Access and Use of Health Services by Chronically Mentally Ill Medicaid Beneficiaries
Moscovine, Ira, Lurie, Nicole, Christianson, Jon, Finch, Michael, Popkin, Michael, Akhtar, Muhammad R., Health Care Financing Review
In 1986, the Health Care Financing Administration (HCFA) authorized six States to demonstrate the efficacy of enrolling Medicaid beneficiaries in prepaid health plans, or health maintenance organizations (HMOs). Minnesota was one of those States, with Hennepin County (containing Minneapolis) serving as an urban site for the demonstration. Hennepin County was unique in that it was the only site in which Medicaid recipients were randomly assigned to prepaid versus FFS care. It was also the site enrolling the broadest cross-section of Medicaid recipients into prepaid plans, including those classified as disabled because of mental illness.
The purpose of this article is to compare the access to and utilization of physical and mental health services for chronically mentally ill individuals who were part of the Hennepin County demonstration. The first section reviews the relevant literature, in order to place the findings in context. The second section describes the operations of the Hennepin County program as they pertain to the research. A third section discusses the evaluation design and data sources, followed by a description of the access to and utilization of services by the prepaid and FFS groups at baseline. The subsequent sections present the differences between the two groups with respect to access and utilization during the year following enrollment in the demonstration. The article concludes with a discussion of the implications of the study and the limitations of the findings as they now stand.
Two quite different models have been proposed that would employ capitated financing for mentally ill public program beneficiaries (Christianson, 1989). Under one model, services would be provided by a "mental health HMO" consisting of community-based mental health providers who agreed to provide all necessary mental health care (and, under some variations, arrange for physical health services as well) for a capitated payment. This model was discussed by Sharfstein (1982) who saw it as a means to rationalize mental health care delivery through substituting community for inpatient care, and using a case management approach to coordinate services. Variants of this approach have been attempted in Utah, Arizona, and Pennsylvania.
A second model involves the mainstreaming of public program beneficiaries who are mentally ill into prepaid plans that would provide both physical and mental health care (Christianson, 1989). The Hennepin County demonstration provides one example of this model.
HMOs have traditionally drawn their enrollees from private employed groups. it is only recently that the enrollment of Medicare and Medicaid beneficiaries in HMOs has reached significant levels. By 1992, an estimated 3.6 million Medicaid recipients (almost 12 percent of the total) were in managed care plans in 36 States with an increasing number of States enrolling entire Medicaid populations (Medicine and Health, 1992). Medicaid beneficiaries are presumed to be less able to protect themselves against the potential for under-service that exists under capitated payments. Some policy analysts have expressed concern that Medicaid beneficiaries who have a chronic mental illness might fare poorly in prepaid plans (Schlesinger, 1986).
There is almost no published research concerning outcomes of any type that are associated with enrolling chronically mentally ill Medicaid beneficiaries in HMOs. A relatively small number of studies have addressed the use of mental health services by employed groups enrolled in HMOs. in one of the few studies that employed a design in which individuals were randomly assigned to a prepaid plan and the FFS system (thus minimizing the potential for selection bias), Manning and Wells (1986) found that HMO enrollees were more likely than individuals covered by FFS insurance to use outpatient mental health services, but had fewer visits to trained mental health specialists. …