Appropriate and necessary healthcare: new language for a new era.

Conceptual and language changes are necessary to accompany the paradigm shift from fee-for-service medicine to managed care. Medical necessity is an inadequate and ambiguous term defined differently by providers, payers, patients, and legislators. The attempt by legislators in Minnesota to develop a universal standard benefits set for healthcare services strikingly underscores the need to define relevant terminology to accompany the transition to managed care. We suggest the term appropriate and necessary healthcare as a state-of-the-art term for the new era of managed care.

The Minnesota Prenatal Care Coordination Project: successes and obstacles.

The Minnesota Prenatal Care Coordination Project was a statewide effort to present systematically education and technical support to providers as they implemented the Minnesota Prenatal Care Initiative for expanded services to high-risk women. Educational methods included holding 12 regional workshops throughout the State, one-to-one contacts by nurse consultants, and newsletters and a guidebook (manual) were distributed to reach community providers. Analysis of the implementation was conducted using site visits, interviews with providers, and reviews of medical records, claims data, and other project documents. Successes in the first year were a twofold increase in the numbers of Medicaid-enrolled women who received risk assessment and enhanced services, more than one-third increase in provider participation, greater collaboration among multidisciplinary providers at the community level, and improved communication between State and local health care agencies. Obstacles included provider resistance to changes in practice, dissatisfaction with the enhanced services package and level of reimbursement, and problems with implementation protocols. The project demonstrated that prenatal care providers will change; they will improve practices and collaboration as a result of personalized education and support.

From data to policy ... to politics. The Minnesotans health care plan for universal access to care.

Calls for major reform of the health care delivery system have been sounded at both the state and federal level. However, given the lack of consensus on health care reform at a federal level, more than half of the states are developing initiatives for universal access to care. In 1989, the Minnesota legislature created the Health Care Access Commission to develop a blueprint for universal access in Minnesota. To assist this effort, we studied the extent and nature of uninsurance and underinsurance within the state. In this article we report the findings of that study and discuss how the findings were first used to develop recommendations for universal access legislation. We then describe the fate of the legislation. Finally, we describe the veto and the creation of HealthRight, the recently enacted plan for health care reform bill in Minnesota. This plan simultaneously expands access to care and aims to contain health care costs.

Ethics and Medicaid: a new look at an old problem.

Recent proposals to reform Medicaid, driven primarily by the need for cost containment, rarely pay explicit attention to values. This paper presents the Medicaid Values Framework, the authors' interpretation of a set of societal ideals embodied in Title XIX of the Social Security Amendments of 1965. The Framework comprises seven interlocking values that are stratified into three interdependent tiers--access, quality, and equity. We use the access and equity tiers to analyze treatment of Aid to Families with Dependent Children (AFDC) and Supplemental Security Income (SSI) recipients under Medicaid. We document striking inequities in eligibility standards and in funding for the two groups--inequities that unexpectedly fail to translate into marked disparities in access to Medicaid. In conclusion, we comment on why the present inequities exist and why they are ethically unacceptable.

Prenatal care use and health insurance status.

Many observers explain the prevalence of inadequate prenatal care in the United States by citing demographic or psychosocial factors. But few have evaluated the barriers faced by women with different health insurance status and socioeconomic backgrounds. In this study of 149 women at six hospitals in Minneapolis, insurance status was significantly related to the source of prenatal care (p less than .0001). Private physicians cared for 52 percent of privately insured, 23 percent of Medicaid-insured, and two percent of uninsured women. Public clinics were the primary source of care for Medicaid and uninsured women, who, compared to privately insured women, experienced longer waiting times (p less than .001) during prenatal visits and were more likely (p less than .01) to lack continuity of care with a provider. Multiple measures, including expanding Medicaid eligibility, may help correct these problems.

Medically uninsured children in the United States: a challenge to public policy.

This article is an examination of the nature and extent of the problem presented by medically uninsured children in the United States. First, the characteristics of the uninsured population are explored with a description of how age, family income, and employment status disproportionately affect families with children. Second, the Medicaid program and its historically inadequate response to this growing problem of uninsured children is examined. Third, the relationship between insurance status and the health and development of children is discussed. Finally, recent public policy initiatives that have been enacted or proposed to address this inequity in the present health care system are reviewed with a recommendation to establish a "Universal Maternal and Child Health Program."

Prenatal care comparisons among privately insured, uninsured, and Medicaid-enrolled women.

Women without health insurance and those covered by Medicaid have been shown to obtain prenatal care later in pregnancy and make fewer visits for care than do women with private insurance. Factors that keep women from obtaining care include inadequate maternity care resources, difficulty in securing financial coverage, and the psychosocial issues of pregnancy. This study identified and compared prenatal care use patterns, insurance coverage changes, and psychosocial factors among 149 women in Minneapolis, MN, with private health insurance, Medicaid, and no health insurance. Little information has been available on the insurance status of women at the start of pregnancy and the paths subsequently taken to obtain financial coverage for prenatal care.

Medically uninsured children in the United States: a challenge to public policy.

This article is an examination of the nature and extent of the problem presented by medically uninsured children in the United States. First, the characteristics of the uninsured population are explored with a description of how age, family income, and employment status disproportionately affect families with children. Second, the Medicaid program and its historically inadequate response to this growing problem of uninsured children is examined. Third, the relationship between insurance status and the health and development of children is discussed. Finally, recent public policy initiatives that have been enacted or proposed to address this inequity in the present health care system are reviewed with a recommendation to establish a "Universal Maternal and Child Health Program."

Barriers and motivators to prenatal care among low-income women.

Substantial evidence exists which links prenatal care to improved birth outcomes. However, low-income and nonwhite women in the United States, who are at greatest risk for poor birth outcomes, continue to receive the poorest prenatal care. The purpose of this study was to identify and compare barriers and motivators to prenatal care among women who lived in low-income census tracts. The stratified sample included recently delivered white, black and American Indian women who received adequate, intermediate, and inadequate prenatal care. Interviews were conducted which focused primarily on the women's perceptions of problems in obtaining prenatal care and getting to appointments. Results indicated that women with inadequate care identified a greater number of barriers and perceived them as more severe. Psychosocial, structural, and socio-demographic factors were the major barriers, while the mother's beliefs and support from others were important motivators. The predictive power of selected barrier variables was examined by a regression analysis. These variables accounted for 50% of the variance in prenatal care use. The results affirm the complexity of prenatal care participation behavior among low-income women and the dominant influence of psychosocial factors. Comprehensive, coordinated and multidisciplinary outreach and services which address psychosocial and structural barriers are needed to improve prenatal care for low-income women.