Partially capitated managed care versus FFS for special needs children

Area of Science:

• Health Services Research
• Pediatric Health Policy
• Managed Care Effectiveness

Background:

• Limited research exists on the effectiveness of Medicaid managed care plans (MCPs) with case management for coordinating services for children with special health care needs (CSHCN).
• Understanding service utilization patterns is crucial for optimizing care delivery for CSHCN.
• The role of case management within MCPs in facilitating access to therapeutic services requires further investigation.

Purpose of the Study:

• To evaluate the impact of enrolling CSHCN in a partially capitated MCP with case management versus a fee-for-service (FFS) model.
• To compare the utilization of speech, occupational, and physical therapy services based on the site of service (school vs. health care sector).
• To identify potential disparities in therapeutic service access between different Medicaid coverage models.

Main Methods:

• Comparative analysis of therapeutic service utilization among CSHCN enrolled in a partially capitated MCP with case management and those in a FFS plan.
• Examination of service use by specific therapy type (speech, occupational, physical) and by service delivery sector (school-based vs. health care sector).
• Statistical comparison of service utilization rates between the two enrollment models.

Main Results:

• Children with special health care needs enrolled in the partially capitated MCP were significantly more likely to receive occupational and physical therapy in the school setting compared to FFS enrollees.
• Children enrolled in FFS were significantly less likely to be regular or frequent users of all examined therapeutic services compared to those in managed care.
• Case management within the MCP appears to facilitate greater access to school-based therapeutic services for CSHCN.

Conclusions:

• Partially capitated Medicaid managed care plans incorporating case management demonstrate effectiveness in coordinating and increasing the utilization of therapeutic services for CSHCN, particularly in school settings.
• Enrollment in FFS plans is associated with reduced access to regular and frequent therapeutic services for CSHCN.
• The findings underscore the importance of integrated case management within managed care for improving access to essential therapies for children with special health care needs.