Providers have also cited low payment rates in the California Medicaid managed care program as a barrier to their participation Tater et al.
Network composition. FFS Medicaid programs typically contract with any qualified provider willing to accept Medicaid payment rates, and Medicaid beneficiaries who receive services through FFS are entitled to freedom of choice among Medicaid providers. Managed care plans can establish their own provider network qualifications, contract terms, and payment rates within parameters required by the terms of the contract with the state.
They generally limit MCO enrollees to a network of providers. MCO provider networks must be sufficient to provide adequate access to all covered services, taking into account the number, type, and geographic distribution of providers, among other factors, but there are no universal metrics to determine sufficiency. The size and scope of the network will affect the types, availability, and quality of services available to enrollees and access can vary substantially within a state, between urban and rural areas, and across states.
Networks with a sufficient number of participating providers may help ensure access to services covered under the contract while narrow networks may deter specialty care or other referrals and inhibit beneficiary choice and access to high quality care. Consumer advocacy organizations worry about inadequate provider networks and breaks in long-standing patient-provider relationships, especially for the high-cost populations that have the most vulnerable health status Sparer ; Corlette et al.
Researchers recently examined a sample of Medicaid MCOs across 14 states and found that on average 12 percent of primary care physicians left the network annually and 34 percent exited over five years. Plans with narrow networks experienced a higher turnover rate than standard network plans Ndumele et al.
Covered benefits. Contracts between the state and MCOs identify which state plan services are the responsibility of the MCO, which if any remain covered by the state, and which if any are provided by other vendors or through other delivery systems. In some cases, benefits that are unique to Medicaid and have not been traditionally delivered through managed care, such as long term services and supports or non-emergency transportation are carved out of the capitated benefit package in order to maintain access to these services.
However, the provision of benefits through multiple delivery systems can introduce new challenges in coordination of care. MCOs must provide all benefits offered under the state plan, but they can provide benefits additional to FFS using the so-called in lieu of policy. Under this policy, MCOs contracts may cover, for enrollees, cost-effective services that are in addition to those covered under the state plan, although the cost of these services cannot be included when determining the payment rates 42 CFR Because MCOs can provide services in addition to those offered under the state plan, access to them may be enhanced for their enrollees.
These services are often enabling services that may contribute to ease of obtaining care such as, case management or transportation services not covered under the state plan, long-term services and supports, or social interventions such as education, equipment, or services provided with partnerships with other organizations.
Contracting specifications and oversight. Medicaid managed care plans are required to meet access and quality standards that do not apply to other Medicaid delivery systems.
As described in greater detail in the following section, there are federal statutory and regulatory requirements, such as standards for access and capacity and a requirement for periodic external quality review, that only apply to MCOs. Further, states may impose additional access and quality requirements on Medicaid MCOs through the procurement and contracting process. States can require plans to meet certain standards e.
Because managed care networks and organizations can be configured, staffed, and funded in many different ways, it is difficult to make general conclusions about their correlation with better or worse access to and quality of care. Studies examining this issue come to different and sometimes conflicting conclusions, again depending on the many factors described above.
Many but not all states report that Medicaid MCO enrollees sometimes face access problems. In a comprehensive synthesis of studies of the impact of Medicaid managed care, the author concluded that Medicaid managed care can and sometimes does provide beneficiaries with improved access, but the scope and extent of such improvements generally are state specific and variable Sparer A synthesis of 16 studies on the potential impact of Medicaid managed care on access to and quality of care for children with special health care needs found no consistent set of findings regarding access to care Wise et al.
Above all, it has enhanced managed care through consolidating care, as well as, addressing the problem of unsustainable costs and uneven quality of care. However, managed care seems to exhibit some drawbacks too. Therefore, this paper will provide a comprehensive overview of managed care, primarily on the advantages and disadvantages of managed care organizations.
Managed care seems to have gained widespread acceptance by states over the past two decades. This phenomenon is attributable to several reasons.
Foremost, the integration of managed care into Medicaid programs has enabled states to control costs associated with the program O'Connell, It is also apparent that managed care has enhanced service utilization within the U.
This implies that managed care organizations have been instrumental in the implementation of value-based payment reforms. Historically, managed care organizations have existed for almost half decade. The emergence of managed care organizations dates back to when the Health Maintenance Organization Act was passed by the Congress.
This was followed by the formation of other managed care organizations. These managed care organizations exhibited distinctions in various aspects. However, this aspect has changed significantly to a point where it is difficult to differentiate between managed care organizations and insurance companies.
Despite the existence of managed care organizations two decades ago or longer, the conventional healthcare model or the fee-for-service model dominated healthcare delivery in the U. In retrospect, it is apparent that managed care has evolved over years into its current form. This evolution seems to have been occurred due to forces in the purchaser delivery system. As a result, virtually all managed care organizations appear relatively the same without, especially on the basis of operational principles.
In the current situation, managed care organizations manage care of Medicaid enrollees through the U. Foremost, the managed care system is responsible for coordinating and monitoring primary care, primarily through tertiary services. Second, the managed care system facilitates prevention and health education. Third, it ensures that the concerned population receives care in appropriate setting.
As such, it is responsible for ensuring that enrollees to these programs receive care from appropriate healthcare providers. For instance, specialists versus primary care specialists or hospitals versus outpatient clinics.
Finally, the system is responsible for aligning incentives, in order to promote cost-effectiveness in care provision. Some of the key approaches for achieving cost-effectiveness include cost-sharing and capitation of providers Sekhri, It is apparent that managed care and the conventional healthcare models exhibit differences. Some of the key differences include the quality of care, payment for care and the way enrollees choose physicians.
Overall, managed care organizations adopt the managed care model which is reasonably distinct from the traditional fee-for-service model. One of the most outstanding characteristics of managed care organizations is the limitation of access to services by enrollees. In this case, the private company assumes the financial risk associated with health insurance coverage.
Under this system, a managed care organization is responsible for establishing its network of healthcare providers who provide services to Medicaid enrollees. Consequently, the state sets the total amount of money for enrollees that it pays the managed care organization. In this case, the organization bears all the financial risk related to coverage. Under this system, the state reimburses Medicaid providers, primarily on the basis of fee-for-service precepts.
As such, enrollees in this program can only receive care from a specified primary care provider. Overall, both systems focus on controlling the cost of care for Medicaid enrollees O'Connell, Regarding the quality of care, the managed care model provides the best care compared to the conventional healthcare model. The fact that enrollees are free to choose their preferred healthcare provider within the network implies that only receive satisfactory care from the best providers.
In another perspective, the collective provision of care to a specified population group attracts competition among healthcare providers, an aspect that has always been associated with improved quality of care. In general, there are different forms of managed care organizations. Therefore, they exhibit differences in the levels of restriction with some of the programs being highly restrictive whereas others are less restrictive with regard to the specific network.
Health Maintenance Organizations refers to organized healthcare systems. These healthcare systems provide a wide range of health services to the specific population that is enrolled into Medicaid programs.
In addition, they provide financing for care provision to enrollees. As such, an HMO acts as a combination of management system responsible healthcare delivery and a health insurer. In principle, these organizations coordinate or provide healthcare services to enrollees in the program, primarily through affiliated healthcare providers.
These healthcare providers are then reimbursed through various platforms, unlike in the traditional health insurance coverage plan where insurance companies reimburse enrollees for their healthcare cost. On the other hand, HMOs ensure appropriateness and quality of health services that they offer to members within their networks Sekhri, Best Accounts. Stock Market Basics. Stock Market. Industries to Invest In. Getting Started. Planning for Retirement.
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