The findings presented here on states' implementation experiences with regard to access and service use are qualitative in nature; they are based on comments by case study respondents, focus group participants, and other sources. Ideally, assessments of service use and access to care should be conducted using quantitative data. In years 2 and 3 of this Congressionally mandated evaluation, such empirical data will be gathered and analyzed, and more definitive analyses of use and access will be presented.
Case study respondents described access to care under SCHIP as good, especially in urban areas. This was attributed largely to the widespread use of managed care, which reportedly has helped increase the number of participating providers, as well as children with a designated source of primary care. Also, it appears that most parents of Medicaid or SCHIP enrollees had a choice of managed care plans in which they could enroll their children, as reported by nearly all focus group participants with Medicaid or SCHIP experience. 55 Case study respondents in California and Missouri characterized access as better in managed care regions of the state (even those with long-standing provider shortages) than in fee-for-service regions. In some states, health plans have influenced state legislatures to approve rate increases for health plans and providers under Medicaid; this, in turn, has helped states and plans recruit more providers to SCHIP and Medicaid. Where Medicaid programs use managed care arrangements similar to those used by SCHIP--mostly, urban areas--access to care also was described as good for Medicaid enrollees.
Nevertheless, case study respondents did report challenges retaining plans and providers in the program. A few health plans quit both the SCHIP and Medicaid programs because payment rates were too low. In addition, physicians in some areas are dropping out of the programs--some because of low payment rates, and some because they do not like managed care. Provider resistance to managed care was cited as contributing to access problems in the more rural regions of Colorado, Missouri, and Texas. In several states, providers participating in Medicaid and SCHIP reportedly limit the number of people they serve, thus limiting access even in more densely populated urban regions. In the two states with behavioral health carve-outs (California and Missouri), problems sometimes surfaced with care coordination across the different systems.
Over time, Medicaid programs in many states have experienced problems with provider participation, either due to shortages of providers in certain regions (such as rural areas) or because of provider unwillingness to accept Medicaid patients into their practices (for example, due to perceived low rates of payment). This was a problem before states introduced managed care, and it has not been resolved by the use of managed care, with the exception of improved access to primary care. SCHIP programs have not been immune to this circumstance, and provider shortages and limited provider participation were cited as problems in rural areas of the study states (more so than in urban areas), especially in areas with a limited managed care infrastructure. In Louisiana, some rural providers have stopped participating in Medicaid and SCHIP because payments are low and because rates have fluctuated in recent years. Provider shortages and low participation rates were described as a problem in many rural regions of Colorado, Missouri, and Texas. Still, as mentioned earlier, California, Colorado, and Texas have used SCHIP to implement managed care models in rural areas that reportedly have improved access compared with the fee-for-service delivery systems used by Medicaid. Rural residents who participated in the consumer focus group study were well aware of the limited access to providers in rural areas, regardless of the type of children's insurance. Finally, the focus group study identified access to specialists as another problem. Getting referrals to specialists often requires lengthy waiting periods. Finding specialists and scheduling appointments is no easy task, either, according to most parents who participated in the focus group study. Often, the intervention of a child's pediatrician or other medical professionals can facilitate these matters.
Long-standing shortages of certain services (especially pediatric, psychiatric, and orthopedic ones) remain under both SCHIP and Medicaid. Informants in several study states noted concerns about access to dental care; shortages of dentists willing to treat Medicaid and SCHIP patients are a major concern in Louisiana and Missouri and in the rural areas of New York. Notably, though, case study respondents reported that managed care has improved access to dental care in California and in the urban areas of New York.
Most SCHIP plans interviewed in the case studies seemed satisfied with their capitation rates, although some noted that rates were too low when they first contracted with the program. Significant concerns about health plan payment rates did surface in Texas, however, where SCHIP payments (based on historic Medicaid costs) reportedly do not reflect the costs of serving children with special health care needs. Because other states have experienced lower or comparable service use rates under SCHIP than under Medicaid, capitation payments currently appear to be adequate to cover the costs of serving SCHIP enrollees. Several health plans in California and New York noted that they were "doing quite well," given enrollees' low service use.
In nearly every state, however, physicians complained about payment levels under both SCHIP and Medicaid. Providers in several states noted that the rates they receive from health plans (in managed care regions) and from the state (in fee-for-service regions) under SCHIP are "just as bad" as those of Medicaid. As one provider put it, basing SCHIP rates on those of Medicaid "was the wrong place to start." Although SCHIP has increased fees in some states, many providers reported that SCHIP and Medicaid payments still do not cover their overhead costs. Low payment levels have reportedly contributed to serious provider shortages in parts of Colorado, Louisiana, Missouri, and Texas. Indeed, some families who participated in the focus group study reported losing access to doctors who decided that accepting patients covered by certain health plans was not in their best interest.
Several case study respondents in Texas suggested that low payments, combined with high enrollment, have raised concerns about access to care. Case study respondents in other states expressed concerns that, without substantial increases in provider payments, access under SCHIP may erode. Some parents in the focus groups reported being treated poorly or at least differently from other families in the physician's office because of their children's insurance coverage.
Alongside access and payment, utilization rates of SCHIP enrollees emerged as a perplexing issue in some of the study states. There is conflicting evidence about whether service use differs between SCHIP enrollees and Medicaid enrollees. The two states with Medicaid expansion programs had examined utilization rates and found that these programs had largely comparable services for SCHIP and Medicaid enrollees--with the exception that Louisiana reported that SCHIP enrollees use fewer emergency room and inpatient hospital services than Medicaid enrollees. 56 Health plans in California and New York reported that SCHIP enrollees use fewer services than Medicaid enrollees. In Texas, however, plans reported that SCHIP enrollees are using more services than Medicaid enrollees; they attributed this both to pent-up demand and to the fact that SCHIP enrolls children with special health care needs (who use a lot of services) into managed care while such children are largely in fee-for-service arrangements under Medicaid.
55. Parents would have liked more information to help them select their children's plans and providers.
56. In Missouri, state officials also reported that service use in both programs has been greater than expected, especially the use of prescription drugs.