IMPACT OF A MEDICAID PRIMARY-CARE PROVIDER AND PREVENTIVE CARE ON PEDIATRIC HOSPITALIZATION

Objective. This study evaluates the impact that a Medicaid managed car e program had on avoidable hospitalization, a form of health care misu se that we hypothesize can be reduced by improved access to and qualit y of primary care in the context of a managed care program. Ambulatory care sensitive (ACS) hospitalizations, a previously defined categoriz ation of hospitalization, as well as all pediatric hospitalizations we re also studied. Intervention. The Maryland Access to Care (MAC) was a fee-for-service, gatekeeper, Medicaid managed care program with assig ned primary medical providers and required Early Periodic Screening, D iagnosis, and Treatment (EPSDT) examinations. Medicaid managed care el ements include: 1) assignment to primary medical provider (PMP) either by voluntary choice or mandatory enrollment of eligible Aid to Famili es With Dependent Children (AFDC), Medical Assistance (medical needy), and Supplemental Security Income; 2) a medical home accessible 24 hou rs a day, 7 days a week; 2) PMP must authorize emergency department (E D), inpatient, and specialty care but there were no disincentives to P MP for referral; 3) fee-for-services reimbursement (with a physician r ate increase) for primary care, authorized specialist care, and hospit alization; and 4) an on-line eligibility verification system was avail able to all medical providers. Pre-enrollment as well as publicity all owed MAC to be phased in rapidly, resulting in 70% to 80% enrollment b y the end of the first program year. Design. The design of this study is that of a pre-and postevaluation of the MAC program using Medicaid claims analysis of data 3 years pre-MAC and 2 years post-MAC. In multi variate analyses, this study also compares MAC-enrolled children to no n-MAC-enrolled children (before and after MAC began) to estimate the i mpact of MAC enrollment while controlling for potential confounders. S etting. State of Maryland from 1989 to 1993. Patients. MAC-eligible ch ildren less than or equal to 18 years of age. Outcome Measures. Claims data were used to define avoidable hospitalization (based on ambulato ry care received before hospitalization), to define ACS hospitalizatio ns (based on the International Classification of Diseases-Clinical Mod ification, Ninth Revision [ICD-9-CM] codes), and to summarize use of a mbulatory and inpatient care.