Medicaid Managed Care Research Articles

Nuts and Bolts of Dental Medicaid Managed Care

North Carolina has adopted managed care for administration of its Medicaid program for management of medical benefits. The North Carolina Medicaid dental program, however, continues to be administered through a traditional fee-for-service model. This article addresses what a managed care model for Medicaid dental could look like in North Carolina.

Commercial insurers' market power and hospital prices in Medicaid managed care.

To examine the relationship between insurers' commercial market power and negotiated prices in Medicaid Managed Care (MMC) plans for hospital care. MMC prices from hospital-disclosed price transparency data as of July 2023 compiled by Turquoise Health, insurance enrollment information from the 2021 Clarivate InterStudy enrollment data. Log-transformed linear regression with hospital and procedure fixed effects estimating the within-hospital MMC price variation as a function of insurers' commercial market share quartile and MMC market share for 15 common outpatient hospital services. A total of 39,049 MMC price samples measured at hospital-procedure-MMC insurer level are merged with county-insurer level market share data. Around 25% of price variation in MMC plans are driven by within-hospital factors. Compared with MMC insurers from the lowest commercial market share quartile (<0.8%), those from the highest commercial market share quartile (>17%) are associated with negotiating 4.6% (95% confidence interval: [2.8%-6.4%], p < 0.001) lower MMC prices for outpatient hospital care, including 3.6% (p < 0.05) for medical/surgical procedures, 3.6% (p < 0.01) for radiology, and 6.7% (p < 0.001) for emergency department visits. MMC insurers with substantial commercial market share negotiate lower MMC prices for multiple outpatient hospital services.

Managing Eating Disorders Within Medicaid-Funded Health Care Systems in California.

This study describes the current management of patients with eating disorders (EDs) served by publicly-funded Medicaid behavioral health systems. Behavioral health leaders across nine counties in California met on a quarterly basis to share experiences, challenges, and lessons in the management of EDs within publicly-funded service systems. Detailed notes were taken, and a qualitative content analysis was undertaken to identify key themes. County leadership noted insufficient outpatient capacity and difficulty building capacity for ED treatment, in addition to extraordinary challenges when facilitating admission to out-of-network higher level of care programs, at significant expense. Several challenges were identified in building an internal ED workforce, including the fact that many providers weren't eager to treat EDs due to training burden, patient complexity, and high levels of clinician burnout. When a higher level of care was required due to lack of outpatient resources or patient symptom severity or complexity, leaders dedicated significant resources to identify and contract with an appropriate program and secure the necessary funds. Our study supports the need for specialized ED treatment and case management, as well as standardized processes and centralized resources, in Medicaid-managed care. Findings also indicate the importance of protecting against clinician burnout, possibly through reduced caseload expectations, financial incentives, or increased support. Future policy change could reduce administrative burden and clinician burnout by facilitating admission to and reimbursement for higher levels of care.

The Effect of Mandatory Medicaid HMOs on Health Access, Utilization, and Health Outcomes for Children

ObjectiveMandatory enrollment into Medicaid-contracted Health Maintenance Organizations (HMOs) is the most common form of Medicaid managed care (MMC), but the effects of this enrollment on children are unclear. We leveraged variation in MMC implementation within and across states over time to examine the effect of mandatory Medicaid HMO enrollment on children’s access, utilization, and health outcomes. MethodsUsing Medical Expenditure Panel Survey data from 2000 to 2018 and multivariable regression models, we estimated the effects of living in a county with mandatory Medicaid HMO enrollment only, compared to other MMC types and FFS combined in one comparison group, on outcomes for children under 18 years. We also evaluated potential effect heterogeneity across age, race/ ethnicity, and for children with special healthcare needs (CSHCNs). ResultsThere were small and non-significant associations between mandatory HMO enrollment and most outcome measures. However, mandatory HMO enrollment was associated with a 1.8 percentage-point decline in the likelihood of having a usual source of care,95% CI[-0.035,-0.001], a 4.2 percentage-point increase in the likelihood of delayed access to care,95% CI[0.012,0.072], and a 2.2 percentage-point reduction in the likelihood of having any outpatient physician visits, 95% CI[-0.043,-0.0004], compared to other MMC and FFS combined in one group. Mandatory HMO enrollment was associated with more difficulty seeing a specialist for CSHCNs. ConclusionsOverall, there is little evidence that mandatory Medicaid HMO enrollment has discernable and consistent effects across a broad range of outcomes. Evaluating how mandatory Medicaid HMOs affect more nuanced healthcare measures especially for children with greater healthcare needs remains an important future research question.

Complexity of patient encounters within a clinically integrated community pharmacy network Medicaid payer program

BackgroundCommunity pharmacists frequently care for patients with complex medical and social needs; however, specific evidence on pharmacist perceptions of what makes a patient encounter complex has not been clearly characterized. There is a need to better understand specific factors that contribute to patient encounter complexity and demonstrate how pharmacists in community settings care for these individuals. ObjectivesThe objectives of this programmatic case study were to: (1) elucidate factors that contributed to patient encounter complexity as a part of a Medicaid Managed Care Organization comprehensive medication management payer program in community pharmacies and (2) curate a series of patient case vignettes that provide evidence of pharmacists care for patients with complex medical and social needs within community pharmacies. MethodsThis qualitative programmatic case study utilized data from semistructured interviews with community pharmacists who provided comprehensive medication management services to Medicaid patients in Pennsylvania. Pharmacists described their most complex patient encounter. Interviews were transcribed and independently coded by 2 investigators. The coded texts were grouped into categories, and a cross-case inductive thematic analysis was performed to identify complexity factors. ResultsThirty pharmacists provided 48 patient case vignettes and 3 complexity factors emerged: (1) care coordination, (2) behavioral health support, and (3) social determinants of health. Representative patient case vignettes were selected to illustrate these factors. ConclusionPharmacists, who participated in a community pharmacy Medicaid Managed Care Organization payer program, provided care to patients with complex health needs. In addition to medication-related problems, specific factors that increased pharmacist perception of encounter complexity were care coordination with other health care providers, behavioral health support, and addressing social determinants of health.

Treatment patterns in patients with newly diagnosed COPD in the USA

BackgroundPrompt and effective management with maintenance therapy (single or dual bronchodilator therapy) is recommended after the initial diagnosis of chronic obstructive pulmonary disease (COPD) to maintain lung function and prevent exacerbations. Contrary to guideline-based recommendations, most patients are not prescribed maintenance treatment at initial diagnosis. The current study assessed the pharmacologic treatment patterns and outcomes of newly diagnosed patients with COPD in the USA.MethodsThis retrospective, noninterventional study used de-identified data from the Inovalon Insights’ database (Commercial, Medicaid Managed Care, and Medicare Advantage–insured individuals) between January 1, 2015, and December 31, 2021. The “patient journey” from initial diagnosis was followed over a 4-year period. The primary outcome measure was the number of moderate or severe exacerbations. Secondary outcome measures included the cumulative incidence of exacerbations, mean cumulative count of moderate and severe exacerbations, rates of moderate and severe exacerbations in patients who remained untreated after diagnosis in 12-month time periods for 4 years, sociodemographic and clinical characteristics, and pharmacologic treatment patterns.ResultsThe cohort consisted of 238,158 newly diagnosed patients with COPD (female [52.9%]; mean age 63.8 years). The majority of patients with COPD had Medicaid as their primary insurance (46.2%). Overall, during the 4-year follow-up period, 32.9% of the patients had at least one moderate or severe exacerbation, and 25.8% and 13.8% experienced moderate and severe exacerbations, respectively. At diagnosis, 86.2% of the patients were untreated and most remained untreated by the end of the follow-up (63.8%). Most patients (62.0%) received long-acting beta-agonist (LABA)/inhaled corticosteroids (ICS) as their initial treatment at diagnosis, and LABA/ICS continued to be the most common initial treatment during the 4-year period (64.0% at year 1; 58.0% at year 4).ConclusionsMost patients with COPD were not treated at initial diagnosis and remained untreated during follow-up. Our data highlight a lack of adherence to recommendations for clinical practice.

M142 - Opioid Use Disorder Treatment in Medicaid Managed Care Plans

M142 - Opioid Use Disorder Treatment in Medicaid Managed Care Plans

Most States Allow Medicaid Managed Care Plans Discretion To Restrict Substance Use Disorder Treatment Benefits.

Managed care plans, which contract with states to cover three-quarters of Medicaid enrollees, play a crucial role in addressing the drug epidemic in the United States. However, substance use disorder benefits vary across Medicaid managed care plans, and it is unclear what role states play in regulating their activities. To address this question, we surveyed thirty-three states and Washington, D.C., regarding their substance use disorder treatment coverage and utilization management requirements for Medicaid managed care plans in 2021. Most states mandated coverage of common forms of substance use disorder treatment and prohibited annual maximums and enrollee cost sharing in managed care. Fewer than one-third of states forbade managed care plans from imposing prior authorization for each treatment service. For most treatment medications, fewer than two-thirds of states prohibited prior authorization, drug testing, "fail first," or psychosocial therapy requirements in managed care. Our findings suggest that many states give managed care plans broad discretion to impose requirements on covered substance use disorder treatments, which may affect access to lifesaving care.

The Spectrum of State Approaches to Medicaid Maternity Care Contracting.

Managed care is how Medicaid agencies principally furnish maternity care. For this reason, the contracts that Medicaid agencies enter into with managed care organizations have attracted strong interest as a means of improving maternal health access, quality, and equity. However, limited research has documented the extent to which states use these agreements to set binding expectations across the maternal health continuum and how states approach the task of maternal health contracting. To explore maternal health contracting within Medicaid Managed Care, this study took a three-phase, sequential approach: (1) an extensive literature review to identify clinical guidelines and expert recommendations regarding maternal health "best practices" for people with elevated health and social needs, (2) a review of the managed care contracts in use across 40 states and Washington, DC, to determine the extent to which they incorporate these best practices, and (3) interviews conducted with four state Medicaid agencies to better understand how states approach maternal health when developing their contracts. The evidence on maternal health best practices reveals nearly 60 "best practices," although the literature review also underscored the extent to which these recommendations are fragmented across numerous professional bodies and government agencies and are thus difficult for Medicaid agencies to ascertain. The contracts themselves reflect an approach to the maternal health continuum in a fragmented and incomplete way. Thematic analysis of interviews with state Medicaid agencies revealed three key approaches to contracting for maternity care: an "organic" approach, an "intentional" approach, and an approach "grounded" in state strategy. The absence of comprehensive, integrated guidelines reflecting the full maternal health continuum likely complicates the contracting task and contributes to incomplete, ambiguous contracts. A major step would be the development of a "best practices tool" that helps state Medicaid agencies translate evidence into comprehensive, clear contracting expectations.

Medicaid Managed Care and Pediatric Dental Emergency Department Visits

Millions of economically disadvantaged children depend on Medicaid for dental care, with states differing in whether they deliver these benefits using fee-for-service or capitated managed care payment models. However, there is limited research examining the association between managed care and the accessibility of dental services. To estimate the association between the adoption of managed care for dental services in Florida's Medicaid program and nontraumatic dental emergency department visits and associated charges. This cohort study used an event-study difference-in-differences design, leveraging Florida Medicaid's staggered adoption of managed care to examine its association with pediatric nontraumatic dental emergency department visits and associated charges. This study included all Florida emergency department visits from 2010 to 2014 in which the patient was 17 years or younger, the patient was a Florida resident, Medicaid paid for the visit, and a primary or secondary International Classification of Diseases, Ninth Revision, code was used to classify a nontraumatic dental condition. Analyses were conducted between May 2023 and April 2024. The county of residence transitioning Medicaid dental services from fee-for-service to a fully capitated managed care program managed by a dental plan. The rate of nontraumatic dental emergency department visits per 100 000 pediatric Medicaid enrollees and the associated mean charges per visit. Nontraumatic dental emergency department visits are a well-documented proxy for access to dental care. Data on emergency department visit counts came from the Florida Agency for Health Care Administration. Medicaid population denominators were derived from the American Community Survey's 5-year estimates. Among the 34 414 pediatric nontraumatic dental emergency department visits that met inclusion criteria across Florida's 67 counties, the mean (SD) age of patients was 8.11 (5.28) years, and 50.8% of patients were male. Of these, 10 087 visits occurred in control counties and 24 327 in treatment counties. Control counties generally had lower rates of NTDC ED visits per 100 000 enrollees compared with treatment counties (123.5 vs 132.7). Over the first 2.5 years of implementation, the adoption of managed care was associated with an 11.3% (95% CI, 4.0%-18.4%; P = .002) increase in nontraumatic dental emergency department visits compared with pre-implementation levels. There was no evidence that the average charge per visit changed. In this cohort study, Florida Medicaid's adoption of managed care for pediatric dental services was associated with increased emergency department visits for children, which could be associated with decreased access to dental care.

Identifying Post-Acute Sequelae of SARS-CoV-2 Among Children in New York State Medicaid Managed Care.

Persons who contract COVID-19 are at risk of developing post-acute sequelae of SARS-CoV-2 (PASC). The objective of this study was to describe the incidence of PASC in a pediatric Medicaid population. Using a retrospective cohort of children enrolled in New York State Medicaid Managed Care we compared incident diagnoses between children with a positive laboratory test for SARS-CoV-2 in 2021 to children without a positive test in 2021 and children with a viral respiratory diagnosis in 2019. Logistic regression models estimated adjusted odds ratios using the Cohen's d statistic to assess the strength of associations. Most unadjusted incidence of clinical outcomes were less than 1% for all cohorts. Relative to the 2021 comparison cohort, significant increases among SARS-CoV-2 cases were observed in sequela of infectious disease conditions, general signs and symptoms, and pericarditis and pericardial disease and for the 2019 comparison, sequela of infectious disease conditions and suicidal ideation. However, associations were mostly determined to be weak or marginal. In this low socioeconomic status pediatric population, incidence of new clinical sequelae was low with mostly weak or marginal increases associated with SARS-CoV-2 infection. Though the incidence was low, some outcomes may be severe. Observed associations may have been impacted by pandemic behavior modification including social distancing policies.

Disparities in insurance status negatively affect patients with infantile hypertrophic pyloric stenosis.

Infantile hypertrophic pyloric stenosis (IHPS) is suspected to have worse outcomes when length of illness prior to presentation is prolonged. Our objective was to evaluate how social determinants of health influence medical care and outcomes for babies with IHPS. A retrospective review was performed over 10years. Census data were used as proxy for socioeconomic status via Geo-Identification codes and correlated with food access and social vulnerability variables. The cohort was subdivided to understand the impact of Medicaid Managed Care (MMC). The cohort (279 cases) was divided into two groups; early group from 2011 to 2015 and late from 2016 to 2021. Cases in the late group were older at the time of presentation (41.5 vs. 36.5days; p = 0.022) and presented later in the disease course (12.8 vs. 8.9days; p = 0.021). There was no difference in race (p = 0.282), gender (p = 0.874), or length of stay. Patients who presented with IHPS after implementation of phased MMC were older, had a longer symptomatic course, and shorter pylorus measurements. Patients with public insurance after the implementation of MMC were more likely to follow-up with an outpatient pediatrician within a month of hospitalization. These results suggest that MMC may have improved access to care for infants with IHPS.

Understanding Barriers and Facilitators to Participating in Diabetes Self-Management Education and Support Services From Multiple Perspectives: Results of a Mixed-Methods Study of Medicaid Members, Medicaid Managed Care Organizations, and Providers in New York State.

This study sought to understand the barriers to and facilitators of diabetes self-management education and support (DSMES) referrals and participation from multiple perspectives in New York. Two common barriers emerged: lack of awareness of DSMES services and limited access to DSMES services. Strategies that could improve DSMES referrals and participation include provider education, outreach to eligible patients, and tailoring of DSMES services to meet participants' cultural needs and preferences. Future research is needed to assess the effectiveness of multicomponent strategies to increase DSMES participation in diverse populations.

Disparities in Access to Diagnostic Evaluation for Alzheimer's Disease in Individuals Dually Eligible for Medicare and Medicaid: A Modeling Study.

Individuals dually eligible for Medicare and Medicaid (duals) may face greater obstacles to access to disease-modifying Alzheimer's treatments in spite of their higher disease burden, because of clinicians' reluctance to accept Medicaid and the so-called "lesser of" policy, under which Medicaid may pay providers lower rates. To project differential wait times for duals compared to Medicare-only beneficiaries by state. We used State Medicaid payment policy and Medicare enrollment data and a Markov model to predict differential wait times for duals and non-duals from 2023 to 2050. We estimated available diagnostic appointments by state for both groups based on reluctance of clinicians to accept Medicaid and the "lesser of" policy for each year. We estimate overall average wait times of almost two years (22.9 months) but almost three times as long for duals (59.8 months) than non-duals (20.7 months) because of higher disease burden. The effects of Medicaid payment policy would increase average wait times for duals to 89 months with 20 states having wait times of 99 months or more, which would effectively deprive duals of access. The added average wait times in many states would effectively deprive duals from access to treatment and translate into avoidable disease progression and mortality. Policy interventions to reduce financial and nonfinancial obstacles are dearly needed to avoid deepening disparities. Examples are coverage arrangements that integrate Medicare and Medicaid coverage, covering the co-payment for physician services in full, and stricter network adequacy requirements for Medicaid Managed Care plans.

Technology, data, people, and partnerships in addressing unmet social needs within Medicaid Managed Care

BackgroundIndividuals with unmet social needs experience adverse health outcomes and are subject to greater inequities in health and social outcomes. Given the high prevalence of unmet needs among Medicaid enrollees, many Medicaid managed care organizations (MCOs) are now screening enrollees for unmet social needs and connecting them to community-based organizations (CBOs) with knowledge and resources to address identified needs. The use of screening and referral technology and data sharing are often considered key components in programs integrating health and social services. Despite this emphasis on technology and data collection, research suggests substantial barriers exist in operationalizing effective systems.MethodsWe used qualitative methods to examine cross-sector perspectives on the use of data and technology to facilitate MCO and CBO partnerships in Kentucky, a state with high Medicaid enrollment, to address enrollee social needs. We recruited participants through targeted sampling, and conducted 46 in-depth interviews with 26 representatives from all six Kentucky MCOs and 20 CBO leaders. Qualitative descriptive analysis, an inductive approach, was used to identify salient themes.ResultsWe found that MCOs and CBOs have differing levels of need for data, varying incentives for collecting and sharing data, and differing valuations of what data can or should do. Four themes emerged from interviewees’ descriptions of how they use data, including 1) to screen for patient needs, 2) to case manage, 3) to evaluate the effectiveness of programs, and 4) to partner with each other. Underlying these data use themes were areas of alignment between MCOs/CBOs, areas of incongruence, and areas of tension (both practical and ideological). The inability to interface with community partners for data privacy and ownership concerns contributes to division. Our findings suggest a disconnect between MCOs and CBOs regarding terms of their technology interfacing despite their shared mission of meeting the unmet social needs of enrollees.ConclusionsWhile data and technology can be used to identify enrollee needs and determine the most critical need, it is not sufficient in resolving challenges. People and relationships across sectors are vital in connecting enrollees with the community resources to resolve unmet needs.

Is Primary Care Adapting to Medicaid Managed Care in North Carolina? Implications for Expansion and Future Managed Care Transitions.

Realizing North Carolina's comprehensive vision for Medicaid transformation requires strengthening the state's primary care infrastructure. This can be done by build-ing upon the value-based care incentives in the Advanced Medical Home model, strengthening payor data, aligning quality measures, easing administrative burdens, investing in primary care and its workforce pipeline, and ensuring pay-ment models adequately support serving Medicaid expan-sion and the growing number of Medicaid health plans.

Factors Associated with Early and Periodic Screening, Diagnostic, and Treatment Services in a Medicaid Managed Care Pediatric Population

Abstract: Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services is a Medicaid benefit for children that addresses their health problems before they become advanced, debilitating, and expensive. We conducted a retrospective cross-sectional analysis of pediatric beneficiaries (newborn to younger than 21 years) enrolled in a Medicaid managed care organization to examine the factors associated with EPSDT screening services completion. We obtained 2018 administrative claims data for beneficiaries continuously enrolled for a minimum of 90 days (n=156,108). Completion of EPSDT screening services among our Medicaid managed care beneficiaries was low. Those having more emergency department visits and hospitalizations, having family medicine practitioners as primary care physicians, belonging to the racial/ethnic group Asian/Pacific Islander/Hawaiian/Alaskan Native/Native American, and 18 to younger than 21 years age group were less likely than others to complete EPSDT services. Our results provide information on segments of pediatric beneficiaries that can be targeted to increase EPSDT screening services completion.

Roles and Responsibilities of Community Health Workers in Louisiana Medicaid Managed Care Organizations.

We explored the roles of community health workers (CHWs) working in Medicaid Managed Care Organizations in Louisiana by conducting 10 interviews with CHWs, supervisors, and administrators. We identified 6 themes: CHWs' backgrounds and training; roles as they related to nationally recognized competencies; team integration; who CHWs serve and how members are identified; metrics for success; and the effects of COVID. CHWs are hired for their community connections. CHWs generally do not receive core competency training, and they focus primarily on improving individual-level health outcomes. Administrators and supervisors may need training and support on CHW competencies, supervision, and using common evaluation indicators.

IMPACT OF PATIENT DEMOGRAPHICS, CLINICAL CHARACTERISTICS, AND SOCIAL DETERMINANTS OF HEALTH ON ADVANCED THERAPY MEDICATION ADHERENCE AND PERSISTENCE IN ULCERATIVE COLITIS ACROSS UNITED STATES PAYER TYPES

Abstract INTRODUCTION Social determinants of health (SDOH) factors such as insurance status, race, ethnicity, and socioeconomic status have been associated with clinical outcomes in ulcerative colitis (UC). We assessed the impact of demographic, clinical, and SDOH factors on advanced therapy medication adherence and persistence in patients (pts) with UC. METHODS Pts with UC who initiated an advanced therapy (Janus kinase inhibitor, sphingosine-1-phosphate receptor agonist, or biologic) were identified using Commercial and Medicaid Managed Care (MMC) claims data from the MORE2 Registry (2017–2022) and Medicare Fee-for-Service (FFS) (2017–2021) claims. Community-level SDOH variables were linked using pt ZIP codes at index date (first advanced UC therapy prescription date from May 01, 2018 up to Jun 30, 2021). Adherence (proportion of days covered [PDC]) and persistence (duration) of treatment were assessed for 1 year post-index. Logistic regression analyses evaluated the associations between demographic, clinical, and SDOH factors and adherence/persistence. RESULTS The number of pts included in the Medicare FFS, Commercial, and MMC plan types were 9,158, 6,706, and 3,170, respectively. Mean PDC were 69%, 72%, and 64% (Fig. a), respectively, and the corresponding proportions of pts with 1-year persistence were 53%, 43%, and 31%, respectively (Fig. b). PDC by percentile is shown in Fig. c. Female pts had lower odds of adherence vs male pts in the Medicare FFS plan only (odds ratio [OR] 0.89; Table). A higher Charlson Comorbidity Index Score was associated with lower odds of adherence in the Medicare FFS and Commercial plans only (OR for both: 0.94; Table). In the 1 year post-index period, a corticosteroid prescription was associated with lower odds of adherence across plan types (OR 0.57–0.66; Table); a 5-aminosalicylic acid prescription was associated with higher odds of adherence in the Medicare FFS and Commercial plans only (OR 1.12–1.15; Table). A mental health condition diagnosis in the 1 year prior to and post-index was associated with lower adherence vs those without among pts with Medicare FFS and Commercial coverage (OR 0.85–0.87; Table). Community-level SDOH variables assessed had no association with adherence (Table); persistence model results were similar (data not shown). CONCLUSION For pts initiating an advanced therapy, there are still unmet treatment needs as demonstrated by mean PDC &amp;lt;80% and full persistence ≤53% across plan types. Adherence and persistence were lower among pts on MMC vs Medicare FFS or Commercial plans. The impact of demographic variables on adherence varied depending on plan type. Higher comorbidity burden, mental health diagnosis, and concomitant steroid use were generally associated with lower adherence to advanced UC therapies. Community-level SDOH variables were not associated with adherence in these populations.

Incentives and Operations of Medicaid Managed Care Plans in New York State: Implications for Procurement Design and Market Evolution.

Several states are considering competitive procurement to help shape Medicaid managed care markets. In New York state, the focus of our study, regulators propose contracts that reward quality improvement and simplify state administration by rewarding plans that operate across several of the state's 62 counties. This case analysis uses novel regulatory data from New York state, obtained via public records request, to examine incentives underlying Medicaid markets and help inform contracting design. The data report plan enrollment by county and plan spending across administrative activities for all 16 Medicaid plans in New York state for 2018. We examine the counties in which plans operate, profitability, and administrative resource allocation. We compare outcomes by tertile of plan profitability, measured as net income per member-month. Plan profitability ranged widely, with the most profitable plan realizing nearly $30 per member-month while the least profitable 5 plans realized net negative earnings. Operational differences across plan profitability emerged most clearly in administrative spending. The most profitable plans reported greater spending on salaries overall and for executive management, and taxes, while the least profitable plans spent more on operational functions including utilization management/ quality improvement, claims processing, and informational systems. We observe modest differences in county rurality and little in geographic breadth. Procurement design that rewards capacity-building in key administrative functions might impact market evolution, given that on average, highly profitable firms spent less on these activities in New York's Medicaid managed care market in 2018.