Impact of a decline in Colorado Medicaid managed care enrollment on access and quality of preventive primary care services
Impact of a decline in Colorado Medicaid managed care enrollment on access and quality of preventive primary care services
复制标题
DOI：
10.1542/peds.2005-0923
复制
发表时间：
2005-12-01
期刊：
影响因子：
8
通讯作者：
Todd, J
中科院分区：
文献类型：
--
作者：
Berman, S;Armon, C;Todd, J
背景。科罗拉多医疗补助计划从1997年开始不再以管理式医疗为主,将孩子从入学健康维护组织(HMO),这需要一个入会者分配的初级保健医生,要么未派职务的医疗费(终于)计划的入学者并不需要有一个初级保健医生(PCP)或初级保健医生的程序(PCPP)的入学者被要求选择一个参与卡式肺囊虫肺炎是可用的。医疗补助计划在hmo中的注册月比例从1997年的75.4%下降到2003年的29%，而在此期间，UFFS计划的注册月比例从18.6%上升到45.6%，PCPP的比例从5.5%上升到25.3%。儿童从HMO管理的医疗保健到UFFS项目的转变提供了一个自然的实验，以评估没有指定的PCP对儿科初级保健服务的影响。我们试图评估将儿童从医疗补助HMO管理的有指定PCP的医疗计划选择性地转移到没有指定PCP的UFFS计划是否限制了儿童进入初级保健医疗之家、推荐健康监督访问和适合年龄的免疫接种。对1999-2003年公布的科罗拉多州健康计划雇主数据和信息集（HEDIS）数据进行了回顾，以确定与UFFS计划相比，参加指定PCP （HMO和PCPP）的医疗补助管理护理计划的科罗拉多州儿童是否更有可能进行任何类型的PCP访问，接受推荐的健康监督访问，并获得充分免疫接种。在分析中，“HMO total”是指参加HMO计划的所有儿童的平均值。Kaiser Permanente被认为是一个标杆，因为它在所有hmo中拥有最高的免疫率。“总科罗拉多州”指的是所有参加医疗补助计划的儿童的平均人数，包括管理医疗和UFFS选项。对于2岁儿童，4:3:2:1:1联合免疫包括4种白喉-破伤风-细胞百日咳疫苗、3种口服脊髓灰质炎病毒疫苗或灭活疫苗、2种乙型肝炎疫苗、1种乙型流感嗜血杆菌疫苗和1种麻疹-腮腺炎-风疹疫苗。1999年，在PCPP、Kaiser Permanente和UFFS项目中，12至24个月大的儿童接受任何形式的PCP就诊的比例为80%。然而，尽管2001年参加PCPP和Kaiser Permanente项目的儿童有任何访问的比例仍然达到了85%，但参加UFFS项目的儿童有任何访问的比例下降了13.9%，降至66.2%。2001年，参加UFFS项目的任何类型PCP就诊的儿童比例（66.2%）明显低于科罗拉多州的总体比例（73.6%）以及PCPP（85.7%）和Kaiser Permanente项目（97.7%）。2001年参加PCPP的12至24个月大的儿童与参加UFFS计划的儿童相比，接受PCP任何类型访问的可能性要高1.3倍。2001年、2002年和2003年参加PCPP计划的儿童与参加UFFS计划的儿童相比，分别有1.4倍、1.9倍和2.6倍的可能性接受了所有6项建议的健康监督访问。2001年、2002年和2003年参加PCPP计划的3至6岁儿童每年接受健康监督访问的可能性分别是参加UFFS计划的儿童的1.3倍、1.5倍和1.4倍。1999年、2001年、2002年和2003年，与参加UFFS计划的儿童相比，参加PCPP计划的2岁儿童接种最新4:3:2:1:1疫苗的可能性分别高出2.0倍、1.4倍、1.5倍和1.8倍。1999年、2001年、2002年和2003年，与参加UFFS计划的儿童相比，参加PCPP计划的青少年接种最新麻疹-腮腺炎-风疹两种疫苗的可能性分别是前者的1.8倍、1.6倍、1.3倍和1.6倍。本研究记录了科罗拉多州医疗补助计划为儿童提供医疗之家福利的能力正在减弱，包括与pcp的访问，推荐的健康监督访问，以及从HMO管理的医疗转移到UFFS计划的免疫接种。Kaiser Permanente取得的高最新免疫接种率表明，免疫接种率的差异反映了护理过程的有效性，而不是医疗补助人口的特征。
Background. Beginning in 1997 the Colorado Medicaid program de-emphasized managed care and shifted children from enrollment in a health maintenance organization ( HMO), which required an enrollee to have an assigned primary care physician, to either the unassigned fee-for-service ( UFFS) program in which the enrollee was not required to have a primary care physician ( PCP) or to the primary care physician program ( PCPP) in which the enrollee was required to select a participating PCP if one was available. The proportion of Medicaid enrollee-months in HMOs dropped from 75.4% in 1997 to 29% in 2003, whereas the proportion of enrollee-months in UFFS programs during this time period increased from 18.6% to 45.6%, and the proportion in the PCPP increased from 5.5% to 25.3%. This shift of children from HMO managed care to the UFFS program provided a natural experiment to assess the impact of not having an assigned PCP on pediatric primary care services.Objective. We sought to assess whether an elective shift of children from Medicaid HMO managed care plans with an assigned PCP to the UFFS program without an assigned PCP restricted access to a primary care medical home, recommended health supervision visits, and age-appropriate immunizations.Methods. Published Colorado Health Plan Employer Data and Information Set ( HEDIS) data for 1999-2003 were reviewed to determine if Colorado children enrolled in Medicaid managed care programs with an assigned PCP ( HMO and PCPP) compared with the UFFS program were more likely to have any type of visit with a PCP, to have recommended health supervision visits, and to be fully immunized. In the analysis, "HMO total" refers to the average of all children participating in HMO plans. Kaiser Permanente was considered a benchmark because it had the highest immunization rates of all HMOs. "Total Colorado" refers to the average of all children enrolled in Medicaid including the managed care and UFFS options. For 2-year-olds, the 4:3:2:1:1 combination immunization included 4 diphtheria-tetanusacellular pertussis vaccines, 3 oral poliovirus vaccines or inactivated polio vaccines, 2 hepatitis B vaccines, 1 Haemophilus influenzae type b vaccine, and 1 measles-mumps-rubella vaccine.Results. In 1999 the percentages of children 12 to 24 months of age having any type of visit with a PCP were > 80% for the PCPP, Kaiser Permanente, and UFFS programs. However, although the proportion with any visit remained > 85% in 2001 for children enrolled in the PCPP and Kaiser Permanente program, the percentage dropped 13.9% to 66.2% for children in the UFFS program. In 2001 the percentage of children with any type of PCP visit enrolled in the UFFS program ( 66.2%) was significantly lower than the total Colorado ( 73.6%) as well as the PCPP ( 85.7%) and Kaiser Permanente program ( 97.7%). Children 12 to 24 months of age enrolled in the PCPP in 2001 were 1.3 times more likely to have any type of visit with a PCP compared with those enrolled in the UFFS program.Children in the PCPP in 2001, 2002, and 2003 were 1.4, 1.9, and 2.6 times more likely, respectively, to have all 6 of the recommended health supervision visits compared with children enrolled in the UFFS program. Children 3 to 6 years old in the PCPP in 2001, 2002, and 2003 were 1.3, 1.5, and 1.4 times more likely, respectively, to have an annual health supervision visit compared with children enrolled in the UFFS program.In 1999, 2001, 2002, and 2003 2-year-old children enrolled in the PCPP were 2.0, 1.4, 1.5, and 1.8 times more likely, respectively, to be up-to-date with 4:3:2:1:1 vaccines compared with children enrolled in the UFFS program. In 1999, 2001, 2002, and 2003 adolescents enrolled in the PCPP were 1.8, 1.6, 1.3, and 1.6 times more likely, respectively, to be up-to-date with 2 measles-mumps-rubella vaccines compared with children enrolled in the UFFS program.Conclusions. This study documents the diminishing ability of the Colorado Medicaid program to provide children access to the benefits of a medical home, including visits with PCPs, recommended health supervision visits, and immunizations as care was shifted to the UFFS program from HMO managed care. The high up-to-date immunization rates achieved by Kaiser Permanente suggest that differences in immunization rates reflect the effectiveness of the care processes rather than the characteristics of the Medicaid population.