The Role of AHCPR Research
This fact sheet describes AHCPR's role in Federal and State policymakers' efforts to control costs and improve the quality of care in the Medicaid program.
Contents
Introduction
Care for Elderly and Disabled Populations
Maternal and Child Health
Research and Technical Assistance on HIV and AIDS
Drug Policy
Informing Consumers
System Financing and Management
Conclusion
References
Introduction
The Federal Medicaid program provides a growing safety net for a broad cross-section of the population, and in particular
for those with severe and costly health care needs. The program currently pays for a third of all births, finances health care
for one in four American children, and covers 60 percent of the poor. Medicaid also pays for half of all nursing home care,
subsidizes acute care for poor Medicare enrollees, and has a large and increasing responsibility for people with disabilities
and AIDS (Rowland, 1995).
Finding a way to control costs and improve the quality of Medicaid services has provided a
growing challenge for both Federal and State policymakers. Although Medicaid expenses in the past grew more slowly
than private health care spending, program costs increased dramatically in the late 1980s and early 1990s, thanks to rapid
eligibility expansion, a national recession, inflation in health care spending, and State use of statutory loopholes to leverage
Federal dollars. Between fiscal years 1988 and 1993, annual Federal and State Medicaid expenditures rose from $54
billion to $131 billion. Between fiscal years 1994 and 1995 these expenditures rose from $144 billion to $159 billion
(Personal Communication, Joseph Dunne, Health Care Financing Administration, April 28, 1997).
In part as an effort to
control these costs, the Medicaid program has moved rapidly in the direction of managed care. By 1995, nearly one-third
of Medicaid recipients (mostly poor children and their parents) were enrolled in some form of managed care (Rowland and
Hanson, 1996). The hope is that these delivery changes can not only control costs but also improve the quality of care.
Both the Health Care Financing Administration and the States are spending a great deal of time developing and
implementing mechanisms to realize these hopes. The role of the Agency for Health Care Policy and Research (AHCPR)
during this process has been to:
- Provide science-based research to support these Federal and State efforts.
- Disseminate research findings and guidelines that managed care plans and providers serving the Medicaid population can
use to lower costs and improve quality.
- Provide technical assistance to State policymakers and administrators
seeking to improve their Medicaid programs.
AHCPR also conducts the Medical Expenditure Panel Survey (MEPS), a
source of data for policymakers and researchers on Medicaid. As a nationally representative survey, MEPS collects
detailed information on Medicaid coverage, costs, utilization, and health status of Medicaid beneficiaries.
AHCPR research
has addressed eight of the inpatient diagnoses and procedures most costly to the Medicaid program. Increasingly, research
also has addressed outpatient and long-term care issues. AHCPR also supports 11 research centers that study patient
outcomes and the effectiveness of medical treatment for conditions that disproportionately affect minority populations.
Finally, through the User Liaison program, the Agency provides technical assistance to State policymakers and Medicaid
officials who are attempting to design and implement changes in their programs.
As discussed below, AHCPR research
and technical assistance falls into six areas of critical importance to the Medicaid program: care for elderly and disabled
populations, maternal and child health, research and technical assistance on HIV and AIDS, drug policy, informing
consumers, and system financing and management.
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Care for Elderly and Disabled Populations
Although only about a
quarter of Medicaid recipients are elderly, blind, and/or disabled, this population accounts for almost 60 percent of program
spending, about $62.6 billion in 1993 (Rowland, 1995). One reason these expenses are so high is that Medicaid pays for
long-term care services, whereas Medicare for the most part does not. Long-term care accounts for about 35 percent of
Medicaid costs, and most of these services go to the elderly, blind, and disabled (Rowland, 1995). Put another way, the
Medicaid program pays for about half of all nursing home care in the U.S., with out-of-pocket payments accounting for
most of the rest (Lair, 1992; Short et al., 1992, cited in Cohen and Spector, 1996). For this reason, AHCPR has devoted a
large and growing part of its research effort to issues surrounding the payment and delivery of long-term care services and
other services for the aged, blind, and disabled population. (For more information, select AHCPR Research on Long-term Care).
In the early 1990s, a significant Agency activity was the
development and dissemination of clinical practice guidelines. For example, acute pain, pressure ulcers, and urinary
incontinence are conditions common to elderly and disabled patients in acute and long-term care settings. Providers
adopting AHCPR guidelines in these areas report that they have been able to speed recovery, improve patient comfort, and
reduce costs. Heritage Manor Nursing Home in Chattanooga, for example, used the incontinence and pressure ulcer
prevention guidelines to increase the percentage of dry patients from under 33 percent to over 76 percent, and reduced the
number of average pressure ulcers from 14 to 5 (AHCPR, 1996a).
For this reason, many States have helped with guideline
dissemination and some have incorporated the guidelines into their quality review protocols. For example:
- Texas State
surveyors of long-term care facilities use the guidelines on pressure ulcers, urinary incontinence, and acute pain to train
staff in each of the 10 operating regions. The Texas Department of Human Services also has distributed copies of all 3
guidelines to its nursing staff and over 1,000 long-term care nursing facilities (AHCPR, 1996a).
- The Maryland Health
Resources Planning Commission has asked nursing homes and other providers to establish clinical practice guidelines
regarding incontinence consistent with those issued by AHCPR (AHCPR, 1996a).
The American Medical
Directors' Association (AMDA) adapted AHCPR-sponsored guidelines for long-term care use (the single greatest program
cost for Medicaid) in five areas: prevention of adult urinary incontinence, evaluation and care for patients with potential
heart failure, detection and treatment of depression, pressure ulcer prevention, and pressure ulcer treatment. This decision
was endorsed by a steering committee of long-term care associations including the American Health Care Association, the
American Association of Homes and Services for the Aging, and the American Society of Consultant Pharmacies. In 1997,
AMDA is developing two guidelines, one on falls and one on altered mental states, that will use AHCPR's guideline on early
Alzheimer's disease along with other information.
Because the evidence-based method of guideline development pioneered by
AHCPR has become well accepted, and because there are now many public and private organizations that develop clinical
practice guidelines, AHCPR no longer sponsors development of guidelines. Instead, the Agency supports Evidence-based
Practice Centers (EPCs) to conduct syntheses of the scientific evidence on clinical topics of national significance that
enable clinicians and health care organizations to develop their own quality improvement initiatives. AHCPR also
participates in a public-private partnership with the American Medical Association and the American Association of Health
Plans has created the National Guideline Clearinghouse™. The Clearinghouse is a comprehensive, Internet-based
source for clinical practice guidelines and related materials.
AHCPR has sponsored research on several issues related to
services for aged, blind, and disabled Medicaid recipients. For example:
- Diabetes and blindness: AHCPR-supported
research demonstrated that appropriate eye screening for diabetics leads to significant cost savings. The study showed that
at current screening rates (about 60 percent of the affected population receiving annual eye exams) government programs
save up to $14,276 per patient, a total of $248 million, including medical costs under Medicaid. The authors estimate that
such screenings preserve 53,986 person-years of sight each year (Chiang, Bassi, and Javitt, 1992; Javitt, Aiello, Chiang,
1994).
- Identifying the frail elderly: AHCPR-sponsored research led to instruments that measure a patient's degree of
independence in activities of daily living as well as cognitive and social functioning. Nursing homes and other providers of
chronic care for the elderly throughout the country are now using these measures as tools to identify their most frail elderly
members and to design and target interventions to help them (AHCPR, 1995a).
Long-term care: A current
AHCPR-funded study is identifying and testing a methodology for measuring the quality of long-term care. Specifically,
the project: (1) identifies dimensions and indicators of nursing home quality using data from Federal administrative
records; (2) develops and tests a model for rating nursing home quality; (3) tests hypotheses regarding the relationship
among structural, process, and outcome components of nursing home quality; (4) tests the usefulness of the developed
rating system for consumers, professionals, and surveyors; and (5) uses the model developed to rate all nursing homes in
the United States. Charlene Harrington, Principal Investigator (Grant No. HS07574; period: 4/1/95-3/31/98).
A second
study sought to develop an outcomes-based quality assurance methodology for nursing homes in Massachusetts. Francis G.
Caro, Principal Investigator (Grant No. HS07585; period: 9/30/93-3/31/96).
A third current study addresses the "transfer-of-asset" policy by
which Medicaid eligibility for nursing home
care is attained by transferring money to
children or otherwise disposing of assets.
The study will examine the impact of
Medicaid rules, including post-l988 spousal
asset waivers, on the purchase of long-term
care insurance and asset accumulation.
Edward Norton, Principal Investigator
(Grant Nos. HS08496, AGl3624, HS09515;
period: 9/30/96-9/29/98).
AHCPR also
funded research that looked at the effect of
Medicaid subsidies on the decision of frail
elderly to enter a nursing home. The same
study also examined the effect on medical
service use when Medicaid recipients are
switched from fee-for-service medical care
to capitated plans. Anthony T. Losasso,
Principal Investigator (Grant No. HS08944;
period: 8/l/95-7/31/96).
- Disabilities: AHCPR awarded the
University of Texas Health Sciences Center
a grant to examine the effectiveness of
alternative treatments for chronic disabling
conditions, such as type II diabetes and
mental health problems, with an emphasis
on the Mexican-American population.
Jacqueline A. Pugh, Principal Investigator
(Grant No. HS07397; period: 9/9/92-2/28/98).
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Maternal and Child Health
Although the aged, blind, and disabled
account for the largest share of program costs,
most Medicaid recipients are poor children and
their mothers. About half of all Medicaid
recipients are children and as noted earlier,
Medicaid pays for about a third of all births in
the United States. AHCPR research has
indicated many ways that Medicaid, and other
providers of care to children and pregnant
women, can increase quality and reduce costs.
For example:
- Diabetes in pregnancy: Preconception care
and enhanced prenatal care for women with
diabetes can prevent complications for
pregnant women and their babies, thereby
increasing quality of care and saving $1,720
per enrolled woman with diabetes. If the
AHCPR-suggested model were followed for
even 20 percent of diabetic pregnancies, the
country could save over $8.6 million a year.
Since the Medicaid program would be likely
to cover at least a third of these pregnancies,
the costs savings for Medicaid could reach
almost $3 million a year (Elixhauser,
Weschler, Kitzmiller, et al., 1993).
- Primary care for high-risk indigent
infants: A demonstration was designed to
reduce mortality among low birthweight
infants after hospital discharge and thereby
reduce the need for intensive care for
premature infants in the first few months
after discharge. Most of the mothers
involved in the study were teenagers from
black and Hispanic Dallas neighborhoods.
Jon E. Tyson, Principal Investigator (Grant
No. HS06837; period: l/1/92-6/30/97).
- Prenatal care and infant health: New
York State began a major expansion of its
Medicaid program in 1990. A current
AHCPR-funded study is examining the
impact of these changes on prenatal care use
and birthweight distribution among African-American,
white, and Hispanic enrollees
between 1988 and 1991. Theodore Joyce,
Principal Investigator (Grant No. HS08424;
period: 9/94-12/95). To help determine
whether large-scale statewide programs can
succeed in reducing adverse birth outcomes,
AHCPR funded an evaluation of particular
components Washington's 1989 Medicaid
expansion. Laura-Mae Baldwin, Principal
Investigator (Grant No. HS06846; period:
4/l/94-9/30/97).
- Middle-ear illness: Otitis media or middle-ear
illness is common in young children.
AHCPR recommendations for reducing
unnecessary interventions for middle-ear
infection in children under 3 could save
many children and their families the trauma
of surgery, and could also save the country
$170 million in medical and indirect costs,
even if only one provider in five adopted the
guidelines. (Lewin, Rubin, and Gold, et al.,
1994). Because Medicaid covers a quarter of
all children, about $40 million of this
savings could accrue to Medicaid programs.
For this reason, State Medicaid programs
such as Oregon's are planning to use the
otitis media guideline as part of their annual
managed care external review.
- Immunizations: An AHCPR-funded study
found that a vaccine program for children
under 6 could prevent 3.7 million
chickenpox cases, 3,900 hospitalizations,
and 52 deaths each year. Net savings in
medical costs and lost work days for
Medicaid patients and their families would
exceed $150 million a year (in 1990 dollars).
If a quarter of these savings accrued to the
Medicaid program, savings could reach over
$37 million a year (Lieu, et al., 1994).
A recent AHCPR study developed strategies
for improving the dissemination and
adoption of all pediatric vaccine guidelines.
Thomas R. Konrad, Principal Investigator
(Grant No. HS07286; period: 7/1/92-6/30/96).
- Preventive and well-child care: Only one-third
of poor preschool children and half of
those from more affluent families receive the
recommended number of well-child visits,
according to a national health survey
conducted by AHCPR (AHCPR, 1994).
Increasing use of these services can improve
outcomes and reduce costs. An AHCPR-funded
study assessed the impact of periodic
feedback and financial incentives on use of
preventive services in a mandatory Medicaid
HMO and found no differences between
intervention and control groups. Alan L.
Hillman, Principal Investigator (Grant No.
HS07634; period: 4/1/93-9/30/96).
- Childhood asthma: An AHCPR-sponsored
project by the American Academy of
Pediatrics examined variations in the care of
acute asthma in pediatric practice as well as
compliance with national guidelines on
asthma treatment. The project documented
that pediatric providers are generally
compliant with national guideline
recommendations for the care of children
with acute asthmatic exacerbations, although
substantial variations from the guideline
were noted for patients with a moderate-to-severe
presentation. Anthony Alario,
Principal Investigator (Grant No. HS07418;
period: 9/30/92-9/29/94).
- Pediatric gastroenteritis: An AHCPR-funded
Pediatric Gastroenteritis Patient
Outcomes Research Project is examining
treatment variations and outcomes for
preschool children with pediatric
gastroenteritis in California, Georgia, and
Michigan. Preliminary findings suggest that
there may be a significant amount of
inappropriate care. Antibiotics were used in
over a quarter of the episodes, despite the
fact that antibiotics are not recommended
for conditions involving viral agents. On the
other hand, study findings suggest that oral
rehydration may be underused. (Pediatric
Gastroenteritis: Treatment Patterns and
Outcomes Among Disadvantaged Children.
Part of the Pediatric Gastroenteritis Patient
Outcomes Research Project. Contract No.
282-90-0043.)
- Family-centered care: A recent study
attempted to determine whether an
intervention program that involves children,
parents, and physicians in treatment
decisions for children with chronic disease
improves the health status of children, as
shown by both clinical variables and self-reports.
Sherrie H. Kaplan, Principal
Investigator (Grant No. HS06897; period:
9/30/91-12/31/95).
- Adolescent health: An AHCPR study
published in the Journal of the American
Medical Association identifies how
providers can encourage urban adolescents
to seek and receive preventive and primary
care. According to the adolescents
interviewed for the study, the most important
provider characteristics are provider hand-washing,
clean instruments, honesty, respect
toward teens, cleanliness, know-how,
carefulness, experience, seronegativity for
HIV, equal treatment of all patients, and
confidentiality (Ginsburg, Slap, Cnaan,
et al., 1995).
- Physician fees: Recent research based on
the 1987 National Medical Expenditure
Survey (NMES) found that children in
States with higher Medicaid physician fees
were more apt to receive their care from
physicians than in more expensive hospital-based
facilities, and therefore total
expenditures for children in the most
generous physician fee States were only
about three-fourths of those in the least
generous States (Cohen and Cunningham,
1995).
- Febrile infants: A current project is
researching variations in diagnosis and
treatment of infants with high fevers among
office-based pediatricians across the
country, and how these differences affect
outcomes and costs. Robert H. Pantell,
Principal Investigator (Grant No. HS06485;
period: 5/l/93-l/31/98).
- Sickle cell disease: An AHCPR-supported
guideline released in 1993 recommends
screening of all newborn babies for sickle
cell disease and for those who test positive,
the administration of protective doses of
penicillin (Smith, Kinney, Ames,
et al., 1993).
- Cancer prevention for minority women:
In a randomized controlled trial,
investigators assessed the impact of a system
of periodic feedback and financial incentives
on physician compliance with cancer
screening guidelines in HealthPASS,
Philadelphia's Medicaid HMO. The study
found that providing feedback and bonuses
to primary care sites did not significantly
improve primary care provider attention to
cancer prevention for minority women over
50. Alan L. Hillman, Principal Investigator
(Grant No. HS07720; period: 9/30/93-9/29/96).
- Assuring quality services: In recent years,
the research community as well as public
and private payers have focused a lot of
attention on development of instruments and
mechanisms for monitoring the quality of
care. Most of these efforts have focused on
adults. A 1995 AHCPR workshop for State
Medicaid directors and other senior State
officials, "Assuring Quality Services for
Children: Opportunities and Challenges in a Changing Health Care System," was designed to help States
find or design the tools and systems they need to assure quality of care for children.
- Pediatric specialists: AHCPR is
sponsoring research on the effects of resources used and quality of care of referrals to pediatric specialists compared to
adult specialists for common and uncommon conditions among Medicaid children. James M. Perrin, Principal Investigator
(Grant No. HS09416; period: 9/30/96-9/29/98).
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Research and Technical Assistance on HIV and AIDS
Currently the
Medicaid program finances care for 53 percent of all persons living with AIDS (PLWA) and up to 90 percent of all
children with AIDS. Medicaid is the largest single payer of direct medical services to PLWAs. Estimated combined Federal
and State Medicaid expenditures will be $3.3 billion in fiscal year 1997 (Personal Communication, Joseph Dunne, Health
Care Financing Administration, April 28, 1997). AHCPR has sponsored over 100 research projects to help State Medicaid
programs control costs and improve quality in care for HIV and AIDS patients. For example:
- PCP prophylaxis: AHCPR
research conducted at Johns Hopkins Hospital shows that early drug interventions can help reduce the incidence of a
common AIDS-related pneumonia. Even if only one AIDS patient
in five received such treatment, the country
could save $48.8 million a year in hospital
costs. Given Medicaid's role in financing care for HIV and AIDS, about $19.5 million of these
savings could be expected to accrue to the Medicaid program (Gallant, McAvinue, Moore, et al., 1995; Grant No.
HS09101).
- Early HIV treatment: A 1994 clinical practice guideline on evaluation and management of early HIV infection
documented that early stage HIV care does not require an array of specialists. Because primary care is generally less costly
than specialist care, the potential may exist for reducing costs while maintaining quality. The guidelines have been used by
peer review organizations such as the Island Peer Review Organization (IPRO) in New York State, as well as other entities
charged with maximizing quality and controlling costs for care to Medicaid and Medicare patients with HIV and AIDS
(AHCPR, 1996a). AHCPR is reaching HIV-infected pregnant women to inform them about the potential benefits of
using AZT to lessen the risk of passing the infection to their babies. Educational materials being developed include
brochures and culturally appropriate products in both English and Spanish (AHCPR, 1995b).
- Support for patients with
AIDS: The Comprehensive Health Enhancement Support System (CHESS) provides on-line services for people facing
major life crises such as AIDS/HIV. A recent study found that AIDS patients who use the CHESS system spend 17 percent
less time in the doctor's office when they visit. These patients also have lower health care costs, fewer hospitalizations, and
shorter hospital stays. In addition to improving the quality of care for AIDS/HIV patients, the study shows, CHESS has
reduced treatment costs from $1,200 per month to less than $1,000 (AHCPR, 1995a).
- Day limits: AHCPR research
found that when Medicaid programs cap the number of paid inpatient days rather than using a diagnostic-related group
(DRG) approach, they have an adverse impact on patient care (Buchanan and Kircher, 1994).
- Home care: A recent study
on home care for terminally ill AIDS patients found that policies that promote dying at home instead of the hospital may
improve patient "quality
of death," but may not lower health care
costs (Bennett, et al., 1995; Grant No.
HS062 11).
- Community services: An AHCPR-supported
evaluation of community-based
programs to improve access to social and
medical services for persons with AIDS
established under a Medicaid waiver found
that these programs expanded health care
delivery systems and provided substantial
services for persons with AIDS. Stephen
Crystal, Principal Investigator (Grant No.
HS06339; period: 9/30/94-9/30/97).
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Drug Policy
Between 1984 and 1993, Medicaid
pharmaceutical expenses increased fourfold
from $1.97 billion a year to $7.97 billion. For
this reason, evaluations of State cost-control
efforts in the pharmaceutical area can be very
helpful to States. Because of considerable State
interest in this issue, in 1995 AHCPR
sponsored a workshop on Medicaid drug
utilization review for State Medicaid directors
and members of State drug utilization review
boards. In addition, the Agency has sponsored
research focusing on the effectiveness of
various mechanisms designed to control drug
costs. For example:
- Advance approval: An AHCPR-funded
Tennessee study found that prior
authorization requirements for nonsteroidal
anti-inflammatory drugs (NSAIDs) can
reduce Medicaid costs by up to half.
Tennessee saved more than $12.8 million in
NSAID costs over 2 years from this
program, with no increase in Medicaid
expenses for other related medical care. If
similar prior authorization measures were
used nationally for even 20 percent of all
NSAID prescriptions, Medicaid could save
$175 million annually in prescription costs
(Smalley and Griffin, 1995; Grant No.
HS07768).
- Payment caps: On the other hand, a New
Hampshire study showed that caps on
Medicaid pharmaceutical benefits can raise
health care costs, at least for certain patients.
In 198 1, New Hampshire briefly imposed a
limit of three prescriptions a month. An
AHCPR-supported evaluation study showed
that, for adult schizophrenic patients, the
resulting increases in acute care and other
medical interventions ($1,530 per patient
over 11 months) exceeded the savings in
outpatient drug costs ($56.54) several-fold
(Soumerai, McLaughlin, Ross-Degnan, et
al., 1994; Grant No. HS05554).
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Informing Consumers
In the context of AHCPR's efforts to provide
information that assists consumers in making
choices among health plans, AHCPR has
targeted a number of its efforts for Medicaid
recipients.
- Multimedia kiosk: The development of the
"Choice Card,"
a multimedia kiosk targeting Medicaid recipients in Oregon and Connecticut, was funded by
AHCPR. The Choice Card allows each individual to indicate what factors, values, and preferences are important, and to
review and compare the relevant information across plans. Lisa Adatto, Contractor (Contract No. 290-95-0041; period:
9/30/95-9/29/97).
- Scorecard: This collaborative effort among AHCPR and various health organizations in Oregon resulted
in the development of a consumer scorecard that allows enrollees in Oregon's managed Medicaid program to obtain
information concerning fees, morbidity rates, and other factors to assist in the selection of a health care provider or plan.
Pam Hanes, Contractor (Contract No. 282-93-0036; period: 1/25/95-9/4/96).
- Workbooks and videos: In an effort to assist
Medicaid recipients and other low-income, disadvantaged, low-literacy, and/or ethnic minority consumers in Rhode Island
who are choosing among health plans, AHCPR funded this project that developed two print guides and a video in English
and Spanish. Christine Zaracadoolas, Contractor (Contract No. 290-97-0002; period: 9/30/95-3/31/97).
- Consumer Assessment of Health Plans Study (CAHPS®): In cooperation with AHCPR, a research consortium is developing a family
of surveys and consumer report formats that will help consumers and purchasers select high-quality health care plans and
services that meet their needs. AHCPR worked with HCFA to develop CAHPS® modules addressing
Medicaid and Medicare. James Lubalin, Ron Hays, and Paul D. Cleary, Principal Investigators (HS09218, HS09204,
HS09205; 9/30/95-9/29/00). (Select to access the CAHPS® Web site.)
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System Financing and Management
Finally, rapid changes in public programs and private
markets have created new challenges for States that cut across programmatic lines: how to work with private-sector plans,
how to measure and monitor quality, how to achieve greater cost-effectiveness, and how to structure financial incentives in
a way that supports quality care. AHCPR has conducted a variety of research initiatives and technical assistance programs
designed to support States in these efforts. For example:
- Managed care: Several AHCPR projects have analyzed the
impact of managed care on access, quality, and costs under the Medicaid program. One study looked at the question of
self-selection into Medicaid managed care. In voluntary managed care systems, does the health status and prior use of
services by children in managed care differ from the health status and prior use by children in fee-for-service? Teresa M.
Herbert, Principal Investigator (Grant No. HS00089; period: 9/1/94-8/31/96). AHCPR also funded a study to examine
whether State and private initiatives to improve access to health insurance coverage have reduced the number of uninsured
and altered their composition. The project developed a data set that can be used to estimate the effects of particular
State-level reforms or policies, including Medicaid managed care. Frank A. Sloan, Principal Investigator (Grant No.
HS08614; period: 4/1/95-3/31/96). A current study synthesizes and classifies existing State approaches and current
evaluations of Medicaid managed care programs, reviewing the effect such waivers have had on rural areas. Thomas
Ricketts, Contractor (Contract No. 290-93-0038; period: 9/30/96-3/31/98). A companion study is conducting an evaluation
of AHCPR's Rural Managed Care Centers. Thomas Ricketts, Contractor (Contract No. 290-93-0038; period: 9/30/96-3/31/98).
- Nationally representative survey: The Medical Expenditure Panel Survey, the third in AHCPR's series of medical
expenditure surveys, collects detailed information each year on health status, health care use and expenses, and health
insurance coverage—public
and private—of individuals and
families in the United States, including
nursing home residents. The survey, which
permits comparisons of services, costs, and
use for Medicaid recipients and others, is
designed to provide researchers and
policymakers with information necessary to
examine the relationship between individual
and family characteristics, including health
insurance and medical care use and
spending.
- Information for policymakers: In June
1995, AHCPR's User Liaison Program
conducted a special workshop on integrated
State health information systems for State
health officers and Medicaid directors in
Public Health Service Regions IV and VI.
State Medicaid directors are invited to all of
AHCPR's User Liaison Program Workshops.
Examples of topics of workshops conducted
in 1996 and 1997 that touched on Medicaid
issues include: Integrated Delivery Systems
in Managed Care, Providing Quality
Services to Children with Special Health
Care Needs Under Managed Care, and Local
Health Departments in a Managed Care
Environment. The impetus for this last
workshop resulted from an AHCPR
publication, Assessing Roles,
Responsibilities, and Activities in a
Managed Care Environment: A Workbook
for Local Health Oficials (AHCPR, 1996b).
Payment and quality. A recently published
study of the Maryland Medicaid program
examined the quality of care provided to
patients in different settings such as
physicians' offices, community health
centers, and hospital outpatient facilities.
Quality was measured by access to primary
care, technical quality, appropriateness of
care, and outcomes. The study found that
there were no consistent differences in
quality across the care sites and no
consistent relationship between cost-efficiency
and quality of care (Starfield,
Powe, Wiener, et al., 1994; Grant No.
HS06 170).
In a separate study of payment and quality
in long-term care, researchers sought to
determine the impact of payment
methodologies and payment levels on
quality of care in nursing homes. They
found that homes paid on a flat-rate
approach use fewer registered nurses (RNs)
but more licensed practical nurses (LPNs)
than homes paid on a cost basis. They also
found that the level of payment affected
staffing levels: in more generous systems,
homes use more LPNs. Higher staffing
levels, in turn, were associated with higher
quality. An increase of .5 RNs per 1,000
residents could translate into an estimated
3,000 fewer deaths annually for residents of
certified nursing homes. Similarly, a higher
intensity of LPN staffing significantly
improves functional outcomes. Despite
these results, the researchers found no direct
relationship between payment methods or
levels and quality (Cohen and Spector,
1996).
- Emergency Room use: Use of the
Emergency Room (ER) for nonemergency
care is a significant problem for Medicaid.
An AHCPR study in Maryland suggests that
requiring preauthorization for nonemergency
ER services does not reduce ER use and can
increase hospitalization rates (Gadomski,
1995).
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Conclusion
The Medicaid program is likely to undergo
considerable change in the future. State
responsibility for financing and delivery of
care for poor and vulnerable populations is
likely to increase, and therefore States will
have an increased need for research,
measurement tools, and technical assistance
programs to help them improve access,
enhance quality, and control costs.
AHCPR will need to work closely with
HCFA and the States to ensure that the
Agency's future research and technical
assistance efforts respond to these changing
State needs.
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References
Agency for Health Care Policy and Research.
Real world use of guidelines. AHCPR Pub. No.
96-R034. Rockville, MD: AHCPR, March 12,
1996a.
Agency for Health Care Policy and Research.
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AHCPR Publication No. 97-0044
Current as of August 1997
Internet Citation:
Meeting Medicaid's Cost and Quality Challenges: The Role of AHCPR Research. AHCPR Program Note. AHCPR Publication No. 97-0044, August 1997. Agency for Health Care Policy and Research, Rockville, MD. http://www.ahrq.gov/research/mednote.htm