Integrated Case Management: Does It Reduce Health Service Disparities Across African American and White Medicaid Beneficiaries?

Evidence of persistent racial and ethnic disparities in health service use is substantial. Even among Medicaid beneficiaries, minority individuals may have lower use of specific health services relative to Whites due to varying degrees of trust in the health system, beliefs about the usefulness of medical treatment, provider stereotyping, or geographic service availability. Prior research demonstrated that a Florida Medicaid disease management program led to reductions in service disparities between Whites and African Americans. We study a Medicaid Integrated Case Management program implemented in Virginia, which shares disease management program objectives but can be applied to a broader range of patients. Two versions of the program are assessed, the latter of which incorporated more patient-focused and targeted approaches in identifying client needs and structuring patient interaction. Both versions of the program were associated with reductions in disparities, especially for physician services and when more targeted, patient-centered approaches were adopted.

The Impact of Integrated Case Management on Health Services Use and Spending Among Nonelderly Adult Medicaid Enrollees.

BACKGROUND: Medicaid plans, whose patients often have complex medical, social, and behavioral needs, seek tools to effectively manage enrollees and improve access to quality care while containing costs. OBJECTIVES: The aim of this study is to examine the effects of an integrated case management (ICM) program operated by a Medicaid managed care plan on health service use and spending for nonelderly, nonpregnant adults. RESEARCH DESIGN: We estimate the relationship between intensity of ICM program involvement and changes in utilization and spending for patients who participated in ICM. We examine whether effects differ between high-risk and lower-risk individuals and between the early and late stages of the program, given that the latter relied on more targeted and patient-centered approaches. Specifically, we estimate linear regressions modeling changes in utilization and spending outcomes as a function of number of program contacts, conditional on number of days over which contacts occurred, as well as individual-level covariates and case manager fixed effects. RESULTS: In the late ICM program period, we observe significant decreases in outpatient utilization associated with program involvement intensity among high-risk ICM participants. We also observe decreases in spending associated with program involvement intensity among the lower-risk group in the late period, although there is no significant impact on spending among high-risk enrollees. CONCLUSIONS: ICM can be a successful strategy for impacting health services use and spending. Our findings suggest that careful program targeting, well-structured client engagement, and direct one-on-one contact are vitally important for achieving program objectives.

Surveillance mammography for Medicaid/Medicare breast cancer patients.

BACKGROUND: Surveillance mammography for breast cancer survivors can detect recurrences early when treatment is most effective. We assessed the receipt of surveillance mammography for elderly breast cancer survivors considering their Medicaid and Medicare dual eligibility and minority status that may make them vulnerable to poor surveillance care. METHODS: We analyzed Michigan Medicare and Medicaid data for patients, age 66 years or older, diagnosed with early stage breast cancer between 1997 and 2000. Using logistic regression and proportional hazards models, we identified individual and area level factors associated with patients' receipt and timeliness of surveillance mammography for up to 3 years post treatment. RESULTS: In the first year post cancer treatment, patients who received breast conserving surgery (BCS) and radiation therapy were more likely to receive surveillance mammography than those treated with BCS alone (OR = 1.82; 95% CI = 1.48-2.24). Patients who received BCS and radiation treatment also had a greater probability of receiving surveillance mammography sooner than those treated with BCS alone (HR = 1.72; 95% CI = 1.56-1.89). Time from treatment to mammography was longer for older (80+ years) versus younger patients (HR = 0.55; 95% CI = 0.45-0.66) and for those with greater comorbidity burden (HR = 0.59; 95% CI = 0.43-0.81). CONCLUSIONS: Regardless of race and dual eligibility, there is a greater likelihood for breast cancer patients who received BCS with radiation to receive surveillance mammography and to receive it sooner than for patients who were treated with BCS alone. IMPLICATIONS FOR CANCER SURVIVORS: Dual eligible, black, and elderly patients are less likely to receive radiation following BCS, thus disparities across the treatment and surveillance continuum need to be further investigated.

Dually eligible and colorectal cancer screening: too little, too late?

BACKGROUND: Cancer screening reduces late-stage diagnosis. Medicare and Medicaid dually eligible patients receive more late stage colorectal cancer (CRC) diagnoses. METHODS: Characteristics of CRC patients diagnosed between 1997 and 2000 were extracted from the Michigan Tumor Registry and Medicare administrative data, Area Resource File, and U.S. Census to assess CRC screening (fecal occult blood testing (FOBT), barium enema, colonoscopy, and sigmoidoscopy) and late stage CRC diagnosis. RESULTS: Adjusted logistic regression models indicated dually eligible patients received less CRC screening (OR 0.68, 95% CI 0.59-0.78, p<.001). There was less late-stage diagnosis with colonoscopy receipt (OR 0.60, 95% CI 0.53-0.69, p<.001), sigmoidoscopy (OR 0.77, 95% CI 0.67-0.89, p<.001), and FOBT (OR 0.77, 95% CI 0.70-0.86, p<.01), but more if patients were dually eligible (OR 1.28, 95% CI=1.12-1.46, p<0.001). CONCLUSIONS: Dually eligible CRC patients were screened less and diagnosed later than Medicare patients. Fecal occult blood testing remains a less invasive and less costly screening option that may reduce late-stage diagnosis in low income populations.

Fruit and vegetable dietary behavior in response to a low-intensity dietary intervention: the rural physician cancer prevention project.

CONTEXT: Increased fruit and vegetable intake can reduce cancer risk. Information from this study contributes to research exploring health disparities in high-risk dietary behavior. PURPOSE: Changes in fruit and vegetable behavior were evaluated to assess the effects of a low-intensity, physician-endorsed dietary intervention in a rural population. METHODS: The study was a randomized trial of 754 patients from 3 physician practices in rural Virginia. Low-literacy nutrition education materials and personalized dietary feedback were administered by mail and telephone. Mixed model analysis of variance was used to determine the effect of the intervention on fruit and vegetable intake behavior, knowledge, intentions, and self-efficacy at 1, 6, and 12 months. FINDINGS: The intervention effect was moderated by age, race, sex, and education. Intake at 1 and 6 months was increased for older and younger participants and those with some college, and further maintained at 12 months by those who did not complete high school. African Americans in the intervention group displayed significantly greater intentions to increase fruit/vegetable intake than whites/others. Knowledge of fruit/vegetable recommendations significantly increased in the intervention group at 12 months, particularly for men. CONCLUSIONS: For the rural population, a low-intensity physician-endorsed self-help dietary intervention was successful in initiating fruit and vegetable dietary changes at 1 and 6 months post-intervention, and increasing intentions to change in African Americans. The relationship of the moderating effects of age, race, sex and education need to be further explored in relation to dietary intervention and dietary behavior change for the rural population.

Influence of patient-provider communication on colorectal cancer screening.

BACKGROUND: Screening reduces incidence and mortality from colorectal cancer (CRC). Despite improved access, screening is suboptimal and disparate among minority groups. Quality of patient-provider communication may impact CRC screening. OBJECTIVES: We examined the relationship between patient-provider communication and socioeconomic variables on the receipt of CRC screening using data from the Medical Expenditure Panel Survey. SUBJECTS: All persons age 50 years or older (N = 8488). MEASURES: Dependent measures were receipt of CRC screening, fecal occult blood testing, and colonoscopy or sigmoidoscopy. Independent variables included demographic characteristics, patient language, and patient-provider communication measures from the Consumer Assessment of Health Plan survey. RESULTS: Patients who felt they had sufficient time with their healthcare provider were more likely to be screened for CRC. Receiving adequate explanation of healthcare needs from provider was a significant predictor of fecal occult blood testing screening. In addition, persons with less than a high school education, the uninsured, or those with low income were associated with reduced likelihood of receiving CRC screening. Asians and Hispanics had a significantly reduced likelihood of receiving screening in comparison with whites; however, after adjusting for language, no significant differences for race or ethnicity were observed. CONCLUSIONS: Adequate time with a healthcare provider and receiving sufficient explanation of the healthcare processes by providers may improve screening rates. Patient-provider communication may be improved by addressing language needs of non-English speaking patients. Overall improved communication may increase CRC screening rates in underserved populations.