Health: Latest Work

Reports

"Report to Congress on the Evaluation of Medicare Disease Management Programs." Arnold Chen, Randall Brown, Dominick Esposito, Jennifer Schore, and Rachel Shapiro, February 2008. Before Medicare Part D, Congress authorized the Medicare disease management demonstration to evaluate whether disease management programs—in conjunction with a comprehensive prescription drug benefit—could improve health outcomes and reduce Medicare expenditures. The demonstration targeted fee-for-service Medicare beneficiaries with advanced congestive heart failure, diabetes, or coronary artery disease. This congressionally mandated study found that, based on the population-based random assignment design, none of the three demonstration programs had impacts on key outcomes of Medicare Part A and B expenditures and service use.

"Health Insurance Exchange Study." Deborah Chollet, Su Liu, Kate Stewart, Alison Wellington, Allison Barrett, Mila Kofman, and Amy M. Lischko, March 2008. In 2007, the state of Minnesota considered establishing a Health Insurance Exchange to serve small groups and individuals, facilitating access to coverage, choice among insurance products, portability of coverage, and affordability. Mathematica studied the coverage, cost, and fiscal impacts of a series of health reforms that might occur coincident with the implementation of the exchange—guaranteed issue and community rating of both small group and individual products, a mandate requiring all residents to obtain coverage, and a requirement that all employers with 11 or more employees offer a Section 125 or “cafeteria” plan. This report estimates the impacts of the reforms alone and in combination. In addition, it explores the range of implementation and legal issues that policymakers in Minnesota would need to address in order to develop an exchange.

“Health Care Access and Use Among Low-Income Children on Subsidized Insurance Programs in California.” Christopher Trenholm, Anna Saltzman, Shanna Shulman, Michael Cousineau, and Dana Hughes, May 2008. This paper summarizes the CaliforniaKids and Healthy Kids programs—county-based insurance programs in California for low-income children. The study examined features of both programs, use of basic health care services by the children enrolled, and typical experiences accessing inpatient and other high-cost care. Children enrolled in the two programs made substantial use of outpatient health care, despite important variation in program features. The study concludes with recommendations on how future research can more rigorously and precisely examine children's access and use of the programs.

"A Profile of Medicaid Institutional and Community-Based Long-Term Care Service Use and Expenditures Among the Aged and Disabled Using MAX 2002." Audra T. Wenzlow, Robert Schmitz, and Kathy Shepperson, January 2008. This report examines how person-level data in the Medicaid Analytic eXtract (MAX) data system can be used to better understand long-term care service use and expenditures, and to evaluate the utility of MAX data for further study of long-term care. The authors compare expenditure and utilization-based measures of the balance of institutional and community-based long-term care services. They also examine long-term care expenditures and utilization for two key groups of enrollees—young disabled enrollees and enrollees ages 65 and older. The article decomposes community-based long-term care expenditures by type of service and summarizes other Medicaid services used and costs incurred in 2002. Executive Summary

"Medicaid-Financed Nursing Home Services: Characteristics of People Served and Their Patterns of Care, 2001-2002." Audra T. Wenzlow, Robert Schmitz, and Jill Gurvey, January 2008. This report describes patterns of Medicaid nursing home utilization for each state and nationally. The authors address the following questions: (1) What are the characteristics of people who use Medicaid nursing home services? (2) How do these people become eligible for Medicaid? (3) How long do Medicaid-covered nursing home spells last and how often do individuals return to nursing homes? They also examine how state policies are associated with nursing home utilization. Executive Summary

"Federal Medical and Disability Program Costs Associated with Diabetes, 2005. Summary of Methods and Key Findings." Marsha Gold, Craig Thornton, Allison Hedley, Cheryl Fahlman, Suzanne Felt-Lisk, Bob Weathers, and Thomas Croghan, September 2007. Diabetes is a growing threat to the nation's health that has serious and costly complications. This paper looks behind the $79.7 billion estimates for 2005 of medical and disability costs to the federal government cited in Mathematica's main study. The estimates include $2.5 billion in disability payments associated with diabetes and $77.2 billion in increased medical costs. Nearly 80 percent of the medical costs to the federal government were incurred in the Medicare program. Without enhanced efforts to control blood glucose, reduce the risk of complications, and prevent the onset of diabetes, federal costs related to diabetes will grow in the future.

"Health Plans' Use of Physician Resource Use and Quality Measures." Timothy Lake, Margaret Colby, and Stephanie Peterson, October 2007. In recent years, health plans have developed measures of health service resource use to assess the efficiency of care that physicians and other providers deliver—primarily relying on tools commonly known as “episode groupers.” This report investigates the use of episode grouper-based measures in the private sector in four health markets around the country: Austin, Boston, Cleveland, and Seattle. Health plans included in the study have multiple years of technical experience implementing physician resource use and quality measures; however, most are still in the early stages of determining the best ways to use these measures in their local markets. The report includes lessons for future quality measurement efforts in Medicare and other programs.

"Assessment of State Capacity to Identify and Track Disparities in the Leading Health Indicators." Allison Hedley Dodd, Melissa Neuman, and Marsha Gold, December 2007. Assessing health status is a core function of public health on the state level. This report summarizes the data available in each state for health assessment, a necessary step in achieving public health goals. Using the leading indicators from Healthy People 2010, the authors found that while data generally are available across all states, gaps do exist. Across states, data sometimes are not available for a few specific health objectives and for certain age groups.

"Leading the Way? Maine's Initial Experience in Expanding Coverage Through Dirigo Health Reforms." Debra J. Lipson, James M. Verdier, Lynn Quincy, Robert Hurley, Elizabeth Seif, Shanna Shulman, and Matt Sloan, December 2007. Since enacting comprehensive health care reform in 2003, Maine's Dirigo Health program has helped expand coverage for low- and moderate-income individuals. By September 2006, about 16,100 individuals were enrolled in two coverage initiatives—DirigoChoice, a subsidized insurance product, and a Medicaid eligibility expansion for low-income parents of dependent children. While these programs are making health coverage more affordable to low-income individuals, small firms, and sole proprietors, with subsidies targeting those most in need, by late 2006 the initiatives had enrolled less than 10 percent of previously uninsured residents. To pay for this expanded coverage, Maine has utilized savings in the overall health care system due to lower uncompensated care and cost controls. However, the funds raised thus far are insufficient to pay for greater subsidized enrollment in Dirigo programs, leading to a search for other financing sources to sustain the program.

"Administration of Mental Health Services by Medicaid Agencies." James Verdier, Allison Barrett, and Sarah Davis, 2007. Medicaid spending for mental health care accounted for 26 percent of total mental health expenditures by all public and private payers combined in 2003, and 10 percent of all Medicaid dollars were spent on mental health services in that year. Medicaid now funds more than half of all mental health services administered by states and could account for two-thirds of such spending by 2017. This report, based on telephone interviews with state Medicaid directors in all 50 states and the District of Columbia between July 2005 and February 2006, provides state-by-state comparative information on how Medicaid and mental health agencies are structured, the degree and extent of their collaboration, how they share authority, and how Medicaid mental health services are funded.

"National Evaluation of the State Children's Health Insurance Program: A Decade of Expanding Coverage and Improving Access." Margo Rosenbach, Carol Irvin, Angela Merrill, Shanna Shulman, John Czajka, Christopher Trenholm, Susan Williams, So Sasigant Limpa-Amara, and Anna Katz, September 2007. Expanding health coverage for children is at the center of policy debates as reauthorization of the 10-year-old State Children's Health Insurance Program (SCHIP) continues. This report presents findings from Mathematica's comprehensive seven-year evaluation of SCHIP for the Centers for Medicare & Medicaid Services. The report highlights states' progress in conducting outreach, averting substitution, improving access, and reducing the number of uninsured low-income children. The study found that SCHIP reduced both the number and rate of uninsured children and improved children's access to health care. From 1997 to 2003, the percentage of uninsured low-income children fell from 25 percent to 20 percent. Enrollment climbed to 6 million children in 2003 and reached 6.6 million in 2006. In addition, access to care improved, although some gaps remain for children with special health care needs and children of minority race/ethnicity. Issue Brief

"SCHIP at 10: A Synthesis of the Evidence on Substitution of SCHIP for Other Coverage." So Limpa-Amara, Angela Merrill, and Margo Rosenbach, September 2007. When SCHIP was enacted in 1997, policymakers sought to safeguard against the substitution of SCHIP for other insurance coverage. This report synthesizes and assesses evidence from published and unpublished literature and state SCHIP annual reports on the magnitude of substitution in SCHIP. Wide-ranging estimates across studies are explained as a function of differences in purposes, methods, and analytic perspectives.

"Evaluation of the Medicaid Value Program: Health Supports for Consumers with Chronic Conditions." Dominick Esposito, Erin Fries Taylor, Kristin Andrews, and Marsha Gold, August 2007. The Medicaid Value Program tested interventions to improve care for adult Medicare beneficiaries with multiple chronic conditions. This report presents findings from Mathematica's evaluation; estimates of program effects, produced by the programs themselves; and case studies for the 10 interventions tested. The program succeeded in generating interest among states and health plans in developing interventions and also was successful in implementation. It was less successful in rigorous, empirical testing of the effectiveness of the interventions. Executive Summary

"Continued Progress in Performance Measurement Reporting by SCHIP." Margo Rosenbach, Anna Katz, and Sibyl Day, September 2006. In recent years, CMS has focused increasing attention on the reporting of program performance measures within SCHIP. This memo analyzes trends in state reporting from fiscal years 2003 to 2005, compares SCHIP performance measures to Medicaid and commercial benchmarks, and makes recommendations for improving performance measurement in SCHIP.

Journal Articles

"A Common Factors Approach to Improving the Mental Health Capacity of Pediatric Primary Care." Larry Wissow, Bruno Anthony, Jonathan Brown, Susan DosReis, Anne Gadomski, Golda Ginsburg, and Mark Riddle, Administration and Policy in Mental Health, July 2008. Strategies used to treat children's mental health problems in primary care have several limitations. This article proposes a new clinical model for delivering mental health services in pediatric primary care and suggests that physicians can efficiently learn a core set of treatment skills and apply them to a broad range of mental health problems. The authors review how implementation of this model would impact the delivery, organization, and funding of pediatric primary care and propose a research agenda to test the model.

“Neo-Materialist Theory and the Temporal Relationship Between Income Inequality and Longevity Change.” Andrew Clarkwest, Social Science & Medicine, May 2008. The author challenges prior fixed effects analyses of the relationship between income inequality and population health. He argues that the temporal relationships are likely to be complex and that fixed effects approaches, though important for addressing confounding, are poorly equipped to capture potential real impacts. Longevity improved less in states with higher levels of inequality, and there is a strong negative association between change in inequality and change in longevity after adjusting for initial levels of state characteristics.

“Dynamics in Medicaid and SCHIP Eligibility Among Children in SCHIP's Early Years: Implications for Reauthorization.” Anna S. Sommers, Lisa Dubay, Linda J. Blumberg, Fredric E. Blavin, and John L. Czajka, Health Affairs, September/October 2007. 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 were income eligible for both programs, and 73 percent of children ever eligible for SCHIP were eligible at other times for Medicaid. The authors note that as SCHIP is reauthorized, Congress will need to give states the tools and financial commitment to ensure that uninsured children are enrolled in and retain coverage for which they are eligible.

"Convergence and Dissonance: Evolution in Private-Sector Approaches to Disease Management and Care Coordination." Glen P. Mays, Melanie Au, and Gary Claxton, Health Affairs, November/December 2007. Disease management approaches survived the 1990s backlash against managed care because of their potential for consumer-friendly cost containment, but purchasers have been cautious about investing heavily in them because of uncertainty about return on investment. This article examines how private-sector approaches to disease management have evolved over the past two years in the midst of the movement toward consumer-driven health care. Findings indicate that these programs have become standard features of health plan design, despite a thin evidence base concerning their effectiveness.

"Receiving Advice About Child Mental Health from a Primary Care Provider: African American and Hispanic Parent Attitudes." Jonathan D. Brown, Lawrence S. Wissow, Ciara Zachary, and Benjamin L. Cook, Medical Care, November 2007. African American and Hispanic youth with mental health problems are less likely than their Caucasian counterparts to receive mental health services. Primary care providers are often the source of mental health care for children and may play a role in reducing disparities. This research investigated parent attitudes associated with receiving advice about child mental health in primary care and whether attitudes differed according to race and ethnicity during 773 visits to 54 providers in 13 clinics. Hispanics were more likely than non-Hispanics to agree that primary care providers should treat child mental health and were more willing to allow their child to receive medications or visit a therapist for a mental health problem if recommended by the provider. African American parents were significantly less willing than Caucasians and Hispanics to allow their child to receive medications for mental health but did not differ in their willingness to visit a therapist. These findings suggest that African American parents are generally as willing as Caucasian parents to have their child's mental health needs addressed in primary care and that primary care may be a particularly good point of intervention for Hispanic youth with mental health problems.

"Authorship and Publication Practices: Evaluation of the Effect of Responsible Conduct of Research Instruction to Postdoctoral Trainees." Carolyn L. Funk, Kirsten A. Barrett, and Francis L. Macrina, Accountability in Research, October 2007. The authors studied postdoctoral trainees funded by National Institutes of Health F32 fellowship awards to test the effectiveness of responsible conduct of research (RCR) education in the areas of authorship and publication practices. Overall, the responses suggested a clear awareness of standards and practices in publication. However, the results failed to suggest that RCR education significantly increased the level of ethically appropriate behavioral responses measured in the study. The authors note the importance of careful articulation of course goals and objectives with attention to the background and experience of the student audience when developing RCR curricula.

"Impact of Drug Coverage on Medical Expenditures Among the Elderly." Boyd H. Gilman, Barbara Gage, Susan Haber, Sonja Hoover, and Jyoti Aggarwal, Health Care Financing Review, fall 2007. The authors compare expenditures for Medicare-covered medical services among enrollees in three state pharmacy assistance programs with spending among low-income residents eligible or near eligible for but not enrolled in these programs, after controlling for between-group differences in demographic, socioeconomic, health status, and insurance status characteristics. The article notes that drug coverage has no discernible effect on the use and cost of inpatient services, but it is associated with a statistically significant increase in Medicare spending for physician services.

"Impact of Multitiered Copayments on the Use and Cost of Prescription Drugs Among Medicare Beneficiaries." Boyd H. Gilman and John Kautter, Health Services Research, September 2007. This article reports on a study that exploits cross-sectional variation on copayment structures among firms with a self-insured retiree health plan to measure the impact of the number of copayment tiers on total and enrollee drug payments, number of prescriptions filled, and generic substitution. The study also assessed the effect of enrollee cost sharing on the cost and use of prescription medications for the long-term treatment of chronic conditions. The researchers found that Medicare beneficiaries in three-tiered plans had 14.3 percent lower total drug expenditures, 14.6 fewer prescriptions filled, and 57.6 percent higher out-of-pocket costs than individuals in lower-tiered plans. While individuals in higher-tiered plans had lower purchases of both brand name and generic prescriptions, a higher percentage of total purchases was filled with generics. The researchers estimated a price elasticity of demand for prescription drugs among the elderly of -0.23, consistent with other studies. Beneficiaries were less responsive to cost sharing incentives when using drugs to treat chronic conditions.

Issue Briefs

"Medicare Advantage in 2008." Marsha Gold, June 2008. Medicare Advantage (MA), a voluntary program that provides beneficiaries with an alternative way to access traditional Medicare benefits, replaced the Medicare+Choice program in 2004 and became fully operational in 2006. This issue brief reviews recent trends in the program and includes information trends in firm participation and market share, changes in beneficiary choice, and growth in MA plans available to employer groups. The brief notes that the number of Medicare beneficiaries in MA plans continues to grow, to 8.2 million at the end of 2007, up from 5.4 million in March 2005. In the first four months of 2008, enrollment increased by more than 800,000. Private fee-for-service plans account for more than half of this new growth. About one in five Medicare beneficiaries (19 percent) is enrolled in an MA plan. In addition, four main players—UnitedHealthcare, Humana, Kaiser, and Blue Cross Blue Shield—accounted for more than half of enrollment at the end of 2007.

"Improving Processes and Increasing Efficiency: The Case for States Participating in a Process Improvement Collaborative." Sheila Hoag and Judith Wooldridge, September 2007. State Medicaid and SCHIP agencies provide vital health coverage to low-income populations and other groups, but they have limited administrative resources to support enrollment and renewal. This brief looks at experiences of some state Medicaid and SCHIP agencies in using a process change model to strengthen the way they approach enrollment and retention, concluding that committed leadership and resources are an effective model for changing Medicaid and SCHIP enrollment and retention processes rapidly and for sustaining improved processes. The brief also explores whether a process improvement collaborative is a worthwhile investment for states, finding that they have much to gain in terms of increased efficiency and savings using the model, which can be applied to any area of state administration.

"Three Independent Evaluations of Healthy Kids Programs Find Dramatic Gains in Well-Being of Children and Families." In Brief #1. Christopher Trenholm, Embry Howell, Ian Hill, and Dana Hughes, November 2007. Since 2001, initiatives have emerged in 25 of California's 58 counties to expand health insurance coverage for children. These initiatives make use of a new insurance product, Healthy Kids, that covers children who are ineligible for Medi-Cal and Healthy Families, California's public programs for children in families with incomes up to 250 percent of the federal poverty level. This brief presents highlights from evaluations of Healthy Kids programs in Los Angeles, San Mateo, and Santa Clara counties. The brief notes that children's access to and use of medical care improved, unmet health care needs declined, and parents of children enrolled in Healthy Kids reported far more confidence that they could obtain care for their children.

Other

"New Hospital Information Technology: Is It Helping to Improve Quality?" Suzanne Felt-Lisk, in Hospital Management New Initiatives/Dimensions, 2008. Although health information technology (IT) is at the center of efforts to improve the nation’s health care system by enhancing patient safety and reducing inefficiencies, little evidence exists to link IT to quality improvements and efficiency gains. This book chapter reprints a May 2006 issue brief reporting on how six types of information technology have affected hospital quality, based on interviews with senior hospital executives. The findings suggest that IT has been an important factor in enhancing quality, particularly in terms of more timely clinical information, diagnosis, and treatment.

"State Comprehensive Access Initiatives." Deborah Chollet, March 2008. Testimony before a House Appropriations Subcommittee at a hearing on Expanding Health Care Access.

"The Medicaid Analytic eXtract (MAX) Chartbook." Audra T. Wenzlow, Dan Finkelstein, Ben Le Cook, Kathy Shepperson, Christine Yip, and David Baugh, 2007. Developed for state Medicaid directors, policymakers, researchers, and others interested in the Medicaid program, the chartbook is a research tool and reference guide on Medicaid enrollees and their Medicaid experience in 2002. It consists of illustrative graphs, descriptive text, and an extensive data appendix with summary national- and state-level information on enrollee demographic and eligibility characteristics, Medicaid service use, and Medicaid expenditures in 2002. Appendix Tables

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