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Agency for Healthcare Research Quality

Health Care Costs and Financing

Children with special health care needs in Medicaid managed care plans receive more needed care than those in Medicaid FFS plans

Relatively few States have required that children with special health care needs (SHCN) enroll in capitated Medicaid managed care plans (providers are paid one fee per patient, regardless of type of care delivered). That's because the financial incentives inherent in such plans may lead to undertreatment, restrict access to specific services and providers, and have adverse effects on quality.

A recent study involved children with SHCN in Washington, DC, who qualified for Supplemental Security Income (SSI) and were enrolled in a partially capitated Medicaid managed care plan. The researchers examined the effects of enrollment in this plan on the children's access to care. The managed care plan was specifically designed for children who qualify for Medicaid because they receive Supplemental Security Income due to a disability (Health Services for Children with Special Needs or HSCSN). The researchers found that these dually enrolled children had fewer unmet health needs than those enrolled in Medicaid fee-for-service (FFS) plans.

The HSCSN's comprehensive care plan assessment, ongoing case management, primary care providers' gatekeeping role, and higher physician reimbursement may have reduced unmet need among children with SHCN, suggests principal investigator, Jean M. Mitchell, Ph.D., of Georgetown University. Dr. Mitchell and Darrell J. Gaskin, Ph.D., of Johns Hopkins University, conducted telephone interviews with a random sample of 1,088 caregivers of children with SHCN in Washington, DC, in 2002. Their work was supported in part by the Agency for Healthcare Research and Quality (HS10912). The researchers examined the children's usual source of care, unmet need for certain health services during the 6-month period prior to the interview, and caregivers' ratings of dimensions of access to services.

The percentage of children who did not receive needed dental care, durable medical equipment/supplies, or prescription drugs was significantly higher among FFS enrollees than among children enrolled in the HSCSN. There were no significant differences by plan type in unmet need for physician/hospital care, mental health services, home health service, or therapy.

See "Do children receiving Supplemental Security Income who are enrolled in Medicaid fare better under a fee-for-service or comprehensive capitation model?" by Drs. Mitchell and Gaskin, in the July 2004 Pediatrics 114(1), pp. 196-204.

Editor's Note: A second study on a related topic found that children dually enrolled in both Medicaid and Michigan's Children's Special Health Care Services for children with special needs who were under 1 year of age or had diagnoses of anemia, hemophilia, asthma, epilepsy, or juvenile diabetes had especially high rates of emergency department use. The study found significant geographic variation in ED use after controlling for diagnoses, race, and other factors. The researchers note the importance and difficulty of developing systems of care to manage complex chronic conditions in low-income populations. For more details, see Pollack, H.A., Dombkowski, K.J., Zimmerman, J.B., and others (2004, June). "Emergency department use among Michigan children with special health care needs: An introductory study." (AHRQ grant HS10441). Health Services Research 39(3), pp. 665-692.

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