Medicaid managed care: The last bastion of the HMO?

Health Affairs

Volumn 23, Issue 2, 2004, Pages 155-167

  Draper, Debra A ^a   Hurley, Robert E ^b   Short, Ashley C ^c,d  

^a MATHEMATICA POLICY RESEARCH   (United States)

^b VIRGINIA COMMONWEALTH UNIVERSITY SCHOOL OF MEDICINE   (United States)

^c CENTER FOR STUDYING HEALTH SYSTEM CHANGE   (United States)

^d UNIVERSITY OF VIRGINIA SCHOOL OF LAW   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; HEALTH CARE; HEALTH CARE ACCESS; HEALTH CARE COST; HEALTH INSURANCE; HEALTH MAINTENANCE ORGANIZATION; HUMAN; MANAGED CARE; MEDICAID;

EID: 1842729497     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.23.2.155     Document Type: Article

References (31)

1. This expansion followed a period of declining enrollment between 1994 and 1998, which largely reflected the effects of welfare reform.
2. Data for 2002 are from the Centers for Medicare and Medicaid Services, "Medicaid Managed Care Enrollment Report, Summary Statistics," 30 June 2003, www.cms.gov/medicaid/mcaidsad.asp (3 November 2003); total Medicaid enrollment data for 1990 are from CMS, "Medicaid Program Statistics (MSIS, formerly HCFA-2082 Report)," www.cms.gov/medicaid/msis/mstats.asp (program statistics - table Mcd90t01.wk1) (3 November 2003); and Medicaid managed care data for 1990 are from N. Kaye, Medicaid Managed Care: A Guide for States, 5th ed. (Portland, Maine: National Academy for State Health Policy, 2001).
3. Data for 2002 are from the Centers for Medicare and Medicaid Services, "Medicaid Managed Care Enrollment Report, Summary Statistics," 30 June 2003, www.cms.gov/medicaid/mcaidsad.asp (3 November 2003); total Medicaid enrollment data for 1990 are from CMS, "Medicaid Program Statistics (MSIS, formerly HCFA-2082 Report)," www.cms.gov/medicaid/msis/mstats.asp (program statistics - table Mcd90t01.wk1) (3 November 2003); and Medicaid managed care data for 1990 are from N. Kaye, Medicaid Managed Care: A Guide for States, 5th ed. (Portland, Maine: National Academy for State Health Policy, 2001).
4. Data for 2002 are from the Centers for Medicare and Medicaid Services, "Medicaid Managed Care Enrollment Report, Summary Statistics," 30 June 2003, www.cms.gov/medicaid/mcaidsad.asp (3 November 2003); total Medicaid enrollment data for 1990 are from CMS, "Medicaid Program Statistics (MSIS, formerly HCFA-2082 Report)," www.cms.gov/medicaid/msis/mstats.asp (program statistics - table Mcd90t01.wk1) (3 November 2003); and Medicaid managed care data for 1990 are from N. Kaye, Medicaid Managed Care: A Guide for States, 5th ed. (Portland, Maine: National Academy for State Health Policy, 2001).
5. The declining HMO enrollment trend noted in commercial insurance (predominantly employer-based) and Medicare is attributed in part to the managed care backlash of the late 1990s. It also reflects the tight labor markets during this same period, which saw employer recruitment and retention strategies include movement to less restrictive insurance options such as PPOs to appease employees. See D.A. Draper et al., "The Changing Face of Managed Care," Health Affairs (Jan/Feb 2002): 11-23.
6. Data for 2002 are from the Centers for Medicare and Medicaid Services, "Medicaid Managed Care Enrollment Report, Summary Statistics"; and data for 1990 are from Kaye, Medicaid Managed Care.
7. Data for 2002 are from the Centers for Medicare and Medicaid Services, "Medicaid Managed Care Enrollment Report, Summary Statistics"; and data for 1990 are from Kaye, Medicaid Managed Care.
8. "HMOs nationally" refers to all HMOs across all insurance sectors - commercial, Medicare, and Medicaid. See InterStudy, Competitive Edge 13.1, Part II: HMO Industry Report (St. Paul: InterStudy, 2002); and Competitive Edge 8.1, Part II: HMO Industry Report (1998).
9. "HMOs nationally" refers to all HMOs across all insurance sectors - commercial, Medicare, and Medicaid. See InterStudy, Competitive Edge 13.1, Part II: HMO Industry Report (St. Paul: InterStudy, 2002); and Competitive Edge 8.1, Part II: HMO Industry Report (1998).
10. See R. Hurley and S. Somers, "Medicaid and Managed Care: A Lasting Relationship?" Health Affairs (Jan/Feb 2003): 77-88; Draper et al., "The Changing Face of Managed Care"; R.E. Hurley and D.A. Draper, "Medicaid Confronts a Changing Managed Care Marketplace," Health Care Financing Review 24, no. 1 (2002): 11-25; and G.P. Mays, R.E. Hurley, and J.M. Grossman, "An Empty Toolbox? Changes in Health Plans' Approaches for Managing Costs and Care," Health Services Research 38, no. 1, Part 2 (2003): 375-393.
11. See R. Hurley and S. Somers, "Medicaid and Managed Care: A Lasting Relationship?" Health Affairs (Jan/Feb 2003): 77-88; Draper et al., "The Changing Face of Managed Care"; R.E. Hurley and D.A. Draper, "Medicaid Confronts a Changing Managed Care Marketplace," Health Care Financing Review 24, no. 1 (2002): 11-25; and G.P. Mays, R.E. Hurley, and J.M. Grossman, "An Empty Toolbox? Changes in Health Plans' Approaches for Managing Costs and Care," Health Services Research 38, no. 1, Part 2 (2003): 375-393.
12. See R. Hurley and S. Somers, "Medicaid and Managed Care: A Lasting Relationship?" Health Affairs (Jan/Feb 2003): 77-88; Draper et al., "The Changing Face of Managed Care"; R.E. Hurley and D.A. Draper, "Medicaid Confronts a Changing Managed Care Marketplace," Health Care Financing Review 24, no. 1 (2002): 11-25; and G.P. Mays, R.E. Hurley, and J.M. Grossman, "An Empty Toolbox? Changes in Health Plans' Approaches for Managing Costs and Care," Health Services Research 38, no. 1, Part 2 (2003): 375-393.
13. See R. Hurley and S. Somers, "Medicaid and Managed Care: A Lasting Relationship?" Health Affairs (Jan/Feb 2003): 77-88; Draper et al., "The Changing Face of Managed Care"; R.E. Hurley and D.A. Draper, "Medicaid Confronts a Changing Managed Care Marketplace," Health Care Financing Review 24, no. 1 (2002): 11-25; and G.P. Mays, R.E. Hurley, and J.M. Grossman, "An Empty Toolbox? Changes in Health Plans' Approaches for Managing Costs and Care," Health Services Research 38, no. 1, Part 2 (2003): 375-393.
14. A Medicaid-focused plan is one that specializes in Medicaid, with at least 75 percent of its membership in Medicaid.
15. For further details, see Kaiser Commission on Medicaid and the Uninsured, "Medicaid and Managed Care," December 2001, www.kff.org/medicaid/ 206803-index.cfm (3 February 2004).
16. For additional information about Medicaid managed care monitoring, see, for example, J. Wooldridge and S.D. Hoag, "Perils of Pioneering: Monitoring Medicaid Managed Care," Health Care Financing Review 22, no. 2 (2000): 61-83; and S. Felt-Lisk, "Monitoring Quality in Medicaid Managed Care: Accomplishments and Challenges at the Year 2000," Journal of Urban Health 77, no. 4 (2000): 536-559.
17. For additional information about Medicaid managed care monitoring, see, for example, J. Wooldridge and S.D. Hoag, "Perils of Pioneering: Monitoring Medicaid Managed Care," Health Care Financing Review 22, no. 2 (2000): 61-83; and S. Felt-Lisk, "Monitoring Quality in Medicaid Managed Care: Accomplishments and Challenges at the Year 2000," Journal of Urban Health 77, no. 4 (2000): 536-559.
18. For additional details on the CTS design, see P. Kemper et al., "The Design of the Community Tracking Study: A Longitudinal Study of Health System Change and Its Effects on People," Inquiry 33, no. 2 (1996): 195-206.
19. AHCCCS is the umbrella system for many of Arizona's public health insurance programs including Medicaid and SCHIP. CalOPTIMA is the managed care entity in Orange County that contracts with California's Medicaid program, Medi-Cal. It is a county-organized health system (a quasi-government organization), which is one of several Medicaid managed care models used in California.
20. Among the seventy-one plans, fifty-seven were commercial plans and fourteen were Medicaid-focused. The majority of commercial plans interviewed, however, did not participate in Medicaid.
21. See R. Hurley, "Medicaid-Focused Health Plans: A Community Health Conspiracy," Paper prepared for the Association for Health Center Affiliated Health Plans (AHCAHP) conference in Washington, D.C., May 2003, www.ahcahp.org/publications/Working%20Papers/hurley03.pdf (21 October 2003).
22. See B.H. Gray and C. Rowe, "Safety-Net Health Plans: A Status Report," Health Affairs (Jan/Feb 2000): 185-193.
23. Draper et al., "The Changing Face of Managed Care."
24. For additional information on care delivery enhancements, see, for example, M. Gold et al., "Participation of Plans and Providers in Medicaid and SCHIP Managed Care," Health Affairs (Jan/Feb 2003): 230-240.
25. More recently, however, states are increasingly using Health Insurance Flexibility and Accountability (HIFA) waivers to pare down benefit levels. States are doing this to expand health insurance coverage to more people within the constraints of existing Medicaid/SCHIP resources.
26. Predictive modeling programs are specialized software programs that assist plans with identifying and intervening with high-risk members. These modeling programs typically use a scoring system to predict a member's expected health care costs over a designated period of time. The specific intervention is then designed based on this score, with members identified as high risk receiving more intensive services such as case management.
27. See P. Cunningham, Mounting Pressures: Physicians Serving Medicaid Patients and the Uninsured, 1997-2001, Tracking Report no. 6 (Washington: Center for Studying Health System Change, December 2002).
28. See R. Hurley et al., "A Longitudinal Perspective on Health Plan-Provider Risk Contracting," Health Affairs (July/Aug 2002): 144-153; and D.A. Draper and M.R. Gold, "Provider Risk Sharing in Medicaid Managed Care Plans," Health Affairs (May/June 2003): 159-167.
29. See R. Hurley et al., "A Longitudinal Perspective on Health Plan-Provider Risk Contracting," Health Affairs (July/Aug 2002): 144-153; and D.A. Draper and M.R. Gold, "Provider Risk Sharing in Medicaid Managed Care Plans," Health Affairs (May/June 2003): 159-167.
30. Since 1999, the year that HMO enrollment peaked nationally, enrollment has declined by more than six million people, or 8 percent, in these managed care arrangements. Over this same period the number of HMOs operating nationally decreased from 643 to 500 - a decline of 22 percent. See InterStudy, Competitive Edge 13.1, Part II: HMO Industry Report (2002), and Competitive Edge 9.2, Part II: HMO Industry Report (1999).
31. Since 1999, the year that HMO enrollment peaked nationally, enrollment has declined by more than six million people, or 8 percent, in these managed care arrangements. Over this same period the number of HMOs operating nationally decreased from 643 to 500 - a decline of 22 percent. See InterStudy, Competitive Edge 13.1, Part II: HMO Industry Report (2002), and Competitive Edge 9.2, Part II: HMO Industry Report (1999).