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Changes in Newborn Delivery During a Period of Rapid Expansion of Medicaid Managed Care in Los Angeles and Orange County. Ruey-Kang Chang, MD, MPH UCLA Medical Center Los Angeles, California. *Partly funded by the Agency for Healthcare Research and Quality (1 R03 HS13217).
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Changes in Newborn DeliveryDuring a Period of Rapid Expansion of Medicaid Managed Care in Los Angeles and Orange County Ruey-Kang Chang, MD, MPH UCLA Medical Center Los Angeles, California *Partly funded by the Agency for Healthcare Research and Quality (1 R03 HS13217)
BACKGROUND • Since its beginning in 1966, Medi-Cal (California Medicaid program) had predominately used a fee-for-service (FFS) health care delivery system • State legislation in 1991 and 1992 allowed under specific circumstances to direct the defaults into managed care and enabled a substantial expansion of Medi-Cal managed care • Medicaid managed care (MMC) may affect the process and outcomes of care
OBJECTIVES • To investigate if the newborn delivery market is becoming decentralized over time with MMC expansion • To determine if decentralization is associated with an increase in the rate of inter-hospital newborn transfer • To examine if decentralization is associated with changes in the process of care (rate of Cesarean section) and outcomes of care (in-hospital mortality)
METHODS • We selected the two largest counties in the California– Los Angeles and Orange County
METHODS– data sources • California Office of Statewide Hospital Planning and Development (OSHPD) • California Vital Statistics, birth record • American Hospital Association database • Of OSHPD data on hospital discharge, all newborns delivered in LA and OC hospitals were identified by ICD-9 diagnostic code (V30-V39)
Types of Insurance • Insurance: Medi-Cal, Private, and Others • Private– grouped from HMO/PHP, PPO, Blue Cross/Blue Shied, indemnity insurance • Others– self pay, charity care, Medicare, worker’s comp, title V, other government, other non-government
Types of Hospitals For Profit (52) Public (11) Non-Profit (61)
Herfindahl-Hirschman Index (HHI) • An index for measuring distribution of market share among healthcare facilities • HHI= Σ(market share of hospital i )2 • HHI values range from 0 (complete even distribution) to 1 (most uneven distribution), the greater HHI, the more uneven distribution in the market
RESULTS • There were 2,351,199 newborn deliveries in LA (1,832,287) and OC (518,922) between 1990-1999 • Total 123 hospitals providing the services, 91 in LA and 32 in OC • The number of newborns per year decreased by 21% over the study period
Decreasing Numbers of Deliveries in County Hospitals LAC-USC Medical Center King-Drew Medical Center Olive View Medical Center Harbor-UCLA Medical Center
CONCLUSONS • Newborn deliveries were decentralized to small community, non-profit hospitals during the period of rapid Medi-Cal Managed Care in the 1990s • Increasing C/S rate and decreasing mortality made Medi-Cal patients look more like the private insurance patients • No increase in inter-hospital newborn transfer or in-hospital mortality was seen in Medi-Cal patients comparing to private insurance patients
Policy Implications • MMC expansion might be one of the important factors led to market decentralization • The Two-Plan Model and COHS model influenced the market in similar ways • Decentralization of NB delivery might affect the process of care, however, outcomes of NB, such as inter-hospital transfer, in-hospital mortality, were not affected
HHI= 5*0.22 =0.2 20% 20% 20% 20% More even distribution 20%
HHI= 0.82 + 4*0.052 =0.65 80% 5% 5% 5% More uneven distribution 5%
