1. THE URBAN INSTITUTE Impacts of Managed Care on SSI Medicaid Beneficiaries: Preliminary Results From A National Study Terri Coughlin Sharon K. Long The Urban Institute AcademyHealth Annual Research Meeting June 2004 Research funded by Centers on Medicare and Medicaid Services

2. THE URBAN INSTITUTE 2 Policy Context Substantial growth of Medicaid Managed Care (MMC) for disabled persons in late ’90s –Pros and cons to shift to MMC –Limited research on impacts of MMC on SSI beneficiaries Study is first step to filling information gap

3. THE URBAN INSTITUTE 3 Focus of Study At the national level, investigate how MMC affects access to care for adult SSI beneficiaries Specific research questions: –What is the overall impact of MMC on access and use by SSI beneficiaries? –Do the impacts differ for capitated managed care programs versus other forms of managed care, such as Primary Care Case Management (PCCM)?

4. THE URBAN INSTITUTE 4 Measure of MMC Focus on whether individual resides in a county in which MMC SSI program exists Impact of being in a MMC environment, not necessarily being enrolled in MMC program –Measures the average effect of MMC program rather than individual effect Framework for analysis: compare access for benes living in MMC counties to those living in counties with fee-for-service (FFS) Medicaid

5. THE URBAN INSTITUTE 5 Share of Counties with MMC or FFS for SSI Beneficiaries, 1996- 2000 Type of Medicaid Program199619982000 All Counties (N=3142) 100% Counties with Any MMC 34%47%53% Mandatory HMO 5%9%13% Mandatory PCCM 19%23%27% Mixed Mandatory HMO/PCCM 5%6%4% Voluntary MMC 5%8%10% Counties with FFS 66%53%47% Source: Constructed from CMS’s National Summary of State Medicaid Managed Care Programs and Medicaid Managed Care Enrollment Report, Medicaid Managed Care Summary for 1996 to 2000

6. THE URBAN INSTITUTE 6 Data Sources 1997-2001 National Health Interview Survey –Nationally representative sample of US population State and community characteristics –Area Resource File, American Hospital Association Annual Survey, Current Population Survey, and Institute’s TRIM Simulation Model MMC data –CMS’s National Summary of State Medicaid Managed Care Programs; Medicaid Managed Care Enrollment Report, Medicaid Managed Care Summary

7. THE URBAN INSTITUTE 7 Study Sample Adults age 19 to 64 who are SSI Medicaid beneficiaries Exclude SSI beneficiaries also on Medicare as they are generally exempt from MMC Restrict to those likely to be full-year Medicaid N = 1947 adults

8. THE URBAN INSTITUTE 8 Empirical Approach Basic Model: Y it = β 0 + β 1 MMC it + β 2 X it + ε it Estimate separately for SSI Medicaid adults in urban and rural areas –Differences in type of MMC –Differences in structure of health care market Estimate two models: –Any MMC vs. FFS –Mandatory HMO vs. FFS To account for complex design of NHIS, use svy estimation in Stata For simplicity, estimate linear probability models

9. THE URBAN INSTITUTE 9 Outcome Measures Usual source of care other than an emergency room (ER) Health care contact or use: –Any health care contact –Physician care –Specialist care –Physician extenders (e.g. nurse practioner) –Inpatient care –ER care –Flu shot

10. THE URBAN INSTITUTE 10 Explanatory Variables Individual/family characteristics –For example, age, gender, race/ethnicity, marital status, income, education Health status: –ADLs, IADLs, cognitive impairment, condition that limits work, fair or poor health County and state characteristics: –For example, county physician and hospital supply, county poverty rate, county HMO penetration rate, state medically needy standard, state Medicaid eligibility rate for standard population Time dummy

11. THE URBAN INSTITUTE 11 Summary of Preliminary Findings Urban Beneficiaries (N=1470) Rural Beneficiaries (N=477) Outcome Model 1: Any MMC Model 2: Mandatory HMO Model 1: Any MMC Model 2: Mandatory HMO Has usual source of care other than ER0.0240.0320.057 *0.040 Over the last 12 months, Any contact with any health care provider-0.041 **-0.043 *0.0370.039 Any office visit to any provider-0.050 *-0.060*0.0430.028 Over the last 12 months, contact with Physician-0.066 *-0.0790.0850.043 Specialist-0.031-0.090 *0.0090.076 Nurse practitioner, physician’s assistant or midwife-0.005-0.017 0.083 **0.106 Hospital stay in last 12 months0.032-0.0050.016-0.020 ER visit in last 12 months-0.019-0.022-0.081-0.092 Flu shot in last 12 months-0.035-0.099-0.0510.066 Source: 1997-2001 National Health Interview Survey *(**) Significantly different from zero at the.10 (.05) level, two-tailed test.

12. THE URBAN INSTITUTE 12 Conclusions Based on Preliminary Findings Find evidence of impacts of MMC on access and use by Adult SSI Medicaid-only beneficiaries, although findings are not strong and vary by area and type of MMC SSI beneficiaries in urban areas: –Less likely to see health care providers SSI beneficiaries in rural areas: –More likely to have USOC and see physician extenders On several outcomes (e.g. ER use, hospital and flu shot) find no significant relationship, regardless of area or type of MMC

13. THE URBAN INSTITUTE 13 Conclusions, cont. Study Caveats –Measure effects of program environment, not individual effects –Small sample sizes (particularly for rural areas) –Measure effects on service use, not on quality or health outcomes Future Work –Consider effects of different types of MMC –Look at different providers –Use alternative analytical frameworks, such as difference in differences –Increase sample sizes