This report examines how five states—Oklahoma, North Carolina, Pennsylvania, Indiana, and Arkansas—have enhanced their Medicaid primary care case management (PCCM) programs to provide more intensive care management and care coordination for high-need beneficiaries, improve financial and performance incentives for primary care providers, and increase use of performance and quality measures. The report is aimed at states that may not have the option of contracting with fully capitated at-risk managed care organizations (MCOs), or that may want to use PCCM programs as an option for beneficiaries and as a source of competition and comparison for MCOs.

Congestive heart failure (CHF) is a leading cause of hospitalization and mortality in the United States, affecting more than 5 million people at an expected cost of $34.8 billion in 2008. This article examines the association of medication adherence via the medication possession ratio with health care use and costs among Medicaid beneficiaries with CHF to estimate potential savings resulting from improved adherence. Using Medicare and Medicaid data for four states, researchers found that total health care costs were $5,910 (23 percent) less per year for adherent beneficiaries compared with nonadherent beneficiaries. Beneficiaries with adherence rates of 95 percent or higher had about 15 percent lower health care costs than those with adherence rates between 80 percent and less than 95 percent ($17,665 vs. $20,747), suggesting that the relationship between adherence and costs is graded. This study is the first to look beyond the 80 percent medication possession ratio threshold used in the relevant literature.

A number of data sets can be used to estimate the size of the nursing home population with mental illness; however, estimates vary because of differences in data collection. The 2004 National Nursing Home Survey (NNHS) estimates that 6.8 percent of nursing home residents had a primary diagnosis of mental illness in that year (6.0 percent of those 65 and older, and 12.9 percent of those under 65). Comparable populations in the Medicaid Analytic eXtract (MAX) data set had fewer mental illness diagnoses, and those in the nursing facility Minimum Data Set (MDS) had more. The authors conclude that the estimates from the NNHS are more reliable, but they are available only at the national level. State- and facility-level estimates would have to be generated with the MDS or MAX data sets, with users being aware of differences in recorded diagnoses among the three, especially the relatively limited diagnoses in the MAX and imprecise diagnoses in the MDS.

This chartbook, prepared for the Centers for Medicare & Medicaid Services, provides a snapshot of Medicaid pharmacy benefit use and reimbursement in 2003 and shows key trends from 1999 to 2003.

Presentation at the Michigan Family Impact Seminar, Lansing, MI.