infants and Toddlers with Disabilities Programs, State Medicaid agencies, and managed care organizations.

Medicaid managed care policies affecting children with disabilities: 1995 and 1996.

The authors present findings from a study of State Medicaid managed care enrollment and benefit policies in 1995 and 1996 for children with disabilities. During this time the number of States serving children through fully capitated plans grew by more than one-third, and enrollment of children receiving Supplemental Security Income (SSI) payments and children in subsidized foster care increased. Most States required plans to provide all mandatory and most optional Medicaid services. Although States have begun to make noticeable improvements in their contract language concerning medical necessity and the early and periodic screening, diagnosis, and treatment (EPSDT) benefit, overall State guidance in these areas remains weak.

Managed care for people with disabilities: caring for those with the greatest need.

Disability is discussed in terms of three categories: conditions that result from biomedical conditions and chronic, lifelong illnesses; role or social functioning difficulties that result from behavioral, developmental, or brain disorders; and conditions that limit physical functioning. The range and depth of services needed by the disabled result in higher costs of health care for this population. Because their service needs vary so widely, no single program can address all of the needs equally. Currently, no integrated public policy or program is specifically designed to serve people with disabilities. Rather, they are served by a range of programs that provide specific benefits (e.g., health, social services, and income). Section 1 of this chapter provides an overview on extending the concept of managed care to disabled populations. Special attention is paid to the financing of health care, the delivery of care, reforming the health care system, the cost-containment potential of managed care, and the need to align care with the nature of the individual disability. In sections 2 and 3, the current status of managed care for two special populations--children and the mentally ill--is discussed in greater detail. Section 2 addresses the characteristics of chronically ill and disabled children, public and private health insurance coverage of children with disabilities, other public programs for chronically ill children, and current directions and strategic choices for managed pediatric care. Section 3 describes the mentally ill and the system of providers that currently supplies care to them, offers some conclusions regarding how managed care is changing the policy debate in mental health care, assesses the key factors affecting policy choices in managed care, and considers prospects for the future shape of managed behavioral health care.

Enhancing preventive and primary care for children with chronic or disabling conditions served in health maintenance organizations.

Health maintenance organizations serve an estimated 20 percent of the child population, approximately 12 million children, many of whom have chronic conditions or disabling conditions. These children consume a disproportionate share of health resources and represent an important challenge in terms of care management. As HMOs increasingly enroll children with private insurance and Medicaid who have various physical, developmental, behavioral, and emotional disorders, they must find new and innovative ways to provide their care. Almost one third of children are affected by chronic conditions, and a smaller percentage (6 percent) suffer from chronic disabling conditions. Seven design elements for enhancing preventive and primary care for children with chronic conditions are presented in this article with illustrative examples from HMOs and state Medicaid programs.

Race, ethnicity, and access to ambulatory care among US adolescents.

OBJECTIVES: Improving the health of minority adolescents will require a better understanding of factors that influence their access to and use of health care. This study describes the differences in health care access and use among White, Black and Hispanic adolescents and evaluates how such differences are influenced by insurance. METHODS: We used data on 7465 10- to 17-year-olds included in the child health supplement to the 1988 National Health Interview Survey. RESULTS: Much higher proportions of Blacks (16%) and Hispanics (28%) than of Whites (11%) were uninsured. Despite having worse reported health status, Black and Hispanic adolescents made notably fewer doctor visits in the past year than their White peers, and were more apt to lack usual sources of routine and acute care as well as continuity between sources of care. Having health insurance was associated with greater increase in access and usage measures for minority youth than for White youth. However, racial differences persisted even after adjusting for health insurance, family income, need, and other factors. CONCLUSIONS: Minority adolescents are particularly vulnerable to the problems of health care access that affect all youth. While health insurance is especially important for increasing appropriate health care use among minority youth, nonfinancial methods of enabling more equitable use also deserve further study.

A decade of Medicaid in perspective: what have been the effects on children?

This study of the Medicaid program analyzes changes in child recipients, costs, and service use during the 1980s to assess the effects of recent federal policy shifts and to project future costs for children. Data presented in this study are from the Health Care Financing Administration's Medicaid Statistical Report for the years 1979, 1985, and 1990, three time-points that demarcate major federal policy shifts. About half of all recipients added to the Medicaid program during the last decade were children; they comprised 14% of the total cost growth experienced by the program. In addition, the eligibility distribution of children receiving Medicaid shifted markedly over the last decade. In 1979, children receiving cash assistance comprised 90% of total child recipients; by 1990, this figure dropped to 72%. Future expansions to the Medicaid program are projected to cost less than the initial expansions. This is because the early expansions disproportionately served infants, who require more hospital services than older children. Despite the major changes in Medicaid eligibility for children during the 1980s, only limited cost shifts occurred in expenditures for children. Children continue to consume a small portion of the Medicaid budget. Congress should explore options for guaranteeing that their share of funding for services will be adequate. Moreover, since future expansions will be far less expensive than those already implemented, accelerating the phase-in process for all poor children may be a more financially feasible policy option than many policymakers anticipate, despite the fiscal hardships facing many states.

How will children and pregnant women fare under current national health insurance proposals?

OBJECTIVE: To compare the following five major national health insurance proposals and their implications for children and pregnant women: the MAtsui "play or pay" bill (HR 3393); the Russo Canadian-type bill (HR 1300); the Rockefeller "play or pay" bill (S 1177); the Stark Medicare-type bill (HR 650); and the president's market reform proposal. RESEARCH DESIGN: Using an analytic framework developed by the Association of Maternal and Child Health Programs, we examine the differences among the five proposals in basic approach, eligibility and enrollment, benefits, cost-sharing requirements, provider reimbursement, and cost-control measures. RESULTS: All of the plans, except for President Bush's, would provide coverage for virtually all children and pregnant women, using a combination of private and public approaches. President Bush's market approach provides financial incentives to purchase health insurance benefit plans that states can design within actuarial limits. The remaining four plans strive for uniformity in benefits, covering physician and hospital services in a manner similar to most plans today. Preventive care benefits extend beyond what has been offered in the past. The four plans differ sharply in their coverage of extended care services, with the Matsui and Russo bills covering the most generous package of benefits. The Rockefeller and Stark plans, on the other hand, require less cost-sharing for their basically preventive and primary care plans. CONCLUSIONS: Most of the health insurance proposals are aimed at extending preventive and primary care health insurance plans to more uninsured Americans. Only the Matsui bill devotes significant attention to developing a comprehensive benefit plan for children and pregnant women. Additional attention should be directed at extended care services for those with special health care needs, the future role of Medicaid, and the public health system infrastructure.

Health insurance coverage of adolescents: a current profile and assessment of trends.

Data from the National Health Interview Survey reveal that 4.7 million or 15% of US adolescents aged 10 through 18 were uninsured in 1989. Among adolescents, 73% were privately insured, 10% were publicly insured, and 2% were both privately and publicly insured. Poor, near-poor, and minority adolescents were at the greatest risk for lack of health insurance coverage. Among adolescents without insurance, cost continued to be cited as the leading barrier to obtaining coverage. A comparison of 1989 National Health Interview Survey data with a previous analysis, in which 1984 data were used, revealed a 10% increase in the proportion of adolescents without insurance coverage. The increase in the proportion of uninsured adolescents was entirely attributable to an erosion of private health insurance coverage. No significant change occurred in the proportion of adolescents with coverage under public programs. Planned expansions of the federally and state-financed Medicaid programs will help to stem further increases in the size of the uninsured adolescent population. However, unless marked improvements occur in the private health insurance sector, progress will be limited.

Prevalence and impact of chronic illness among adolescents.

A sample of 7465 persons aged 10 to 17 years from the 1988 National Health Interview Survey on Child Health was used to assess the prevalence and impact of chronic conditions in adolescents. We defined a condition as chronic if it was first noted more than 3 months before the interview or a condition that ordinarily would be of lengthy duration, such as arthritis or heart disease. An estimated 31.5% of US adolescents were reported to have one or more chronic conditions. The most commonly reported chronic conditions included respiratory allergies, asthma, and frequent or severe headaches. Chronic conditions had widely varying impact on adolescent activity levels. On average, adolescents with chronic conditions experienced 3.4 bed days and 4.4 school absence days related to their chronic conditions in the year before the interview. Adolescents with chronic conditions were also reported to experience 35% more behavioral problems than their counterparts without chronic conditions. Adolescents with multiple chronic conditions had substantially more bed days, school absence days, and behavioral problems than adolescents with a single chronic condition. Implications of these findings are discussed.

Financing health services in school-based clinics. Do nontraditional programs tap traditional funding sources?

This telephone survey of directors of 50 school-based clinics (SBCs) examined the influence of organizational factors on use of traditional funding sources, such as Medicaid and private insurance. These factors included: initial funding source (Robert Wood Johnson Foundation's School-Based Adolescent Health Care Program vs. comparison), administrative structure, age of clinic, and state Medicaid policy. Results indicated that over half (51%) of the clinics used Medicaid as a funding source to some extent, while fewer (32%) used private insurance. Use of Medicaid and private insurance, however, varied with the initial funding source, administrative structure, and age of the clinic. Initial funding source and age of the clinic were the strongest predictors of Medicaid usage. Barriers to traditional funding sources, as well as methods used to overcome constraints, are discussed. The importance of the link between a nontraditional health care delivery system, the school-based clinic, and the traditional funding sources of Medicaid and private insurance is examined in light of the organizational factors which facilitate this link.

Young adults with special health care needs: prevalence, severity, and access to health services.

Health care needs of disabled young adults and access to care are analyzed using the 1984 National Health Interview Survey, a nationally representative sample of 10,394 randomly selected noninstitutionalized young adults aged 19 to 24. In 1984, 1.4 million young adults (almost 6%) suffered from disabilities. The leading cause of disability was diseases of the musculoskeletal system and connective tissue. Young adults living in poverty, in households where the family reference person had less than a high school education, and who were male were at elevated risk of disability. Disabled young adults made almost three times as many physician contacts and were hospitalized for close to six times as many days as nondisabled young adults. One of every 5 disabled young adults was uninsured in 1984. Forty-one percent of disabled Hispanic 19- to 24-year-olds and 51% of disabled young adults of other races were uninsured compared with 19% of whites and blacks. Research and financing policy implications are discussed.

Genetic counseling in Catholic hospitals. Facilities must provide guidance to keep pace with new knowledge and techniques.

As advances in the knowledge of human genetics change the practice of medicine, Catholic healthcare facilities will, according to ethicists, be increasingly obliged to provide genetic counseling services to their patients. Facilities should ensure that counselors make genetic information available in a context in which no pressure, overt or subtle, is exerted to use that information in a way that may violate an individual's value system. Some hospitals may, for example, set up a separate genetic counseling department, which does not diagnose or treat genetic disorders but does facilitate access to these treatments when patients need them. Effective counseling requires accurate, current knowledge about tests and treatments, as well as about theological discussions and Church decisions on the subject. Counselors also need to be aware of some typical misconceptions people have about genetic disease. Catholic hospitals should also work with other Catholic organizations to influence legislation addressing human genetic issues, especially when such legislation addresses reproductive rights.

Financing health care for adolescents: problems, prospects, and proposals.

Currently, one in every seven adolescents, aged 10-18, is uninsured. This translates to nearly 5 million uninsured adolescents nationwide. Uninsured adolescents, as opposed to insured adolescents, are more likely to be members of poor and minority families. In addition, adolescents without health insurance use fewer health services than their insured counterparts even after controlling for health status differences. Improving the health insurance status of adolescents is becoming an important public policy objective, although Congress recently rejected legislation that would have expanded Medicaid coverage for poor adolescents. Despite this setback, legislators and child health associates are increasingly striving for public and private insurance expansions for adolescents. These efforts are described, and the prospects for future improvements in health insurance coverage of adolescents are discussed.

Health care expenditure patterns for adolescents.

Health care expenditure patterns are described using a sample of 2,767 adolescents aged 10 to 18 years from the National Medical Care Utilization and Expenditure Survey. Average total per capita health care expenditures were $525. Average out-of-pocket expenses were $151 in 1988 dollars. The burden of out-of-pocket expenses was distributed unevenly among the families of adolescents. The 10% of adolescents with the highest expenses accounted for 65% of all out-of-pocket expenses. The presence of health insurance coverage greatly reduced the risk of incurring burdensome out-of-pocket expenses. Health policy interventions to improve health insurance coverage of adolescents are discussed.