Health plan responses to managed care regulation

Little effort has been made to understand operational responses of health plans to the cascade of regulation imposed on them in the past decade. Using data from the Community Tracking Study, we cast some light on this area and illustrate how regulatory initiatives have produced both intended and unintended consequences. The findings both confirm speculation about regulatory effects and reveal some surprising and troubling developments.     

A typology of Medicaid managed care

This article presents a typology for use in classifying and interpreting the findings of the growing empirical literature on managed care initiatives in the Medicaid program. Six key program attributes are identified for use in examining similarities and differences among these programs. Several alternative arrangements for each attribute are described from among the more than 60 different programs attempted. The typology is illustrated with five specific program designs, and selected empirical results from them are used to demonstrate how the typology can be employed.     

The impact of Medicaid managed care on primary care physician participation in Medicaid

OBJECTIVES: Medicaid managed care has been touted as an important vehicle for increasing physician participation in Medicaid. Although there is anecdotal evidence that the opportunity to participate in Medicaid via managed care increases physician participation, no empirical study has validated the claim. This study explores the relationship between Medicaid managed care penetration at the county-level and the likelihood that a physician practicing in that county will participate in Medicaid. RESEARCH DESIGN: We used 3 waves of a large, nationally representative sample of primary care physicians from the Community Tracking Study followed across time (1996-2001) to estimate the impact of changing Medicaid managed care penetration levels on physician participation in the program. County-level Medicaid managed care penetration rates were collected directly from state Medicaid agencies for the study. FINDINGS: In cross-sectional bivariate and multivariate analyses, Medicaid managed care penetration is significantly associated with physician participation in Medicaid; however, the relationship is nonmonotonic, of small magnitude and generally not in the anticipated direction. Our analyses indicate that a 10 percentage point increase in managed care penetration would reduce the likelihood that physicians participate in Medicaid on average by 2.9 percentage points. Although commercial MCO penetration exhibited a small positive, linear relationship with physician participation, this was not sufficient to offset the effects of Medicaid-dominant MCO penetration. Panel data analysis supported these findings. CONCLUSIONS: This study failed to find that increases in Medicaid managed care lead to increased primary care physician participation in Medicaid during the period 1996-2001.     

Medicaid managed care: there's more for states to do

Medicaid is a cornerstone of this country's health care system, covering over 50 million people and supplying one in five health care dollars in the United States. Medicaid is again a contested issue in state capitols, where states facing sluggish revenues target Medicaid since it is the second largest and fastest growing component of state spending. Managed care was the policy tool many states embraced in order to slow Medicaid spending, and while managed care has had some successes in improving Medicaid services, it has not met states' expectations for cost savings. This analysis explores several reasons why these savings have not been realized, and proposes policy reforms for state Medicaid programs that would make Medicaid coverage more stable, thereby increasing the ability of managed care plans and network providers to work with Medicaid beneficiaries to change patterns of care and realize real savings.     

Medicaid families under managed care. Anticipated behavior

This study reports the results of a household survey of 495 Medicaid clients eligible under the Aid to Families with Dependent Children program in Monroe County, New York. The purpose of the study has been to examine the views and to anticipate the health care choices/decisions of Medicaid clients prior to their enrollment in a new, county-wide Medicaid-managed care program. The findings indicate significant ethnic differentials among the Medicaid poor, both in the choice of care source and in the reasons offered for that choice. Forty percent of those interviewed would like to change to a new source of care, but less than 13% can actually be expected to change. Private practice arrangements were the preferred source of care, yet distance to such sources appears to represent a major stumbling block to access. This study suggests that the managed-care approach being offered in Monroe County may offer the Medicaid eligibles a new stigma-free way of affiliating with a health care provider. This is being recognized by those surveyed as an important element. The study demonstrates that the choices made by the Medicaid recipients are perfectly rational given the recipients' knowledge of Medicaid and the health care system, and the general conditions in which they find themselves. These findings have important implications for the move of Medicaid programs from the fee-for-service to the managed-care/HMO system.     

The impact of financial incentives on utilization and outcomes of diabetes prevention programs among Medicaid managed care adults in New York state

Diabetes prevalence has risen rapidly and has become a global health challenge. The Diabetes Prevention Program (DPP) has been shown to prevent or delay the development of diabetes among individuals with prediabetes. Yet, diabetes prevention studies within the Medicaid population are limited and results are mixed. This study aimed to evaluate the impact of different financial incentive strategies on the utilization of the DPP for Medicaid managed care adults in New York State.A four-arm randomized controlled trial was conducted among Medicaid managed care adult enrollees diagnosed with prediabetes and/or obesity. Study participants were offered a 16-week DPP with various incentive strategies based on class attendance and weight loss as follows: Attendance-Only, Weight-Loss Only, and both Attendance and Weight-Loss. A control group was offered DPP with no incentives for attendance or weight loss. We evaluated the impact of incentives on achievement of the program completion and weight-loss milestone.Participants who received incentives for the Attendance-Only class were least likely to be lost to follow-up, more likely to complete the program, and had two times higher percentage of meeting the weight-loss milestone compared to the control group. Results for the other incentive cohorts were mixed. A strong positive association was observed for participants who attended 9 or more classes and weight-loss regardless of incentive strategies.Providing monetary incentives for DPP class attendance had a positive impact on program completion and achieving the weight-loss milestone. However, the results from this study indicate that participant enrollment and retention remained challenges despite the incentives.     

Serving people with developmental disabilities in Medicaid managed care.

Concurrent with the sweeping changes in health care during the past decade, particularly in Medicaid financed health care, has been the reshaping of social policy toward people with developmental disabilities. The extent to which managed care entities match the themes now driving social services for people with mental retardation and other developmental disabilities (cerebral palsy, autism, etc.) is the extent to which they will be successful in serving this unique group of consumers of managed health care. The authors suggest a number of considerations for managed care organizations that increasingly serve significant numbers of this population.     

The contribution of Medicaid managed care to the increasing undercount of Medicaid beneficiaries in the Current Population Survey

BACKGROUND: The Current Population Survey (CPS) is an important source of data for comparing beneficiaries across insurance groups. However, the CPS routinely underestimates the Medicaid population, and for unexplained reasons these underestimates have been increasing over time. OBJECTIVE: We sought to determine whether the penetration of Medicaid managed care is associated with the magnitude of the underestimate of Medicaid beneficiaries in the CPS using a pooled cross-sectional comparison of survey and administrative databases on all California Medicaid beneficiaries younger than 65 years of age. MEASURES: We compared the CPS estimates of Medicaid beneficiaries in California from 1995 to 1999 with the gold-standard number derived from the Medicaid eligibility file for the same time period and examined the association between the CPS underestimate and penetration of managed care in the beneficiary's county. RESULTS: The CPS underestimated the Medicaid population by approximately a third. At the county level, errors in estimated numbers of Medicaid beneficiaries in the CPS increased in association with the penetration of Medicaid managed care. Each percentage point increase in the penetration of managed care was associated with an underestimate in the CPS of 0.4 percentage points. CONCLUSION: A substantial portion of the increase in the underestimates of the number of Medicaid beneficiaries in the CPS can be explained by the growth of Medicaid managed care. Steps must be taken to improve the CPS if this survey is to remain useful for making accurate estimates of Americans' health insurance status.     

Success of Medicaid managed care using a public-private sector model

This article provides an overview of Wisconsin's Mandated Medicaid Managed Care Initiative--the physician network--Wisconsin Independent Physicians Group (WIPG) that provides and manages the medical services for many of these Medicaid recipients and the public and private sector partnership that has helped to make this program successful. Special programs, such as the Prenatal Support Program, implemented by WIPG are described along with detail regarding the successful outcomes resulting from the programs. The article also includes the quality of care, improved outcomes and financial success of the Initiative when compared to the state's Medicaid fee-for-service program counterpart. Additional discussion includes capitation versus fee-for-services payments, mandated versus voluntary enrollment, and combining social services with medical services to improve health outcomes.     

Health status of the New York City prison population

During a two-week period in June 1975, all 1,420 prisoners admitted to New York City Correctional Facilities were studied to determine the prevalence of current and past health conditions. Information was obtained from a standard admission health examination. Almost three-quarters of the male and female prisoners were 30 years or less. Of the study population, 57 per cent were black, 24 per cent were Hispanic and 17 per cent were white. Forty-one per cent reported a history of illicit drug use. More than one-quarter of the prisoners reported a present illness and three-fifths received at least one diagnosis. Commonly diagnosed conditions included drug abuse, psychiatric disorder, trauma, and alcohol abuse. Seven per cent of male prisoners had a previous psychiatric hospitalization. On examination, new trauma was noted in 10 per cent of the male population. In addition to these findings, a history of seizure disorder was reported in 4 per cent of the male population. Health services within prisons must be able to manage the most pressing problems in this population-substance abuse and psychiatric disorder and provide care for the range of conditions that is similar to that found in the general population for this age group.     

Effects of a prior-authorization policy for celecoxib on medical service and prescription drug use in a managed care Medicaid population

BACKGROUND: Prior authorization (PA) is a poorly studied but commonly employed policy used by health care payers to manage the rising costs of pharmacy benefits. OBJECTIVE: The aim of this study was to evaluate the intended and unintended effects of a PA policy for celecoxib on pharmacy and medical-service utilization in a Medicaid managed-care organization. METHODS: This was a retrospective, interrupted time-series analysis of 22 monthly health-related utilization rates from January 1, 1999, to October 31, 2000. All Medicaid claims for CareOregon (a managed-care organization) and a fee-for-service program were reviewed. A model was constructed to evaluate changes in utilization of therapeutically related drug classes (eg, conventional nonsteroidal anti-inflammatory drugs [NSAIDs], gastrointestinal agents), office and emergency-department encounters, and hospitalizations before and after the PA policy was implemented on November 16, 1999. A secondary analysis evaluated these changes among a sample of prior NSAID users. RESULTS: After the PA policy was implemented, use of celecoxib was immediately reduced from 1.07 to 0.53 days' supply per person-year (58.9%; 95% CI, 50.0%-67.9%). The monthly rate of increase was also reduced (P < 0.001). Utilization changes were not observed in other drug classes. Similar changes were observed in the secondary analysis. An 18% (95% CI, 2.2%-33.9%) nonsignificant increase in emergency-department visits was observed in the entire sample after the PA policy was implemented. However, a similar change was not observed in the secondary analysis of prior NSAID users. No other changes in medical service encounters were noted after the PA policy was activated. CONCLUSIONS: This observational study found that celecoxib use was substantially reduced after the implementation of a PA policy. No important changes in use of other drug classes were detected. The overall increase in emergency-department visits--although not observed among previous NSAID users--should be explored on the individual level.