Dispelling myths about emergency department use: majority of Medicaid visits are for urgent or more serious symptoms.

Contrary to conventional wisdom that Medicaid patients often use hospital emergency departments (EDs) for routine care, the majority of ED visits by nonelderly Medicaid patients are for symptoms suggesting urgent or more serious medical problems, according to a new national study by the Center for Studying Health System Change (HSC). About 10 percent of nonelderly Medicaid patient ED visits are for nonurgent symptoms, compared with about 7 percent for privately insured nonelderly people. Nonetheless, there are clearly opportunities to develop less-costly care options than emergency departments for both nonelderly Medicaid and privately insured patients. To reduce ED use, policy makers might consider how to encourage development of care settings that can quickly handle a high volume of potentially urgent medical problems. Policy makers may want to focus initially on conditions that account for high ED volume that could likely be treated in less resource-intensive settings. For example, diagnoses of acute respiratory and other common infections in children and injuries together account for about 53 percent of ED visits by children aged 0 to 12 covered by Medicaid and almost 60 percent of ED visits by privately insured children aged 0 to 12. While some infections and injuries will be too serious to treat elsewhere, lower-cost settings that can provide a moderate intensity of care and urgent response time likely could reduce emergency department use.

Physician willingness and resources to serve more Medicaid patients: perspectives from primary care physicians.

OBJECTIVE: Sixteen million people will gain Medicaid under health reform. This study compares primary care physicians (PCPs) on reported acceptance of new Medicaid patients and practice characteristics. DATA AND METHODS: Sample of 1,460 PCPs in outpatient settings was drawn from a 2008 nationally representative survey of physicians. PCPs were classified into four categories based on distribution of practice revenue from Medicaid and Medicare and acceptance of new Medicaid patients. Fifteen in-depth telephone interviews supplemented analysis. FINDINGS: Most high- and moderate-share Medicaid PCPs report accepting "all" or "most" new Medicaid patients. High-share Medicaid PCPs were more likely than others to work in hospital-based practices (20%) and health centers (18%). About 30% of high- and moderate-share Medicaid PCPs worked in practices with a hospital ownership interest. Health IT use was similar between these two groups and high-share Medicare PCPs, but more high- and moderate-share Medicaid PCPs provided interpreters and non-physician staff for patient education. Over 40% of high- and moderate-share Medicaid PCPs reported inadequate patient time as a major problem. Low- and no-share Medicaid PCPs practiced in higher-income areas than high-share Medicaid PCPs. In interviews, difficulty arranging specialist care, reimbursement, and administrative hassles emerged as reasons for limiting Medicaid patients. POLICY IMPLICATIONS: PCPs already serving Medicaid are positioned to expand capacity but also face constraints. Targeted efforts to increase their capacity could help. Acceptance of new Medicaid patients under health reform will hinge on multiple factors, not payment alone. Trends toward hospital ownership could increase practices' capacity and willingness to serve Medicaid.

Small group employer participation in New Mexico's State Coverage Insurance program: lessons for federal reform.

OBJECTIVE: To identify factors associated with small group employer participation in New Mexico's State Coverage Insurance (SCI) program. DATA SOURCES: Telephone surveys of employers participating in SCI (N=269) and small employers who inquired about SCI (N=148) were fielded September 2008-January 2009. STUDY DESIGN: Descriptive and multivariate analyses investigated differences between employer samples, including employer characteristics, concerns that applied to the business when deciding whether to participate in SCI, prior offerings of insurance to workers, and perceived affordability of the program. DATA COLLECTION/EXTRACTION METHODS: Unweighted employer samples yielded 88 and 75 percent response rates for the participating and inquiring employers, respectively. PRINCIPAL FINDINGS: The administrative issue most commonly selected by inquiring employers as applying to their business was difficulty understanding how eligibility requirements applied to their business and its employees (53.5 percent). Inquiring businesses were significantly more likely to report concern about affording to pay the premiums in the first month (35.6 versus 18.7 percent) and the cost to the business over the long run (46.5 versus 26.6 percent) relative to participating employers. From the model results, businesses with the fewest full-time employees (zero to two) were 19 percentage points less likely to participate relative to businesses with six or more full-time employees. CONCLUSIONS: Administrative and cost barriers to participation in SCI reported by employers suggest that the tax credit offered to small businesses under new federal provisions, which merely offsets the employer portion of premium, could be more effective if accompanied by additional supports to businesses.

Dynamics in Medicaid and SCHIP eligibility among children in SCHIP's early years: implications for reauthorization.

Two-thirds of children in the United States were income-eligible for Medicaid or the State Children's Health Insurance Program (SCHIP) at some point from 1996 to 2000. One in five children were income-eligible for both programs, and 73 percent of children ever eligible for SCHIP were eligible at other times for Medicaid. As SCHIP is reauthorized, Congress will need to give states the tools and financial commitment to assure that uninsured children are enrolled in and retain the coverage for which they are eligible.

Access to health insurance, barriers to care, and service use among adults with disabilities.

No studies to date have examined access to insurance coverage or medical care for a broadly defined population of uninsured nonelderly adults with disabilities. This analysis uses the 2002 National Survey of America's Families to examine access to coverage, access to care, and service use for a large sample of adults with disabilities, with a focus on the uninsured. All disabled groups reported unmet need and service use greater than their nondisabled counterparts with the same insured status. Access to coverage was most problematic for low-income adults with work limitations but no other indication of disability, with over one-third uninsured. This group deserves greater policy attention.

The impact of Medicaid managed care on pregnant women in Ohio: a cohort analysis.

OBJECTIVE: To examine the impact of mandatory HMO enrollment for Medicaid-covered pregnant women on prenatal care use, smoking, Cesarean section (C-section) use, and birth weight. DATA SOURCES/STUDY SETTING: Linked birth certificate and Medicaid enrollment data from July 1993 to June 1998 in 10 Ohio counties, 6 that implemented mandatory HMO enrollment, and 4 with low levels of voluntary enrollment (under 15 percent). Cuyahoga County (Cleveland) is analyzed separately; the other mandatory counties and the voluntary counties are grouped for analysis, due to small sample sizes. Study Design. Women serve as their own controls, which helps to overcome the bias from unmeasured variables such as health beliefs and behavior. Changes in key outcomes between the first and second birth are compared between women who reside in mandatory HMO enrollment counties and those in voluntary enrollment counties. County of residence is the primary indicator of managed care status, since, in Ohio, women are allowed to "opt out" of HMO enrollment in mandatory counties in certain circumstances, leading to selection. As a secondary analysis, we compare women according to their HMO enrollment status at the first and second birth. DATA COLLECTION/EXTRACTION METHODS: Linked birth certificate/enrollment data were used to identify 4,917 women with two deliveries covered by Medicaid, one prior to the implementation of mandatory HMO enrollment (mid-1996) and one following implementation. Data for individual births were linked over time using a scrambled maternal Medicaid identification number. PRINCIPAL FINDINGS: The effects of HMO enrollment on prenatal care use and smoking were confined to Cuyahoga County, Ohio's largest county. In Cuyahoga, the implementation of mandatory enrollment was related to a significant deterioration in the timing of initiation of care, but an improvement in the number of prenatal visits. In that county also, women who smoked in their first pregnancy were less likely to smoke during the second pregnancy, compared to women in voluntary counties. Women residing in all the mandatory counties were less likely to have a repeat C-section. There were no effects on infant birth weight. The effects of women's own managed care status were inconsistent depending on the outcome examined; an interpretation of these results is hampered by selection issues. Changes over time in outcomes, both positive and negative, were more pronounced for African American women. CONCLUSIONS: With careful implementation and attention to women's individual differences as in Ohio, outcomes for pregnant women may improve with Medicaid managed care implementation. Quality monitoring should continue as Medicaid managed care becomes more widespread. More research is needed to identify the types of health maintenance organization activities that lead to improved outcomes.

The implementation of Medicaid managed care for pregnant women in Ohio: a case study.

More than one-third of all births in the United States are financed by Medicaid. In 2001, more than 50% of all Medicaid beneficiaries were enrolled in a managed care plan, and participation by these plans in Medicaid is expected to grow. The care of pregnant women and their infants can be significantly affected by managed care practice. However, equally important are the state regulations that influence Medicaid managed care markets.