Reports from the field-Medicaid/Medicare Issues

Managed Medicaid programs successful in rural area

Two recently released studies suggest that managed Medicaid programs significantly improve health care for the rural poor.

The first study assessed the number of 2-year-olds in a national sample of 8,100 who were up-to-date on their immunizations; the count was based on the 1988 National Maternal and Infant Health Survey and its 1991 Longitudinal Follow-up. Researchers found that 33% of poor children and 44% of other children had up-to-date immunizations. Poor children with public sources of routine pediatric care were more likely to have their full immunization series than poor children with private sources of routine care.

Researchers also found that more extensive Medicaid coverage for the poor was associated with a greater likelihood of having full immunization series among poor children; however, they noted that the effects of expanded Medicaid coverage were limited.

For roughly 60% of poor children in the study covered by Medicaid, additional Medicaid coverage did not increase the likelihood of more complete immunization.

The second study focused on the estimated 703,000 Medicaid beneficiaries in rural areas in capitated managed care plans and the even larger number participating in primary care case management programs (PCCM). Researchers did a case study of 10 states that have implemented Medicaid managed care programs to determine the impact of those programs on access to care.

In 1997, researchers conducted telephone interviews with 130 key officials in the 10 states, such as state agency representatives, rural care providers, representatives of managed care organizations, and consumer advocates. They found that implementing PCCM and managed care programs was possible even in remote rural areas.

Steps to success

They noted these steps that appear essential for success:

• States should allow greater time and effort to implement programs in rural areas.

• States should allow enough time to build provider networks.

• States should provide adequate time to build support for the program through interaction with local representatives.

• States should design geographic program boundaries that recognize local use patterns.

Researchers also noted that building provider networks in rural areas requires more time and effort due to rural providers' inexperience with managed care and communication barriers.

[See: Mayer ML, Clark SJ, Konrad TR, et al. The role of state policies and programs in buffering the effects of poverty on children's immunization receipt. Am J Public Health 1999; 89:164-170. See also: Felt-Lisk S, Silberman P, Hoag S, Slifkin R. Medicaid managed care in rural areas: A ten-state follow-up study. Health Aff 1999; 18:238-245.]

Families of disabled neglect their own care

A recent study found that among poor families, the effects of having a disabled family member were more likely to reduce medical care use and expenditures among nondisabled family members.

The study found that adults in poor families with a disabled family member were 16% less likely to visit a physician than adults in high-income families with a disabled family member. Researchers suggest that public programs recognize the potential rationing effect that occurs when income is limited and one family member uses the bulk of health care resources.

[See: Altman BM, Cooper PF, Cunningham PJ. The case of disability in the family: Impact on health care utilization and expenditures for non-disabled members. Milbank Quarterly 1999; 77:39-75.]

Reports from the field-Cardiology

Race, sex influence cardiac care decisions, study finds

A recent study found that a patient's race and sex may influence physicians' recommendations for cardiac catheterization.

The study found blacks and women with chest pain had relative odds of referral for cardiac catheterization that were 60% of the odds for whites and men, with the greatest disparity in testing for black women. Black women in the study fared the worst, with relative odds for catheterization that were 40% of those for white men.

How it was done

The carefully controlled study used computer multimedia technology to address the study question. Actors posing as patients, including two black men, two black women, two white men, and two white women described their chest pain using the same scripts reporting identical clinical symptoms. The actors wore identical gowns, used similar hand gestures, and reported having the same insurance coverage and occupation.

Researchers asked 720 primary care physicians at annual meetings of professional societies to review the patient's medical data, assess his or her diagnosis, and recommend further diagnostic tests. Physicians were told that they were participating in a study of clinical decision making.

[See: Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physician's recommendations for cardiac catheterization. N Engl J Med 1999; 340:618-626.]

Subsequent strokes result in higher costs, poorer outcomes

Patients who suffer a second or third stroke have poorer outcomes and higher health care costs than patients suffering a first stroke. In addition, fewer patients survive a second or third stroke and are more disabled if they do survive.

Researchers used administrative claims from a random 20% sample of nearly 50,000 Medicare patients admitted to U.S. hospitals with a primary diagnosis of cerebral infarction in 1991. They reviewed hospitalization data from the previous four years to classify patients as having either a first or recurrent stroke. Patients' survival and direct medical costs were followed for 24 months after stroke. Researchers found:

• 57% of first-stroke survivors were alive 24 months following stroke, compared with 48% of those suffering a recurrent stroke.

• Medical costs were similar for the initial hospital stay and in the first three months after stroke for first-stroke and recurrent-stroke patients.

• Medical costs for months four to 24 following stroke were roughly $375 more per month for recurrent stroke patients than for first-stroke patients.

Researchers note that most of the monthly medical costs were attributable to nursing home use and acute hospitalization costs.

[See: Samsa GP, Bian J, Matchar DB. Epidem iology of recurrent cerebral infarction: A Medi care claims-based comparison of first and recurrent strokes on two-year survival and cost. Stroke 1999; 30:338-349.]