Ambulatory care sensitive hospitalizations and emergency visits: experiences of Medicaid patients using federally qualified health centers.

BACKGROUND: Federally Qualified Health Centers (FQHCs) serve as regular sources of preventive and primary care for low-income families within their communities and are key parts of the health care safety net. OBJECTIVES: Compare admissions and emergency room visits for ambulatory care sensitive conditions (ACSCs) among Medicaid beneficiaries relying on FQHCs to other Medicaid beneficiaries. RESEARCH DESIGN: Retrospective analysis of 1992 Medicaid claims data for 48,738 Medicaid beneficiaries in 24 service areas across five states. SUBJECTS: Medicaid beneficiaries receiving more than 50% of their preventive and primary care services from FQHCs are compared with Medicaid beneficiaries receiving outpatient care from other providers in the same areas. Exclusions-managed care enrollees, beneficiaries more than age 65, dual eligibles (Medicaid and Medicare), and institutionalized populations. MEASURES: Admissions and emergency room (ER) visits for a set of chronic and acute conditions, known in the literature as ambulatory care sensitive conditions (ACSCs). RESULTS: Medicaid beneficiaries receiving outpatient care from FQHCs were less likely to be hospitalized (1.5% vs. 1.9%, P < 0.007) or seek ER care (14.9% vs. 15.7%, P < 0.02) for ACSCs than the comparison group. Controlling for case mix and other demographic variables, the odds ratios were, for hospitalizations, OR, 0.80; 95% CI, 0.67 to 0.95; P < 0.01, and for ER visits, OR, 0.87; 95% CI, 0.82 to 0.92; P < 0.001. CONCLUSIONS: Having a regular source of care such as FQHCs can significantly reduce the likelihood of hospitalizations and ER visits for ACSCs. If the reported differentials in ACSC admissions and ER visits were consistently achieved for all Medicaid beneficiaries, substantial savings might be realized.

Caregiving: challenges and implications for women's health.

Informal and unpaid care is an integral feature of the U.S. health care system for the nation's sick, disabled, frail, and terminally ill. Much of what we know about caregiving is based on interviews with caregivers and, in some cases, care recipients. Prior studies have either not been based on a nationally representative sample or have collected very little information about non-caregivers. This study, using the Commonwealth Fund 1998 Survey of Women's Health, uses a nationally representative sample of caregivers and non-caregivers to examine the health impact of providing informal and unpaid care, focusing primarily on women. Our findings indicate that caregivers experience double jeopardy. They are significantly more likely to be in poor health and to have experienced problems getting needed care. These findings suggest that it is time to explore alternative or complements to informal caregiving. They underscore the need to find more equitable ways to share caregiving costs and risk, and provide support to assist those who currently provide care.

Prevalence of violence and its implications for women's health.

This study estimates the lifetime prevalence of violent experiences and their relationship to health and the use of health services in U.S. women aged 18-64 years. The Commonwealth Fund's 1998 Survey of Women's Health provides a nationally representative sample. Use of weighted data allows projections to be made to the U.S. population. Over four of ten women in the U.S. are likely to have experienced one or more forms of violence, including child abuse (17.8%), physical assault (19.1%), rape (20.4%), and intimate partner violence (34.6%). In multivariate logistic regression models that control for sociodemographic characteristics, violence-particularly intimate sexual violence-is significantly related to poorer physical and mental health and increased problems with access to medical care. Only one-third of women who experience violence have discussed it with a physician. Health care professionals need to initiate the conversation about violence and offer referrals for needed services.

The impact of managed care on the mix of vulnerable populations served by community health centers.

This article examined the impact of managed care involvement on vulnerable populations served by community health centers (CHCs), while controlling for center rural-urban location and size, and found that centers involved in managed care have served a significantly smaller proportion of uninsured patients but a higher proportion of Medicaid users than those not involved in managed care. The results suggest that the increase in Medicaid managed care patients may lead to a reduced capacity to care for the uninsured, thus hampering CHCs from expanding access to health care for the medically indigent.

Categorical funding to seamless systems of care: the challenge for community-based primary care providers.

Integrating categorical funding to design "seamless systems of care" for individual patients is a challenge faced by many local community-based providers. Providers may choose to develop separate site-specific categorical programs for patients with human immunodeficiency virus (HIV) [e.g., specialized treatment site or a homeless clinic] or integrate these programs with their general primary care population. Regardless of program location, providers have developed patterns for finding the most appropriate medical home for a patient with multiple categorical risks. Medical records reviews and patient interviews indicate the importance of case managers in service coordination, although clinical issues appear more readily coordinated than situational ones. Provider dependence solely on case managers for service coordination, across sites and programs may become problematic in the era of managed care without a supportive information system that tracks client use and a records system that integrates clinical and social service notes. Local providers have encountered difficulties in exchanging essential medical information, even within a single agency, under state statutes regarding confidentiality of HIV test results.

Performance of community health centers under managed care.

The Bureau of Primary Health Care, a division of the Health Resources and Services Administration of the Department of Health and Human Services, Public Health Service, commissioned a study to evaluate the performance of community health centers (CHCs) under managed care. This article reports on the findings of the bureau's study, which examined the managed performance of seven CHCs that contract with health maintenance organizations (HMOs). The experience of these centers can provide valuable insights for other CHCs and the HMOs with which they partner. Policy makers contemplating the role of CHCs in managed care will also benefit from these findings.

Mental health services: critical component of integrated primary care and substance abuse treatment.

The documented high incidence of mental health disorders among individuals in substance abuse treatment argues for the importance of studying the provision of mental health services to this population. This survey documents how the Linkage Programs assembled an array of mental health services based on the assessed health care needs of clients. Specialty and nonspecialty personnel addressed the extensive mental health needs of ethnically diverse, multiproblem clients with substance abuse problems. The innovative use of nonconventional providers, however, did not eliminate the shortfall between the number of clients with mental health problems and the number who were referred to and received mental health services; nor did it enable all Linkage Programs to address the mental health needs of the most severely ill clients. There is a continuing need to forge relationships between mental health providers and integrated providers of primary care and substance abuse treatment.

Case management for special populations. Moving beyond categorical distinctions.

Case management has evolved as a flexible, pragmatic, and compassionate strategy for improving client access and care continuity within fragmented systems of health and social services. The first-generation case management programs have been designed for various settings that serve different "target" populations with varying social, medical, and psychological needs. This proliferation of categorical case management programs is a mixed blessing. While a categorical focus reflects both historical and public financing priorities, it creates a potentially duplicative and inefficient system in an era of limited resources. As the federal government assumes a more substantial role in supporting case management, greater attention is being given to accountability--demonstrating value-added benefits and identifying best practices for structuring case management. The essential first step is reaching agreement on two critical dimensions of case management, major goals and essential services. This article, based on a review of the literature, examines the extent to which seemingly disparate programs for special populations share common attributes, and thus present opportunities for structuring client-focused rather than categorical case management programs. The authors seek to stimulate a dialogue that would lead to specification of common goals and essential services, and a cross-cutting framework for designing client-focused case management programs.

Health plan selection in the Federal Employees Health Benefits Program.

A survey of over 8,500 employees of the U.S. Department of Health and Human Services (DHHS) during the May 1982 open season, supplemented by enrollment data for all DHHS employees enrolled in the Federal Employees Health Benefits Program (FEHBP), was used to study insurance plan selection when multiple fee-for-service options as well as HMOs are available. There is evidence of biased selection of health risks in the FEHBP, yet historically the program has exhibited considerable stability. The stability may be attributable partly to control over entry and over changes in benefits and premiums and partly to inertia on the part of enrollees. In spite of large changes in relative premiums and benefits, only 21 percent of all enrollees in the DHHS switched plans during the May 1982 open season. Those employees who did switch plans astutely identified bargains; on average they lowered their annual contribution to premium by almost 40 percent while maintaining the level of benefits. Insurance plans offering relatively generous coverage of a particular service attract a disproportionately high share of enrollees who expect substantial use of that service. The extent of adverse or beneficial selection into HMOs depends on the price and the comprehensiveness of benefits of each available fee-for-service option.