Health Care Cost Containment System Research Articles

Evaluating the network adequacy of vision care services for children in Arizona: A cross sectional study.

Vision challenges are among the most prevalent disabling conditions in childhood, affecting up to 28% of school-age children. These issues can impact the development, learning, and literacy skills of affected children. While vision problems are correctable with timely diagnosis and treatment, insufficient networks can impede children's access to comprehensive, and high-quality care. The study aims to determine where pediatric vision care network adequacy exists in the state of Arizona and where there are gaps in receiving vision care for children. This cross-sectional study assessed the adequacy of pediatric vision care networks in Arizona through a "secret shopper" phone survey. Calls were made to practices that accept Arizona's Medicaid program, Arizona Health Care Cost Containment System (AHCCCS) and/or commercial insurance. Providers were contacted following a standardized script to schedule routine appointments on behalf of 10 and 3-year-old patients enrolled in either Medicaid or commercial health insurance plans. The study examined various components of children's access to vision care services, including the reliability of provider directory information, time until the next available appointment, bilingual service offerings, ages served, region of practice and types of care available. A total of 556 practices in Arizona were evaluated through simulations as patients on AHCCCS, and 510 practices were assessed through simulations as patients with commercial health insurance plans. The average wait time for the next available appointment was 13 days for both insurance types. Alarmingly, up to 74% of vision care practices in Arizona do not serve children covered by AHCCCS. Furthermore, only 41% provide services to children 5 years and younger. Our findings underscore the need to improve access to vision care services for children in Arizona, especially racial/ethnic minorities, low-income groups, and rural residents.

Impact of the COVID-19 pandemic on pediatric Medicaid dental claims in Arizona.

To examine the role COVID-19 had on access to dental services among children in Arizona by comparing paid pediatric dental claims made before and during the pandemic. In a retrospective descriptive study, we examined Medicaid paid claims for dental services among pediatric patients from March through December 2019 and during the outbreak in 2020. Using dental claims data obtained from the Centers for Health Information and Research at Arizona State University (ASU), we analyzed Medicaid (Arizona Health Care Cost Containment System [AHCCCS]) reimbursed dental services. During the COVID-19 pandemic, paid preventive dental claims for children aged birth to 21 years decreased in 2020 compared to the same time period in 2019. Pediatric patients in Arizona utilized fewer dental services and had less access to credentialed Medicaid dental providers during the pandemic. Further, rural counties had statistically significant fewer preventive, minor restorative, major restorative, and endodontic claims compared to urban counties. Arizona rural counties also had fewer providers who were paid $10,000 or more per year during 2020 than in 2019. COVID-19 has had a detrimental impact on pediatric dental service utilization. While dental services were provided during the COVID-19 pandemic, preventive and restorative dental claims dropped for rural Arizona children aged birth to 21 years. This reveals potential negative impacts on oral health. Further research should examine the direct and indirect impact the COVID-19 pandemic has had on dental service utilization and oral health for the general pediatric population.

Impact of Expanding Telephonic Codes in a State Medicaid Program During COVID-19.

Background: The recent pandemic caused by the 2019 novel coronavirus (COVID-19) resulted in declaration of a national emergency (NE) in March 2020. The Centers for Medicare and Medicaid Services quickly responded with temporary expansion of telehealth coverage policies. Aim: To determine the impact of implementing a temporary telephonic code set in a state Medicaid population by comparing the utilization patterns of telehealth claims before and after a NE announcement. Methods: This was a retrospective cohort study conducted with the Arizona Medicaid program, the Arizona Health Care Cost Containment System (AHCCCS). Data include telehealth claims submitted to AHCCCS between January and May 2020 by contracted managed care organizations. Results: Approximately 2.3 million telehealth claims were analyzed in this study. Utilization of the audio-visual (A/V) modality increased 1,610% and telephonic visits increased 408% compared with pre-NE. Compared with pre-NE, three provider type groups increased their utilization of telephonic visits from 1.8% to 50.8% as a result of the temporary telephonic set post-NE. Rural counties had higher rates of telephonic modality adoption, whereas urban counties adopted the A/V modality more readily. Ten telephonic codes constituted 87% of all telehealth claims, with the majority of those codes used for behavioral health and established office visit types. Conclusion: The telephonic modality was adopted more frequently in rural areas and the A/V modality in urban areas. There were several new provider types utilizing telehealth as a result of the temporary telephonic code set implementation.

Tucson Shares Blueprint for Crisis System Success

Tucson Shares Blueprint for Crisis System Success

Human papillomavirus vaccine guideline adherence among Arizona’s Medicaid beneficiaries

Cancers caused by human papillomavirus (HPV) can be prevented with the timely uptake and completion of the HPV vaccine series. Series completion is associated with increased vaccine effectiveness and longevity of protection. Medicaid beneficiaries are among populations with higher HPV vaccine uptake; however, little research describes factors that influence their HPV vaccine series completion. This study reports on a secondary data analysis of Arizona Medicaid data (Arizona Health Care Cost Containment System) from years 2008–2016. We summarized patient data using descriptive statistics and explored relationships between demographic variables and HPV vaccine administration information using bivariate logistic regression. Results of this analysis showed that females were more likely to complete the series as compared to males, and the age group that had the greatest odd of vaccine completion were 13–17-year-olds, the catch-up vaccine population. White Medicaid beneficiaries were most likely to adhere to HPV vaccine guidelines, followed by Hispanic beneficiaries. Patients receiving care in urban settings were more likely to complete the HPV vaccine series than people receiving care in rural areas of the state. Although statistically insignificant, people living with HIV were less likely to complete the 3-dose series. Future work should focus on ensuring that HPV vaccine age-eligible Medicaid, including people living with HIV, adhere to HPV vaccine guidelines. Expanding programs such as Vaccines for Children and scope of practice for dental professionals to offer the vaccine may provide additional options for Medicaid beneficiaries to vaccinate.

Using Surveillance Data to Respond to an Outbreak of Congenital Syphilis in Arizona Through Third-Trimester Screening Policies, 2017-2018.

The number of congenital syphilis (CS) cases in Arizona quadrupled from an average of 14 cases annually before 2017 to 61 cases in 2018, and a statewide outbreak was declared. The Arizona Department of Health Services (ADHS) analyzed statewide surveillance data to identify missed opportunities for prevention and collaborated with the Arizona Health Care Cost Containment System (AHCCCS) to inform response activities. ADHS developed a metric to identify missed opportunities for CS prevention during pregnancy by using medical records, vital records, and case investigation notes for all mothers of infants born with CS from January 1, 2017, through June 30, 2018. AHCCCS conducted a cost-effectiveness analysis to calculate the effect of increasing perinatal syphilis screening. Arizona had 57 cases of CS during the study period, of which 17 (29.8%) could have been prevented through third-trimester screening for women who were in prenatal care but screened late (n = 9), were infected after their first prenatal visit screen (n = 7), or were reinfected after an initial reactive syphilis test and appropriate treatment and not rescreened (n = 1). The estimated net cost of combining the additional primary (screening) and secondary (treatment) costs of a third-trimester screen for all pregnant AHCCCS members and the estimated total per-year savings of all newborn hospitalizations was $527. Third-trimester syphilis screening could prevent CS in regions where syphilis transmission is high. Partnering with health insurance agencies to evaluate the cost effectiveness of screening recommendations may improve the accuracy of the estimate of the potential cost savings by using insurance agency-specific data for the population at risk for CS.

Epidemiology of Pediatric Traumatic Brain Injury and Hypothalamic-Pituitary Disorders in Arizona.

Traumatic brain injury (TBI) in children can result in long-lasting social, cognitive, and neurological impairments. In adults, TBI can lead to endocrinopathies (endocrine system disorders), but this is infrequently reported in children. Untreated endocrinopathies can elevate risks of subsequent health issues, such that early detection in pediatric TBI survivors can initiate clinical interventions. To understand the risk of endocrinopathies following pediatric TBI, we identified patients who had experienced a TBI and subsequently developed a new-onset hypothalamic regulated endocrinopathy (n = 498). We hypothesized that pediatric patients who were diagnosed with a TBI were at higher risk of being diagnosed with a central endocrinopathy than those without a prior diagnosis of TBI. In our epidemiological assessment, we identified pediatric patients enrolled in the Arizona Health Care Cost Containment System (AHCCCS) from 2008 to 2014 who were diagnosed with one of 330 TBI International Classification of Diseases (ICD)-9 codes and subsequently diagnosed with one of 14 central endocrinopathy ICD-9 codes. Additionally, the ICD-9 code data from over 600,000 Arizona pediatric patients afforded an estimate of the incidence, prevalence, relative risk, odds ratio, and number needed to harm, regarding the development of a central endocrinopathy after sustaining a TBI in Arizona Medicaid pediatric patients. Children with a TBI diagnosis had 3.22 times the risk of a subsequent central endocrine diagnosis compared with the general population (±0.28). Pediatric AHCCCS patients with a central endocrine diagnosis had 3.2-fold higher odds of a history of a TBI diagnosis than those without an endocrine diagnosis (±0.29). Furthermore, the number of patients with a TBI diagnosis for one patient to receive a diagnosis of a central endocrine diagnosis was 151.2 (±6.12). Female subjects were more likely to present with a central endocrine diagnosis after a TBI diagnosis compared to male subjects (64.1 vs. 35.9%). These results are the first state-wide epidemiological study conducted to determine the risk of developing a hypothalamic-pituitary disorder after a TBI in the pediatric population. Our results contribute to a body of knowledge demonstrating a TBI etiology for idiopathic endocrine disorders, and thus advise physicians with regard to TBI follow-up care that includes preventive screening for endocrine disorders.

Temporal association of implementation of the Arizona Health Care Cost Containment System (AHCCCS) with changes in dental-related emergency department visits in Maricopa County from 2006 to 2012.

To evaluate changes in emergency department (ED) dental-related visits in Maricopa County before and after the elimination of dental benefits for adult Medicaid-insured patients as of October 2010. Hospital visits extracted from a hospital discharge dataset were used to calculate a yearly rate ratio of dental-related versus non-dental-related ED visits (as a comparison group) for adults, children, and payer types. Changes in ED visits over time were evaluated from 2006 to 2012. Overall, 1.3 percent of all ED visits (8,030,767) were for dental-related purposes. Medicaid-insured patients accounted for 41.9 percent and 44.3 percent of all dental-related ED visits in 2006 and 2012, respectively. The rate ratio for the percentage of dental-related versus non-dental-related ED visits in each age category and payer type showed little fluctuation over time indicating no evidence of change in the dental-related ED visits as a proportion of the overall number of visits due to the cuts in the dental benefits for adult Medicaid-insured patients. We found no evidence that cuts in dental benefits for adult Medicaid-insured patients resulted in increased dental-related ED visits in Maricopa County during the study period. Rather, we found evidence of a shift in payer type after the 2010 policy change where dental-related ED visits by self-paid patients increased as dental-related ED visits by Medicaid-insured patients decreased. Such payer shifts will result in high uncompensated care burdens for providers and, ultimately, governmental payers.

Are low income patients receiving the benefits of electronic health records? A statewide survey

There are concerns that physicians serving low-income, Medicaid patients, in the United States are less likely to adopt electronic health records and, if so, that Medicaid patients will be denied the benefits from electronic health record use. This study seeks to determine whether physicians treating Medicaid patients were less likely to have adopted electronic health records. Physician surveys completed during physicians' license renewal process in Arizona were merged with the physician licensing data and Medicaid administrative claims data. Survey responses were received from 50.7 percent (6,780 out of 13,380) of all physicians practicing in Arizona. Physician survey responses were used to identify whether the physician used electronic health records and the degree to which the physician exchanged electronic health records with other health-care providers. Medicaid claims data were used to identify which physicians provided health care to Medicaid beneficiaries. The primary outcome of interest was whether Medicaid providers were more or less likely to have adopted electronic health records. Logistic regression analysis was used to estimate average marginal effects. In multivariate analysis, physicians with 20 or more Medicaid patients during the survey cycle were 4.1 percent more likely to use an electronic health record and 5.2 percent more likely to be able to transmit electronic health records to at least one health-care provider outside of their practice. These effects increase in magnitude when the analysis is restricted to solo practice physicians This is the first study to find a pro-Medicaid gap in electronic health record adoption suggesting that the low income patients served by Arizona's Health Care Cost Containment System are not at a disadvantage with regard to electronic health record access and that Arizona's model of promoting electronic health record adoption merits further study.

Predictive risk modelling for forecasting high-cost patients: a real-world application using Medicaid data

Approximately two-thirds of healthcare costs are accounted for by 10% of the patients. Identifying such high-cost patients early can help improve their health and reduce costs. Data from the Arizona Health Care Cost Containment System provides a unique opportunity to exploit state-of-the-art data analysis algorithms to mine data and provide actionable findings that can aid cost containment. A novel data mining approach is proposed for this challenging healthcare problem of predicting patients who are likely to be high-risk in the future. This study indicates that the proposed approach is highly effective and can benefit further research on cost containment. Reference to this paper should be made as follows: Moturu, S.T., Johnson, W.G. and Liu, H. (2010) 'Predictive risk modelling for forecasting high-cost patients: a real-world application using Medicaid data', Int. J. Biomedical Engineering and Technology, Vol. 3, Nos. 1/2, pp.114-132.

Managed care and health care reform: everything old is new again.

A 1991 New York Times article reported that the “pioneering” state of Arizona, a “late starter in Medicaid,” had provided a health system model for the nation in the Arizona Health Care Cost Containment System (AHCCCS). At that time, AHCCCS was the only Medicaid program in the United States in which nearly all beneficiaries were enrolled in managed care organizations (MCOs) that were reimbursed on a prepaid capitated basis. Because of a physician participation rate exceeding 50%, remarkably high for a Medicaid program, AHCCCS had brought about truly mainstream managed care for the low-income members that it served, the article reported: “In much of the country, [Medicaid beneficiaries] would be left to seek treatment in shoddy ‘Medicaid mills’ or, at great public expense, in overcrowded emergency rooms. ... In Arizona, things are different.”1 Glowing press coverage of the program continued. In 1995, a Time Magazine article observed that AHCCCS was being “hailed as a model of managed care” because of the program’s emphasis on primary and preventive care, prohibitions against “cherry picking” healthy enrollees, and use of “intensely competitive” bidding to award contracts to MCOs.2 “The most remarkable thing,” Time reported, “is that the state government managed to come up with a program that makes just about everybody happy: the patients, the doctors, the bureaucrats and the number crunchers.”2 AHCCCS did not become the dominant national model for health care financing and delivery as predicted in the 1990s.3 But AHCCCS became the Phoenix in 2009, when it was once again described as “a proven, efficient model for national health reform,” this time by an Arizona legislator who is a proponent of current health care reform proposals.4 More importantly, this cycle of events was not limited only to AHCCCS; it is a pattern that has been repeated over the past several decades in the United States. Insights into public opinion about managed care, consumer choice, and preventive medicine are critical to understanding the prospects for the structure of health care financing and delivery in the United States in the coming years.

Awareness and implementation of tobacco dependence treatment guidelines in Arizona: Healthcare Systems Survey 2000

BackgroundThis paper presents findings from the Tobacco Control in Arizona Healthcare Systems Survey, conducted in 2000. The purpose of the survey was to assess the status of Arizona healthcare systems' awareness and implementation of tobacco cessation and prevention measures.MethodsThe 20-item survey was developed by The University of Arizona HealthCare Partnership in collaboration with the Arizona Department of Health Services Bureau of Tobacco Education and Prevention. It was mailed to representatives of Arizona's 40 healthcare systems, including commercial and Medicare managed care organizations, "managed Medicaid" organizations, Veterans Affairs Health Care Systems, and Indian Health Service Medical Centers. Thirty-three healthcare systems (83%) completed the survey.ResultsThe majority of healthcare systems reported awareness of at least one tobacco cessation and prevention clinical practice guideline, but only one third reported full guideline implementation. While a majority covered some form of behavioral therapy, less than half reported covering tobacco treatment medications. "Managed Medicaid" organizations administered through the Arizona Health Care Cost Containment System were significantly less likely to offer coverage for behavioral therapy and less likely to cover pharmacotherapy than were their non-Medicaid counterparts in managed care, Veterans Affairs Health Care Systems and Indian Health Service Medical Centers.ConclusionArizona healthcare system coverage for tobacco cessation in the year 2000 was comparable to national survey findings of the same year. The findings that only 10% of "Managed Medicaid" organizations covered tobacco treatment medication and were significantly less likely to cover behavioral therapy were important given the nearly double smoking prevalence among Medicaid patients. Throughout the years of the program, the strategic plan of the Arizona Department of Health Services Bureau of Tobacco Education and Prevention has included the goal of identifying and eliminating tobacco related disparities for special populations, including low-income groups. Of importance, in 2008 the Arizona Health Care Cost Containment System was authorized to provide tobacco cessation pharmacotherapy as a covered benefit for its members.

Food Cravings, Ethnicity and Other Factors Related to Eating Out

Objective: Our objective was to study factors related to eating patterns, specifically whether certain food cravings were associated with frequency of meals eaten away from home.Methods: Data were collected from 277 patients from a family medicine residency office in Arizona. The survey questionnaire included information about the respondents’ demographics, socioeconomic status, food cravings, as well as, number of meals eaten away from home. The food craving inventory included foods in four categories identified by factor analysis: fast foods, carbohydrates, sweets and snacks. Data on food cravings were factor analyzed and scale scores were derived.Results: Being a Hispanic adult, working outside the home, and cravings for individual food items were related to eating more meals away from home. If the mother was working outside the home, the youngest child ate an average of two additional meals away from home each week. In general respondent’s cravings for some specific food items were also related to higher numbers of meals their child ate away from home. Cravings for both fast food and snacks were positively correlated with adult eating out. None of the respondents’ scale scores were related to child’s eating away from home. Adults with Arizona Health Care Cost Containment System insurance (AHCCCS—a form of Medicaid) and older adults were less likely to eat away from home compared to patients with other types of insurance.Conclusions: Socioeconomic status, ethnicity, and food cravings are related to adult and child patterns of eating meals away from home.

Heterogeneity of risk in a managed home health care population.

To examine the distribution of risk and the correlation between risks in a home care population with regard to several important adverse outcomes. Researchers and policy makers have long recognized the heterogeneity of home care populations. Most research in this area focuses on identifying predictors of adverse outcomes. The degree of the heterogeneity of risks is much more poorly understood. Yet understanding the degree of risk heterogeneity at the population level is important because it has implications for the extent to which the level of care should vary among recipients. Patients enrolled in the Arizona Health Care Cost Containment System (AHCCCS) program, between the December 1992 and April 1998. Estimating the risk for nursing home placement, hospitalization, death, and functional decline. Estimating discrete time hazard models. From these models the predicted risk for each outcome is estimated and the distribution and correlation of predicted risks is examined. Model fit is assessed through split sample techniques and by examining the ratio of predicted to actual outcomes for selected sub-groups. The estimates reveal a wide variation in predicted risk. The ratio of predicted risk at the 90th percentile relative to the 10th percentile ranges from 4.99 for nursing home admission to 6.65 for hospitalization. The distributions of predicted risks are all skewed, particularly the distributions for death and nursing home admission. Predicted nursing home risk is highly correlated with the predicted risk for death (rho = 0.71). The predicted risk for hospitalization is not strongly correlated with the predicted risk for either death or nursing home admission. The wide variation in risk among home care patients suggests that efficient allocation of resources would require variation in spending and targeting of services based on patient characteristics. Greater research regarding the effectiveness of home care for different sub-populations is called for.

Congential heart disease in the Medicaid population of Southern Arizona

Birth prevalence of congenital heart disease (CHD) in the general population is approximately 8/1,000 live births. 1 Mayberry J.C. Scott W.A. Goldberg S.J. Increased birth prevalence of cardiac defects in Yuma, Arizona. J Am Coll Cardiol. 1990; 16: 1696-1700 Abstract Full Text PDF PubMed Scopus (21) Google Scholar , 2 Fixler D.E. Pastor P. Sigman E. Eifler C.W. Ethnicity and socioeconomic status impact on the diagnosis of congenital heart disease. J Am Coll Cardiol. 1993; 21: 1722-1726 Abstract Full Text PDF PubMed Scopus (62) Google Scholar , 3 Mitchell S.C. Korones S.B. Berendes H.W. Congenital heart disease in 56,109 births. Circulation. 1971; 43: 323-332 Crossref PubMed Scopus (943) Google Scholar , 4 Goldberg S.J. Lebowitz M.D. Graver E.J. Hicks S. An association of human congenital cardiac malformations and drinking water contaminants. J Am Coll Cardiol. 1990; 16: 155-164 Abstract Full Text PDF PubMed Scopus (136) Google Scholar , 5 Ferencz C. Rubin J.D. McCarter R.J. Brenner J.I. Neill C.A. Perry L.W. Hepner S.I. Downing J.W. Congenital heart disease prevalence at live birth. Am J Epidemiol. 1985; 121: 31-36 Crossref PubMed Scopus (792) Google Scholar , 6 Ferencz C, Rubin JD, Loffredo CA, Magee CA. Epidemiology of congenital heart disease. The Baltimore-Washington Infant Study 1981–1989, vol. 4. Perspectives Ped Cardiol Future, Mount Kisco, NY: Futura. Google Scholar , 7 Richards M.R. Merritt K.K. Samuels M.H. Langmann A.G. Congenital malformations of the cardiovascular system in a series of 6,053 infants. Pediatrics. 1955; 15: 12-32 PubMed Google Scholar , 8 Kerrebign K.F. Incidence in infants and mortality from congenital malformations of the circulatory system. Acta Pediatr Scand. 1966; 55: 316-320 Crossref PubMed Scopus (16) Google Scholar , 9 Carlgren L.E. The incidence of congenital heart disease in children born in Gothenberg, 1944–1950. Br Heart J. 1959; 21: 40-50 Crossref PubMed Scopus (136) Google Scholar Approximately 4 million children are born each year in the United States, and of these, almost 1.3 million are born into poverty. 10 Allen HD, Taubert KA, Deckelman RJ, Driscoll D, Dunningham A, Gidding SS, Herndon P, Kavey RW, Mullins C, Snider AR, Strong WB, Washington R. Poverty and cardiac disease in children. AJDC 1991;145:550–552. Google Scholar Assuming the same rate of CHD among children in poverty as in the general population, we would expect that approximately 10,400 infants with CHD would be born into families in poverty each year. Our clinical observations in Southern Arizona suggested that the prevalence of CHD may be increased among our Medicaid patients. Previous studies have not shown this to be true. 2 Fixler D.E. Pastor P. Sigman E. Eifler C.W. Ethnicity and socioeconomic status impact on the diagnosis of congenital heart disease. J Am Coll Cardiol. 1993; 21: 1722-1726 Abstract Full Text PDF PubMed Scopus (62) Google Scholar , 11 Chung C.S. Myrianthopoulos N.C. Yoshizaki H. Racial and prenatal factors in major congenital malformations. Hum Genet. 1968; 20: 44-60 Google Scholar However, these data were collected in 1968 and from 1971 to 1984 and therefore may not apply today under different socioeconomic and health care circumstances. This study was thus designed to determine the risk of CHD in patients without chromosomal disorders whose mothers were on Medicaid at the time of their conception and/or birth compared with the CHD prevalence in patients whose mothers were not on Medicaid during either time period. It is important to indicate that Medicaid in Arizona is offered only to families or persons who fall at or below 30% of the federal poverty level. Therefore, this study will assess the occurrence of CHD in the most impoverished group of families receiving Medicaid health care in Arizona. ∗ In Arizona, the Medicaid program is named the Arizona Health Care Cost Containment System (AHCCCS). We will refer to the program as Medicaid for ease of recognition to most readers.

Medicaid reform and the American states: case studies on the politics of managed care

Preface Introduction by Mark R. Daniels The Alabama Medicaid Reform Plan by Rene P. McEldowney Arizona Health Care Cost Containment System by Michelle A. Saint-Germain Managed Health Care in California: The Economic and Political Issues and the Strategic Plan by Patricia H. Wilson The Diamond State Health Plan: Delaware's Experience with Medicaid Managed Care by Eric D. Jacobson and Amy B. Droskoski Medicaid in a Managed Care Environment: The Florida Experience by Khi V. Thai Medicaid Reform in Kansas: A Cautious Approach by Jocelyn M. Johnston, Raymond G. Davis, and Michael H. Fox Managed Care or Managed Politics? Medicaid Reforms in Maryland by Thomas R. Oliver and Karen Anderson Oliver Economic Constraints and Political Entrepreneurship: Medicaid and Managed Care in Michigan by Michael Harris and Rhonda S. Kinney Medicaid Managed Care in the Empire State by Kent Gardner and David Bond Ohiocare: The Waiver That Wasn't by James Boex, Laura C. Yancer, and Terry F. Buss Soonercare: Reforming Medicaid with Managed Care Oklahoma Style by William Parle and Ron Woosley Medicaid Reform in Oregon by Leonard H. Friedman and Brenda Goldstein Medicaid Reform in South Dakota by David L. Aronson Medicaid Reform in Tennessee by Mark R. Daniels Medicaid Reform in the Lone Star State: State of Texas Access Reform *Star* by Aaron Knight and Carol Waters Uncertain Prospects: West Virginia and Medicaid Reform by L. Christopher Plein Selected Bibliography Index

Physician participation in Medicaid managed care.

Medicaid programs throughout the United States are moving away from fee-for-service medicine and increasingly towards managed care models in attempts to control rising health care costs. This study examines the participation of physicians in Arizona's prepaid, managed care Medicaid program, the Arizona Health Care Cost Containment System (AHCCCS). In particular, it considers the reasons that physicians decide to participate in AHCCCs, and for participants, the possible impact of these reasons on whether they participate fully or on a limited basis. A mail survey was sent to 300 primary care physicians in Arizona, of which 171 completed surveys were returned. Results suggested that physicians tend to participate because of reimbursement, approval of the 'type' of medicine that managed care allows them to practice, and their belief in Medicaid-type programs. Physician attitudes toward the patients, while generally negative, do not keep them from participating in Medicaid. However, the type of patients in AHCCCS is related to physician satisfaction with the AHCCCS health plans, as is reimbursement. The study indicates differences in the reasons for participation between Arizona's physicians and those in fee-for-service Medicaid programs of other states.

Use of Perinatal and Infant Health Services by Mexican-American Medicaid Enrollees

Objectives. —Lack of health insurance and a regular source of medical care are barriers affecting use of health services by Mexican Americans. We studied perinatal and infant health service use by Mexican-American women and non-Hispanic white women and their infants enrolled in Arizona's Medicaid program and explored characteristics associated with use of health services. Design. —A descriptive comparative study that used data collected from office records, birth certificates, and household interviews. Setting. —Participants resided in the state's most populous county and were enrolled in the Arizona Health Care Cost Containment System, a health maintenance organization—oriented Medicaid demonstration project. Subjects. —Random sample of 308 Mexican-American mother-infant dyads and 312 non-Hispanic white mother-infant dyads. The women were enrolled before the sixth month of pregnancy and for 60 days post partum; their infants were continuously enrolled throughout their first year. Outcome Measures. —Timing and number of prenatal visits and a modified Kessner Index, postpartum visits, number and purpose of office visits during the infants' first year, and immunizations received. Results. —Mexican Americans averaged fewer prenatal visits than non-Hispanic whites (8.6 vs 10.2 visits) and were less likely to have care (41.1% vs 52.8%). Both groups of mothers are well below the 68% of women nationally who receive adequate prenatal care. Controlling for important socioeconomic status and cultural characteristics, ethnicity had a strong independent effect on the number of prenatal visits and adequacy of prenatal care. Mexican-American infants made fewer visits (8.2 vs 9.8) and completed fewer age-appropriate immunizations than non-Hispanic whites. Conclusions. —Health insurance and a regular source of care are insufficient conditions for ensuring adequate use of maternal and child health services by Mexican-American Medicaid enrollees. Factors associated with their less frequent use of these preventive health services include higher numbers of children, transportation problems, and less assistance from their support system. ( JAMA . 1994;272:297-304)

The impact of Medicaid managed care on the public health system in Arizona: case study.

This article examines the impact of a statewide Medicaid managed care program, the Arizona Health Care Cost Containment System (AHCCCS), on the local public health system in Arizona. Based on interviews with current and former state and local public health officials, the authors describe public health concerns with capitated health care delivery systems that rely on gatekeeper systems to control utilization. The authors identified difficulties in gauging the extent of the problem, since neither public health nor managed care systems collect data on use of public health clinics by AHCCCS beneficiaries. Relationships between public health officials and managed care officials are characterized by tensions resulting from differing outlooks about access, eligibility, and the need for preventive health services. The report concludes with recommendations developed by the Association of State and Territorial Health Officials (ASTHO) Primary Care Committee on roles for state health agencies in ensuring development of appropriate managed care delivery systems for vulnerable populations.

Use of Perinatal and Infant Health Services by Mexican-American Medicaid Enrollees

Lack of health insurance and a regular source of medical care are barriers affecting use of health services by Mexican Americans. We studied perinatal and infant health service use by Mexican-American women and non-Hispanic white women and their infants enrolled in Arizona's Medicaid program and explored characteristics associated with use of health services. A descriptive comparative study that used data collected from office records, birth certificates, and household interviews. Participants resided in the state's most populous county and were enrolled in the Arizona Health Care Cost Containment System, a health maintenance organization-oriented Medicaid demonstration project. Random sample of 308 Mexican-American mother-infant dyads and 312 non-Hispanic white mother-infant dyads. The women were enrolled before the sixth month of pregnancy and for 60 days post partum; their infants were continuously enrolled throughout their first year. Timing and number of prenatal visits and a modified Kessner Index, postpartum visits, number and purpose of office visits during the infants' first year, and immunizations received. Mexican Americans averaged fewer prenatal visits than non-Hispanic whites (8.6 vs 10.2 visits) and were less likely to have "adequate" care (41.1% vs 52.8%). Both groups of mothers are well below the 68% of women nationally who receive adequate prenatal care. Controlling for important socioeconomic status and cultural characteristics, ethnicity had a strong independent effect on the number of prenatal visits and adequacy of prenatal care. Mexican-American infants made fewer visits (8.2 vs 9.8) and completed fewer age-appropriate immunizations than non-Hispanic whites. Health insurance and a regular source of care are insufficient conditions for ensuring adequate use of maternal and child health services by Mexican-American Medicaid enrollees. Factors associated with their less frequent use of these preventive health services include higher numbers of children, transportation problems, and less assistance from their support system.