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PubMed2000

Reimbursement impact of medicaid managed care organizations replacing standard medicaid.

STUDY OBJECTIVE: To evaluate the reimbursement difference for Medicaid managed care organization (MMCO) enrollees compared with Medicaid enrollees for emergency department patients with disease conditions that appear to meet the "prudent layperson" definition of an emergency medical condition. METHODS: This study used a retrospective reimbursement review of computerized billing data of reimbursement denials for 4 procedures (using Current Procedural Terminology codes for endotracheal intubation, cardiopulmonary resuscitation, central line placement, and lumbar puncture) and 1 International Classification of Diseases, ninth revision condition (chest pain) on MMCO patients from 7 MMCOs compared with standard Medicaid patients presenting to 4 EDs during a 6-month period (January through June 1998). Exclusion criteria were late bills that did not allow at least 90 days for payment and bills submitted on behalf of patients that were not covered at the time of service by Medicaid or MMCO. Data were analyzed using Fisher's exact test. RESULTS: The total number of MMCO and Medicaid patients evaluated/total ED patients evaluated was 5,153/63,552 and 6,020/63, 552, respectively. The number of nonreimbursed procedures/total number of procedures performed on MMCO and Medicaid patients was 35/93 and 14/88, respectively (P <.05). The number of nonreimbursed chest pain patients/total chest pain patients evaluated for MMCO and Medicaid enrollees was 65/277 and 12/199, respectively (P <.05). CONCLUSION: MMCOs reimburse significantly less than Medicaid does for ED patients with conditions that a prudent layperson would consider an emergency.

Confidence Intervals↗
PubMed1981

Capitation payment for medicaid pharmacy services: impact on non-medicaid prescriptions.

Although pharmacy organizations have been instrumental in the movement to repeal antisubstitution laws, there is evidence that under the current fee-for-service system pharmacists have not exercised their newly obtained prerogatives freely. A previous study has demonstrated that paying pharmacists on a capitation basis for their Medicaid patients effects a highly significant increase in the rate of generic substitution. The present study was conducted to determine whether the pharmacists' newly acquired generic substitution habits "spill over" from Medicaid prescriptions as a result of capitation reimbursement. The results indicate that pharmacists who participated in the capitation experiment for the Medicaid drug program significantly increased their rate of generic substitution on non-Medicaid prescriptions. It was concluded that the same pharmacies that increased their substitution rate in the Medicaid program under capitation also increased their substitution rate on non-Medicaid prescriptions. Finally, generic substitutions in both the Medicaid and non-Medicaid studies generally involved the same labelers as well as drugs in the same therapeutic categories and with the same generic classifications.

Capitation Fee↗
PubMed2006

Comparison of parental report of blood lead testing in children enrolled in Medicaid with Medicaid claims data and blood lead surveillance reports.

The purposes of this study were to identify the congruence of blood lead testing based on parental self-reports with Medicaid claims and blood lead surveillance records, and to determine factors associated with agreement between parental reports of blood lead tests and Medicaid claims or blood lead surveillance records. Data were obtained from a cross-sectional mailed survey of a randomly selected sample of parents of children 1-2 years old enrolled in Medicaid (n=532) and from existing Medicaid claims and blood lead surveillance records. Fifty-six percent of survey respondents reported their child had a blood lead test completed. Of these, only 56% could be confirmed with Medicaid claims/blood lead surveillance data. Logistic regression analysis revealed the odds of blood lead testing per parental report confirmed with Medicaid claims/blood lead surveillance data were 2.6 times greater if the child had > or =3 provider visits, 2.5 times greater if parents reported receiving a reminder about blood lead testing, 2.2 times greater if parents reported receiving information about lead poisoning, 1.6 times greater if residing in an urban county, and 1.5 times greater if the child was more than 2 years old. In conclusion, parents are not always aware if their child had a blood lead test. Information and reminders about blood lead testing should be distributed to parents of young children enrolled in Medicaid and frequently reviewed by healthcare providers.

Adolescent↗
PubMed1979

Comparing the medical utilization and expenditures of low income health plan enrollees with Medicaid recipients and with low income enrollees having Medicaid eligibility.

The study examines the medical care (hospital, physician, drug, diagnostic) utilization and expenditures of low income persons enrolled in a prepaid health plan with a matched group of Medicaid recipients. The study also examines the medical care utilization of low income persons enrolled in a prepaid health plan with a similar group of low income persons enrolled in the health plan but also eligible for Medicaid benefits. Utilization and population-at-risk data were obtained from the Kaiser-Permanente Medical Care Program of Portland, Oregon and from the State of Oregon Welfare Division. A hypothesis of lower hospital utilization by low income enrollees compared with Medicaid recipients was accepted. A hypothesis of higher ambulatory care utilization was accepted for diagnostic procedures and prescription use, but rejected for office visit utilization. An analysis of the findings appeared to implicate the Medicaid program for differences observed. The hypotheses of no significant differences in inpatient and ambulatory medical care utilization of low income health plan enrollees with and without Medicaid eligibility were generally rejected. Low income enrollees with concurrent Medicaid had consistently higher utilization rates for all services resulting in substantially higher medical care expenditures per person. The findings appear to contribute some useful information to planning or establishing policy for Medicaid Prepayment programs or other programs enrolling low income persons in prepaid health plans or HMOs.

Adolescent↗
PubMed1999

A conflict of strategies: Medicaid managed care and Medicaid maximization.

OBJECTIVE: To examine the influence of state strategies aimed at increasing federal Medicaid matching dollars on the design of states' Medicaid managed care programs. STUDY DESIGN: Data obtained from the 1996-1997 case studies of 13 states to examine how states have adapted the design of their Medicaid managed care programs in part because of maximization strategies, to accommodate the many roles and responsibilities that Medicaid has assumed over the years. PRINCIPAL FINDINGS: Our study showed that as states made the shift to managed care, some found that the responsibilities undertaken in part through maximization strategies proved to be in conflict with their Medicaid managed care initiatives. Among other things, the study revealed that most states included provisions that preserved the health care safety net, such as adapting the managed care benefit package and promoting the participation of safety net providers in managed care programs. In addition, most of the study states continued to pay special subsidies to safety net providers, including hospitals and clinics. CONCLUSIONS: States have made real progress in moving a large number of Medicaid beneficiaries into managed care. At the same time, many states have specially crafted their managed care programs to accommodate safety net providers and existing funding mechanisms. By making these adaptations states, in the long run, may compromise the central goals of managed care: controlling costs and improving Medicaid beneficiaries' access to and quality of care.

Economics, Hospital↗
PubMedDate not supplied

Drug utilization review of sedative/hypnotic agents in Texas Medicaid patients. Texas Medicaid Vendor Drug Program Drug Utilization Review Board.

OBJECTIVE: To assess use of sedative/hypnotic agents in Texas Medicaid patients and evaluate practitioner receptiveness to intervention letters concerning sedative/hypnotic prescribing generated by the Texas Medicaid Drug Utilization Review (DUR) Board. DESIGN: Retrospective DUR. SETTING: Texas Medicaid retrospective DUR program. PATIENTS OR OTHER PARTICIPANTS: 244 Texas Medicaid patients and 291 Texas physicians. INTERVENTION: Patient profiles for Texas Medicaid patients were reviewed retrospectively to quantify sedative/hypnotic prescribing practices. Intervention letters were prepared and sent to physicians directly involved in the care of patients receiving excessive sedative/hypnotic therapy. Physician responses were categorized based on information presented in the intervention letter and circumstances surrounding the identified patient. Prescribing practices were assessed approximately 1 year after the intervention to determine the impact of intervention letters on prescribing. MAIN OUTCOME MEASURE: Physician response to intervention letter. RESULTS: Responses were received from 208 of 291 physicians (71.5%). Approximately 40% of physicians agreed in principle with the suggestions offered by the Texas Medicaid DUR Board to minimize chronic sedative/hypnotic use. Almost one-half of these physicians had discontinued sedative/hypnotic therapy for the identified patients 1 year after the intervention. Approximately 9% justified continued sedative/hypnotic use based on patient diagnosis or refractory response to treatment, and 55 physicians (26.4%) were unwilling to alter therapy because of patient-specific factors. CONCLUSION: Through the use of retrospective DUR, Texas Medicaid patients receiving excessive amounts of sedative/hypnotic agents were identified and improvements in sedative/hypnotic therapy were initiated. DUR can be useful not only in identifying problem areas, but also in encouraging physicians to modify prescribing practices through educational means.

Adolescent↗
PubMed2005

Medicaid: Medicaid: eligibility--2005. End of Year Issue Brief.

Medicaid, a joint federal-state program started in 1965 as Title XIX of the Social Security Act, provides health insurance coverage to low-income children, parents meeting specific income thresholds, pregnant women, the elderly and people with disabilities. In 2003, Medicaid provided health care insurance to approximately 40.2 million low-income Americans. That same year, 45 million Americans had no health insurance at all. In order to reduce the number of uninsured people in the United States, state legislators have introduced hundreds of bills over the past decade to expand health insurance coverage to low-income citizens. Health insurance has been extended for low-income children through Medicaid expansions, the State Children's Health Insurance Program (SCHIP) and other medical assistance programs. States, in partnership with the federal government, have also made it easier for disabled individuals to qualify for Medicaid through Ticket-to-Work legislation (which allows individuals with disabilities to remain in the workforce and keep their Medicaid coverage). They also have expanded coverage for senior citizens, especially for their prescription drug needs through Medicaid Pharmacy Plus waivers. In fact, from 1997 to 2003, monthly Medicaid enrollment rose from 31.2 million to 40.6 million recipients.

Adult↗
PubMed2001

How much did the Medicaid expansions for children cost? An analysis of state Medicaid spending, 1984-1994.

The authors examine the relationship between the Medicaid eligibility expansions for children and state Medicaid spending during the period from 1984 to 1994. They find that the Medicaid expansions had relatively low incremental cost per enrollee--substantially below the average Medicaid expenditure for children. Expansion children tend to be older and have fewer disabilities. Moreover, many of the most expensive expansion children would have been covered by Medicaid-medically-needy provisions had the expansions not occurred. The authors examine the implications of our findings for intensified Medicaid outreach efforts and for the State Children's Health Insurance Program.

Adolescent↗
PubMed1986

Medicaid and non-Medicaid case mix differences in Colorado nursing homes.

Profiles of case mix and related variables were compared for 1,064 Medicaid and 459 non-Medicaid residents of 65 freestanding nursing homes in Colorado in 1980. The results point to substantial case-mix differences, with Medicaid residents typically characterized by fewer and less intense long-term care problems as well as greater independence in functioning (ADLs). Policy impacts of these findings in Colorado have included a legislatively mandated home and community-based care program as well as a more stringent preadmission certification program for Medicaid clients. The method of comparing Medicaid and non-Medicaid case mix in nursing homes appears to have policy relevance for other states as well. Research implications in the areas of measuring severity of long-term care problems and measuring residents' functional abilities apart from services received are also suggested.

Activities of Daily Living↗
PubMed1990

Access to office-based physicians under capitation reimbursement and Medicaid case management. Findings from the Children's Medicaid Program.

This study reports the effects of a voluntary Medicaid case-management demonstration on the primary care provided to young children by office-based physicians. The MDs who participated were reimbursed at rates higher than the regular Medicaid fee schedule, either through augmented fees for specific services or through monthly capitation payments. Using the Medicaid Management Information System (MMIS) claims data, we compared the rates at which children in the experimental program and children in the regular Medicaid program were seen by a physician during a one-year period. The majority of experimental children received regular and frequent care from primary care physicians during the demonstration. After controlling for race and prior utilization differences, we found that augmented fee-for-service children received more primary care from office-based physicians than children in the regular Medicaid program. Capitation children received at least the same amount of primary care as children in the regular Medicaid program. We interpret our data to mean that capitation payment, untied to the delivery of services, does not necessarily reduce access to primary care and that higher fees for physicians who treat children may, in fact, increase access.

Capitation Fee↗
PubMed1994

Medicaid physician payment reform: using the Medicare Fee Schedule for Medicaid payments.

OBJECTIVES: The purpose of this article is to provide estimates of the costs of basing Medicaid physician payment levels on the new resource-based Medicare Fee Schedule. Two possible policy options are considered: setting all Medicaid physician fees at the Medicare Fee Schedule level and setting only office visit fees at the new Medicare levels. METHODS: Data on Medicaid physician fees, use patterns, and the Medicare Fee Schedule are used to develop state-level estimates of expenditure changes under each option. RESULTS: Setting Medicaid rates at the Medicare Fee Schedule level could increase expenditures by $3.2 to $4.1 billion nationally; the other option would result in substantially lower increases in expenditures. Because of the current variations in Medicaid physician fees and in the breadth of eligibility across states, the cost of adopting the Medicare Fee Schedule varies considerably among states. CONCLUSIONS: Adopting the new Medicare Fee Schedule for Medicaid payments, proposed by policy-makers as a way to increase access to appropriate medical care, could double physician expenditures in some states. Adoption of more limited versions of the fee schedule might achieve some access gains at lower costs.

Fee Schedules↗
PubMed1980

Large medicaid practices and medicaid mills.

There is growing concern that large Medicaid practices (LMPs) may be "Medicaid mills" in which low-quality care is provided. Based on survey data, this study sought to determine whether physicians who treat a disproportionate number of Medicaid patients are in fact operating mills. While practices with at least 30% Medicaid patients are a minority of all practices (15.8%), nearly 60% of all Medicaid patients receive care there. There is no evidence that LMPs can be characterized as Medicaid mills. Visit lengths are shorter in LMPs, but only by two minutes. Nor is there any widespread abuse of ancillary services, skimping on auxiliary staff, or excessive incomes. The LMP physicians, however, do tend to be older, to be trained in foreign medical schools, and to have fewer credentials, such as board certification.

Credentialing↗
PubMed1996

Medicaid Program; Medicaid eligibility quality control, progressive reductions in federal financial participation for FYs 1982-84, payment for physician billing for clinical laboratory services, and utilization control of skilled nursing facility services: removal of obsolete requirements--HCFA. Final rule.

This final rule removes several obsolete sections of the Medicaid regulations that specify rules and procedures for disallowing Federal financial participation for erroneous medical assistance payments due to eligibility and beneficiary liability errors as detected through the Medicaid eligibility quality control program for assessment periods from 1980 through June 1990. The Medicaid regulations that contain the rules and procedures for the progressive reductions in Federal financial participation in medical assistance expenditures made to the States for fiscal years 1982 through 1984 are removed to reflect the repeal of the statutory bases for the reductions. The Medicaid regulations that provide for physician billing for clinical laboratory services that a physician bills or pays for but did not personally perform or supervise are removed to reflect the statutory repeal of this provision. In addition, the rule removes obsolete regulations that prescribe requirements concerning utilization control of Medicaid services furnished in skilled nursing facilities. This rule is part of the Department's initiate to reinvent health care regulations and eliminate obsolete requirements.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1983

Medicare and Medicaid program; withholding the federal share of payments to recover Medicare or Medicaid overpayments--Health Care Financing Administration. Proposed rule.

We propose to amend Medicare and Medicaid regulations to implement sections 905 of the Omnibus Reconciliation Act of 1980 (Pub. L. 96-499) and 2104 of the Omnibus Budget Reconciliation Act of 1981 (Pub. L. 97-35). Section 905 expands HCFA's authority to withhold the Federal share of Medicaid payments in order to recover Medicare overpayments. Section 2104 provides new authority for HCFA to withhold Medicare payments to recover Medicaid overpayments. The provisions apply with respect to institutions or persons that participate (or have participated) in both programs, and to whom an overpayment under either program may have been made but cannot be recovered under that program. The intent of the statute is to facilitate recovery through offset of payments due the entity under the second program. Previously, HCFA could suspend Federal Medicaid payments to State agencies to recover Medicare overpayments for an institutional provider of Medicare services when that provider (1) had withdrawn or been terminated from participation in the Medicare program; (2) failed to repay or make satisfactory arrangements to repay the appropriate information to determine the amount of overpayment, if any. No authority existed with respect to individual practitioners or other suppliers, nor was there any provision for recovering Medicaid overpayments through Medicare.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2005

Medicaid: Medicaid: waivers--2005. End of Year Issue Brief.

In 1965, President Lyndon Johnson signed the Social Security Act into law, which was designed to help the elderly and the poor receive needed health insurance. This landmark legislation ushered in a new chapter of federal assistance in providing health care, authorizing the creation of both Medicare under Title XVIII and Medicaid under Title XIX. Since January 1966, states have administered medical assistance and medical assistance to the aged programs under Title XIX, with the federal government paying from 50 percent to 85 percent of the cost. When Medicaid was created in 1965 as a joint federal-state medical assistance program, states were initially under strict guidelines to comply with federal requirements in order to receive matching funds from the federal government. However, after years of experience with the program, and with different states having different needs and challenges due to demographics such as size and population, an abundance or paucity of urban areas, age of the population, quantity of providers, and other factors, the federal government eventually allowed "waivers" to the Social Security Act to help states best meet the needs of their Medicaid recipients and to contain costs in their Medicaid programs. In short, the term waiver is used to describe the statutory authority under which the federal government, through the Centers for Medicare and Medicaid Services (CMS), allows states to receive federal matching funds for its programs even though the state is no longer in compliance with technical requirements of the Social Security Act.

Adult↗
PubMed1986

Medicaid myths: trends in Medicaid expenditures and the prospects for reform.

Medicaid expenditures, which had reached more than +32 billion by 1981, have grown substantially throughout the program's history. As a result, the conventional wisdom is that Medicaid expenditures represent a significant public-policy problem. Using other measures, however, it can be shown that the program is much less of a problem than it appears to be. By 1981, spending for Medicaid represented only 12.7 percent of total state spending and had contributed only 14.2 percent to the overall growth in state expenditures since 1965. Moreover, considering only the funds which states raise from in-state sources, the median share of state budgets accounted for by Medicaid was just 5.6 percent, and only 7 states spent as much as 9 percent of their own money on the program. These figures suggest that the marginal reductions in Medicaid expenditures which would result from typical program changes are likely to be so small that rational state officials might be unwilling to incur the political opposition of powerful provider groups or the resistance of large state bureaucracies by proposing substantial reforms. The major exceptions are the few states with very large programs where even small proportional savings would amount to millions of dollars. We conclude that, given its present federal-state form and the current distribution of expenditures, it is unlikely that major reforms will be enacted because the stakes are too small for most states and the federal interest is too diffused.

Health Expenditures↗
PubMed2005

Medicaid: Medicaid: benefits and services--2005. End of Year Issue Brief.

Medicaid provides health care insurance for low-income children, some parents who meet income thresholds, pregnant women, the elderly and the disabled. In order to receive federal funds for Medicaid, each state must offer coverage for the following mandatory health care services: (1) Inpatient and outpatient hospital services; (2) Physician services; (3) Medical and surgical dental services; {4) Nursing facility services; (5) Home health care services; (6) Family planning services; (7) Rural health clinic services; (8) Laboratory and x-ray services; (9) Pediatric and family nurse practitioner services; (10) Federally qualified health center services; (11) Nurse-midwife services; (12) Early and periodic screening, diagnosis and treatment (EPSDT) services for individuals under age 21 In addition to the required services mentioned above, states can also choose to cover additional services under their Medicaid plans, and these often include prescription drugs, nonmedical or surgical dental services, clinic services, and vision and hearing services. It is up to each state to decide what to include with the mandated services to create their Medicaid benefit package. Because of the variety of people to whom state Medicaid programs offer health insurance, states have gone back and forth on what services to include in their benefit packages. Some states offer extensive benefits with few restrictions on access to services, while others offer a minimal number of optional benefits. Cost, most often, is the deciding factor on whether or not to offer coverage.

Forecasting↗
PubMed2005

Medicaid: Medicaid: provider reimbursement--2005. End of Year Issue Brief.

Since Title XIX of the Social Security Act was enacted in 1965, state Medicaid programs have operated under tight budget constraints. States have recognized that reimbursement rates, whether traditional fee-for-service rates or capitation rates for managed care providers, must be sufficient in order to ensure that Medicaid programs have enough providers to deliver care. However, states have often looked to save money by lowering payments to providers who deliver health care services to Medicaid beneficiaries. This cost crunch has resulted in provider payment rates that are often substantially below market rates. State legislatures, program administrators and providers have sought to find the proper balance between adequate levels of reimbursement and cost control measures. However, dissatisfaction with low reimbursement levels has caused some providers to cease participating in the Medicaid program. This has had a detrimental affect on Medicaid recipients' access to health services. States have become aware of the problem and have tried to revise their rates to find the elusive balance between adequate reimbursement and fiscal control.

Cost Control↗