National and state trends in enrollment and spending for dual eligibles under age 65 in Medicaid managed care.

BACKGROUND: To reduce costs and improve care, states are increasingly enrolling individuals with disabilities in Medicaid managed care. Many states allow or require adults who are dually eligible for Medicaid and Medicare to enroll in these plans. OBJECTIVE: This study (1) quantifies changes in enrollment by managed care arrangement for duals under age 65, between 2005 and 2008 and (2) compares enrollment and spending between dual eligibles and Medicaid-only beneficiaries. METHODS: We used Medicaid Analytic eXtract data to compare the Medicaid enrollment and spending for all-year, full-benefit dual eligibles ages 21-64 with that of Medicaid-only Supplemental Security Income (SSI) and disabled beneficiaries. The study population was classified into 9 types of managed care to quantify enrollment and calculate expenditures by year. RESULTS: Nationwide, the proportion of adult duals in managed care increased from 2005 to 2008, with the expansion of prepaid health plans (PHPs) (31.0%-46.6%), particularly behavioral health PHPs, driving the increase. In 2008, Medicaid-only disabled adults were three times as likely as dual adults to enroll in comprehensive managed care (CMC) (35.1% versus 11.7%). Average Medicaid expenditures per enrollee differed markedly by managed care arrangement and state. CONCLUSIONS: From 2005 to 2008, there was little expansion of CMC among adult duals, while the use of PHPs to cover carved out services increased greatly. New federal initiatives aim to reduce barriers to enrolling duals into comprehensive, integrated managed care. With expanded enrollment, it will be important to monitor enrollment and evaluate whether integration improves care.

Migration patterns for Medicaid enrollees 2005-2007.

BACKGROUND: Although Medicaid is a federal program, it is administered primarily by the states. Enrollees move from state to state, but their migration patterns have remained largely unknown. There are concerns about the possibility of enrollment gaps, lack of health insurance coverage, breaks in continuity of care, unmet need, risks to health status, and increased system-wide costs due to uncompensated care and the use of higher cost emergency room services because of enrollment gaps. There is also concern about the extent to which people enrolled in more than one state are double counted. OBJECTIVE: To examine the migration of Medicaid enrollees across states. METHODS: We use 2005-2007 Medicaid enrollment records that were unduplicated and linked across states and over the study period. We report descriptive statistics on enrollee migration across states. RESULTS: Among all enrollees, 3.7 percent moved to another state at least once and most moved only once. Overall, 72.2 percent of moves did not result in an enrollment gap, whereas 8.2 percent of moves resulted in gaps of fewer than three months, and 11.4 percent of moves resulted in gaps of more than six months. CONCLUSIONS: These initial findings provide a context for further examining the consequences of enrollee moves on their health and on program expenditures. The consequences of enrollment gaps will become increasingly important as the Medicaid population grows under the provisions of the Affordable Care Act.

Adding an alcohol-related risk score to an existing categorical risk classification for older adults: sensitivity to group differences.

OBJECTIVES: To evaluate a new alcohol-related risk score for research use. DESIGN: Using data from a previously reported trial of a screening and education system for older adults (Computerized Alcohol-Related Problems Survey), secondary analyses were conducted comparing the ability of two different measures of risk to detect post-intervention group differences: the original categorical outcome measure and a new, finely grained quantitative risk score based on the same research-based risk factors. SETTING: Three primary care group practices in southern California. PARTICIPANTS: Six hundred sixty-five patients aged 65 and older. MEASUREMENTS: A previously calculated, three-level categorical classification of alcohol-related risk and a newly developed quantitative risk score. RESULTS: Mean post-intervention risk scores differed between the three experimental conditions: usual care, patient report, and combined report (P<.001). The difference between the combined report and usual care was significant (P<.001) and directly proportional to baseline risk. The three-level risk classification did not reveal approximately 57.3% of the intervention effect detected by the risk score. The risk score also was sufficiently sensitive to detect the intervention effect within the subset of hypertensive patients (n=112; P=.001). CONCLUSION: As an outcome measure in intervention trials, the finely grained risk score is more sensitive than the trinary risk classification. The additional clinical value of the risk score relative to the categorical measure needs to be determined.

Tandem mass spectrometry program implementation challenges for state newborn screening programs: national survey of barriers and issues.

OBJECTIVE: A national survey was undertaken to identify the barriers faced by states that have already implemented tandem mass spectrometry (MS/MS) screening and those that have not yet done so. METHODS: In April 2004, a 10-question survey was mailed to 106 individuals identified as key newborn screening contacts in each state. The survey requested information on issues that affected the state's ability to expand newborn screening to include MS/MS technology. RESULTS: Representatives from 51 of 53 states/territories responded to the survey. Of the 51 responding states, 32 (63%) said that they are offering MS/MS screening currently. The top 2 issues that most affected the ability of states to add MS/MS screening were difficulty acquiring support within the organization (66%) and funding limitations (63%). The screening criteria that were most difficult to address were knowledge about the natural history of MS/MS-detectable disorders if untreated (37%), the short-term costs of screening and diagnosis (36%), and the long-term follow-up costs (34%). The top-ranked laboratory issues were the high costs of equipment and supplies (53%) and the development of appropriate population-specific cutoff values (41%). The top-ranked follow-up issues were the availability of accepted protocols and guidelines for MS/MS diagnostic evaluations (59%) and the availability of adequate educational materials describing the disorders (44%). CONCLUSIONS: Several of the issues identified can be addressed through improved, more-comprehensive, patient surveillance systems that track patient health status and health services utilization, although other approaches need to be developed. Through a better understanding of these issues and challenges, the community of professionals who are concerned with the quality and scope of newborn screening may be better able to help states develop strategies to overcome these barriers.