We used the following hierarchical criteria to aid in the selection process:
- Availability of Medicaid claims and enrollment data in the SMRF files
- Ability to identify foster care children in the SMRF files
- Identifiable foster care population of at least 10,000 children, to detect significant health conditions that are relatively rare events
- Degree to which children are enrolled in Medicaid managed care
- Variation in features of state foster care systems
As of August 1998, 34 states were participating in SMRF in 1995; 27 of these states were able to identify children who qualify for Medicaid because they are in some form of foster care or receive adoption assistance (Table II.1).(1)
Seven of the 27 states California, Pennsylvania,(2) Florida, New Jersey, Washington, Wisconsin, and Georgia(3) had foster care populations of more than 10,000 children, and Indiana had a population of nearly 10,000 children. Four additional states Missouri, Colorado, Kansas, and Minnesota each had populations between 6,000 and 8,000 children. The remaining states all had foster care populations of less than 5,000 children.
After we narrowed the list of states to the seven with at least 10,000 children in foster care, we considered two additional factors, namely the extent of Medicaid managed care enrollment and variations in state program characteristics. We now turn to a discussion of each factor.
Use of Medicaid Managed Care
There has been a trend in recent years toward the use of managed care for Medicaid-eligible children in general and foster care children in particular (Battistelli 1997). By 1996, 22 states had enrolled at least some foster care children into capitated (prepaid) Medicaid managed care, and 17 of these states required at least some of these children to enroll in managed care (NASHP 1997). The use of Medicaid managed care poses significant challenges for this study because the claims data for children in capitated managed care plans are missing from the SMRF files. And without claims data, we cannot answer the research questions posed in this study.
Of the seven states with at least 10,000 Medicaid foster care children, all but one had overall Medicaid managed care penetration rates of 20 percent or less in 1994:
|* Includes enrollment in capitated plans. Excludes primary care case management (PCCM) enrollment.
Sources: National Institute for Health Care Management 1995; U.S. Department of Health and Human Services 1995.
One caveat is that the managed care penetration rate was likely to vary across age groups and eligibility categories and children may have had above average rates of managed care enrollment. Our strategy, therefore, was to choose the three states with the largest foster care populations California, Pennsylvania, and Florida to ensure adequate sample sizes for the foster care analyses, while recognizing that the sample sizes in the other categories of eligibility would be more than adequate for our purposes.
California had by far the largest foster care population (nearly 100,000 in 1995), and, for that reason alone, was of great interest as a potential study state. Pennsylvania and Florida were next in size of foster care population, with 24,000 and 21,000 Medicaid children in foster care, respectively. We concluded that the relatively large size of the foster care population compensated for the level of managed care enrollment in these two states (20 percent in Pennsylvania, 16 percent in Florida). These large sample sizes have afforded us the opportunity to compare patterns of utilization and expenditures within the foster care population.
Variation in State Program Characteristics
We researched two key program characteristics to ensure that the three states varied on important factors. The first is whether the foster care programs are administered at the state or county level. The foster care programs in two of the states, California and Pennsylvania, are state supervised and county administered, while the program in Florida is state-administered (Child Welfare League of America 1999). Thus, we might expect to see more intrastate variation in utilization patterns in the two county-administered programs.
The second characteristic is the presence of a health passport program.(4) All three states have implemented health passport programs statewide, with Florida's and Pennsylvania's passports dating back to 1989 and 1990, respectively. California's health passport program was implemented statewide in February 1995. None of the states use an electronic (computerized) passport record (Lutz and Horvath 1997).