Managed care for uninsured adults: The rise and fall of a university-based program

Objective: To assess the impact of CU CARE, a managed care program for medically indigent adults developed by University Hospital (UH) in Denver and Kaiser Permanente, on outpatient and inpatient utilization. Study Design: Pre-post study with concurrent comparison groups. Patients and Methods: Administrative claims from 19941996 were analyzed for all enrollees in a state-funded medically indigent program (intervention group) compared with Medicaid patients and uninsured adults rated as "self-pay" who were ineligible for the medically indigent program. Results: In 1994, before initiation of CU CARE, UH provided care to 10,118 medically indigent, 5330 Medicaid, and 7626 self-pay patients; similar numbers received care in 19951996, but only 12% of medically indigent patients received care in both time periods. The proportion of medically indigent patients with 1 or more primary care visits increased by 185% (from 10.9% in 1994 to 31.1% in 1995-1996). Medically indigent patients had relative declines of 36% in specialty clinic visits, 25% in emergency department visits, 40% in hospital visits, and 31% in visit costs between 1994 and 1995-1996. All these changes were significant compared with Medicaid and self-pay patients. The impact on acute care utilization was greater for medically indigent patients who used UH in both 1994 and 1995-1996. Conclusions: This managed care program increased utilization of primary care and reduced specialty and acute care utilization. However, the program was scaled back in 1997 and terminated in 2000 because of problems with care coordination across institutions, increasing costs (particularly pharmacy costs), and competitive pressures.