Provider risk sharing in medicaid managed care plans

Health Affairs

Volumn 22, Issue 3, 2003, Pages 159-167

  Draper, Debra A ^a   Gold, Marsha R ^a  

^a MATHEMATICA POLICY RESEARCH   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; COMPARATIVE STUDY; ECONOMICS; HEALTH CARE PLANNING; HEALTH INSURANCE; HUMAN; MEDICAID; ORGANIZATION AND MANAGEMENT; POVERTY; RISK MANAGEMENT; UNITED STATES; UTILIZATION REVIEW;

HUMANS; MANAGED CARE PROGRAMS; MEDICAID; POVERTY; RISK SHARING, FINANCIAL; STATE HEALTH PLANS; UNITED STATES;

EID: 0038387468     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.22.3.159     Document Type: Review

References (39)

1. M. Gold et al., "Financial Risk Sharing with Providers in Health Maintenance Organizations," Inquiry (Spring 2002): 34-44;
2. InterStudy, Competitive Edge 11.1, Part II: HMO Industry Report (St. Paul, Minn.: InterStudy, 2001);
3. T. Lake et al., Health Plans' Selection and Payment of Health Care Providers, 1999 (Washington: Medicare Payment Advisory Commission, May 2000);
4. J. Robinson and L. Casalino, "The Growth of Medical Groups Paid through Capitation in California," New England Journal of Medicine 333, no. 25 (1995): 1684-1687;
5. and S. Shortell, R. Gillies, and D. Anderson, "The New World of Managed Care: Creating Organized Delivery Systems," Health Affairs (Winter 1994): 46-64.
6. R. Hurley et al., "A Longitudinal Perspective on Health Plan-Provider Risk Contracting," Health Affairs (July/Aug 2002): 144-153;
7. D. Draper et al., "The Changing Face of Managed Care," Health Affairs (Jan/Feb 2002): 11-17;
8. and J. Robinson and L. Casalino, "Reevaluation of Capitation Contracting in New York and California," 17 May 2001, www.healthaffairs. org/WebExclusives/Robinson_Web_Excl_051701.htm (25 February 2003).
9. InterStudy reports the following capitation use rates by HMOs using this type of reimbursement method for any portion of reimbursement: primary care physicians, 63 percent; specialists, 42 percent; and hospitals, 25 percent. The data are as of 1 July 2000. InterStudy, Competitive Edge 11.1.
10. Gold et al., "Financial Risk Sharing";
11. and Robinson and Casalino, "The Growth of Medical Groups."
12. Gold et al., "Financial Risk Sharing";
13. and Lake et al., Health Plans' Selection and Payment.
14. Lake et al., Health Plans' Selection and Payment.
15. Gold et al., "Financial Risk Sharing."
16. T. Lake, M. Gold, and R. Hurley, "HMO Provider Networks in Medicare+Choice: Comparing Medicare and Commercial Lines of Business," Managed Care Quarterly 9, no. 4 (2001): 16-22.
17. Centers for Medicare and Medicaid Services, "2001 Medicaid Managed Care Enrollment Report," www.cms.gov/medicaid/managedcare/mmcss01.asp (25 February 2003).
18. R. Hurley and D. Draper, "Medicaid Confronts a Changing Managed Care Marketplace," Health Care Financing Review (Fall 2002): 11-25.
19. V. Smith et al., Medicaid Spending Growth Results from a 2002 Survey (Washington: Kaiser Commission on Medicaid and the Uninsured, September 2002).
20. For additional details about the study methodology, see M. Gold et al., Medicaid and SCHIP Managed Care: Plan Participation, Provider Networks, and Quality Improvement (Washington: Mathematica Policy Research, March 2002).
21. The eleven states selected were among thirteen states with the largest Medicaid managed care enrollment nationally. Oregon and Tennessee were excluded because of the extensive research that has been conducted on Medicaid managed care in these states.
22. D. Draper and M. Gold, "Customizing Medicaid Managed Care - California Style," Health Affairs (Sep/Oct 2000): 233-238. A total of 109 health plans were interviewed, but seven of these plans participated only in SCHIP. Because questions about risk sharing were only asked of the Medicaid-participating plans, the seven SCHIP-only plans are not included here.
23. Lake et al., Health Plans' Selection and Payment.
24. Questions about the scope of risk-sharing arrangements were asked of plans for their largest global capitation and largest professional services capitation arrangements.
25. Considering the national policy focus on rising prescription drug costs, we wanted to determine whether plans shift risk for these costs to providers. Otherwise, we did not ask about specific medical services for which plans shift risk to providers.
26. Hurley et al, "A Longitudinal Perspective";
27. Draper et al., "The Changing Face of Managed Care";
28. and California Medical Association, The Coming Medical Group Failure Epidemic (San Francisco: CMA, 1999).
29. Hurley and Draper, "Medicaid Confronts a Changing Managed Care Marketplace."
30. The literature on provider participation in Medicaid generally predates the transition to managed care. See, for example, R. Deprez, M. Agger, and L. McQuinn, "Access to Physicians, Obstetric Care Use, and Adequacy of Prenatal Care for Medicaid Patients in Maine: 1985-1989," Obstetrics and Gynecology 88, no. 3 (1996): 443-450;
31. J. Perloff, P. Kletke, and J. Fossett, "Which Physicians Limit Their Medicaid Participation and Why," Health Services Research 30, no. 1 (1995): 7-26;
32. E. Adams, "Effect of Increased Medicaid Fees on Physician Participation and Enrollee Service Utilization in Tennessee, 1985-1988," Inquiry 31, no. 2 (1994): 173-187;
33. and F. Sloan, J. Mitchell, and J. Cromwell, "Physician Participation in State Medicaid Programs," Journal of Human Resources 13, Supplement (1978): 211-245.
34. M. Gold et al., "Participation of Plans and Providers in Medicaid and SCHIP Managed Care," Health Affairs (Jan/Feb 2003): 230-240.
35. Hurley and Draper, "Medicaid Confronts a Changing Managed Care Marketplace."
36. See Gold et al., Medicaid and SCHIP Managed Care, for further details on special preferences and protections that Medicaid plans extend to traditional providers.
37. B. Gray and C. Rowe, "Safety-Net Health Plans: A Status Report," Health Affairs (Jan/Feb 2000): 185-193.
38. Gold et al., "Participation of Plans and Providers."
39. M. Gold, "Medicare+Choice: An Interim Report Card," Health Affairs (July/Aug 2001): 120-138.