In a comprehensive synthesis of studies of the impact of Medicaid managed care, the author concluded that Medicaid managed care can and sometimes does provide beneficiaries with improved access, but the scope and extent of such improvements generally are state specific and variable Sparer A synthesis of 16 studies on the potential impact of Medicaid managed care on access to and quality of care for children with special health care needs found no consistent set of findings regarding access to care Wise et al.
Many of the studies examined data prior to , and because they are state- and program-specific and almost always lack a control group, it is difficult to make generalizations to more recent data, particularly in expansion states. A study of Medicaid managed care in Texas concluded that overall, consumer satisfaction reflects that MCOs are meeting the healthcare needs of their members and satisfaction scores meet or exceed national and dashboard standards on a number of key measures Sellers Dorsey The researchers concluded that children with Type 1 diabetes enrolled in Medicaid managed care plans were less likely to be readmitted within 90 days of discharge, possibly indicating greater access to services that helped them prevent readmissions Healy-Collier et al.
A survey of state Medicaid programs found that over two-thirds of responding states with MCOs reported that Medicaid beneficiaries enrolled in MCOs sometimes experience access problems.
Problems with access to dental care, pediatric specialists, psychiatrists and other behavioral health providers, and other specialists e. At the same time, improved access to care — both primary and specialty care — was the most frequently cited perceived benefit of managed care relative to fee-for-service. Some states indicated that where an access problem existed, it usually paralleled a similar problem encountered by persons with other types of insurance, for example, due to provider shortages and other market factors.
The survey, however, did not directly collect information on access problems in fee-for-service Medicaid Gifford A secret shopper study conducted by the Office of the Inspector General found that slightly more than half of Medicaid providers could not offer appointments to enrollees. Notably, 35 percent could not be found at the location listed by the plan and another 8 percent were at the location but said that they were not participating in the plan.
An additional 8 percent were not accepting new patients. Among the providers who offered appointments, the median wait time was 2 weeks.
However, over a quarter had wait times of more than 1 month, and 10 percent had wait times longer than 2 months. Finally, primary care providers were less likely to offer an appointment than specialists; however, specialists tended to have longer wait times OIG Inadequacies in access to specialist care, stemming from system-wide shortages of specialists and the maldistribution of the specialist workforce, can be worse in Medicaid than among privately insured individuals. Particularly in rural areas, long distances to reach providers and public transportation patterns can create barriers to adequate access; indeed, patients may have to travel 50 to miles to see a specialist.
Access to dental services is often especially challenging, and more so in rural areas. Gaps in access to specialty care may grow even wider if MCOs enroll more beneficiaries with complex needs, who may rely on specialists as their primary care providers or make more use of selected specialized services, such as mental health care Gold and Paradise It is not clear whether managed care provides better or worse access to care than FFS. The same synthesis of research on Medicaid managed care plans shows mixed success in improving access to care.
There is some evidence of increased likelihood of a usual source of care and reduced emergency department visits Sparer One study found that the transition to Medicaid managed care in Puerto Rico was associated with an increased use of prenatal care services Marin et al. Another study in Mississippi concluded that the number of medications filled, number of office visits, intensity of office visits, total pharmacy costs and total outpatients costs, all of which are indicators of improved access, were found to increase after the shift to managed care.
Days of inpatient stay, inpatient costs and emergency department costs all decreased, which is consistent with the incentives provided under a capitated payment system Ramachandran et al. Researchers also found that the transition from FFS to Medicaid managed care in South Carolina was associated with an Conversely, a study of the Florida Medicaid program found that Medicaid managed care patients are more likely to be hospitalized for ambulatory care sensitive conditions than were Medicaid FFS enrollees.
These results suggest that Medicaid managed care enrollees faced greater barriers to accessing primary and preventive health care services than their FFS counterparts Park and Lee Based on these findings, both administrators and practitioners have a role in maintaining awareness regarding their perceptions and should work collaboratively to address issues of concern. Similarly, promoting trust and commitment at the organizational level is important.
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Culture clashes, turf battles, job changes, sometimes even layoffs: Welcome to the world of integrated healthcare. Strategies for Healthcare Excellence 1 General Accounting Office Health Care Financing Administration. Medicare managed care contract report. Medicare managed care market penetration for all medicare plan contractors Author, Baltimore, MD.
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Abstract Managed care is reshaping our health care system, although long-term care is only beginning to feel its effects. Table 1. Characteristics of Sampled Facilities and Residents.
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Love Limits. Looking for your next opportunity? Physician-Scientist Faculty Position. Infectious Disease Physician. Senior Clinician. States determine how they will deliver and pay for care for Medicaid beneficiaries. Medicaid managed care organizations MCOs provide comprehensive acute care and in some cases long-term services and supports to Medicaid beneficiaries. MCOs accept a set per member per month payment for these services and are at financial risk for the Medicaid services specified in their contracts.
States have pursued risk-based contracting with managed care plans for different purposes, seeking to increase budget predictability, constrain Medicaid spending, improve access to care and value, and meet other objectives. While the shift to MCOs has increased budget predictability for states, the evidence about the impact of managed care on access to care and costs is both limited and mixed. Figure 1: As of July , 40 states used capitated managed care models to deliver services in Medicaid.
States pay Medicaid managed care organizations MCOs a set per member per month payment for the Medicaid services specified in their contracts. Under federal law, payments to Medicaid MCOs must be actuarially sound.
Plan rates are usually set for a month rating period and must be reviewed and approved by CMS each year. States may use a variety of mechanisms to adjust plan risk, incentivize plan performance, and ensure payments are not too high or too low, including risk sharing arrangements, risk and acuity adjustments, medical loss ratios MLRs , or incentive and withhold arrangements. As a result, many states are evaluating options to make adjustments to existing MCO rates and risk sharing mechanisms in response to unanticipated COVID costs and conditions that have led to decreased utilization.
Under existing Medicaid managed care authority, states have several options to address payment issues that have arisen as a direct result of the COVID pandemic. As of July ,
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