1. The Impact of SCHIP Enrollment and Managed Care Organizational Characteristics on Preventive Care Elizabeth Shenkman, PhD Bruce Vogel, PhD Lise Youngblade, PhD The University of Florida June 2004 Funded by the Agency for Healthcare Research and Quality (AHRQ) with co-funding from the David and Lucile Packard Foundation, and the Health Resources and Services Administration (AHRQ No. HS10463)

2. Background Adolescents at risk for morbidity and mortality – risky behaviors Preventive care visits Privacy Counseling SCHIP contract with managed care organizations (MCOs) to form provider network and deliver services Does SCHIP and the MCOs’ organizational characteristics influence preventive care, privacy, and counseling?

3. Study Design Longitudinal follow-up of 11.5 to 17 year olds newly enrolled in SCHIP and one year post- enrollment Adolescent interviews Demographic characteristics Risky behaviors – drinking, sexual activity, depression, seat belt use Preventive care visits Counseling during visits

4. Study Design MCO Characteristics For profit, not-for-profit Percentage of providers reimbursed fee-for-service (FFS) Adolescents with special health care needs (ASHCN) exempt from prior authorizations Provider profiling for quality standards Prior authorization required for referrals Allows specialists to function as primary care providers (PCPs)

5. Study Sample 918 SCHIP enrollees Time 1 502 at Time 2 No significant differences in age, presence of special needs, family income, or gender Mean age 14.2(1.6) Mean income $22,794($8,811)

6. Health and Sociodemographic Characteristics

7. Risky Behaviors

8. Health Care Experiences: Time 1 and Time 2

9. Enrollees are 80-90% more like to have privacy during a visit. Enrollees are 66% more likely to have a usual source of care. Enrollees are 35% less likely to get counseling during their visits. CHIPEnrollment RiskBehaviors PhysicianVisit? Usual Source Usual Source of Care MCO MCOCharacteristics Odds Ratio = 0.65 Counseling Odds Ratio = 1.8-1.9 Privacy | Visit Odds Ratio = 2.85 Teens who have privacy during their visits are almost three times as likely to receive counseling. Odds Ratio = 1.66 SCHIP ENROLLMENT Our Recursive Statistical Model

10. SCHIP Enrollment Influences: Usual Source of Care 66% greater odds of a usual source of care Private Visit 1.9 times more likely to have a private visit Counseling SCHIP directly reduces the likelihood of counseling BUT increases the likelihood of privacy, which increases the likelihood of counseling. The effects seem to offset each other.

11. Teens in for-profit plans are twice as likely to report receiving counseling. Teens in plans where CSHCNs are exempt from prior utilization have fewer risky behaviors. Teens in plans that use provider quality profiling are 2.4 times more likely to report a usual source of care. Teens in plans where CSHCNs are exempt from prior authoriziation are twice as likely to receive counseling. CHIPEnrollment RiskBehaviors PhysicianVisit? Usual Source Usual Source of Care Odds Ratio = 1.74 Counseling Privacy | Visit Odds Ratio = 2.4 Profiling MCO CHARACTERISTICS Odds Ratio = 2.0 For Profit MCO MCOCharacteristics Odds Ratio = 2.0 No Prior Authorization Odds Ratio = 1.6 No Prior Authorization -

12. MCO Characteristics Influence: Usual Source of Care Provider quality profiles – 2.4 times more likely Receipt of Counseling During Visit For-profit – 2 times more likely CSHCN exempt from prior authorization – 1.6 times more likely No other MCO influences seen

13. Older teens are more likely than younger teens to report having a private visit. Black non-Hispanics teens are 40%, less likely than White non-Hispanic teens to report having a preventive care visit. Hispanic teens are 42% less likely than White non-Hispanic teens to report having a preventive care visit. Hispanic teens are 66% less likely than White non-Hispanic teens to report having a usual source of care. CHIPEnrollment RiskBehaviors PhysicianVisit? Usual Source Usual Source of Care MCO MCOCharacteristics Black Non-Hispanic Odds Ratio = 0.60 Counseling Hispanic Odds Ratio = 0.58 Privacy | Visit Age SOCIODEMOGRAPHICCHARACTERISTICS Hispanic Odds Ratio = 0.34

14. Sociodemographic Characteristics Influence: Usual Source of Care Hispanics – 66% less likely than White non-Hispanic children Preventive Care Visits Hispanics – 42% less likely Black non-Hispanics – 40% less likely Privacy During Visit Odds increase with age

15. If the visit is private, the teen is almost three times as likely to receive counseling. Depressed teens are twice as likely to report having a preventive care visit. Teens with special health care needs are more than twice as likely to have a preventive care visit. If the teen has special health care needs, she is 2.6 times more likely to receive counseling. CHIPEnrollment RiskBehaviors PhysicianVisit? Usual Source Usual Source of Care MCO MCOCharacteristics Odds Ratio = 2.85 Counseling Privacy | Visit Depression Odds Ratio = 2.0 OTHER FACTORS ASHCN Odds Ratio = 2.3 Odds Ratio = 2.57 Odds Ratio = 1.74 A teen having one additional risk behavior is 1.7 times more likely to receive counseling.

16. Other Influences: Preventive Care Visits Depression – 2 times more likely to have a visit If ASHCN – 2 times more likely to have visit Counseling If the visit is private – 3 times more likely to get counseling If ASHCN – 2.5 times more likely to get counseling One reported risk behaviors 1.7 times more likely to get counseling than those with none. See increasing odds with increasing numbers of risk behaviors

17. Summary SCHIP improves access to usual source of care and private visits Limited number of MCO characteristics important for usual source of care and counseling Black non-Hispanic and Hispanic children remain at risk after enrollment for not having a usual source of care or receiving a preventive care visit

18. Summary Health status – presence of special needs, reporting feelings of depression important for visits Physicians targeting counseling towards those with risky behaviors and not all adolescents Ensuring privacy during visits very important Strongest effects on preventive care, privacy and counseling related to individual adolescent characteristics