Overview and implications of Medicaid managed care for people with developmental disabilities.

The inclusion of people with developmental disabilities in managed care as part of general efforts by states to enroll and Medicaid recipients in such plans was reviewed. Managed care was defined and the processes by which managed care organizations deliver services were explained. Escalating costs and utilization were discussed as the primary reason for the shift to managed care. The use of Medicaid Section 1115 waivers by states to include Medicaid recipients was explored. The relation between acute health care and long-term care, and the utilization patterns in each, were briefly described. Finally, elements of managed care that are particularly important to people with developmental disabilities, such as care coordination, maintenance of quality, and individual and family support, were discussed.

Technical elements, demonstration projects, and fiscal models in Medicaid managed care for people with developmental disabilities.

We presented a general model of the structure and functioning of managed care and described elements (provider networks, fiscal elements, risk estimation, case-mix, management information systems, practice parameters, and quality improvement) critical to service delivery for people with developmental disabilities. A number of technical elements of managed care systems were delineated and reviewed in relation to the inclusion of people with developmental disabilities. Several managed care demonstration projects were described and, finally, a multi-year hypothetical budget model, including long-term care, was presented as a framework for considering how managed care affects specific service structures. Implications for people with developmental disabilities were discussed.

Characteristics of hospitalizations for people with developmental disabilities: utilization, costs, and impact of care coordination.

Hospitalizations and the impact of care coordination were studied in two large databases for people with developmental disabilities. Acute care admissions for alternate years between 1983 and 1991 were analyzed and compared to the data for the nondisabled population of New Jersey. The statewide dataset included 22,294 admissions; the coordinated dataset included 692 admissions to a community hospital. Under the diagnostic-related group reimbursement system, admissions for the general population remained constant, whereas hospital days and average length of stay dropped during the study period. Increases in admissions (56%) and days (42%) were found for people with developmental disabilities. Their total hospital charges rose 206%, almost twice the rate for the general population. Care coordination moderated all of these differences.

An evaluation of care coordination in controlling inpatient hospital utilization of people with developmental disabilities.

All admissions of people with developmental disabilities to a community hospital over 3 years were examined to evaluate the impact of a coordinated care model on length of stay and hospital charges. Admissions were divided into two groups, those receiving either coordinated care (program group) or routine care by community physicians (usual care group). The program group had shorter average lengths of stay and lower hospital charges than did the usual care group, especially when charges were adjusted for case mix. Similarity of severity across the groups was measured by number of discharge diagnoses and Medicaid case weights. Over the 3 years, for the 115 admissions in the program group, these differences amounted to more than $200,000 in potentially unnecessary hospital charges. Implications of care coordination services for community-based health care planning were presented.

Replication of a managed health care initiative for people with mental retardation living in the community.

To improve understanding of the cost-effectiveness of a managed health care program for individuals with mental retardation, we have described financing, utilization, and outcomes of the Developmental Disabilities Center at Morristown Memorial Hospital. The costs and benefits of health care coordination, a key feature of this program, were discussed. Under this model, annual, unreimbursed costs of health care coordination in 1989 averaged $668 for people with severe mental retardation. However, the total reimbursable costs of inpatient care were reduced. In addition, medical outcome data from ongoing research projects suggest that the program has been an important vehicle for improving the health of people with mental retardation in the community. The costs, revenues, and financing of this program were presented in order to assist candidate sites in the replication of this model. The role of this type of program in health care reform was discussed.

Managed health care services for people with mental retardation: impact on inpatient utilization.

All admissions of people with mental retardation to a community hospital during one year were examined to determine the effects of a managed-care model on selected outcome variables. Hospitalization outcomes for patients receiving health care services through the program (care coordination group) were compared to those not enrolled (usual care group). Patients in the care coordination group were found to have shorter hospital stays, when adjusted for diagnosis-related groups; fewer readmissions; and were less severely ill upon admission. Cost data were extrapolated to show that costs of care coordination activities were partially offset by reductions in inpatient utilization.