Market and Beneficiary Characteristics Associated With Enrollment in Medicare Managed Care Plans and Fee-for-Service

Medicaid programs increasingly finance competing, capitated managed care plans rather than administering fee-for-service (FFS) programs. We study how the transition from FFS to managed care affects high- and low-cost infants (blacks and Hispanics, respectively). We find that black-Hispanic disparities widen—e.g., black mortality and preterm birth rates increase by 15 percent and 7 percent, respectively, while Hispanic mortality and preterm birth rates decrease by 22 percent and 7 percent, respectively. Our results are consistent with a risk-selection model whereby capitation incentivizes competing plans to offer better (worse) care to low- (high-) cost clients to retain (avoid) them in the future. (JEL H75, I12, I18, I38, J13, J15)

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Racial and Ethnic Differences in Receipt of Primary Care Services Between Medicaid Fee-for-Service and Managed Care Plans

Journal of Ambulatory Care Management ◽

10.1097/01.jac.0000278986.18428.12 ◽

2007 ◽

Vol 30 (3) ◽

pp. 264-273 ◽

Cited By ~ 7

Author(s):

Hilary K. Seligman ◽

Arpita Chattopadhyay ◽

Eric Vittinghoff ◽

Andrew B. Bindman

Keyword(s):

Primary Care ◽

Managed Care ◽

Ethnic Differences ◽

Fee For Service ◽

Racial And Ethnic Differences ◽

Care Plans ◽

Care Services ◽

Primary Care Services

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Risk Selection among SSI Enrollees in TennCare

INQUIRY The Journal of Health Care Organization Provision and Financing ◽

10.5034/inquiryjrnl_39.2.152 ◽

2002 ◽

Vol 39 (2) ◽

pp. 152-167 ◽

Cited By ~ 2

Author(s):

Steven C. Hill ◽

Craig Thornton ◽

Christopher Trenholm ◽

Judith Wooldridge

Keyword(s):

Managed Care ◽

Care Program ◽

Risk Selection ◽

Fee For Service ◽

Health Care Needs ◽

Care Needs ◽

Medicaid Managed Care ◽

Care Plans ◽

Alternative Measures ◽

Selection For

The issue of risk selection is especially important for states that enroll blind and disabled beneficiaries of Supplemental Security Income (SSI) in Medicaid managed care. SSI beneficiaries have persistent needs for care, have a wide variety of chronic conditions, and often need atypical and complex services. Risk selection occurs when the health care needs of beneficiaries enrolled in a specific plan differ systematically from the needs of the overall beneficiary population and payments do not reflect those needs. We assess the extent of risk selection among managed care plans for SSI beneficiaries over the first three years of Tennessee's Medicaid managed care program, TennCare. Using claims data containing fee-for-service expenditures prior to enrollment in managed care, we find substantial evidence of persistent risk selection among plans. Results are robust to most alternative measures of risk selection for most plans.

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Empowered and disempowered voices of low-income people with disabilities on the initiation of government-funded, managed health care

10.31234/osf.io/4dcw6 ◽

2016 ◽

Author(s):

Kathleen McAuliff ◽

Judah Viola ◽

Christopher Keys ◽

Lindsey T. Back ◽

Amber E. Williams ◽

...

Keyword(s):

Managed Care ◽

Focus Groups ◽

Family Caregivers ◽

Low Income ◽

Hospital Admissions ◽

Evaluation Research ◽

Care Program ◽

Fee For Service ◽

Care Plans ◽

Managed Care Organizations

The health and healthcare of vulnerable populations is an international concern. In 2011, a Midwestern state within the U.S. mandatorily transitioned 38,000 Medicaid recipients from a fee-for-service system into a managed care program in which managed care companies were contracted to provide recipients’ healthcare for a capitated rate. In addition to cost savings through reductions in preventable and unnecessary hospital admissions, the goals of the managed care program (MCP) included: (1) access to a more functional support system, which can support high and medium risk users in the development of care plans and coordination of care, and (2) choice among competent providers. The population transitioned was a high-need, high-cost, low-income, and low-power group of individuals. The evaluation research team used focus groups as one of many strategies to understand the experience of users during the first two years of this complex change effort. The article explores empowerment in terms of users and their family caregivers’ ability to make meaningful choices and access resources with regard to their healthcare. Specifically, factors empowering and disempowering users were identified within three thematic areas: (1) enrollment experiences, (2) access to care and (3) communication with managed care organizations and providers. While the change was not optional for users, a disempowering feature, there remained opportunities for other empowering and disempowering processes and outcomes through the transition and new managed care program. The results are from 74 participants: 65 users and 9 family caregivers in 11 focus groups and six interviews across two waves of data collection. MCP users felt disempowered by an initial lack of providers, difficulty with transportation to appointments, and challenges obtaining adequate medication. They felt empowered by having a choice of providers, good quality of transportation services and clear communication from providers and managed care organizations. Recommendations for increasing prospects for the empowerment of healthcare users with disabilities within a managed care environment are presented.

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Comparing Care for Dual-Eligibles Across Coverage Models: Empirical Evidence From Oregon

Medical Care Research and Review ◽

10.1177/1077558717740206 ◽

2017 ◽

Vol 76 (5) ◽

pp. 661-677 ◽

Cited By ~ 2

Author(s):

Hyunjee Kim ◽

Christina J. Charlesworth ◽

K. John McConnell ◽

Jennifer B. Valentine ◽

David C. Grabowski

Keyword(s):

Managed Care ◽

Financial Incentives ◽

Service Use ◽

Fee For Service ◽

Care Plans ◽

Dual Eligibles ◽

Dual Eligible ◽

Coverage Models ◽

Substantial Heterogeneity

Dual-eligible beneficiaries or “duals” are individuals enrolled in both the Medicare and Medicaid programs. For both Medicare and Medicaid, they may be enrolled in fee-for-service or managed care, creating a mix of possible coverage models. Understanding these different models is essential to improving care for duals. Using All-Payer All-Claims data, we empirically described health service use and quality of care for Oregon duals across five coverage models with different combinations of fee-for-service, managed care, and plan alignment status across Medicare and Medicaid. We found substantial heterogeneity in care across these five coverage models. We also found that duals in plans with aligned financial incentives for Medicare and Medicaid experienced more improvement in their care relative to those with nonaligned Medicare Advantage and Medicaid managed care plans. These results highlight the importance of developing policies that account for the heterogeneity of the dual population and their coverage options.

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Better Quality of Care or Healthier Patients? Hospital Utilization by Medicare Advantage and Fee-for-Service Enrollees

Forum for Health Economics & Policy ◽

10.1515/fhep-2012-0037 ◽

2013 ◽

Vol 16 (1) ◽

pp. 137-161 ◽

Cited By ~ 8

Author(s):

Lauren Hersch Nicholas

Keyword(s):

New York ◽

Managed Care ◽

Clinical Information ◽

Care Utilization ◽

Fee For Service ◽

Medicare Beneficiaries ◽

Preventable Hospitalizations ◽

Care Plans ◽

Proxy Measure ◽

Enrollment Data

Abstract Do differences in rates of use among managed care and Fee-for-Service Medicare beneficiaries reflect selection bias or successful care management by insurers? I demonstrate a new method to estimate the treatment effect of insurance status on health care utilization. Using clinical information and risk-adjustment techniques on data on acute admission that are unrelated to recent medical care, I create a proxy measure of unobserved health status. I find that positive selection accounts for between one-quarter and one-third of the risk-adjusted differences in rates of hospitalization for ambulatory care sensitive conditions and elective procedures among Medicare managed care and Fee-for-Service enrollees in 7 years of Healthcare Cost and Utilization Project State Inpatient Databases from Arizona, Florida, New Jersey and New York matched to Medicare enrollment data. Beyond selection effects, I find that managed care plans reduce rates of potentially preventable hospitalizations by 12.5 per 1000 enrollees (compared to mean of 46 per 1000) and reduce annual rates of elective admissions by 4 per 1000 enrollees (mean 18.6 per 1000).

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