Utilization, Costs, and Access to Primary Care in Fee-for-Service and Managed Care Plans

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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Documentation of Contraception and Pregnancy Intention In Medicaid Managed Care

Health Services Research and Managerial Epidemiology ◽

10.1177/2333392817748870 ◽

2018 ◽

Vol 5 ◽

pp. 233339281774887 ◽

Cited By ~ 1

Author(s):

Heike Thiel de Bocanegra ◽

Alia McKean ◽

Philip Darney ◽

Erin Saleeby ◽

Denis Hulett

Keyword(s):

Primary Care ◽

Family Planning ◽

Managed Care ◽

Contraceptive Method ◽

Infant Health ◽

Random Effect ◽

Pregnancy Intention ◽

Care Providers ◽

Medicaid Managed Care ◽

Care Plans

Context: Clinical guidelines recommend the documentation of pregnancy intention and family planning needs during primary care visits. Prior to the 2014 Medicaid expansion and release of these guidelines, the documentation practices of Medicaid managed care providers are unknown. Methods: We performed a chart review of 1054 Medicaid managed care visits of women aged 13 to 49 to explore client, provider, and visit characteristics associated with documentation of immediate or future plans for having children and contraceptive method use. Five managed care plans used Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes to identify providers with at least 15 women who had received family planning or well-woman care in 2013. We conducted multilevel logistic regression analyses with documentation of contraceptive method and pregnancy intention as outcome variables and clinic site as the level 2 random effect. Results: Only 12% of charts had documentation of pregnancy intention and 59% documented contraceptive use. Compared to women with a family planning visit reason, women with an annual, reproductive health, or primary care reason for their visit were significantly less likely to have contraception documented (odds ratio [OR] = 11.0; 95% confidence interval [CI] = 6.8-17.7). Age was also a significant predictor with women aged 30 to 49 (OR = 0.6; 95% CI = 0.4-0.9), and women aged 13 to 19 (OR = 0.2; 95% CI = 0.1-0.6) being less likely to have a note about pregnancy intention in their chart. Pregnancy intention was more likely to be documented in multispecialty clinics (OR = 15.5; 95% CI = 2.7-89.2). Conclusions: Interventions to improve routine medical record documentation of contraception and pregnancy intention regardless of patient age and visit characteristics are needed to facilitate the provision of family planning in managed care visits and, ultimately, achieving better maternal infant health outcomes and reduced costs.

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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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Physician Deselection: The Dynamics of a New Threat to the Physician-Patient Relationship

American Journal of Law & Medicine ◽

10.1017/s009885880001203x ◽

1997 ◽

Vol 23 (4) ◽

pp. 511-537

Author(s):

Richard S. Liner

Keyword(s):

Primary Care ◽

Managed Care ◽

Care Physician ◽

Fee For Service ◽

Patient Relationship ◽

Physician Patient Relationship ◽

Green Is ◽

One Year ◽

Physician Patient ◽

Managed Care Organizations

Dr. Julia Green is a primary care physician (PCP) licensed to practice medicine in the Commonwealth of Massachusetts. On October 1, 1994, Dr. Green signed a one-year, renewable contract with Allcare Health Plan (AHP). Pursuant to the terms of the contract, on January 1, 1995, AHP placed her on its select list of PCPs available to its 100,000 covered lives (“enrollees”). Dr. Green provided for all primary care and specialist referrals for those enrollees who chose her as their physician. AHP paid her on a fee-for-service (FFS) basis for all preapproved procedures and treatments.Dr. Green felt that this contract might decrease her autonomy slightly; however, she also felt that it would increase her patient pool significantly and lessen the burden of collecting fees directly from patients. Dr. Green knew that choosing not to sign the contract would preclude AHP enrollees from making her their PCP because AHP only covered treatment provided by its own physicians. She further feared that as enrollment in managed care organizations (MCOs) increases, and more of her colleagues sign managed care contracts, her pool of potential patients would decrease drastically.

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Potemkin Protections: Assessing Provider Directory Accuracy and Timely Access for Four Specialties in California

Journal of Health Politics Policy and Law ◽

10.1215/03616878-9626866 ◽

2021 ◽

Author(s):

Abigail Burman ◽

Simon F. Haeder

Keyword(s):

Primary Care ◽

Managed Care ◽

Primary Care Providers ◽

Urgent Care ◽

Regulatory Regime ◽

Care Providers ◽

California Department ◽

Care Plans ◽

Consumer Access ◽

Timely Access

Abstract Context: Accurate provider directories and whether consumers can schedule timely appointments are crucial determinants of health access and outcomes. We assessed whether consumers can rely on provider directories to find in-network primary care providers, cardiologists, endocrinologists, and gastroenterologists for 2018 and 2019 for all managed care plans in California and whether they can access these providers in a timely manner. Method: We used large, random, and representative surveys of provider directories for all managed care plans in California for four specialties obtained from the California Department of Managed Health Care with a total of 657,012 observations (290,711 for 2018 and 475,524 for 2019). Findings: Surveys were able to verify provider directory entries for the four specialties for 59% to 76% of listings or 78% to 88% of providers reached. Moreover, we found that consumers were able to schedule urgent care appointments for 28% to 54% of listings or 44% to 72% of appropriately listed providers. For general care appointments, the percentages ranged from 35% to 64% of listed providers or 51% to 87% of appropriately listed providers. Differences across markets were generally small related to accuracy. Medi-Cal plans outperformed other markets with regards to timely access. Primary care consistently outperformed all other specialties. Timely access rates were higher for general appointments than for urgent care appointments. Conclusions: Despite the fact that California is one of the most active and well-resourced regulators in the nation, we found concerning results for consumers when it comes to locating in-network providers and gaining timely access. This raises questions about the regulatory regime as well as consumer access and health outcomes.

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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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