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Access to care among disabled adults on Medicaid.

INTRODUCTION


Disabled individuals account for about one-sixth of the Medicaid Medicaid, national health
insurance program in the United States for low-income persons; established in 1965 with passage
of the Social Security Amendments and now run by the Centers for Medicare and Medicaid
Services. caseload case*load
n.
The number of cases handled in a given period, as by an attorney or by a clinic or social services
agency.


caseload
Noun but more than one-third of program expenditures (Kaiser
Commission on Medicaid and the Uninsured, 2001). Yet, little is known
about the health needs of disabled Medicaid beneficiaries and their
experiences under the Medicaid Program (Davis and O'Brien O'Bri*en , Edna Born 1932.

Irish writer whose works, including The Lonely Girl (1962) and Johnny I Hardly Knew You (1977),
explore the lives of women in modern-day Ireland.

Noun 1. 1906;
Hagglund et al., 1999; Meyer and Zeller, 1999; Hill and Wooldridge 2000;
Center for Health Care Strategies Inc., 2000; Shalala, 2000). State
administrative data provide little or no information on a
beneficiary's disabling dis*a*ble
tr.v. dis*a*bled, dis*a*bling, dis*a*bles
1. To deprive of capability or effectiveness, especially to impair the physical abilities of.

2. Law To render legally disqualified. condition, health care needs, and barriers
to care. Surveys of the disabled Medicaid population can provide more
indepth information on how the disabled are faring, however, such
surveys are rare. Until very recently, disabled Medicaid enrollees have
not been the central subject of a major survey.


With State's growing efforts to move disabled Medicaid
beneficiaries into managed care, interest in better understanding the
needs and experiences of those individuals has escalated. Accordingly,

CMS (1) See content management system and color management system.

(2) (Conversational Monitor System) Software that provides interactive communications for IBM's
VM operating system. recently funded a survey that focuses on the health and health care
experiences of disabled Medicaid beneficiaries in New York City New York City: see New York,
city.
New York City

City (pop., 2000: 8,008,278), southeastern New York, at the mouth of the Hudson River. The
largest city in the U.S. . New
York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts,
Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and
Ontario and the Canadian province of was selected for the study because of plans by the State to
implement mandatory capitated managed care for disabled Medicaid
beneficiaries in the future. Thus, in addition to providing important
new information about the experiences of disabled Medicaid
beneficiaries, the survey provides a baseline The horizontal line to which the bottoms of lowercase
characters (without descenders) are aligned. See typeface.

baseline - released version for a future evaluation of
the impacts of the shift to mandatory managed care on disabled
beneficiaries. In this article, we use that survey data to explore
differences in access to and use of care among key subgroups of the
disabled Medicaid population--adults with physical disabilities, mental
illness, and MR/DD MR/DD Mental Retardation and Other Developmental Disability . We address
three related questions:


* Does access and use under Medicaid vary for individuals with
physical disabilities, mental illness, and MR/DD?


* Can the differences in their health care experiences be explained
by their differing health care needs or, alternatively, are there
persistent differences in access to care under Medicaid for some groups
of disabled persons?


* Beyond disabling condition, what other characteristics of the
disabled population (e.g., health status, functional limitations)

predict greater difficulties with accessing care under the Medicaid
Program?


We focus on the health care experiences of non-aged adults who are
eligible for Medicaid by virtue of their receipt of Supplemental
Security Income Supplemental Security Income

A Social Security program established to help the blind, disabled, and poor. (SSI (1) See server-
side include and single-system image.

(2) (Small-Scale Integration) Less than 100 transistors on a chip. See MSI, LSI, VLSI and ULSI.

1. (electronics) SSI - small scale integration.
2. ), the Federal program that provides cash assistance
to needy need*y
adj. need*i*er, need*i*est
1. Being in need; impoverished. See Synonyms at poor.

2. Wanting or needing affection, attention, or reassurance, especially to an excessive degree.
age, blind, and disabled individuals. To qualify for SSI on the
basis of disability, an individual must be severely disabled, such that
he or she is "... unable to engage in any substantial gainful gain*ful
adj.
Providing a gain; profitable: gainful employment.


gainful*ly adv. activity by reason of a medically determined physical or mental
impairment Impairment

1. A reduction in a company's stated capital.

2. The total capital that is less than the par value of the company's capital stock.

Notes:
1. This is usually reduced because of poorly estimated losses or gains.

2. expected to result in death or that has lasted, or can be
expected to last, for a continuous period of at least 12 months"
(U.S. House of Representatives, 2000).



By broadening our knowledge of the disabled population, we can
better address the gaps in the current health care system, including
identifying areas in which there may be opportunities for more effective
and efficient delivery of care for key population subgroups. Further,
this information will help States and managed care organizations in
developing managed care programs that better meet the varied needs of
vulnerable Medicaid beneficiaries.


DATA AND METHODS


Data


We rely on a telephone survey of 816 disabled adult SSI
beneficiaries fielded in New York City in 1999-2000. A comparable survey
was also fielded in Westchester County, New York. Because the findings
were broadly similar in both New York City and Westchester County, for
simplicity in presentation we have limited this article to New York
City. However, the consistency of the findings for New York City and
Westchester County provides some support for the generalizability of
these findings beyond New York City.


At the time of the survey, approximately 10 percent of the sample
of disabled beneficiaries was already voluntarily enrolled in Medicaid
managed care. (1) Most were individuals who had entered Medicaid managed
care while enrolled in the Temporary Assistance for Needy Families Temporary Assistance for
Needy Families (TANF, often pronounced "TAN-if") is the July 1, 1997, successor to the Aid to
Families with Dependent Children program, providing cash assistance to indigent American
families with dependent children through the United States Department of (TANF TANF
Temporary Assistance for Needy Families (previously known as AFDC) ) Program and chose to
continue in managed care after their
eligibility for SSI was established.


The sample for the survey was identified through State enrollment
records for the Medicaid Program. Since information on disabling
conditions is not available through State program records, we matched

with Social Security Administration records for the SSI Program to
obtain information on the primary disabling condition. Our study focuses
on non-aged adult SSI beneficiaries living in the community. We also
limited the study sample to SSI beneficiaries who were to be included in
the future switch to mandatory Medicaid managed care. Thus, we excluded
from our sample Medicare Medicare, national health insurance program in the United States for
persons aged 65 and over and the disabled. It was established in 1965 with passage of the Social
Security Amendments and is now run by the Centers for Medicare and Medicaid Services.
recipients, individuals receiving long-term
care services under Medicaid waiver The voluntary surrender of a known right; conduct supporting
an inference that a particular right has been relinquished.

The term waiver is used in many legal contexts. programs, and the homeless. We also
limited the study to those on Medicaid for the entire past year to
ensure consistency between the outcome measures describing health care
use and the period of Medicaid enrollment. (2) In selecting the survey
sample, we stratified stratified /strat*i*fied/ (strati-fid) formed or arranged in layers.

strat*i*fied
adj.
Arranged in the form of layers or strata. on the basis of disabling condition. Random
samples were selected within each strata.


The survey collected information on access to and use of care,
along with socioeconomic, health status, and disability information.
Information was sought directly from the Medicaid beneficiary beneficiary

Person or entity (e.g., a charity or estate) that receives a benefit from something (e.g., a trust, life-
insurance policy, or contract). A primary beneficiary receives proceeds from a trust or insurance
policy before any other. whenever
possible. However, there were instances in which the sample member was
not able to complete the survey. Approximately 18 percent of the sample
members relied on a proxy respondent In Equity practice, the party who answers a bill or other
proceeding in equity. The party against whom an appeal or motion, an application for a court
order, is instituted and who is required to answer in order to protect his or her interests. , including
37 percent of sample
members with MR/DD, 15 percent of those with mental illness, and 13
percent of those with physical disabilities. The two most common reasons
for using a proxy were language issues and the beneficiary being
mentally incapable of responding to the survey. Because of the

possibility that responses provided by a proxy differ from those that
would have been provided by the sample member if he or she were able to
respond to the survey, we control for proxy respondents In the context of marketing research, a
representative sample drawn from a larger population of people from whom information is
collected and used to develop or confirm marketing strategy. in the
multivariate analysis. However, care must be taken in interpreting that
control variable since the presence of a proxy respondent may also
capture severity of disability and/or language barriers to care. (3)


The overall response rate for the survey was 56 percent. Almost all
of the non-response was due to an inability to locate sample members
rather than a refusal by those who were located to participate in the
survey. (4) Once a sample member was located, the cooperation rate was
94 percent. Survey weights were developed to reflect the probability of
selecting each individual for the survey and to adjust for survey
non-response. The adjustments for non-response were based on the
administrative data available for both respondents and non-respondents,
which included basic demographic information along with primary
disabling condition and geographic location. The analyses reported here
have been weighted using these sample weights.


Missing data were a relatively minor problem for the explanatory ex*plan*a*to*ry
adj.
Serving or intended to explain: an explanatory paragraph.


ex*plan variables included in our regression analysis In statistics, a mathematical method of
modeling the relationships among three or more variables. It is used to predict the value of one
variable given the values of the others. For example, a model might estimate sales based on age
and gender. : less than 3 percent of
the individuals had missing values In statistics, missing values are a common occurrence. Several
statistical methods have been developed to deal with this problem. Missing values mean that no
data value is stored for the variable in the current observation. . We used hot-deck imputation
IMPUTATION. The judgment by which we declare that an agent is the cause of his free action, or
of the result of it, whether good or ill. Wolff, Sec. 3. procedures to assign values for individuals
with missing values for the
explanatory variables.



Measures of Health Care Access and Use--We focus on key aspects of
access to care as presented in a standard analytic an*a*lyt*ic or an*a*lyt*i*cal
adj.
1. Of or relating to analysis or analytics.

2. Expert in or using analysis, especially one who thinks in a logical manner.

3. Psychoanalytic. framework (Andersen
1968, 1995; Andersen and Aday 1978; Andersen, McCutcheon The name McCutcheon or
MacCutcheon may refer to: People
Malcolm Wallace McCutcheon (1906-1969), a Canadian politician Bill McCutcheon (1924-2002),
American actor John T. McCutcheon (1870-1949), American political cartoonist Martine
McCutcheon (b. , and Arday,
1983). We consider potential access and realized access. In this study,
potential access is measured as the presence of a usual source of care
and unmet un*met
adj.
Not satisfied or fulfilled: unmet demands. need. Realized access is measured by the actual use of
health
care services, including visits to the emergency room (ER), hospital
stays, outpatient outpatient /out*pa*tient/ (-pa-shent) a patient who comes to the hospital, clinic, or
dispensary for diagnosis and/or treatment but does not occupy a bed.

out*pa*tient
n. visits for physical and mental health care, and
receipt of three preventative health care services--a dental care visit,
an immunization immunization: see immunity; vaccination. against influenza influenza or flu,
acute, highly contagious disease caused by a virus; formerly known as the grippe. There are three
types of the virus, designated A, B, and C, but only types A and B cause more serious contagious
infections. , and, for females, a Pap smear Pap smear
or Papanicolaou smear

Sample of cells from the vagina and cervix of the uterus for laboratory staining and examination to
detect genital herpes and early-stage cancer, especially of the cervix. Developed by the Greek-
born U.S. . Higher
levels of hospital and ER use indicate potential access problems if that
use stems from problems obtaining care in other settings. Since we
cannot identify avoidable hospitalizations or inappropriate ER use from
the survey, we interpret higher levels of hospital and ER use among the
disabled Medicaid beneficiaries as suggestive of suggestive of Decision making adjective
Referring to a pattern by LM or imaging, that the interpreter associates with a particular-usually

malignant lesion. See Aunt Millie approach, Defensive medicine. problems with access to
primary care, particularly when combined with high levels of unmet need
and difficulties obtaining care.


Finally, we consider the disabled individuals' assessment of
their ease of access to care. Specifically, we asked the survey
respondents to rate various aspects of their health care as excellent,
very good, good, fair, or poor. We consider their rating of the ease of
finding a doctor who will accept Medicaid and the ease of getting
specialist, mental health, and emergency care.


Methods


We conduct both descriptive and multivariate analyses. In the
descriptive analyses, we compare individuals with mental illness and
MR/DD to those with physical disabilities. This comparison allows us to
identify differences in access to and use of health care among the three
subgroups.


The multivariate analysis has two objectives: (1) to determine
whether the differences in health care experiences among the three
subgroups can be explained by differences in their personal
characteristics and health care needs, and (2) to identify
characteristics of the disabled Medicaid population that are associated
with greater difficulties in obtaining care. In addressing these issues,
we estimate multivariate models of access and use as a function of the
primary disabling condition of the individual--mental illness, MR/DD, or
physical disability--and his or her demographic, health, and disability
characteristics. The variables included in the multivariate analysis
reflect the predisposition predisposition /pre*dis*po*si*tion/ (-dis-po-zishun) a latent susceptibility to
disease that may be activated under certain conditions.

pre*dis*po*si*tion
n.
1. of an individual to use services, factors
that enable or impede im*pede
tr.v. im*ped*ed, im*ped*ing, im*pedes

To retard or obstruct the progress of. See Synonyms at hinder1.


[Latin imped use, and the individual's need for services
(Anderson Anderson, river, Canada
Anderson, river, c.465 mi (750 km) long, rising in several lakes in N central Northwest Territories,
Canada. It meanders north and west before receiving the Carnwath River and flowing north to
Liverpool Bay, an arm of the Arctic , 1968). In addition to those measures, we also control for
whether the survey responses were obtained from a proxy respondent for
the sample member. Since all of the outcome measures are binary Meaning two. The principle
behind digital computers. All input to the computer is converted into binary numbers made up of
the two digits 0 and 1 (bits). For example, when you press the "A" key on your keyboard, the
keyboard circuit generates and transfers the number 01000001 to the variables, we estimate logit
The logit function is an important part of logistic regression: for more information, please see that
article.

In mathematics, especially as applied in statistics, the logit regression regression, in psychology:
see defense mechanism.
regression

In statistics, a process for determining a line or curve that best represents the general trend of a
data set. models.


Results


Overview of the Sample


Health and Disability Status--Although our sample of SSI
beneficiaries are all disabled, there is a great deal of variation in
their health status and dependency dependency

In international relations, a weak state dominated by or under the jurisdiction of a more powerful
state but not formally annexed by it. Examples include American Samoa (U.S.) and Greenland
(Denmark). that is reported both within and
across the subgroups (Table 1). Among individuals with physical
disabilities, two-thirds report that they are in fair or poor health
(versus good, very good, or excellent), and almost 75 percent report
needing help with activities of daily living (ADLs) i.e., bathing,

dressing, eating, transferring, using the toilet, or getting around the
home and/or instrumental activities of daily living instrumental activities of daily living A series of
life functions necessary for maintaining a person's immediate environment-eg, obtaining food,
cooking, laundering, housecleaning, managing one's medications, phone use; IADL measures a
(IADLs) i.e., meal
preparation, shopping, finances, housework, using the telephone, or
managing medications. Of particular importance to their ability to
access health care, 36 percent reported needing assistance getting
around their home (i.e., mobility limitations) and 13 percent reported
needing assistance using the telephone.


Compared with the physically disabled, individuals with MR/DD tend
to be significantly healthier--almost two-thirds were in good, very
good, or excellent health. However, those with MR/DD are significantly
more likely than the physically disabled to need help with their daily
activities. In general, as might be expected given the nature of their
primary disability, individuals with MR/DD require less assistance with
AD Ls and more assistance with IADLs than the physically disabled.
Specifically, we find that MR/DD beneficiaries are less likely to have
mobility limitations, but more likely to require assistance with meal
preparation, shopping, finances, using the telephone, and managing their
medications.


In contrast to those with MR/DD, individuals with mental illness
report similar levels of health and disability status as those with
physical disabilities. Like the physically disabled, about two-thirds of
the mentally ill report their health as fair or poor and about 70
percent report needing assistance with one or more ADLs or IADLs.
However, the patterns of dependency reported by the two subgroups
differ: individuals with mental illness are significantly less likely to
need help with bathing, using the toilet, or getting around their home,
but more likely to need help managing their medications.


Demographic and Socioeconomic Characteristics--Beyond the health
and disability-related challenges to obtaining care, many in the
subgroups of SSI beneficiaries face other challenges. For example, many
have limited formal education, potential language barriers, and limited
financial resources (Table 2). Further, most are from racial and ethnic

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