Quality of Care for Chronic Conditions Among Disabled Medicaid Enrollees: An Evaluation of a 1915 (b) and (c) Waiver Program.

IMPORTANCE: Examining the impact of Medicaid-managed care home-based and community-based service (HCBS) alternatives to institutional care is critical given the recent rapid expansion of these models nationally. OBJECTIVE: We analyzed the effects of STAR+PLUS, a Texas Medicaid-managed care HCBS waiver program for adults with disabilities on the quality of chronic disease care. DESIGN, SETTING, AND PARTICIPANTS: We compared quality before and after a mandatory transition of disabled Medicaid enrollees older than 21 years from fee-for-service (FFS) or primary care case management (PCCM) to STAR+PLUS in 28 counties, relative to enrollees in counties remaining in the FFS or PCCM models. MEASURES AND ANALYSIS: Person-level claims and encounter data for 2006-2010 were used to compute adherence to 6 quality measures. With county as the independent sampling unit, we employed a longitudinal linear mixed-model analysis accounting for administrative clustering and geographic and individual factors. RESULTS: Although quality was similar among programs at baseline, STAR+PLUS enrollees experienced large and sustained improvements in use of ß-blockers after discharge for heart attack (49% vs. 81% adherence posttransition; P<0.01) and appropriate use of systemic corticosteroids and bronchodilators after a chronic obstructive pulmonary disease event (39% vs. 68% adherence posttransition; P<0.0001) compared with FFS/PCCM enrollees. No statistically significant effects were identified for quality measures for asthma, diabetes, or cardiovascular disease. CONCLUSION: In 1 large Medicaid-managed care HCBS program, the quality of chronic disease care linked to acute events improved while that provided during routine encounters appeared unaffected.

Planning: fixed-foreperiod event-related potentials during the Tower of London task.

Slow wave ERPs were recorded from 28 young adults as they generated plans for various difficulty levels of a fixed-foreperiod version of the Tower of London task. The resulting waveform included three segments: (1) a left-lateralized negative early-interval wave, which was frontally maximal but not sensitive to difficulty, (2) a right-lateralized frontally maximal mid-interval wave, which was more positive for more difficult problems, and (3) a left lateralized centrally maximal negative-ramping contingent negative variation (CNV) late wave, which was more negative for more difficult problems. The current study adds to the current literature in that it finds that the frontal and central neural utilization with difficulty changes across plan generation. This suggests that plan generation should be considered in terms of when component processes of planning are differentially utilized as plan generation unfolds.