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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. KEYWORDS asthma, child, disruptions to care continuity, managed care programs, Medicaid, 1 | INTRODUCTION Managed care is the dominant model of financing and delivery for over 70 million Americans who receive health insurance coverage through Medicaid. (1) In 2016, approximately 70% [...]

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. Key Words. Medicaid, managed care, continuity of coverage, natural experiment, Discontinuous Medicaid enrollment has been shown to negatively impact health outcomes and impose substantial costs on patients and state Medicaid budgets. Lapses in continuous Medicaid enrollment can lead to foregone [...]

Since 1965, the US federal government has incentivized physicians to practice in high-need areas of the country through the designation of Health Professional Shortage Areas (HPSAs). Despite its being in place for more than half a century and directing more than a billion dollars annually, there is limited evidence of the HPSA program’s effectiveness at reducing geographic disparities in access to care and health outcomes. Using a generalized difference-in-differences design with matching, we found no statistically significant changes in mortality or physician density from 1970 to 2018 after a county-level HPSA designation. As a result, we found that 73 percent of counties designated as HPSAs remained physician shortage areas for at least ten years after their inclusion in the program. Fundamental improvements to the program’s design and incentive structure may be necessary for it to achieve its intended results.

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. Key Words. Medicaid, managed care, quality, Under the Affordable Care Act (ACA), 31 states and the District of Columbia have accepted federal funds to expand their Medicaid programs to all citizens or qualifying residents with income [...]