Abstract
BackgroundIn the United States (US), Medicaid capitated managed care costs are controlled by optimizing patients’ healthcare utilization. Adults in capitated plans utilize primary care providers (PCP) more than emergency departments (ED), compared to fee-for-service (FFS). Pediatric data are lacking. We aim to determine the association between US capitated and FFS Medicaid payment models and children’s outpatient utilization.MethodsThis retrospective cohort compared outpatient utilization between two payment models of US Medicaid enrollees aged 1–18 years using Truven’s 2014 Marketscan Medicaid database. Children enrolled > 11 months were included, and were excluded for eligibility due to disability/complex chronic condition, lack of outpatient utilization, or provider capitation penetration rate < 5% or > 95%. Negative binomial and logistic regression assessed relationships between payment model and number of visits or odds of utilization, respectively.ResultsOf 711,008 children, 66,980(9.4%) had FFS and 644,028(90.6%) had capitated plans. Children in capitated plans had greater odds of visits to urgent care, PCP-acute, and PCP-well-child care (aOR 1.21[95%CI 1.15–1.26]; aOR 2.07[95%CI 2.03–2.13]; aOR 1.86 [95%CI 1.82–1.91], respectively), and had lower odds of visits to EDs and specialty care (aOR 0.82 [95%CI 0.8–0.83]; aOR 0.61 [95%CI 0.59–0.62], respectively), compared to FFS.ConclusionsThe majority of children in this US Medicaid population had capitated plans associated with higher utilization of acute care, but increased proportion of lower-cost sites, such as PCP-acute visits and UC. Health insurance programs that encourage capitated payment models and care through the PCP may improve access to timely acute care in lower-cost settings for children with non-complex chronic conditions.
Highlights
In the United States (US), Medicaid capitated managed care costs are controlled by optimizing patients’ healthcare utilization
Children in FFS Medicaid plans are associated with greater expenditures [9] and in concordance with this, the portion of children enrolled in capitated managed care organizations (MCO) are rising and FFS plans declining [4, 10, 11]
What remains unknown is the association of current payment models on outpatient care-seeking behavior in children, after the major healthcare policy changes associated with the Affordable Care Act (ACA) in 2010 and the 2014 Medicaid expansion
Summary
In the United States (US), Medicaid capitated managed care costs are controlled by optimizing patients’ healthcare utilization. As public policy advocates for children, pediatric providers should have awareness of whether capitated payment models are associated with children’s use of cost-effective locations, such as the PCP. The effect of Medicaid payment models on children’s healthcare utilization was studied 2–3 decades ago, when the enrollment and management of Medicaid managed care differed greatly from today’s landscape. These studies found Medicaid managed care prepaid plans (akin to today’s capitated plans) were associated with no change in well child visits, and no change or decreased ED visits [12,13,14]. This study aims to describe the association of current Medicaid payment models with children’s utilization of outpatient care
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