OBJECTIVESPersons with schizophrenia are heavy and persistent users of Medicaid services. Interruptions in their Medicaid coverage may have serious consequences for the mental health of these individuals and their subsequent use of mental health services. This study sought to determine the impact of interruptions in Medicaid coverage on the use of Medicaid-reimbursed inpatient psychiatric services over a four-year period.METHODSInpatient Medicaid claims and eligibility files for 1,830 Medicaid beneficiaries with schizophrenia in Utah from December 1990 to December 1994 were used to identify differences in hospital admissions and total number of days in a hospital associated with interrupted Medicaid coverage. Of the 1,830 Medicaid beneficiaries identified, 1,463 experienced continuous Medicaid eligibility, and 367 had interruptions in their eligibility.RESULTSInterruptions in Medicaid coverage were associated with an average of.63 more psychiatric hospitalizations per beneficiary over the four-year period, representing an 86 percent higher hospital admission rate. This increase appeared to be largely due to a subset of persons who have much higher hospitalization rates after an interruption in Medicaid coverage. Interruptions in Medicaid coverage were associated with a mean of 8.3 more days of psychiatric hospitalization over the four-year period, representing 61 percent more hospital days.CONCLUSIONSMedicaid beneficiaries who experience interruptions in coverage have, on average, a significantly greater use of inpatient psychiatric services while participating in Medicaid than beneficiaries with continuous Medicaid coverage. These findings suggest potential benefits of maintaining continuous Medicaid eligibility for beneficiaries with a severe mental illness.

OBJECTIVE:Changes in the process of psychiatric care received by Medicaid beneficiaries with schizophrenia were examined after the introduction of capitated payments for enrollees of some community mental health centers (CMHCs) under the Utah Prepaid Mental Health Plan.METHODS:Data from the medical records of 200 patients receiving care in CMHCs participating in the prepaid plan were compared with data from the records of 200 patients in nonparticipating CMHCs, which remained in a fee-for-service reimbursement arrangement. Using the Process of Care Review Form, trained abstracters gathered data characterizing general patient management, social support, medication management, and medical management before implementation of the plan in 1990 and for three follow-up years. Using regression techniques, differences in the adjusted changes between third-year follow-up and baseline were examined by treatment site.RESULTS:By year 3 at the CMHCs participating in the plan, psychotherapy visits decreased, the probability of a patient's terminating treatment or being lost to follow-up increased, the probability of having a case manager increased, the probability of a crisis visit decreased (but still exceeded that at the nonplan sites), and the probability of treatment for a month or longer with a suboptimal dosage of antipsychotic medication increased. Only modest changes in the process of care were observed at the nonplan CMHCs.CONCLUSIONS:Change in the process of psychiatric care was more evident at the sites participating in the plan, where traditional therapeutic encounters were de-emphasized in response to capitation. The array of changes raises questions about the vigor of care provided to a highly vulnerable group of patients.

The proportion of the United States population without health insurance continues to grow. How will this affect the health of the nation? Prior research suggests that the uninsured are at risk for poor health outcomes. They use fewer medical services and have higher mortality rates than do insured persons. The episodic nature of uninsurance and its prevalence among disadvantaged groups makes it difficult to ascertain the health effects of uninsurance. The goal of this review is to assist researchers and policy makers in choosing methodologies to assess the effects of uninsurance. It provides a compendium of methods that have been used to examine the health consequences of uninsurance, the populations in which these methods have been used, and the strengths and weaknesses of different approaches. The review highlights the need for more longitudinal studies that focus on community-based samples of the uninsured.

Capitation reduced Medicaid costs but had limited effects on most measures of process and outcome. Clients under capitation with the poorest mental health at baseline performed more poorly over time on some measures.

This study assesses whether Minnesota's high-risk insurance pool is successful at insuring those denied health insurance coverage because of preexisting medical conditions. Eight hundred and twenty-nine individuals who had been denied health insurance coverage were interviewed. At the time of the survey, 80 percent of the sample had obtained coverage, 22 percent through the state's high-risk insurance pool. Seventeen percent remained uninsured. Logistic regression was used to identify correlates of remaining uninsured. Younger age and less education were significantly associated with being uninsured versus enrolling in the high-risk pool. Younger age, less education, unemployment, being non-White, and having worse mental health were significantly associated with being uninsured versus having non-high-risk pool insurance. Despite the presence of a large high-risk pool in Minnesota, specific groups are identified as being at risk for remaining uninsured after being denied health insurance.

As part of an evaluation of the Utah Prepaid Mental Health Plan, the Process of Care Review Form was developed to assess the quality of the process of psychiatric care provided by Utah's community mental health centers (CMHCs) to clients with schizophrenia. This article briefly reviews issues in. the measurement of quality of care and describes the development and implementation of the form. The 67-item form was designed for use by a trained abstracter to gather data from CMHC medical records in six areas: general management of the patient, medication management, medical management, social support, psychiatric hospitalization, and psychiatric assessment. A 59-item version of the form that omits the section on psychiatric assessment has been used in three waves of data collection to document data spanning five years (1990-1994) in the evaluation of the process of psychiatric care in the Utah plan. It is currently being used longitudinally to examine differences between Utah CMHCs receiving capitated payments and those paid on a fee-for-service basis by Medicaid.

OBJECTIVE:To describe Minnesota's health care system reform efforts and their implications for other state and national reform initiatives, document the rate of uninsurance in 1990 and 1995 with special attention to childrens' access to health insurance, and examine the effectiveness of MinnesotaCare, a voluntary state-subsidized health care plan, in serving its target population.DESIGN:Three cross-sectional telephone surveys: 2-stage random samples of Minnesotans of all ages in 1990 and 1995 and a stratified random sample of MinnesotaCare enrollees in 1994.PARTICIPANTS:For the 2 statewide surveys, 10310 respondents participated in 1990 and 11519 in 1995; more detailed information was collected on approximately 1600 respondents in each survey. Eight hundred MinnesotaCare enrollees participated in the third survey conducted in 1994.MAIN OUTCOME MEASURE:Changes in rates of uninsurance.RESULTS:While the rate of uninsurance increased at the national level, the point-in-time Minnesota rate remained stable and low at 6% between 1990 and 1995. The proportion of children uninsured for 12 months or more decreased from 5.2% in 1990 to 3.1% in 1995, while the proportion of uninsured single adults remained stable at approximately 11%. There was no evidence that MinnesotaCare enrollees are gaming the program, or that the program has resulted in significant erosion from the private market.CONCLUSIONS:MinnesotaCare has enabled the state to maintain a low rate of uninsurance and has reduced this rate among its primary target: children. The program has been less effective in enrolling single adults, although it may be too early to witness the effects of recent expansions targeting this group. Minnesota's experience suggests that other state and national reform efforts aimed at reducing uninsurance, particularly among children, are likely to be successful.

Hospitalization rates for chronic medical conditions vary across small areas and are associated inversely with community income. The authors studied whether variation in hospitalization rates can be attributed to differences in physician practice style. Using census and hospital discharge data, hospitalization rates were calculated for asthma, congestive heart failure, and diabetes in 40 medical service areas in California. The authors surveyed a random sample of 1,530 emergency physicians, general internists, and family and general practitioners in these areas, and measured clinical admission threshold by asking physicians whether they would hospitalize patients presented in 15 vignettes of graded severity. The authors measured social admission predisposition by asking how physicians' admission decisions would be influenced by social characteristics that increase patients' vulnerability to illness, including homelessness and drug use; 1,090 physicians responded (71%). There was significant variation across areas in both the clinical (P < 0.0001) and social (P < 0.001) admission scores. Variation in hospitalization rates correlated with physicians' clinical (r =.34, P = 0.03) and social (r =.36, P = 0.02) admission scores. However, in a multiple linear regression analysis that included community sociodemographic factors, physician practice style was not associated significantly with hospitalization rates. Physician practice style varies across areas, but does not explain variation in admission rates for chronic medical conditions after adjusting for community sociodemographic factors. Using methods such as practice guidelines or utilization review to re-set physicians' threshold for admission may not be effective in reducing hospitalizations for chronic medical conditions.

BACKGROUND:A 1995 article showed that the discipline of the person who determines what constitutes a serious quality of care issue is significantly associated with the type of issues identified as serious. Moreover, what is a serious issue for one organization or provider may be a minor issue for another.METHODS:Six hundred hospital administrators, physicians, nurses, and quality managers in 72 hospitals rated the seriousness of issues they had identified in their own hospitals. A panel of 90 external hospital administrators, physicians, and quality managers rated a condensed set of the same issues.RESULTS:Across all the hospitals, internal scores were significantly lower (less serious) than external scores. Internal respondents consistently rated issues identified in their hospital lower than did external raters. The mean internal rating was .60 times the score for the anchor issue ("late lab or x-ray results," assigned a score of 300), while the mean external rating was 1.73 times the anchor score.DISCUSSION:Convergence of internal and external perceptions of the seriousness of quality of care issues in hospitals cannot be assumed. This raises questions about the effects of applying external judgments on seriousness of quality of care issues, such as those used in report cards or other external reports on hospital quality of care.CONCLUSION:There is greater conformity of viewpoint when respondents are asked to adopt an industrywide perspective rather than an internal one. External raters are more likely to consider problems serious than are internal raters, possibly because they do not have local knowledge of mitigating circumstances.

Although generalist physicians appear to be more likely than specialists to provide care for poor adult patients, they may still perceive financial and nonfinancial barriers to caring for these patients. We studied generalist physicians' attitudes toward caring for poor patients using focus groups and used the results to design a survey that tested the generalizability of the focus group findings. The focus groups included a total of 24 physicians in 4 California communities; the survey was administered to a random sample of 177 California general internists, family physicians, and general practitioners. The response rate was 70%. Of respondents, 77% accepted new patients with private insurance; 31% accepted new Medicaid patients, and 43% accepted new uninsured patients. Nonwhite physicians were more likely to care for uninsured and Medicaid patients than were white physicians. In addition to reimbursement, nonfinancial factors played an important role in physicians' decisions not to care for Medicaid or uninsured patients. The perception of an increased risk of being sued was cited by 57% of physicians as important in the decision not to care for Medicaid patients and by 49% for uninsured patients. Patient characteristics such as psychosocial problems, being ungrateful for care, and noncompliance were also important. Poor reimbursement was cited by 88% of physicians as an important reason not to care for Medicaid patients and by 77% for uninsured patients. Policy changes such as universal health insurance coverage and increasing the supply of generalist physicians may not adequately improve access to care unless accompanied by changes that address generalist physicians' financial and nonfinancial concerns about providing care for poor patients.

Background: Relatively ignored in the literature on quality improvement (QI) in health care is the question of who defines the issues in quality of care and decides how those issues will be addresses.Methods: In late 1992, 669 hospital administrators, quality assurance (QA) coordinators, physicians, and nurses in 72 hospitals in six states were surveyed by telephone. Respondents were asked to identify the most serious issue related to quality of care in their hospital.Results: Of all the respondents, hospital administrators were most likely to identify quality issues related to organization/institutional issues. QA coordinators, mos of whom had nursing backgrounds, were most likely to identify organizational and patient care issues. Physician responses were distributed approximately evenly across issues related to physicians, to the organization, and to patient care. Nurses were most likely, to Identify issues related to patient care and patient satisfaction.Discussion: The findings validate the viewpoint that ''quality is in the eye of the beholder'' and that the eye is conditioned by the discipline in which hospital staff have been trained and socialized. As total quality management and continuous quality improvement approaches are implemented, and participants from many disciplines are involved in QI, a wide range of issues that have both a direct and indirect effect on patient care are likely to be addressed.Conclusion: The findings of this study suggest that surveys kat Specifically target certain disciplinary groups may yield important information about issues related to quality of care.

PURPOSE: To measure the quality of care for hypertensive and diabetic elderly Medicaid beneficiari es enrolled in managed care versus fee-for-service (FFS) plans.METHODS: Individuals enrolled in the Medicaid Demonstration project in Hennepin County, Minnesota, were randomly assigned to receive their care either in one of seven managed care health plans in which the Medicaid payment for their cave was capitated or in an FFS plan. Two hundred ninety-one hypertensives and 96 diabetics who were aged 65 years or over at the beginning of the evaluation were interviewed at baseline and followed for 1 year. Drug and nondrug therapy, monitoring, monthly medication costs, and access to medications were assessed.RESULTS: The prepaid and FFS did not differ in drug or nondrug therapy, with the exception that slightly more FFS enrollees were on human insulin after 1 year. Mean monthly medication costs and access to medications were similar for both groups.CONCLUSIONS: In this randomized trial, we were unable to detect differences in the process of care for hypertensive and diabetic Medicaid enrollees.

Purpose: To determine the effect on health and functional status outcomes of enrollment of noninstitutionalized elderly Medicaid recipients in prepaid plans compared with traditional fee-for-service Medicaid.Design: A randomized controlled trial. Beneficiaries were randomly assigned to prepaid care in one of seven capitated health plans compared with fee-for-service care. Only the Medicaid portion of their care was capitated. Patients were followed for 1 year.Setting: The Medicaid Demonstration Project in Hennepin County, Minnesota, which includes Minneapolis.Patients: 800 Medicaid beneficiaries who were 65 years or older at the beginning of the evaluation. Beneficiaries were interviewed at baseline (time 1) and 1 year later (time 2). Ninety-six percent of beneficiaries were available for follow-up interviews at time 2.Main Outcome Measures: General health status, physical functioning, mental health status, activities of daily living, instrumental activities of daily living, corrected visual acuity, and blood pressure and glycosylated hemoglobin measurements for hypertensive and diabetic persons, respectively.Results:There were no differences between prepaid and fee-for-service groups in the number of deaths (20 compared with 24, P > 0.2), the proportion in fair or poor health (56.5% compared with 59.7%, P > 0.2), physical functioning, activities of daily living, visual acuity, or blood pressure or diabetic control. Patients in the prepaid group reported a trend toward better general health rating scores (10.2 compared with 9.8, P = 0.06) and well-being scores (10.0 compared with 9.7, P = 0.07) than patients in the fee-for-service group. The difference in the likelihood of a patient in the prepaid group having a physician visit relative to the fee-for-service group was -16.5% (adjusted odds ratio, 0.46; 95% CI, 0.29 to 0.74) and for an inpatient visit was -11.2% (adjusted odds ratio, 0.55; CI, 0.32 to 0.94).Conclusions: There was no evidence of harmful effects of enrolling elderly Medicaid patients in prepaid plans, at least in the short run. Whether these findings also apply to settings in which health maintenance organizations are formed exclusively for Medicaid patients should be studied further.

Public health policies often have disproportionate effects on the poor and other vulnerable groups. Standard survey techniques are often difficult to apply to these vulnerable populations, and many data bases systematically omit such individuals. The purpose of this paper is to review our experience in collecting primary survey data from public hospital, mentally ill, HIV-infected, and non-English-speaking patients. Important issues in conducting research on these populations include proper selection of subjects and comparison groups and difficulties involved in recruitment and enrollment of subjects. Maintaining longitudinal data on these populations is difficult and often requires tracking, secondary contacts, home visits and community outreach, and the use of organizations, institutions, and networks. Investigators must also pay careful attention to ethical issues involved in conducting research on vulnerable populations.

This article has two objectives: to quantify the access and utilization of services received by chronically mentally ill Medicaid recipients, and to compare service utilization and access under prepayment and fee-for-service (FFS) payment. The study setting is Hennepin County (Minneapolis), Minnesota, where 35 percent of Medicaid recipients were randomly assigned to receive services from prepaid plans. An algorithm was developed to identify recipients with chronic mental illness, resulting in 739 study participants, split approximately evenly between prepayment and FFS Medicaid. Data were collected through in-person surveys at baseline, and after 1 year. We found slight improvements in the majority of access measures studied and no significant decreases in the use of inpatient or outpatient services for enrollees in prepaid health plans. The results support efforts to expand the use of prepaid health plans to meet the needs of non-institutionalized chronically mentally ill Medicaid beneficiaries.

Physician involvement in health care reform must go beyond the roles of organized medicine, and must occur on a local as well as national level. We outline a variety of ways for practicing physicians to become involved in health care reform and in redefining the fundamental purposes of the health care system. Our actions as physicians during the next few years can help shape reform. The choice now is to lead or be left behind.

Medical insurance claims are increasingly important as a source of data in monitoring health care utilization and patient outcomes and in identifying patient cohorts for research. In a study that attempted to verify that those with Medicaid claims for treatment of schizophrenia did indeed have the disorder, two psychiatrists evaluated clinical information obtained from primary mental health care providers in relation to DSM-III-R criteria. The psychiatrists classified 86.8 percent of 319 patients with claims for treatment of schizophrenia and 27.5 percent of 156 patients with claims for treatment of other psychiatric diagnoses as definitely or probably having schizophrenia. The authors conclude that most diagnoses of schizophrenia listed on Medicaid claims are accurate, but that a substantial number of individuals with schizophrenia may not be identified by claims data.