Payment levels, resource use, and insurance risk of medicaid versus private insured in three states.

Concerns with access and costs in the Medicaid program often lead policy makers to consider alternatives. These include subsidizing poor persons' purchases of health insurance in private markets or integrating Medicaid beneficiaries into commercial managed care systems. As policy makers consider such alternatives, a persistent question is, apart from the disabled within Medicaid, do younger Medicaid enrollees represent a different insurance risk than people of similar age and sex within private insurance pools? We use 1994 data from Georgia, Mississippi, and California to assess relative payment levels, resource use/costs, and risk-adjusted utilization of fee-for-service (FFS) Medicaid enrollees versus privately insured people. When resources are valued at private prices, the use by Medicaid enrollees represents a higher cost. After risk adjustment, Medicaid enrollee resource use appears higher than expected for the privately insured only for outpatient facility visits in the southern states and for inpatient days by pregnant women in California Medi-Cal. Indeed, we find evidence that Medicaid enrollees are underserved relative to their health needs. Given the higher dollar value of their resource usage, apparently obtained under FFS at discounted provider rates, and the lack of evidence on significant overuse relative to need, their integration into private provider systems appears challenging.

Factors affecting physician provision of preventive care to Medicaid children.

Medicaid data for California, Georgia, Michigan, and Tennessee were used to analyze changes in fee and non-fee policies on physicians' service provision to children, before and after the enactment of the Omnibus Budget Reconciliation Act of 1989 (OBRA-1989). Only Michigan raised Medicaid preventive fees relative to the private sector. Higher relative fees increased child caseloads of participating physicians and the likelihood of providing preventive care. However, fee policy is less effective in urban poor areas due to residential segregation. Michigan's and Georgia's non-fee policy changes appeared effective in increasing EPSDT participation relative to the other States.

Costs of smoking during pregnancy: development of the maternal and child health smoking attributable mortality, morbidity and economic costs (MCHSAMMEC) software.

The development and availability is described of new, user friendly software, the Maternal and Child Health Smoking Attributable Mortality, Morbidity and Economic Costs (MCHSAMMEC), that will allow states and other entities to estimate pregnancy related, smoking attributable costs for their population. The methodology underlying the MCHSAMMEC software, including calculations used in the prevalence based analysis of smoking attributable mortality and costs of infant neonatal care, are described, along with design and data management features and possible applications of the software for policy and program development at various levels of the health care system.

Variation in state Medicaid expenditures 1984-92: the behavioral impact of the matching federal grant.

Although the federal Medicaid matching grant was designed to decrease disparities in state Medicaid spending, significant inequities persist. A potential reason for this is that states substitute federal for state funds and therefore expenditures in low-income, low-spending states are not stimulated. This study uses a fixed-effects model on pooled state expenditure data for 1984-92 to examine the fiscal response of states to the federal Medicaid grant. Results indicate that states' responses to the grant were to raise fewer tax dollars but still spend more by using federal funds. Significant substitution was found during the study period. Findings have implications for deliberations on grant structures for Medicaid and other federal/state programs.

Determining cost savings from attempted cephalic version in an inner city delivering population.

The use of external cephalic version (ECV) is increasingly seen as an important clinical management strategy for breech presentation infants. Currently, 75% of women with breech presentation at term undergo Cesarean delivery risking adverse outcomes and incurring higher costs. ECV, if successful, reduces the rate of breech presentation at delivery and the need for Cesarean delivery. Data from an inner-city population of delivering women were examined to determine the effectiveness of ECV among these minority, low income women. Hospital clinical and Medicaid claims data for 679 deliveries with breech presentation were studied. Decision tree analysis indicated ECV was successful for 48% of those attempted. Based on amounts billed Medicaid, attempting ECV reduced the use of resources by a little over $3,000 per delivery. Sensitivity analysis showed, however, that the savings may be as low as $906. Multivariate analysis confirmed the independent effect of attempting ECV on the probability of Cesarean delivery.

An elementary school-based health clinic: can it reduce medicaid costs?

OBJECTIVE: School-based health services have evolved from primarily controlling communicable disease to comprehensive programs with direct services, education, and improvement of the school environment. School-based health clinics (SBHCs), currently 1157 in number, are used to reach children for preventive and other routine care. Although several studies have examined the costs and effects of such programs, few, if any, have examined their potential to save Medicaid program outlays. The objective of this study was to assess the effect of the Whitefoord Elementary School-Based Health Clinic (WESBHC), located in Atlanta, Georgia, on health care costs paid by Georgia Medicaid over the 1994-1996 period. This clinic has been in operation since late 1994. DESIGN: The analysis uses 1994-1996 claims data for Medicaid-enrolled children 4 through 12 years old served by the WESBHC and similar children in a comparison school district without such a clinic. Descriptive and multivariate analyses are used to discern the differences in the changes in Medicaid expenses per child-year enrolled for these 2 groups of children. Both those who only used the WESBHC sporadically and those for whom it was their medical home were identified for analysis. RESULTS: The descriptive analysis shows that although there were no significant differences in the Medicaid expenses for the WESBHC and comparison children in 1994, before the operation of the WESBHC, by 1995, the WESBHC children had significantly lower emergency department expenses. In addition, they had higher Early Periodic Screening Diagnosis and Treatment preventive care expenses. By 1996, the WESBHC children had significantly lower inpatient, nonemergency department transportation, drug, and emergency department Medi- caid expenses. Multivariate analysis confirmed the effect of the WESBHC on lowering emergency department expenses. CONCLUSIONS: The results strongly suggest that the operation of a SBHC can have effects on the child's use of services and health care expenses. Given that these clinics serve all those who come for care and many of these are low-income children, these savings are likely to accrue to the Medicaid program of the state. As states continue to implement Medicaid-managed care for their child populations, they will need to consider the ability of SBHCs to participate in and receive Medicaid revenues through health maintenance organization networks.

Costs of smoking: a focus on maternal, childhood, and other short-run costs.

Estimating the costs attributable to smoking is helpful for evaluating appropriate tax policy, informing both public and private managers of health care, and evaluating alternative smoking cessation programs. While the smoking-attributable costs of chronic conditions have been well studied, these costs are less relevant to health maintenance organizations (HMOs) and employers whose populations are younger and transient. Costs incurred in the short run, such as those related to smoking during pregnancy and environmental tobacco smoke exposure (ETS) of children, are more relevant. In this article, the authors review studies of these sources of smoking-attributable costs as well as studies that focus on smoking-attributable outcomes and costs from the employer or HMO perspective. Subsidies may be necessary to induce employers to recognize the full social benefits of smoking cessation programs.

Effects of smoking during pregnancy. Five meta-analyses.

BACKGROUND: The purpose of this study was to estimate, using meta-analysis, pooled odds ratios for the effects of smoking on five pregnancy complications: placenta previa, abruptio placenta, ectopic pregnancy, preterm premature rupture of the membrane (PPROM), and pre-eclampsia. METHODS: Published articles were identified through computer search and literature review. Five criteria were applied to those studies initially identified to determine those eligible for the meta-analysis. A random effects model was applied to derive pooled odds ratios for the eligible studies for each pregnancy complication. Meta-analyses were repeated on subsets of the studies to confirm the overall results. RESULTS: Smoking was found to be strongly associated with an elevated risk or placenta previa, abruptio placenta, ectopic pregnancy, and PPROM, and a decreased risk of pre-eclampsia. All pooled odds ratios were statistically significant. The pooled ratios ranged from 1.58 for placenta previa to 1.77 for ectopic pregnancy. The pooled odds ratio for pre-eclampsia was 0.51 and all subset analyses confirmed this seemingly protective effect. CONCLUSIONS: Smoking during pregnancy is a significant and preventable factor affecting ectopic pregnancy, placental abruption, placenta previa, and PPROM. The findings of smoking's apparently protective effect on pre-eclampsia should be balanced with these harmful effects. In addition, the biological linkage between smoking and pre-eclampsia is not yet well understood. Pregnant women should be advised to stop smoking in order to reduce the overall risk of pregnancy complications as well as any risk of adverse impact on the unborn child.

Costs of maternal conditions attributable to smoking during pregnancy.

CONTEXT: Despite known adverse health effects, many women continue to smoke during pregnancy. Public attention has now focused on the economic as well as health effects of this behavior. OBJECTIVE: To estimate health care costs associated with smoking-attributable cases of placenta previa, abruptio placenta, ectopic pregnancy, preterm premature rupture of the membrane (PPROM), pre-eclampsia, and spontaneous abortion. DESIGN: Pooled odds ratios were used with data on total cases to estimate smoking-attributable cases. Estimated average costs for cases of ectopic pregnancy and spontaneous abortion were used to estimate smoking-attributable health care costs for these conditions. Incremental costs, or costs above those for a "normal" delivery, were used to estimate smoking-attributable costs of placenta previa, abruptio placenta, PPROM, and pre-eclampsia associated with delivery. SETTING: National estimates for 1993. PARTICIPANTS: Data from the National Hospital Discharge Survey (NHDS) and claims data from a sample of large, self-insured employers across the country. RESULTS: Smoking-attributable costs ranged from $1.3 million for PPROM to $86 million for ectopic pregnancy. Smoking during pregnancy apparently protects against pre-eclampsia and saves between $36 and $49 million, depending on smoking prevalence. Over all conditions smoking-attributable costs ranged from $135 to $167 million. CONCLUSIONS: Smoking during pregnancy is a preventable cause of higher health care costs for the conditions studied. While smoking during pregnancy was found to be protective against pre-eclampsia and, hence, saves costs, the net costs were still positive and significant. Effective smoking-cessation programs can reduce health care costs but clinicians will perhaps need to manage increased cases of pre-eclampsia in a cost-effective manner.

Returns on investment in public health: effect of public health expenditures on infant health, 1983-1990.

In this study, we developed a broad conceptual framework focusing on how public health expenditures impact the nation's health. We then applied this framework to infant health outcomes and, using an eight-year state panel database, empirically analyzed how state public health expenditures, ceteris paribus, impact a state's level of teenage births and the receipt of prenatal care. Two hypotheses were tested. Hypothesis 1 states that over time, public health expenditures and public health activities, ceteris paribus, significantly decrease births to mothers less than 20 years of age. Hypothesis 2 states that over time, public health expenditures and public health activities, ceteris paribus, significantly decrease the number of infants whose mothers received late or no prenatal care. We find support for both hypotheses but observe that the way public health expenditures are measured has an impact on the findings. Other important implications of the study are noted. To our knowledge, this is the first article that has taken an aggregate state perspective over time and applied it to specific measures of infant health.

The use of EPSDT and other health care services by children enrolled in Medicaid: the impact of OBRA'89.

To increase the participation of Medicaid children in the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program and to improve their health, Congress included several provisions in the Omnibus Budget Reconciliation Act of 1989 (OBRA'89) that addressed problematic program features. The impact of these provisions on children's health service use was investigated in a study funded by the Health Care Financing Administration. After conducting site visits to four states, the authors analyzed claims data for the children residing there and found evidence that, in 1992, these states placed a higher priority on improving the effectiveness of EPSDT than they did before 1989. The states' efforts to expand the EPSDT provider base and to enhance outreach and service provision were either directly or indirectly inspired by OBRA'89. The authors also found evidence of a significant impact on provider participation and caseloads and on children's use of both preventive care and diagnostic and treatment services. However, the effects were modest in comparison to the size of the progress that is required.

The provision of primary dental care for patients with special needs.

The Community Dental Service (CDS) has increasingly become associated with providing primary dental care for those people who are unable to access care by the usual means. The work reported here examines the provision of primary dental care by using the notion of a dental service continuum to demonstrate that in the treatment of patients with special needs the CDS acts as a safety net service. One hundred and twenty-four General Dental Service (GDS) practices and 33 CDS practices took part in the survey. The results suggest that both services provide primary dental care for a wide range of patients with special needs. Dentists in the GDS and CDS treat and care for different populations of patients with special needs. It is proposed that a continuum of service provision exists.

Determining the clinical efficacy and cost savings of successful external cephalic version.

OBJECTIVE: The aim of this study was to determine predictors of successful external cephalic version and to calculate the associated cost savings achieved with success. STUDY DESIGN: A retrospective study of 203 women with singleton gestations who underwent external cephalic version was performed. Descriptive, univariate, and multivariate analyses were performed on patient-specific risk data to predict successful version. National claims data were used for the cost simulation. RESULTS: Higher parity (p = 0.02), transverse-oblique presentation (p = 0.001), posterior placenta (p = 0.001), and a longer duration of pregnancy (p = 0.001) significantly increased the likelihood of a successful version. Heavier maternal weight was negatively associated with successful version (p = 0.05). The cost simulation revealed an average savings of $2462 for each successful version. CONCLUSION: This study identifies clinical variables associated with an increased external cephalic version success rate. If, in fact, successful external cephalic version reduces both maternal and fetal morbidity associated with cesarean delivery and, as demonstrated in this analysis, the costs associated with the delivery, then greater effort should be made to maximize the success rate of external cephalic version.

Patterns of pharmacy participation in Medicaid: implications for enrollee access.

Little attention has been given to pharmacy participation in Medicaid and enrollee access to pharmacy services despite the potential for treatment problems if appropriate drug regimens are not followed. This study presents an economic model of pharmacy participation in Medicaid and descriptive and multivariate analyses of participation rates. A key variable was the adequacy of Medicaid payments for drugs dispensed to Medicaid enrollees. This was found to positively affect county-level pharmacy participation and, in turn, participation rates were a positive and significant determinant of the number of prescriptions per enrollee. Pharmacy location, size, and type also affected participation rates and enrollee utilization.

Equity in the Medicaid program: changes in the latter 1980s.

The possibility of health care reform has helped focus attention on equity in the receipt of health care. This is a particular issue for the Medicaid program, as State variations in eligibility and payment policies have historically created inequity. This study examines equity for Medicaid beneficiaries and State taxpayers during the latter 1980s. Findings indicate that federally mandated expansions significantly increased equity in the coverage of the poor, but inequality in real resources per enrollee remained significant. Although equity improved from 1984 through 1991, the increased use of provider-specific tax and voluntary donation (T&D) programs by traditionally high-spending States played an important role in the 1992 figures.

Effect of increased Medicaid fees on physician participation and enrollee service utilization in Tennessee, 1985-1988.

Integration of low-income persons, now covered largely through Medicaid, into mainstream provider networks requires sufficient numbers of physicians willing to serve them. This paper examines a 1986 change in fees in Tennessee that was aimed explicitly at increasing physician participation in Medicaid. County/monthly panel data from 1985-1988 were used to examine visits per enrollee, physician participation, and caseloads. Higher fees were found to lead to increased participation in both urban and rural countries, but were less effective in increasing the number of visits per enrollee in urban areas and physician caseloads in both urban and rural areas. A measure of the residential segregation of Medicaid enrollees within each county was found to have a negative influence on the number of visits per enrollee, on participation, and on caseloads when measured across all participating physicians.

State Medicaid pharmacy payments and their relation to estimated costs.

Although prescription drugs do not appear to be a primary source of recent surges in Medicaid spending, their share of Medicaid expenditures has risen despite efforts to control costs. As part of a general concern with prescription drug policy, Congress mandated a study of the adequacy of Medicaid payments to pharmacies. In this study, several data sources were used to develop 1991 estimates of average pharmacy ingredient and dispensing costs. A simulation was used to estimate the amounts States pay. Nationally, simulated payments averaged 96 percent of estimated costs overall but were lower for dispensing costs (79 percent) and higher for ingredient costs (102 percent).

Asset spend-down in nursing homes. Methods and insights.

The issue of how many elderly are affected by catastrophic nursing home expenses is a major part of the debate over if and/or how to reform long-term-care financing. Currently, there is some discussion regarding the magnitude of this catastrophic event, referred to as "asset spend-down", among the elderly. National data suggest the magnitude is small, while state-specific studies indicate it is greater. In addition, the literature regarding asset spend-down has presented two different measures of its magnitude, further confusing the issue. These two measures, each based on different denominators, have often been presented without adequate explanation. In this study, the authors review both measures and analyze reasons for the differences observed across studies. Major reasons identified include the type of sample used, the mix of payor source at admission, the length of time covered by the data, data on payor source/Medicaid eligibility, and the ability to observe multiple nursing-home stays within the data. Using the measure based on the number of persons who are private pay at admission, these studies indicate that approximately one fourth will eventually deplete assets. The second measure, based on a count of Medicaid residents at a point in time, indicates approximately one third were private pay when admitted. Study results indicate that national studies have underestimated the extent of spend-down due to national-level data limitations, while state-specific studies inevitably refect the specific state data set available and circumstances particular to each state. More state studies and a better understanding of asset transfer are needed.