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Objective: To evaluate the effect of a forced disruption to Medicaid managed care plans and provider networks on health utilization and outcomes for children with persistent asthma., Data Sources: Medicaid managed care administrative claims data from 2013 to 2016, obtained from a southeastern state., Study Design: A difference-in-difference analysis compared patients' outpatient, inpatient, and emergency department (ED) utilization and receipt of recommended services before and after implementation of a statewide redistribution of patients among nine managed care plans., Data Collection/extraction Methods: Enrollment data for children with asthma were linked to the administrative claims. Children were included if they had a diagnosis of persistent asthma in 2013 and if they were enrolled continuously throughout 2014-2016., Principal Findings: Among the 28 537 children with asthma, 26% were forced to switch their managed care plan after the redistribution. Of these, 67% also switched their primary care provider (PCP). Relative to those who remained in their plan, disruption was associated with an additional 2.1 percentage-point decrease in the number of children who had an outpatient visit per quarter [95%CI -2.8, -1.3], from 71% to 66% (compared to plan stayers: 74% to 71%). Among children experiencing a change to their plan, there was overall a decrease in the proportion of children receiving an asthma-specific visit per quarter, but there was less of a decrease in children that also changed their PCP [1.6 percentage points, 95%CI 0.7, 2.5], from 9.7% to 8.3% (compared to those who did not switch their PCP: 12% to 8.6%). Indicators of asthma care quality and emergent care utilization were not significantly different between the two periods., Conclusions: While there was a decrease in the number of outpatient visits associated with forced disruption of Medicaid managed care plans for children with persistent asthma, there were no consistent associations with worse asthma quality performance or higher emergent health care utilization., (© 2021 Health Research and Educational Trust.)

Importance: Enrollment in Medicaid managed care plans has increased rapidly, particularly in national commercial insurance plans. Whether the type of managed care plan is associated with the use of health services for Medicaid beneficiaries is unknown., Objective: To compare the use of outpatient and acute care between Medicaid enrollees randomly assigned to a national commercial managed care plan or a local Medicaid-focused managed care plan., Design, Setting, and Participants: This natural experiment of a cohort of Medicaid enrollees randomly assigned to 2 managed care plans in a Northeastern US state was conducted from June 30, 2009, to June 30, 2013. Statistical analysis was performed from September 1, 2019, to August 30, 2020., Interventions: Assignment to a Medicaid-focused insurance plan or a commercial managed care plan., Main Outcomes and Measures: Outpatient visits, emergency department visits, and total inpatient and ambulatory care-sensitive hospitalizations., Results: A total of 8010 patients were included in the analysis: 4737 were assigned to a Medicaid-focused plan (2795 female [59.0%]; mean [SD] age, 17.8 [3.2] years) and 3273 to a commercial managed care plan (1915 female [58.5%]; mean [SD] age, 17.9 [3.3] years). Those randomly assigned to the Medicaid-focused plan had a mean (SD) of 6.67 (9.18) annual outpatient visits per person, and those assigned to the commercial plan had a mean (SD) of 8.36 (11.77) annual outpatient visits per person (adjusted absolute difference, 1.72 [95% CI, 1.31-2.13]; 22% relative difference). The increased use of outpatient visits in the commercial plan was associated with an increase in specialty care visits (mean [SD], 2.34 [6.31] visits in Medicaid-focused plan vs 3.75 [9.32] visits in commerical plan; adjusted absolute difference, 1.43 visits [95% CI, 1.25-1.56 visits]; 61% relative difference). Mean (SD) annual emergency department visits were 0.49 (1.39) per person in the Medicaid-focused plan and 0.51 (1.40) in the commercial plan (adjusted absolute difference, 0.02 [95% CI, -0.02 to 0.05]). Mean (SD) annual inpatient admissions were 0.067 (0.45) per person in the Medicaid-focused plan and 0.069 (0.53) in the commercial plan (adjusted absolute difference, 0.003 [95% CI, -0.01 to 0.02]). Plan assignment was not significantly associated with ambulatory care-sensitive admissions. Results were consistent in instrumental variables analyses that accounted for disenrollment and switching., Conclusions and Relevance: Compared with Medicaid managed care enrollees assigned to a Medicaid-focused plan, those assigned to a commercial plan had more outpatient visits, particularly for specialty care, but had similar rates of emergency department visits and hospitalizations. These findings suggest that the type of managed care plan may be associated with health services use and spending among Medicaid beneficiaries and that random assignment may help states understand how well different plans perform for enrollees.

Background: Medicaid managed care plans change provider networks frequently, yet there is no evidence about the performance of exiting providers relative to those that remain., Objectives: To investigate the association between provider cost and quality and network exit., Design: Observational study with provider network directory data linked to administrative claims from managed care plans in Tennessee's Medicaid program during the period 2010-2016., Participants: 1,966,022 recipients assigned to 9593 unique providers., Main Measures: Exposures were risk-adjusted total costs of care and nine measures from the Healthcare Effectiveness Data and Information Set (HEDIS) were used to construct a composite annual indicators of provider performance on quality. Outcome was provider exit from a Medicaid managed care plan. Differences in quality and cost between providers that exited and remained in managed care networks were estimated using a propensity score model to match exiting to nonexiting providers., Key Results: Over our study period, we found that 21% of participating providers exited at least one of the Medicaid managed care plans in Tennessee. As compared with providers that remained in networks, those that exited performed 3.8 percentage points [95% CI, 2.3, 5.3] worse on quality as measured by a composite of the nine HEDIS quality metrics. However, 22% of exiting providers performed above average in quality and cost and only 29% of exiting providers had lower than average quality scores and higher than average costs. Overall, exiting providers had lower aggregate costs in terms of the annual unadjusted cost of care per-member-month - $21.57 [95% CI, - $41.02, - $2.13], though difference in annual risk-adjusted cost per-member-month was nonsignificant., Conclusions: Providers exiting Medicaid managed care plans appear to have lower quality scores in the year prior to their exit than the providers who remain in network. Our study did not show that managed care plans disproportionately drop high-cost providers.

Objective: To assess the impact of assignment to a Medicaid-focused versus mixed managed care plan on continuity of Medicaid coverage., Data Sources: 2011-2016 Medicaid claims from a Northeastern state., Study Design: Following the exit of a Medicaid managed care insurer, Medicaid administrators prioritized provider networks in reassigning enrollees, but randomly assigned beneficiaries whose providers were equally represented in the two plans. We leveraged the natural experiment created by random plan assignment and conducted an instrumental variable analysis., Data Collection: We analyzed Medicaid claims for 12,083 beneficiaries who were members of the exiting Blue Cross Blue Shield plan prior to January 1, 2011., Principal Findings: Managed care plan type did not significantly impact continuous enrollment in the Medicaid program. Greater outpatient utilization and the presence of a special need among children were associated with longer enrollment in Medicaid., Conclusions: Managed care plans did not differ in their capacity to keep Medicaid beneficiaries continuously enrolled in coverage, despite differences in plan features., (© Health Research and Educational Trust.)

Background: Declining job satisfaction and concurrent reductions in Medicaid participation among primary care providers have been documented, but there is limited qualitative work detailing their first-hand experiences treating Medicaid patients. The objective of this study is to describe the experiences of some primary care providers who treat Medicaid patients using in-depth qualitative analysis., Methods: We conducted qualitative interviews with 15 primary care providers treating Medicaid patients in a Northeastern state. Participant recruitment efforts focused on including different types of primary care providers practicing in diverse settings. Qualitative interviews were conducted using a semi-structured interview protocol. We developed a coding scheme to analyze interview transcripts and identify themes., Results: Providers expressed challenges effectively meeting their patients' needs under current policy. They described low Medicaid reimbursement and underinvestment in care coordination programs to adequately address the social determinants of health. Providers shared other concerns including poor access to behavioral health services, discontinuous Medicaid coverage due to enrollment and renewal policies, and limited reimbursement for alternative pain treatment. Providers offered their own suggestions for the allocation of financial investments, Medicaid policy, and primary care practice., Conclusions: Underinvestment in primary care in Medicaid may detract from providers' professional satisfaction and hinder care coordination for Medicaid patients with complex healthcare needs. Policy solutions that improve the experience of primary care providers serving Medicaid patients are urgently needed to ensure sustainability of the workforce and improve care delivery.

Objective: To assess the effect of the 2014 Medicaid expansion on Medicaid managed care plan quality., Data Sources: Three composite measures of plan-level quality constructed from the Health Care Effectiveness Data and Information Set., Study Setting: One hundred and sixty-three plans in 27 Medicaid expansion states and 100 plans in 14 nonexpansion states., Study Design: Quasi-experimental difference-in-differences (DID) analysis, comparing quality before (2011-13) and after (2014-15) Medicaid expansion in states that elected to expand Medicaid eligibility and those that did not., Principal Findings: Mean plan enrollment increased from 130,533 to 274,259 in expansion states and from 105,449 to 148,194 in nonexpansion states. The proportion of enrollees receiving recommended preventive care increased from 62.6 to 65.2 percent in expansion states and from 59.3 to 62.5 percent in nonexpansion states (adjusted DID: -0.7 percentage points [95% CI -2.2, 0.7]). The proportion of enrollees receiving recommended chronic disease care management increased from 65.4 to 66.0 percent in expansion states and from 62.5 to 63.1 percent in nonexpansion states (adjusted DID: 1.1 percentage points [95% CI -0.5, 2.6]). We observed similar patterns for the receipt of recommended maternity care., Conclusions: Medicaid expansion increased enrollment in managed care plans, but it did not result in erosion of quality., (© Health Research and Educational Trust.)

Importance: Medicaid recipients have consistently reported less timely access to specialists than patients with other types of coverage. By 2018, state Medicaid agencies will be required by the Center for Medicare and Medicaid Services (CMS) to enact time and distance standards for managed care organizations to ensure an adequate supply of specialist physicians for enrollees; however, there have been no published studies of whether these policies have significant effects on access to specialty care., Objective: To compare ratings of access to specialists for adult Medicaid and commercial enrollees before and after the implementation of specialty access standards., Design, Setting, and Participants: We used Consumer Assessment of Healthcare Providers and Systems survey data to conduct a quasiexperimental difference-in-differences (DID) analysis of 20 163 nonelderly adult Medicaid managed care (MMC) enrollees and 54 465 commercially insured enrollees in 5 states adopting access standards, and 37 290 MMC enrollees in 5 matched states that previously adopted access standards., Main Outcomes and Measures: Reported access to specialty care in the previous 6 months., Results: Seven thousand six hundred ninety-eight (69%) Medicaid enrollees and 28 423 (75%) commercial enrollees reported that it was always or usually easy to get an appointment with a specialist before the policy implementation (or at baseline) compared with 11 889 (67%) of Medicaid enrollees in states that had previously implemented access standards. Overall, there was no significant improvement in timely access to specialty services for MMC enrollees in the period following implementation of standard(s) (adjusted difference-in-differences, -1.2 percentage points; 95% CI, -2.7 to 0.1), nor was there any impact of access standards on insurance-based disparities in access (0.6 percentage points; 95% CI, -4.3 to 5.4). There was heterogeneity across states, with 1 state that implemented both time and distance standards demonstrating significant improvements in access and reductions in disparities., Conclusions and Relevance: Specialty access standards did not lead to widespread improvements in access to specialist physicians. Meaningful improvements in access to specialty care for Medicaid recipients may require additional interventions.

Importance: State Medicaid programs have increasingly contracted with insurers to provide medical care services for enrollees (Medicaid managed care plans). Insurers that provide these plans can exit Medicaid programs each year, with unclear effects on quality of care and health care experiences., Objective: To determine the frequency and interstate variation of health plan exit from Medicaid managed care and evaluate the relationship between health plan exit and market-level quality., Design, Setting, and Participants: Retrospective cohort of all comprehensive Medicaid managed care plans (N = 390) during the interval 2006-2014., Exposures: Plan exit, defined as the withdrawal of a managed care plan from a state's Medicaid program., Main Outcomes and Measures: Eight measures from the Healthcare Effectiveness Data and Information Set were used to construct 3 composite indicators of quality (preventive care, chronic disease care management, and maternity care). Four measures from the Consumer Assessment of Healthcare Providers and Systems were combined into a composite indicator of patient experience, reflecting the proportion of beneficiaries rating experiences as 8 or above on a 0-to-10-point scale. Outcome data were available for 248 plans (68% of plans operating prior to 2014, representing 78% of beneficiaries)., Results: Of the 366 comprehensive Medicaid managed care plans operating prior to 2014, 106 exited Medicaid. These exiting plans enrolled 4 848 310 Medicaid beneficiaries, with a mean of 606 039 beneficiaries affected by plan exits annually. Six states had a mean of greater than 10% of Medicaid managed care recipients enrolled in plans that exited, whereas 10 states experienced no plan exits. Plans that exited from a state's Medicaid market performed significantly worse prior to exiting than those that remained in terms of preventive care (57.5% vs 60.4%; difference, 2.9% [95% CI, 0.3% to 5.5%]), maternity care (69.7% vs 73.6%; difference, 3.8% [95% CI, 1.7% to 6.0%]), and patient experience (73.5% vs 74.8%; difference, 1.3% [95% CI, 0.6% to 1.9%]). There was no significant difference between exiting and nonexiting plans for the quality of chronic disease care management (76.2% vs 77.1%; difference, 1.0% [95% CI, -2.1% to 4.0%]). There was also no significant change in overall market performance before and after the exit of a plan: 0.7-percentage point improvement in preventive care quality (95% CI, -4.9 to 6.3); 0.2-percentage point improvement in chronic disease care management quality (95% CI, -5.8 to 6.2); 0.7-percentage point decrease in maternity care quality (95% CI, -6.4 to 5.0]); and a 0.6-percentage point improvement in patient experience ratings (95% CI, -3.9 to 5.1). Medicaid beneficiaries enrolled in exiting plans had access to coverage for a higher-quality plan, with 78% of plans in the same county having higher quality for preventive care, 71.1% for chronic disease management, 65.5% for maternity care, and 80.8% for patient experience., Conclusions and Relevance: Between 2006 and 2014, health plan exit from the US Medicaid program was frequent. Plans that exited generally had lower quality ratings than those that remained, and the exits were not associated with significant overall changes in quality or patient experience in the plans in the Medicaid market.

Background: Recent parity legislation will require many insurers and the federal Medicare program to reduce mental health copayments, so that they are equivalent to copayments for other covered services. The effect of changes in mental health cost sharing has not been well studied, particularly among elderly populations., Objective: To examine the consequences of increasing and decreasing copayments on the use of outpatient mental health services among the elderly., Research Design: Difference-in-differences (DID) design comparing the use of outpatient mental health care in Medicare plans that changed mental health copayments compared with concurrent trends in matched control plans with unchanged copayments., Study Population: A total of 1,147,916 enrollees aged 65 years and older in 14 Medicare plans that increased copayments by ≥ 25%, 3 plans that decreased copayments by ≥ 25%, and 17 matched control plans with unchanged copayments., Results: In 14 plans that increased mental health copayments from a mean of $14.43 to $21.07, the proportion of enrollees who used mental health services remained at 2.2% in the year before and year after the increase (adjusted DID, 0.1 percentage points; 95% confidence interval, 0.0-0.1). Among 3 plans that decreased copayments from a mean of $25.00 to $8.33, utilization rates were 1.2% before and after the decrease (adjusted DID, 0.1 percentage points; 95% confidence interval, -0.2 to 0.3). Stratified analyses by age, gender, race, and presence of a disability yielded similar results., Conclusions: Few older adults in managed care plans used outpatient mental health services. Among this population, increasing or decreasing mental health copayments had negligible effects on the likelihood of using outpatient mental health care.

Background: Medicaid managed care plans change provider networks frequently, yet there is no evidence about the performance of exiting providers relative to those that remain. Objectives: To investigate the association between provider cost and quality and network exit. Design: Observational study with provider network directory data linked to administrative claims from managed care plans in Tennessee's Medicaid program during the period 2010–2016. Participants: 1,966,022 recipients assigned to 9593 unique providers. Main Measures: Exposures were risk-adjusted total costs of care and nine measures from the Healthcare Effectiveness Data and Information Set (HEDIS) were used to construct a composite annual indicators of provider performance on quality. Outcome was provider exit from a Medicaid managed care plan. Differences in quality and cost between providers that exited and remained in managed care networks were estimated using a propensity score model to match exiting to nonexiting providers. Key Results: Over our study period, we found that 21% of participating providers exited at least one of the Medicaid managed care plans in Tennessee. As compared with providers that remained in networks, those that exited performed 3.8 percentage points [95% CI, 2.3, 5.3] worse on quality as measured by a composite of the nine HEDIS quality metrics. However, 22% of exiting providers performed above average in quality and cost and only 29% of exiting providers had lower than average quality scores and higher than average costs. Overall, exiting providers had lower aggregate costs in terms of the annual unadjusted cost of care per-member-month − $21.57 [95% CI, − $41.02, − $2.13], though difference in annual risk-adjusted cost per-member-month was nonsignificant. Conclusions: Providers exiting Medicaid managed care plans appear to have lower quality scores in the year prior to their exit than the providers who remain in network. Our study did not show that managed care plans disproportionately drop high-cost providers. [ABSTRACT FROM AUTHOR]

Health plans use selective physician networks to control costs while improving quality. However, narrow (limited) networks raise concerns about reduced access to and continuity of care. In the period 2010-15, the proportion of Medicaid managed care plans in fourteen states with narrow primary care physician networks--that is, the plans that employed 30 percent or less of those physicians in their market--declined from a peak of 42 percent in 2011 to 27 percent in 2015. On average, plans experienced a 12 percent annual turnover rate, with 34 percent of primary care physicians exiting within five years. Turnover was 3 percentage points higher in plans with narrow networks after one year, and 20 percentage points higher after five years, compared to turnover in plans with non-narrow networks. These findings suggest that efforts to maintain adequate physician networks must monitor not only the breadth of the networks, but also the continuity within them. [ABSTRACT FROM AUTHOR]