Medicaid policy and the substitution of hospital outpatient care for physician care.

This article explores the effects of reimbursement and utilization control policies on utilization patterns and spending for physician and hospital outpatient services under state Medicaid programs. The empirical work shows a negative relationship between the level of Medicaid physician fees relative to Medicare and private fees, and the numbers of outpatient care recipients, suggesting that outpatient care substitutes for physician care in states with low fee levels. In addition, it shows a positive relationship between Medicaid physician fees and outpatient spending per recipient, suggesting that in low-fee states outpatient departments are providing some types of care that could be provided in a physician's office. Finally, the analysis demonstrates that reimbursement and utilization control policies have significant effects in the expected directions on aggregate Medicaid spending for physician and outpatient services.     

Varying health care provider objectives and cost-shifting: the case of retail pharmacy in the US.

In this paper we investigate the relationship between health care provider objectives, cost-shifting, and prices by exploring the relationship between state Medicaid pharmacy reimbursements and average prices paid by pharmacy retail customers for four distinct pharmaceutical products across the US in 1994. We develop a more general theory than past researchers to enable provider objectives to vary with Medicaid pharmacy reimbursement levels. We find that provider objectives and the direction of relationship between Medicaid pharmacy reimbursements and retail prices vary with Medicaid pharmacy reimbursement levels. At high Medicaid pharmacy reimbursement levels we find a consistent negative relationship across products. At low Medicaid pharmacy reimbursement levels, the direction of the relationship is product-specific. As a result, policy-makers should be aware that policies affecting reimbursements from government-sponsored health insurance will also affect retail customers that include the uninsured. Paradoxically, for certain products if a state cuts a generous Medicaid reimbursement level this could hurt uninsured patients, whereas cuts in a stingy Medicaid reimbursement rate may help uninsured patients.     

Freedom of choice: Medicaid, managed care, and California family planning clinics.

Access to out-of-plan family planning services for Medicaid beneficiaries enrolled in managed care plans in California has been limited by poor relationships between family planning clinics and contracting managed care plans. Plans either delay or fail to reimburse claims from non-network family planning agencies; family planning staff are unmotivated to identify managed care members through financial screening, to cover costs with other funds, or to refer members back to plan. In addition, plans and clinics fail to coordinate the care of managed care clients by sharing medical records. Based on findings from a pilot project, California will try to facilitate relationships between plans and family planning agencies rather than directly pay out-of-plan claims.     

Lessons learned: Illinois providers’ perspectives on implementation of Medicaid coverage for abortion

ObjectiveOn January 1, 2018, Illinois became the first Midwestern state to cover abortion care for Medicaid enrollees. This study describes state implementation of the policy, the impact on abortion providers, and lessons learned.Study DesignWe documented abortion providers’ perspectives on the service delivery consequences of Medicaid coverage for abortion in Illinois. We conducted in-depth interviews with clinicians and administrators (N = 23) from 15 Illinois clinics, including clinics that provided other services and those primarily providing abortion. We conducted interviews in person or by phone between April and October 2019. They lasted ≤100 minutes, were audio-recorded, transcribed, and coded in Dedoose. We developed code summaries to identify salient themes across interviews.ResultsAll participants supported the law and expected benefits to patients. Many struggled to implement the policy because of difficulties obtaining certification to bill the state Medicaid program, confusing and cumbersome paperwork requirements, reimbursement delays, confusing claim denials, and uncertain protocols for Medicaid patients covered under the exceptions defined by the Hyde Amendment. Nearly all participants expressed concern that low reimbursement rates were insufficient to cover costs. Implementation was easier for multiservice clinics and those nested in larger institutions. Several clinics closed during implementation; one clinic opened. Clinics leveraged internal resources, external funding, and technical assistance to ensure that Medicaid enrollees could receive care without costs.ConclusionsImplementing Medicaid coverage for abortion requires proactive and responsive state institutions, improvements to reimbursement processes, and adequate reimbursement rates. In Illinois, successful implementation depended on clinic adaptability, external support, and advocacy.ImplicationsOur research suggests that successful, sustainable implementation of Medicaid coverage for abortion depends on state policies that allow clinics to enroll patients, process claims in 30 to 90 days, and receive reimbursements covering the cost of care. Without these measures, ensuring immediate patient access may depend upon clinics mobilizing resources and external transitional support.     

Evidence for Action: Addressing Systemic Racism Across Long-Term Services and Supports

Long-term services and supports (LTSS), including care received at home and in residential settings such as nursing homes, are highly racially segregated; Black, Indigenous, and persons of color (BIPOC) users have less access to quality care and report poorer quality of life compared to their White counterparts. Systemic racism lies at the root of these disparities, manifesting via racially segregated care, low Medicaid reimbursement, and lack of livable wages for staff, along with other policies and processes that exacerbate disparities. We reviewed Medicaid reimbursement, pay-for-performance, public reporting of quality of care, and culture change in nursing homes and integrated home- and community-based service (HCBS) programs as possible mechanisms for addressing racial and ethnic disparities. We developed a set of recommendations for LTSS based on existing evidence, including (1) increase Medicaid and Medicare reimbursement rates, especially for providers serving high proportions of Medicaid-eligible and BIPOC older adults; (2) reconsider the design of pay-for-performance programs as they relate to providers who serve underserved groups; (3) include culturally sensitive measures, such as quality of life, in public reporting of quality of care, and develop and report health equity measures in outcomes of care for BIPOC individuals; (4) implement culture change so services are more person-centered and homelike, alongside improvements in staff wages and benefits in high-proportion BIPOC nursing homes; (5) expand access to Medicaid-waivered HCBS services; (6) adopt culturally appropriate HCBS practices, with special attention to family caregivers; (7) and increase promotion of integrated HCBS programs that can be targeted to BIPOC consumers, and implement models that value community health workers. Multipronged solutions may help diminish the role of systemic racism in existing racial disparities in LTSS, and these recommendations provide steps for action that are needed to reimagine how long-term care is delivered, especially for BIPOC populations.     

Insurance-related Practices at Title X-funded Family Planning Centers under the Affordable Care Act: Survey and Interview Findings

Introduction

Given the recent reforms in the United States health care system, including the passage and implementation of the Affordable Care Act, as well as anticipated upcoming changes to health care coverage, it is critical that publicly funded health care providers understand how to effectively work with their states' Medicaid programs and the private health insurance plans in their service areas to provide high-quality contraceptive care to the millions of women relying on services at these sites annually.

The availability and use of publicly funded family planning clinics: U.S. trends, 1994-2001

CONTEXT: It is important to monitor trends among publicly funded family planning clinics to determine where clinics are successfully meeting the contraceptive service needs of low-income women and where more effort is needed.
METHODS: Service data for all U.S. agencies and clinics providing subsidized family planning services were collected for 2001 and compared with similar data collected for 1997 and 1994. Trends reflecting clinic structure and capacity were analyzed at the national and state levels. Client numbers were compared with numbers of women needing publicly funded contraceptive services to create a measure of met need for states and groups of states, according to Medic-aid family planning waiver status.
RESULTS: In 2001, some 7,683 publicly funded family planning clinics provided contraceptive services to 6.7 million women–representing an 8% rise in clinics and a 2% increase in clients since 1994. Change varied by type of provider and clinic location. Health departments and Planned Parenthood affiliates served more clients at fewer sites; community health centers served fewer clients at more sites. One-third of states experienced growth in clinic capacity, with 5–65% increases in met need. In another third of states, met need declined by 5% or more. States with income-based Medicaid family planning waivers served 24% more clients, with met need increasing from 40% to 50%.
CONCLUSIONS: Among states, there has been tremendous variation in the ability of publicly funded family planning clinics to serve women. Implementation of income-based Medicaid family planning waivers in some states was associated with clinics' serving greater numbers of women. Further efforts are needed to ensure access to family planning services for low-income women in every state.     

Medicaid in the inner city: the case of maternity care in Chicago

The growing concentration of lower-income groups, including Medicaid patients, in homogeneous inner-city areas such as Chicago casts considerable doubt on the effectiveness of expanding Medicaid eligibility and raising physician reimbursement to improve access to maternity care. There are few private office-based physicians providing prenatal care in these areas, and most pregnant women and infants are treated by private-office-based physicians in very high-volume practices, prompting concern about the quality of care. Increasing the supply of providers is required to enhance access to maternity services in inner cities. Expanding eligibility and raising reimbursement rates are more apt to benefit "near-poor" women, who are more spatially dispersed, than clustered-poor female populations.     

Extending Medicaid coverage for family planning services: Alabama's first four years

OBJECTIVES: This study examines whether Alabama's Medicaid family planning demonstration program reaches a different segment of the population than the health department-based Title X family planning program, whether service use rates differ across clients using care within and outside of the Title X provider system, and whether additional risk assessment and care coordination services provided by health department personnel increase the likelihood that family planning clients return for follow-up visits over time. METHODS: Administrative data from four years of operation of the program were used to examine characteristics of the clientele, differences in services used across provider types included in the program, and the impact of risk assessments and care coordination on return visit rates. RESULTS: The number of family planning service users increased dramatically over the four-year period, but were more similar demographically to Title X clients than to Medicaid maternity clients. Growth was greatest among clients of non-Title X providers. Newly covered services, including risk assessments and care coordination, were available mostly to Title X clients, and these services were associated with a greater likelihood that clients returned for care in subsequent years. CONCLUSION: Expanded provider networks can increase the number of low income women using family planning services while risk assessment and care coordination can improve the effectiveness of these services. However, enhanced services may not be equally available across provider systems. Additional outreach efforts are needed to reach women eligible for publicly supported family planning services who are not currently using these services.     

State Medicaid and private payer reimbursement for telemedicine: An overview

Individual states in the USA were given the option of paying for telemedicine services with Medicaid (i.e. federal health-care funds administered by the state) in 1998, when the Health Care Financing Administration (HCFA) published final rules for Medicare payment for teleconsultations in health professional shortage areas (HPSAs). It was left to telemedicine practitioners in each state to negotiate the scope of the services covered with the state Medicaid office. Three reports of data gathered by 2002-03 surveys on state reimbursement policies have been reviewed, with additional information from a brief informal 2005 survey conducted by the author. In the seven years since 1998, 34 states have added coverage of telemedicine services to their Medicaid programmes, although there are wide variations in service coverage, payment policies, and geographical and other restrictions. There is less published information on private payer reimbursement. One survey performed by AMD Telemedicine (AMD) and the American Telemedicine Association (ATA) showed that over half of the 72 telemedicine programmes in 25 states delivering billable services were being reimbursed by private payers. In 1999, 43% of responding telemedicine networks saw reimbursement as a barrier to long-term sustainability, while in 2004 only 22% did so. It appears that some progress has been made in Medicaid and private payer reimbursement for telemedicine.     

Outcomes for medicaid clients with substance abuse problems before and after managed care

Medicaid conversion from fee for service to managed care raised numerous questions about outcomes for substance abuse treatment clients. For example, managed care criticisms include concerns that clients will be undertreated (with too short and/or insufficiently intense services). Also of interest are potential variations in outcome for clients served by organizations with assorted financial arrangements such as for-profit status versus not-for-profit status. In addition, little information is available about the impact of state Medicaid managed care policies (including client eligibility) on treatment outcomes. Subjects of this project were Medicaid clients aged 18–64 years enrolled in the Oregon Health Plan during 1994 (before substance abuse treatment managed care, N=1751) or 1996–1997 (after managed care, N=14,813), who were admitted to outpatient non-methadone chemical dependency treatment services. Outcome measures were retention in treatment for 90 days or more, completion of a treatment program, abstinence at discharge, and readmission to treatment. With the exception of readmission, there were no notable differences in outcomes between the fee for service era clients versus those in capitated chemical dependency treatment. There were at most minor differences among various managed care systems (such as for-profit vs not-for-profit). However, duration of Medicaid eligibility was a powerful predictor of positive outcomes. Medicaid managed care does not appear to have had an adverse impact on outcomes for clients with substance abuse problems. On the other hand, state policies influencing Medicaid enrollment may have substantial impact on chemical dependency treatment outcomes.     

The provision and funding of contraceptive services at publicly funded family planning agencies: 1995-2003

CONTEXT: Publicly funded family planning agencies face significant challenges in delivering quality services to low-income women because of the higher costs of newer contraceptive methods, changes in health care financing and a growing uninsured population. METHODS: In 2003, 627 of a nationally representative sample of 956 U.S. agencies receiving public funding for family planning services responded to an eight-page survey. Responses were compared with results from similar surveys in 1995 and 1999 to describe changes in the availability of contraceptive methods, policies on method provision and funding issues. Variation was examined by agency type and Title X funding status. RESULTS: Between 1995 and 2003, the number of contraceptive methods available to women increased and agencies reduced barriers to oral and emergency contraceptives by liberalizing policies for their provision. By 2003, many agencies offered the newest contraceptive methods available-the progestin-only IUD (58%), the patch (76%) and the vaginal ring (39%). However, more than half of agencies did not stock certain methods because of their cost, and some key funding sources had declined. Between 1995 and 2003, the proportion of agencies receiving Medicaid funding fell from 91% to 80%, and the proportion of clients paying full fee for their contraceptive services fell from 19% to 14%. The share of agencies waiving fees for adolescents fell from 66% in 1999 to 44% in 2003. CONCLUSIONS: Continued funding challenges limit the ability of publicly funded providers to offer all available methods to all women.     

Medicare Part B reimbursement and the perceived quality of physician care

The maximum amount physicians can charge Medicare patients for Part B services depends on Medicare reimbursement rates and on federal and state restrictions regarding balance billing. This study evaluates whether Part B payment rates, state restrictions on balance billing beyond the federal limit, and physician balance billing influence how beneficiaries rate the quality of their doctor’s care. Using nationally representative data from the 2001 to 2003 Medicare Current Beneficiary Survey, this paper finds strong evidence that Medicare reimbursement rates, and state balance billing restrictions influence a wide range of perceived care quality measures. Lower Medicare reimbursement and restrictions on physicians’ ability to balance bill significantly reduce the perceived quality of care under Part B.     

The Impact of Reproductive Health Legislation on Family Planning Clinic Services in Texas

We examined the impact of legislation in Texas that dramatically cut and restricted participation in the state’s family planning program in 2011 using surveys and interviews with leaders at organizations that received family planning funding.Overall, 25% of family planning clinics in Texas closed. In 2011, 71% of organizations widely offered long-acting reversible contraception; in 2012–2013, only 46% did so. Organizations served 54% fewer clients than they had in the previous period. Specialized family planning providers, which were the targets of the legislation, experienced the largest reductions in services, but other agencies were also adversely affected.The Texas experience provides valuable insight into the potential effects that legislation proposed in other states may have on low-income women’s access to family planning services.Publicly funded family planning clinics have been a key component of the health care safety net for low-income women in the United States and will remain essential points of access under the Affordable Care Act.1,2 Title X, the federal program dedicated to family planning, provides crucial infrastructural support for a network of clinics and subsidizes the cost of family planning services for uninsured women. In many states, Medicaid family planning waivers or state plan amendments constitute another source of support, and they reimburse clinics for services provided to eligible women. These programs can help fill gaps in coverage for those who lose other insurance because of changes in income or employment or other life events.3However, the degree to which low-income women can rely on publicly funded providers for subsidized family planning services has become increasingly dependent on policies enacted by state legislatures, which recently have taken on a large role in determining not only the amount of funding that goes to family planning but also the types of organizations that are eligible to receive it. Since 2010, several states have made significant cuts to their family planning budgets, and in 5 states, funding for family planning services was disproportionately reduced relative to other health programs.4 Additionally, since 2011, 16 states have proposed legislation that effectively blocks specialized family planning providers from receiving any public funding such as Title X or bars those that also provide abortion services from receiving funds, including Medicaid.5,6 This legislation may be aimed at defunding entities providing abortion care, such as Planned Parenthood, even though federal dollars cannot be used to pay for abortions in almost all cases.One of the most striking examples of legislation affecting the delivery of publicly funded family planning services took place in Texas, which in 2011 both dramatically cut and restricted participation in the state’s family planning program. We examined the impact of the 2011 legislation on family planning providers in Texas. We have reported on our findings from surveys and in-depth interviews with leaders at organizations across the state that received public funding before the legislation and our analysis of state administrative data. The Texas experience provides valuable insight into the potential effects that legislation proposed in other states may have on low-income women’s access to family planning services.     

Reimbursement and access to physicians' services under Medicaid.

Several recent studies have shown that physician participation in state Medicaid programs is directly related to the generosity of their reimbursement levels. The implication is that when states reduce fees, Medicaid eligibles suffer because their access to physicians' services is thereby limited. The results presented in this paper do not support this implication. Multivariate analyses of utilization and site-of-visit patterns among non-elderly Medicaid eligibles indicate that stringent physician reimbursement practices do not impede access to ambulatory care when all sites at which a doctor may be seen are considered.     

Smile Alabama! Initiative: Interim Results From a Program to Increase Children's Access to Dental Care

ABSTRACT: Alabama faced an oral health crisis, with decreasing dental provider participation and increasing enrollment of Medicaid-eligible children. In response, the Smile ALabama! initiative was designed to improve oral health care services for Medicaid-eligible children by increasing the number of participating dentists by 15% and the number of children receiving dental care annually by 5% by January 31, 2004. The initiative is composed of 4 specific components: claims processing, dental reimbursement, provider education and recruitment, and recipient education. Specific interventions were implemented for each component. From fiscal year 1999 to fiscal year 2002, enrollment of targeted Medicaid children increased 32.7%. During this same period, the number of participating dental providers in the Alabama Medicaid dental program increased by 127 providers, a 38.7% increase. The number of children receiving dental services increased from 82 600 in fiscal year 2999 to 130 208 in fiscal year 2002, a 57.1% total increase, with a 4.8% increase in the annual dental visit rate. The experience suggests that access fo oral health care services can be improved through a multidimensional, strategically planned dental outreach initiative in spite of dramatic increases in Medicaid enrollment .     

Moral hazard in nursing home use

Nursing home expenditures are a rapidly growing share of national health care spending with the government functioning as the dominant payer of services. Public insurance for nursing home care is tightly targeted on income and assets, which imposes a major tax on savings; moreover, low state reimbursement for Medicaid patients has been shown to lower treatment quality, and bed supply constraints may deny access to needy individuals. However, expanding eligibility, increasing Medicaid reimbursement, or allowing more nursing home bed slots has the potential to induce more nursing home use, increasing the social costs of long-term care. A problem in evaluating this tradeoff is that we know remarkably little about the effects of government policy on nursing home utilization. We attempt to address this shortcoming using multiple waves of the National Long-Term Care Survey, matched to changing state Medicaid rules for nursing home care. We find consistent evidence of no effect of Medicaid policies on nursing home utilization, suggesting that demand for nursing home care is relatively inelastic with respect to public program generosity. From a policy perspective, this finding indicates that changes in overall Medicaid generosity will not have large effects on utilization.     

Family planning clinic services in the United States: patterns and trends in the late 1990s.

CONTEXT: Publicly funded family planning clinics are a vital source of contraceptive and reproductive health care for millions of U.S. women. It is important periodically to assess the number and type of clinics and the number of contraceptive clients they serve. METHODS: Service data were requested for agencies and clinics providing publicly funded family planning services in the United States in 1997. The numbers of agencies, clinics and female contraceptive clients were tabulated according to various characteristics and were compared with similar data for 1994. Finally, county data were tabulated according to the presence of family planning clinics and private physicians likely to provide family planning care and according to the number of female contraceptive clients served compared with the number of women needing publicly funded care. RESULTS: In 1997, 3,117 agencies offered publicly funded contraceptive services at 7,206 clinic sites. Forty percent of clinics were run by health departments, 21% by community health centers, 13% by Planned Parenthood affiliates and 26% by hospitals or other agencies. Overall, 59% of clinics received Title X funding. Agencies operated an average of 2.3 clinics, and clinics served an average of 910 contraceptive clients per year. Altogether, clinics provided contraceptive services to 6.6 million women-approximately two of every five women estimated to need publicly funded contraceptive care. The total number of providers and the total number of women served remained stable between 1994 and 1997; at the local level, however, clinic turnover was high. Some 85% of all US counties had one or more publicly funded family planning clinics; 36% had one or more clinics, but no private obstetrician-gynecologist. CONCLUSIONS: Publicly funded family planning clinics are distributed widely throughout the United States and continue to provide contraceptive care to millions of US women. Clinics are sometimes the only source of specialized family planning care available to women in rural counties. However, the high rate of clinic tumover and the lack of significant growth in clinic numbers suggest that limited funding and rising costs have hindered the further expansion and outreach of the clinic network to new geographic areas and hard-to-reach populations.     

Rethinking Medicaid Coverage and Payment Policy to Promote High Value Care: The Case of Long-Acting Reversible Contraception

Context

Long-acting reversible contraception (LARC) is the most effective reversible method to prevent unplanned pregnancies. Variability in state-level policies and the high cost of LARC could create substantial inconsistencies in Medicaid coverage, despite federal guidance aimed at enhancing broad access. This study surveyed state Medicaid payment policies and outreach activities related to LARC to explore the scope of services covered.