Medicaid Managed Care Penetration Research Articles

Removing PA requirements for buprenorphine did not increase prescriptions

A study of 23 states from 2015 to 2019 found that the removal of prior authorization (PA) requirements, thought to be a barrier to buprenorphine prescribing, in Medicaid programs did nothing to increase prescribing. The study, “Removal of Medicaid Prior Authorization Requirements and Buprenorphine Treatment for Opioid Use Disorder,” which published in JAMA Health Forum on Oct. 4, did show some association in increased prescribing in states with low prescribing levels at baseline, but not in states with higher baseline prescribing. The findings do not mean that prior authorization—a technique used by payers to control utilization—is not a barrier, but rather, that it is not the only barrier, and that other barriers must be removed in order to increase prescribing of buprenorphine. Study results showed that: 1) six states in the sample removed Medicaid PAs for at least one buprenorphine formulation; 2) states that kept their PA requirements had lower buprenorphine prescribing and lower Medicaid managed care penetration, but similar opioid overdose rates to states that removed the PA requirements; and 3) for states with below‐median baseline buprenorphine prescribing, PA removal was associated with increased buprenorphine prescriptions, while states with above‐median prescribing showed no change. The researchers concluded that more efforts are needed to increase availability of buprenorphine. The lead author is Paul J. Christine, M.D., Ph.D., of the University of Colorado School of Medicine.

Removal of Medicaid Prior Authorization Requirements and Buprenorphine Treatment for Opioid Use Disorder

Buprenorphine treatment for opioid use disorder (OUD) is associated with decreased morbidity and mortality. Despite its effectiveness, buprenorphine uptake has been limited relative to the burden of OUD. Prior authorization (PA) policies may present a barrier to treatment, though research is limited, particularly in Medicaid populations. To assess whether removal of Medicaid PAs for buprenorphine to treat OUD is associated with changes in buprenorphine prescriptions for Medicaid enrollees. This state-level, serial cross-sectional study used quarterly data from 2015 through the first quarter (January-March) of 2019 to compare buprenorphine prescriptions in states that did and did not remove Medicaid PAs. Analyses were conducted between June 10, 2021, and August 15, 2023. The study included 23 states with active Medicaid PAs for buprenorphine in 2015 that required similar PA policies in fee-for-service and managed care plans and had at least 2 quarters of pre- and postperiod buprenorphine prescribing data. Removal of Medicaid PA for at least 1 formulation of buprenorphine for OUD. The main outcome was number of quarterly buprenorphine prescriptions per 1000 Medicaid enrollees. Between 2015 and the first quarter of 2019, 6 states in the sample removed Medicaid PAs for at least 1 formulation of buprenorphine and had at least 2 quarters of pre- and postpolicy change data. Seventeen states maintained buprenorphine PAs throughout the study period. At baseline, relative to states that repealed PAs, states that maintained PAs had lower buprenorphine prescribing per 1000 Medicaid enrollees (median, 6.6 [IQR, 2.6-13.9] vs 24.1 [IQR, 8.7-27.5] prescriptions) and lower Medicaid managed care penetration (median, 38.5% [IQR, 0.0%-74.1%] vs 79.5% [IQR, 78.1%-83.5%] of enrollees) but similar opioid overdose rates and X-waivered buprenorphine clinicians per 100 000 population. In fully adjusted difference-in-differences models, removal of Medicaid PAs for buprenorphine was not associated with buprenorphine prescribing (1.4% decrease; 95% CI, -31.2% to 41.4%). For states with below-median baseline buprenorphine prescribing, PA removal was associated with increased buprenorphine prescriptions per 1000 Medicaid enrollees (40.1%; 95% CI, 0.6% to 95.1%), while states with above-median prescribing showed no change (-20.7%; 95% CI, -41.0% to 6.6%). In this serial cross-sectional study of Medicaid PA policies for buprenorphine for OUD, removal of PAs was not associated with overall changes in buprenorphine prescribing among Medicaid enrollees. Given the ongoing burden of opioid overdoses, continued multipronged efforts are needed to remove barriers to buprenorphine care and increase availability of this lifesaving treatment.

State-Level Variation in Medicaid Managed Care Enrollment and Specialty Care for Publicly Insured Children

Medicaid and Children's Health Insurance Program cover almost 50% of children with special health care needs (CSHCN). CSHCN often require specialty services and have been increasingly enrolled in Medicaid managed care (MMC) plans, but there is a dearth of recent national studies on specialty care access among publicly insured children and particularly CSHCN. To provide recent, nationwide evidence on the association of MMC penetration with specialty care access among publicly insured children, with a special focus on CSHCN. This cross-sectional study used nationally representative data from the 2016 to 2019 National Survey of Children's Health to identify publicly insured children in 41 states that administered comprehensive managed care organizations for Medicaid. Data analysis was performed from May 2022 to March 2023. Form CMS-416 data were used to measure state-year level share of Medicaid-enrolled children who were covered by MMC (ie, MMC penetration). Measures of specialty care access included whether, in the past year, the child had (1) any visit to non-mental health (MH) specialists, (2) any visit to MH professionals, and (3) any unmet health care needs and (4) whether the caregiver ever felt frustrated getting services for their child. Logistic regression models were used to examine the association of MMC penetration with specialty care access among all publicly insured children, and separately for CSHCN and non-CSHCN. Among 20 029 publicly insured children, 7164 (35.8%) were CSHCN, 9537 (48.2%) were female, 4110 (37.2%) were caregiver-reported Hispanic, and 2812 (21.4%) were caregiver-reported non-Hispanic Black (all percentages are weighted). MMC was not associated with significant changes in any visit to non-MH specialists and unmet health care needs. In addition, MMC penetration was positively associated with caregiver frustration among all children (adjusted odds ratio, 1.23; 95% CI, 1.03-1.48; P = .02) and was negatively associated with any visit to MH professionals among CSHCN (adjusted odds ratio, 0.75; 95% CI, 0.58-0.98; P = .04). In this cross-sectional study evaluating MMC and specialty care access for publicly insured children, increased MMC enrollment was not associated with improved specialty care access for publicly insured children, including CSHCN. MMC was associated with less access to specialties like MH and increased frustrations among caregivers seeking services for their children.

State-Level Managed Care Penetration in Medicaid and Rates of Preventive Care Visits for Children.

To examine time trends in receipt of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services in serial cohorts of Medicaid beneficiaries <21 years, as Medicaid managed care (MMC) was adopted by states. Using annual state-level data from the Centers for Medicare & Medicaid Services, we performed national analyses of Medicaid beneficiaries <21 years from 2000 to 2017. We used generalized linear models to assess the relationship between MMC enrollment and EPSDT encounters, accounting for repeated measures, first at the national level overall and then specifying random effects at the state level. From 2000 to 2017, there was an increase at the national level in Medicaid beneficiaries <21 years enrolled in MMC, from 65% to 94%. At the national level, for every additional 100 enrollees in MMC there was an associated increase of 36 beneficiaries with an EPSDT visit (95% confidence interval: 19-53; P < .001). When accounting for state-level variation, for every additional 100 enrollees in MMC, there was an increase of 6 beneficiaries with an EPSDT visit (95% confidence interval: 2-10; P=.003). Examining the association between MMC penetration and EPSDT participation within each state, including the 50 states and Washington DC, there were 17 states with a significant positive association between MMC ratio and EPSDT participation, and 6 states with a significant negative association. As managed care has become the predominant form of Medicaid coverage, there has been a modest increase in preventive visits as indicated by EPSDT participation, with marked variation across states.

Engaging Consumers in Medicaid Program Design: Strategies from the States.

Policy Points As Medicaid programs grow in scale and complexity, greater consumer input may guide successful program design, but little is known about the extent to which state agencies are engaging consumers in the design and implementation of programs and policies.Through 50 semistructured interviews with Medicaid leaders in 14 states, we found significant variation in consumer engagement approaches, with many common facilitators, including leadership commitment, flexible strategies for recruiting and supporting consumer participation, and robust community partnerships. We provide early evidence on how state Medicaid agencies are integrating consumers’ experiences and perspectives into their program design and governance. ContextConsumer engagement early in the process of health care policymaking may improve the effectiveness of program planning and implementation, promote patient‐centric care, enhance beneficiary protections, and offer opportunities to improve service delivery. As Medicaid programs grow in scale and complexity, greater consumer input may guide successful program design, but little is known about the extent to which state agencies are currently engaging consumers in the design and implementation of programs and policies, and how this is being done.MethodsWe conducted semistructured interviews with 50 Medicaid program leaders across 14 states, employing a stratified purposive sampling method to select state Medicaid programs based on US census region, rurality, Medicaid enrollment size, total population, ACA expansion status, and Medicaid managed care penetration. Interview data were audio‐recorded, professionally transcribed, and underwent iterative coding with content and thematic analyses.FindingsFirst, we found variation in consumer engagement approaches, ranging from limited and largely symbolic interactions to longer‐term deliberative bodies, with some states tailoring their federally mandated standing committees to engage consumers. Second, most states were motivated by pragmatic considerations, such as identifying and overcoming implementation challenges for agency programs. Third, states reported several common facilitators of successful consumer engagement efforts, including leadership commitment, flexible strategies for recruiting and supporting consumers’ participation, and robust community partnerships. All states faced barriers to authentic and sustained engagement.ConclusionsSharing best practices across states could help strengthen programs’ engagement efforts, identify opportunities for program improvement reflecting community needs, and increase participation among a population that has traditionally lacked a political voice.

Consumer Engagement Strategies Among State Medicaid Agencies

Research ObjectiveTo understand how state Medicaid agencies engage consumers in programmatic and administrative decision making, including motivations behind these efforts; perceived benefits; and barriers and facilitators.Study DesignSemi‐structured interviews with 50 Medicaid program leaders across 14 states were conducted using a stratified purposive sampling method based on US census region, rurality, Medicaid enrollment size, total population, ACA expansion status, and Medicaid managed care penetration. Interviews were audiorecorded and professionally transcribed, and content and thematic analyses were conducted using an inductive approach.Population StudiedState Medicaid agencies.Principal Findings States vary in approaches to consumer engagement. All states reported a federally mandated Medical Care Advisory Council (MCAC), but a number of states customized these standing committees and adopted multi‐pronged approaches to engage different Medicaid populations. Common mechanisms of consumer engagement included standing committees for specific Medicaid topics (eg, long‐term care) or specific programmatic changes (eg, implementing a new managed care program); advocacy group meetings; town halls; and a variety of survey, focus group, and online input‐gathering mechanisms. Motivations for engaging consumers included identifying problems proactively; utilizing enrollee perspectives to improve health prevention and services; and assessing program efficacy, consumer experience, and impact of policy or care delivery changes. Few states linked consumer engagement with the mission of Medicaid; those that did emphasized goals like improving program value, enhancing “patient‐centered” care, and strengthening health equity. Active states formed partnerships with advocacy groups, foundations, and community organizations to support consumer recruitment and participation, facilitate meetings, and provide transportation or travel reimbursement. Strategies for meaningful consumer engagement included ensuring a feedback loop to communicate how consumer feedback is being used; investing time and staffing to facilitate effective interactions with consumers; aligning agency goals with consumer expectations; and training consumer participants to better understand technical language and Medicaid policy complexities. States with less‐robust engagement efforts described a number of common barriers, notably budget and staffing constraints, difficulty recruiting a diverse group of consumers, and sustaining participation over time. While many states could point to theoretical and anecdotal benefits of early consumer engagement, none collected data or monitored its effects. Few states knew of consumer engagement efforts occurring elsewhere in Medicaid, and none reported formal mechanisms for sharing experiences and learnings with other states. States with managed care plans described requiring plans to implement consumer engagement efforts, but none had systematic mechanisms to bring MCO level feedback back to state agencies. ConclusionsThere is significant heterogeneity in states’ efforts to involve consumers in Medicaid policy and programmatic decision making. States with robust efforts tended to be proactive, using diverse approaches and partnering with community organizations. While most states ensured minimum public‐ and consumer‐advocate representation on oversight committees, representation alone was insufficient.Implications for Policy or PracticeAs Medicaid programs grow in size and complexity, leaders face increased expectations to include input from consumers when making programmatic and administrative decisions. Sharing best practices across states could help strengthen consumer engagement efforts despite varying resource constraints and Medicaid program characteristics; identify opportunities for program improvement that reflects community needs; and increase public engagement among a population that has traditionally lacked political voice.Primary Funding SourceThe Robert Wood Johnson Foundation.

Associations Between the Patient Protection and Affordable Care Act Medicaid Primary Care Payment Increase and Physician Participation in Medicaid

The Patient Protection and Affordable Care Act (ACA) increased 2013 to 2014 Medicaid payment rates for qualifying primary care physicians (PCPs) and services to higher Medicare payment levels, with the goal of improving primary care access for Medicaid enrollees. To evaluate the payment increase policy and to assess whether it was associated with changes in Medicaid participation rates or Medicaid service volume among PCPs. This study used 2012 to 2015 IMS Health aggregated medical claims and encounter data from PCPs eligible for the payment increase practicing in all states except Alaska and Hawaii and included 20 723 PCPs with observations in each month from January 1, 2012, to December 31, 2015. Data are for professional services performed in ambulatory settings, including office, hospital outpatient department, and emergency department. Regression models were used to test whether outcomes differed in months subject to higher payment rates relative to months before the increase and after the expiration of the increase in some states. The models controlled for time-invariant physician characteristics and time-varying characteristics, such as Medicaid enrollment. Interaction terms were included to estimate differential associations in subgroups of states (eg, by Medicaid managed care penetration) and physicians (eg, by specialty). Physician-month records subject to higher Medicaid payment rates were flagged using state-specific implementation and end dates for the payment increase. Five outcomes were measured for each physician-month observation, including (1) an indicator for seeing any patients enrolled in Medicaid, (2) an indicator for seeing more than 5 patients enrolled in Medicaid, (3) the Medicaid share of total patients, (4) a count of new patient evaluation and management visits furnished to patients enrolled in Medicaid, and (5) a count of existing patient evaluation and management visits furnished to patients enrolled in Medicaid. Among 20 723 PCPs, the payment increase had no association with PCP participation in Medicaid or Medicaid service volume. The estimated average marginal effects for all 5 outcomes were not statistically distinguishable from 0. This null result was robust to sensitivity analyses, including different time trend specifications and analyses focusing on the payment increase implementation and expiration time frames. Descriptively, the Medicaid share of patients increased by about 25% from 2012 to 2015, although the share did not increase differentially in states and months subject to higher payment rates. The limited duration and design of the payment increase may have dampened its effectiveness. Future efforts to improve access through payment changes or other means can benefit from better understanding of the outcomes of this policy.

Medicaid Managed Care in Florida and Racial and Ethnic Disparities in Preventable Emergency Department Visits.

In an effort to address health care spending growth, coordinate care, and improve access to primary care in the Medicaid program, Florida implemented the Statewide Mandatory Managed Care (SMMC) program in May of 2014. The objective of this study is to investigate the impact of implementation of mandatory managed care in Medicaid on the preventable emergency department (ED) utilizations, with a focus on racial/ethnic minorities. The primary data source is the universe of Florida ED visit and inpatient discharge data from 2010 to 2015, maintained by the Florida Agency for Health Care Administration. We adopt the New York University Billing's ED Classification Algorithm to create measures for preventable ED visits. Using difference-in-differences estimation, we examine preventable ED visits for Florida residents aged 18-64 with a primary payer of Medicaid (treatment group) and private health insurance (control group) pre-SMMC and post-SMMC reform. Our findings show that SMMC is statistically significantly associated with more reductions in preventable ED visits among non-Hispanic African American (incidence rate ratio=0.81; 95% confidence interval, 0.70-0.94) and Hispanic (incidence rate ratio=0.72; 95% CI, 0.60-0.87) Medicaid enrollees relative to their white counterparts. We also find significant reduction of racial/ethnic disparities only in counties with above median preimplementation Medicaid managed care penetration rate. Our findings suggest that implementation of Medicaid mandatory managed care in Florida is associated with reduced racial/ethnic disparities in preventable ED visits.

Mandatory Statewide Medicaid Managed Care in Florida and Hospitalizations for Ambulatory Care Sensitive Conditions.

To investigate the impact of implementation of the Statewide Medicaid Managed Care (SMMC) program in Florida on access to and quality of primary care for Medicaid enrollees, measured by hospitalizations for ambulatory care sensitive conditions (ACSCs). We examine inpatient data obtained from the Agency for Health Care Administration for 285 hospitals in Florida from January 2010 to June 2015. The analysis includes 3,645,515 discharges for Florida residents between the ages 18 and 64 with a primary payer of Medicaid or private insurance. We use a difference-in-differences approach, comparing the change in the incidence of ACSC-related inpatient visits among Medicaid patients before and after the implementation of SMMC, relative to the change among the privately insured. After implementation of SMMC, Medicaid patients experienced a 0.35 percentage point slower growth in overall ACSC-related inpatient visits, and a 0.21 percentage point slower growth in chronic ACSC-related inpatient visits. The effects were significant in counties with above median Medicaid managed care penetration rates. Implementing mandatory managed care in Medicaid in Florida leads to slower growth in inpatient visits for conditions that can potentially be prevented with improved access to outpatient care.

The Adoption and Discontinuation of Clinical Services by Local Health Departments

We identified factors associated with local health department (LHD) adoption and discontinuation of clinical services. We used multivariate regression with 1997 and 2008 LHD survey and area resource data to examine factors associated with LHDs maintaining or offering more clinical services (adopter) versus offering fewer services (discontinuer) over time and with the number of clinical services discontinued among discontinuers. Few LHDs (22.2%) were adopters. The LHDs were more likely to be adopters if operating in jurisdictions with local boards of health and not in health professional shortage areas, and if experiencing larger percentage increase in non-White population and Medicaid managed care penetration. Discontinuer LHDs eliminated more clinical services in jurisdictions that decreased core public health activities' scope over time, increased community partners' involvement in these activities, had larger increases in Medicaid managed care penetration, and had lower LHD expenditures per capita over time. Most LHDs are discontinuing clinical services over time. Those that cover a wide range of core public health functions are less likely to discontinue services when residents lack care access. Thus, the impact of discontinuation on population health may be mitigated.

Managerialism and medical charity: How employing and pre-paying doctors affects the provision of free care in the United States

Since the mid-nineteenth century, the American Medical Association’s code of ethics has mandated that physicians provide charity care. However managerialism has threatened the likelihood of physicians’ providing charity care. Specifically, physicians who recently became employees, or whose revenue became predominantly pre-paid, also became less likely to provide free care. Moreover, physicians with an increased proportion of revenue from Medicaid, or in counties with high Medicaid managed care penetration, were less likely to provide charity, perhaps due in part to a reduced ability to cost-shift. Despite upcoming health reform, managerial strategies that employ or pre-pay physicians are likely to leave many millions of uninsured without access to charity care from physicians.

How Does Medicaid-Managed Care Impact Reporting of Medicaid Status?

To resolve a conflict in the literature on whether Medicaid-Managed Care (MMC) impacts the Medicaid Undercount. California county-level data (1995-1997) on MMC penetration, public use data from the Current Population Survey (CPS) (1995-1997), and restricted CPS data matched to administrative records on Medicaid enrollment (2001-2002). We explore the robustness of previous results from the literature first using aggregate data and alternative models. We then examine CPS data linked to Medicaid enrollment data to estimate models of Medicaid reporting errors related to MMC. The Census Bureau linked administrative data on Medicaid enrollment to the CPS. Other data used were public use. We find similar results to a previous study using aggregate data that suggest that MMC worsens reporting of Medicaid enrollment. However, using alternative methods we find those results are not statistically significant and can have opposite signs. Our linked CPS microdata analysis suggests that MMC improves reporting. The article concludes with implications of these results for policy makers. It is unlikely that increased MMC penetration explains the increased Medicaid Undercount.

The Effects of Medicaid Reimbursement on the Access to Care of Medicaid Enrollees: A Community Perspective

Previous research has not found a strong association between Medicaid reimbursement levels and enrollees' access to medical care, even though higher fees increase the acceptance of Medicaid patients by physicians. This study shows that high Medicaid acceptance rates by physicians in a community are more important than fee levels per se in affecting enrollees' access to medical care. Although high fee levels increase the probability that individual physicians will accept Medicaid patients, high fee levels do not necessarily lead to high levels of physician Medicaid acceptance in an area. Numerous other physician practice, health system, and community characteristics also affect Medicaid acceptance. The effects of Medicaid fees on Medicaid acceptance are substantially lower in areas with high Medicaid managed care penetration and for physicians who practice in institutional settings. The results suggest that a broad range of factors need to be considered to increase access to physicians for Medicaid enrollees.

The Impact of Medicaid Managed Care on Primary Care Physician Participation in Medicaid

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. 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. 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. 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.