Health Care Systems and HMOs

In this special presentation, the United Kingdom’s secretary of state for health, the Rt. Hon. Andy Burnham, M.P., will argue that now is the time for England and America to share much-needed perspective and knowledge and to bust a medical myth or two.

Bradford Gray traces HMOs movement from the periphery to the center of the American health care system and from depiction as policy solution to policy problem. The paper describes where HMOs came from, how they became important, and how they came to act in ways that generated the managed care backlash of the 1990s. He shows that the problems of the HMO movement came partly from compromises in the original HMO Act of 1973 as well as later policy decisions regarding sources of capital, the ERISA exemption from state regulation, and the Internal Revenue Service's hostility toward nonprofits. (History and Health Policy in the United States edited by Rosemary A. Stevens, Charles E. Rosenberg, and Lawton R. Burns, Rutgers University Press, 2006.)

This study explores how mandatory Medicaid managed care (MMC) programs affect access to care and use among full-year Medicaid beneficiaries, using data from the 1997 and 1999 National Survey of America’s Families. The authors compare Medicaid enrollees in FFS and MMC counties. To control for unobserved county differences, the authors estimate difference-in-difference models using a comparison group of privately insured individuals. The effects of MMC vary by type of program, with weaker effects for PCCM programs relative to programs that require mandatory HMO enrollment. The strongest finding is that HMO programs lower emergency room use by Medicaid adults. (Garrett, Bowen, and Zuckerman, Stephen. July 2005. "National Estimates of the Effects of Mandatory Medicaid Managed Care Programs on Health Care Access and Use, 1997-1999." (Medical Care 43(7):649-657.)

This paper examines the impact of mandatory HMO enrollment for Medicaid-covered pregnant women on prenatal care use, smoking, c-section use, and birth weight, using linked birth certificate and Medicaid enrollment for 10 Ohio counties. Women serve as their own controls, which helps to overcome the bias from unmeasured variables such as health beliefs and behavior. Changes in key outcomes between the first and second birth are compared between women who reside in mandatory HMO enrollment counties and those in voluntary enrollment counties. Authors found that the effects of HMO enrollment on prenatal care use and smoking were confined to Cuyahoga County, Ohio's largest county. In Cuyahoga, the implementation of mandatory enrollment was related to a significant deterioration in the timing of initiation of care, but an improvement in the number of prenatal visits. In that county also, women who smoked in their first pregnancy were less likely to smoke during the second pregnancy, compared with women in voluntary counties. Changes over time in outcomes, both positive and negative, were more pronounced for African-American women. Authors conclude that, with careful implementation and attention to women's individual differences, outcomes for pregnant women may improve with Medicaid managed care implementation. (Health Services Research 39(4), 2004.)

This case study examines Ohio's implementation of mandatory HMO enrollment for pregnant women in Medicaid from 1995 to 2000. Findings indicate that the two-step process of determining Medicaid eligibility and HMO enrollment may discourage early care initiation among women new to Medicaid at the time of their pregnancy. HMOs took extensive steps to identify and link pregnant women to services. State requirements for monitoring quality forced plans to invest in data systems, and allowed better refinement of capitation rates. Ohio's new Preferred Option program automatically assigning enrollees to a plan may encourage plan participation in the Medicaid market. (Sommers, Anna S., Howell, Embry M. October 2003. "The Implementation of Medicaid Managed Care for Pregnant Women in Ohio: A Case Study." Managed Care Interface, 16(10): 27-31,34.)