This component addressed the first research question, concerning effects on barriers to care, access, utilization, and satisfaction.
Most respondents reported little change after MMC, which did not significantly affect barriers to access. Uninsured respondents experienced major access barriers. A substantial proportion of Medicaid adults reported transportation as a barrier to care. Adult Medicaid and Medicare recipients enjoyed the most favorable access. Medicaid recipients were more likely to utilize an emergency department than other groups. No differences emerged by insurance category in satisfaction. In logistic regression analyses, uninsured adults and children showed greater barriers and less access than those in other insurance categories; no significant changes occurred after MMC.
Both Medicaid and uninsured patients reported cost as barriers to physician services and medications (despite Medicaid's coverage for both). Medicaid recipients remained more likely to report transportation barriers and emergency department visits. All groups except Medicare reported cost as a barrier to dental services. The uninsured were significantly less likely and Medicaid recipients were as likely as other respondents to report a regular PCP or to have visited a physician (). For children, respondents' answers showed the same overall patterns.
Barriers to Care, Access, Utilization, and Satisfaction for Low-Income Adults and Children, by Insurance Category, 18-Month Survey
In logistic regression analyses (), the uninsured remained significantly more likely to report persisting barriers to care, as well as reduced access and utilization. Medicaid children experienced favorable access and utilization. Comparing their situation with the time before MMC, uninsured adults reported the quality of their care as significantly worse, while adult Medicaid recipients and Hispanics (the latter with borderline statistical significance) reported a favorable change in quality ().
Relationship of Respondent Characteristics to Key Measures of Health Services, 18-Month Survey (Logistic Regression Model)
Perception of Change in Health Care Quality since MMC Began (Logistic Regression Model), 18-Month Survey
We examined changes in insurance over time. For adults with Medicaid coverage before MMC, 12.7 percent obtained private insurance by the time of the 18-month survey, while 25.4 percent became uninsured (). Among these same respondents, 38 percent obtained full- or part-time employment. Only 22.2 percent of the latter employed respondents gained private insurance, while 37.4 percent reported lack of insurance.
Comparison of Insurance Categories of Respondents before Implementation of MMC, and at the Time of the 18-Month Survey
In this survey, we performed more detailed analyses of respondents' current cost and transportation barriers.2
About 25 percent of respondents with Medicaid reported a cost barrier. Forty-nine percent of uninsured adults and 32 percent of uninsured children were unable to see a doctor during the prior year due to cost. About one-quarter of adults and 10 percent of children with Medicaid experienced cost barriers to seeing a physician or dentist and to obtaining a prescription. One-third of Medicaid adults and 15 percent of Medicaid children reported transportation barriers.
We examined current direct medical costs (out-of-pocket payments) and indirect medical costs (waiting and travel times). Most adults and children (57 and 72 percent) on Medicaid reported no out-of-pocket expenditures; by comparison, most adults (80 percent) and children (60 percent) with private insurance incurred such expenditures. On average, respondents with some type of insurance coverage including Medicaid experienced shorter wait times (31–35 minutes) than those without insurance (42–45 minutes). Despite perceived transportation barriers, adults and children with Medicaid reported the shortest travel time to a physician's office, about 20 minutes on average; uninsured adults reported the longest average travel time, 43 minutes.
The ethnographic work aimed to answer the second research question, about changes that took place in workload, processes of supervision, visions of service ethics, financial stress, and provider accountability at safety net institutions and in the communities that the institutions served.
Initial improvements occurred after MMC. According to safety net providers, advantages included the requirement of a PCP, emergency department case managers, and expansion of prenatal case management services. MCOs also sent reminders to parents to schedule well child exams. Disruptive transfers of hospitalized patients at the onset of MMC, experienced in some other states, did not occur. Most Medicaid patients expressed satisfaction with MMC, along the lines of: “without Salud!, we wouldn't be able to afford health care,” or, “I am diabetic and would be on the street if I didn't have Salud!”
Regarding workload, safety net personnel experienced the transition to MMC as stressful and chaotic. Rosters of patients and PCPs were unavailable. Telephone systems to inform patients and staff members about MMC often were busy or inoperable. Workload increased, due to increased administrative procedures and paperwork. MCOs' separate contracts with medical laboratories, BHOs, pharmacies, and transportation agencies led to confusion. Over time, providers' heavier workload persisted, although stress decreased with increased knowledge about MMC procedures.
Medicaid eligibility procedures grew more complex. About one-third of Medicaid applicants did not understand and/or did not complete the process. Clients who went to urban ISD offices to establish eligibility almost uniformly reported an inimical climate. With welfare reform and simultaneous staff cutbacks, ISD eligibility workers—who processed Medicaid applications—saw their caseloads increase from about 300 to as many as 700 clients. While arising from the larger policy environment rather than MMC, difficulties in eligibility determination contributed to access problems that uninsured people reported in the surveys.
Safety net institutions experienced heightened financial stress. Not one had prior experience with MMC, and only a few practice sites had received substantial managed care payments from MCOs for privately insured patients. The institutions encountered greater challenges in collecting Medicaid revenues and in using Medicaid to subsidize care for the uninsured. All CHCs received less income, due to delays and denials of payment. Providers lost capitation payments because MMC randomly assigned patients to new PCPs. Private practitioners experienced higher overhead costs due to MMC.
More adverse effects arose at rural sites than at urban sites. Outside urban areas, MCO penetration rates remained relatively low. Consequently, about 20 percent of rural MMC patients were assigned to PCPs more distant than nearby CHCs. Because of the financial problems, six private PCPs decided to retire, to sell their practices, to move, or to open other practice sites for insured patients.
As a financial strategy, providers affiliated with more than one MCO, and rural providers initiated a coalition to increase their leverage in bargaining. Another strategy involved opening new part-time clinics or offices, offering new services, and reducing clinic hours. The latter cutback contributed to reduced access for uninsured people, as revealed in the survey component.
Regarding service ethics, all safety net providers decided to buffer patients from obstacles imposed by MMC. CHCs and one emergency department stopped requesting preapproval for visits. A CHC for the homeless maintained services for MMC patients but did not seek reimbursement from the MCOs. Indian Health Service facilities accepted American Indian patients with Medicaid, while the MCOs received patients' capitation payments. Providers' advocacy efforts included making phone calls for patients, helping them fill out forms, offering transportation, and assisting them in the enrollment process. Another buffering strategy involved “creative coding” in billing procedures so that MMC covered services that patients needed.
A crisis occurred in mental health services. MCOs initiated strict cost control and accountability measures in collaboration with BHOs, which authorized lower levels of care for acutely ill patients. Safety net institutions sustained financial losses as BHOs delayed or withheld service authorizations and reimbursements. Increased workload contributed to clinicians' stress, burnout, and turnover. Sixty child and adolescent mental health programs closed; agencies that remained reduced services. A net decline of 17 child psychiatrists in the state occurred after MMC. Of 47 licensed child psychiatrists, nine did not accept MMC patients. Eighty-six percent of psychologists accepted Medicaid before MMC; 34 percent did so afterward. In 2000, the state government verified that MMC recipients received lower levels of care than their conditions warranted. The federal government withdrew New Mexico's waiver to include mental health services under MMC. Later, the Bush administration reversed this decision but required extensive changes in the system (Willging et al. 2003
; Willging 2005
Ethnography clarified processes that contributed to declining immunization coverage (as observed in the sentinel events component). Reduced funding for immunizations at public health clinics resulted from the state government's decision to require immunizations by MCOs. PCPs found, however, that immunizations increased costs and reduced efficiency. Some PCPs contracting under MMC informally referred children to CHCs and public health clinics for immunizations, even though these institutions had received reduced funding. Waiting times for immunizations increased.
Sentinel Events Component
This component aimed to answer the third research question, concerning trends in patterns of sentinel health events.
Birth and Death Certificates ()
MMC did not reverse a decreasing trend in the proportion of births with a high level of prenatal care, for both high- (Cochran–Armitage Z=−9.87, p<.001) and low-income areas (Z=−2.67, p=.010). The proportion of births with a low level of prenatal care continued to rise. A previous improving trend in the mean first month of prenatal care did not continue after MMC.
Changes in Key Sentinel Events. (A) Prenatal Care. (B) Immunization Coverage Level Estimates.
Hospital Inpatient Discharge Data
Regarding age-adjusted rates of hospital admissions for conditions sensitive to outpatient care, hospitalizations for asthma decreased significantly after MMC, while those for diabetes and angina pectoris did not. An overall trend in rate or length of hospitalization for these conditions did not emerge.
New Mexico Tumor Registry
During the first 3 years after MMC, the proportion of early stage diagnoses of breast cancer increased significantly; rates of cervical and lung cancer did not change.
National Immunization Survey ()
Immunization coverage levels decreased significantly after MMC implementation. In 1996, for the 4:3:1 vaccination series, New Mexico had achieved a coverage level of 80 percent and ranked 30th in the nation. By 2000, this level decreased to 72 percent, and New Mexico ranked 50th. The proportion of those vaccinated by public sources decreased significantly, while those by private providers, who received capitated payments for children covered by MMC, increased only marginally. (As noted above, ethnographic data suggested that reduced funding for public heath clinics and MCOs' referrals of children with MMC coverage to safety net providers for immunizations contributed to the decrease in coverage levels.)
Data on Reportable Diseases
The incidence of vaccine-preventable diseases fluctuated considerably before and after MMC, but no temporal pattern emerged.