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The American Journal of Managed Care September 2019
VA Geriatric Scholars Program’s Impact on Prescribing Potentially Inappropriate Medications
Zachary Burningham, PhD; Wei Chen, PhD; Brian C. Sauer, PhD; Regina Richter Lagha, PhD; Jared Hansen, MStat; Tina Huynh, MPH, MHA; Shardool Patel, PharmD; Jianwei Leng, MStat; Ahmad Halwani, MD; and B. Josea Kramer, PhD
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Ravi B. Parikh, MD, MPP; Sachin H. Jain, MD, MBA; and Amol S. Navathe, MD, PhD
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Jan E. Berger, MD, MJ
Medicaid Managed Care: Issues for Enrollees With Serious Mental Illness
Jean P. Hall, PhD; Tracey A. LaPierre, PhD; and Noelle K. Kurth, MS
Multi-Payer Advanced Primary Care Practice Demonstration on Quality of Care
Musetta Leung, PhD; Christopher Beadles, MD, PhD; Melissa Romaire, PhD; and Monika Gulledge, MPH; for the MAPCP Evaluation Team
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Suhas Gondi, BA; Timothy G. Ferris, MD, MPH; Kavita K. Patel, MD, MSHS; and Zirui Song, MD, PhD
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Brian E. McGarry, PT, PhD; and David C. Grabowski, PhD
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Changes in Ambulatory Utilization After Switching From Medicaid Fee-for-Service to Managed Care
Lisa M. Kern, MD, MPH; Mangala Rajan, MBA; Harold Alan Pincus, MD; Lawrence P. Casalino, MD, PhD; and Susan S. Stuard, MBA
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Cassandra Leighton, MPH; Evan Cole, PhD; A. Everette James, JD, MBA; and Julia Driessen, PhD
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Evelyn T. Chang, MD, MSHS; Rebecca Piegari, MS; Edwin S. Wong, PhD; Ann-Marie Rosland, MD, MS; Stephan D. Fihn, MD, MPH; Sandeep Vijan, MD; and Jean Yoon, PhD, MHS
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Changes in Ambulatory Utilization After Switching From Medicaid Fee-for-Service to Managed Care

Lisa M. Kern, MD, MPH; Mangala Rajan, MBA; Harold Alan Pincus, MD; Lawrence P. Casalino, MD, PhD; and Susan S. Stuard, MBA
Transitioning from Medicaid fee-for-service to Medicaid managed care was associated with a significant decrease in ambulatory utilization, especially among beneficiaries with 5 or more chronic conditions.
ABSTRACT

Objectives: To observe any change in ambulatory care utilization after switching from Medicaid fee-for-service (FFS) to Medicaid managed care (MC).

Study Design: We conducted a statewide longitudinal study of 21,048 adult Medicaid beneficiaries in New York State who switched from FFS to MC in 2011 or 2012, with 2 sets of controls (n = 21,048 with continuous FFS; n = 21,048 with continuous MC) who were matched on age, gender, dual-eligible status, and number of chronic conditions.

Methods: We measured ambulatory care utilization in the 12 months before and 12 months after the switch date, using regression to adjust for case mix and account for matching.

Results: Overall, switching from Medicaid FFS to Medicaid MC was associated with greater absolute decreases over time in ambulatory visits and providers compared with controls (–1.49 visits vs continuous FFS and –1.60 visits vs continuous MC; each P <.0001; –0.10 providers vs continuous FFS and –0.12 providers vs continuous MC; each P <.0001). The subset of switchers with 5 or more chronic conditions had the greatest absolute decreases in visits (–5.88 visits vs continuous FFS and –5.98 visits vs continuous MC; each P <.0001) and providers (–1.37 providers vs continuous FFS and –1.39 providers vs continuous MC; each P <.0001). Significant decreases in visits and providers were also observed for switchers with 3 to 4 chronic conditions but not for those with 0 to 2 chronic conditions.

Conclusions: Switching from Medicaid FFS to Medicaid MC was associated with a decrease in ambulatory utilization, especially for the sickest patients.

Am J Manag Care. 2019;25(9):e254-e260
Takeaway Points

In this longitudinal study of Medicaid beneficiaries in New York State, we examined patterns of ambulatory care before versus after switching from fee-for-service (FFS) to managed care (MC). We included 2 concurrent matched control groups: those with continuous FFS and those with continuous MC.
  • Overall, switching from Medicaid FFS to Medicaid MC was associated with a significant decrease in ambulatory visits and providers compared with changes over time in both control groups.
  • The largest decreases in ambulatory visits and providers were seen in the subset of “switchers” with 5 or more chronic conditions.
In an attempt to control healthcare costs, several states across the country (including California, Florida, New York, Ohio, and Texas) are transitioning many of their Medicaid fee-for-service (FFS) beneficiaries into managed care (MC) programs.1-3 According to the president of Medicaid Health Plans of America, a trade organization that advocates on behalf of Medicaid health plans, “More states are moving away from the fragmented care of the antiquated fee-for-service model toward the capitated coordinated care model of managed care organizations.”3 However, there has been no evidence that MC actually provides less-fragmented care (that is, less-diffuse and more-concentrated care) than FFS. Indeed, the chairperson of the Medicaid and CHIP Payment and Access Commission, created by Congress to advise legislators on Medicaid policy, has said, “We all talk about managed care as a better way to deliver care than fee-for-service, and we know that from a payment perspective. But we really need to learn more about how these plans handle…chronic illness and the sicker and frailer populations.”2

We sought to determine how the pattern of ambulatory care visits and providers (including the extent of fragmentation) changes after a beneficiary switches from Medicaid FFS to Medicaid MC. We also sought to determine whether any change in ambulatory care varied with the number of chronic conditions. To address these aims, we analyzed statewide claims for Medicaid beneficiaries in New York from 2010 to 2013, a time period that coincided both with a New York initiative to transition more beneficiaries to MC and with Medicaid expansion under the Affordable Care Act.4,5

METHODS

Overview

We conducted a longitudinal statewide study of adult Medicaid beneficiaries (≥18 years) in New York who were continuously enrolled for the years 2010 to 2013. We identified beneficiaries who switched once from Medicaid FFS to Medicaid MC during the study period. We then compared those beneficiaries’ ambulatory care patterns with those of 2 matched control groups: Medicaid beneficiaries with continuous FFS and Medicaid beneficiaries with continuous MC. The Weill Cornell Medicine Institutional Review Board approved the study protocol.

Data

We used statewide Medicaid claims for 2010 to 2013, extracting the following claim-level variables: beneficiary study identifier (ID), beneficiary date of birth, beneficiary gender, date of service, insurance product type (FFS vs MC), rendering provider ID, rendering provider specialty, Current Procedural Terminology (CPT) codes, and International Classification of Diseases, Ninth Revision codes. Claims had the same level of detail, regardless of insurance product type. We also extracted monthly beneficiary-level enrollment data, including dual-eligible status.

Study Sample and Variables

We included adult Medicaid beneficiaries (≥18 years) in New York who were continuously enrolled from January 1, 2010, to December 31, 2013 (48 months). We then restricted the cohort to only those who had 4 or more ambulatory visits each year, because we sought to focus on those with higher levels of utilization and because characterizing patterns of care based on 3 or fewer visits can yield statistically unstable estimates (Figure 1).6 To define ambulatory visits, we used a modified version of the definition of ambulatory visits from the National Committee for Quality Assurance (NCQA), which is a list of applicable CPT codes.7 The NCQA definition excludes emergency department visits. Our modifications restricted the definition to evaluation and management visits for adults in an office setting.8 We excluded those beneficiaries who had outlier observations (>99.9th percentile) for the counts of visits or providers for those visits, as those values may be erroneous.

We restricted the sample to (1) those who had switched once during the study period from FFS to MC, (2) those who had continuous FFS, and (3) those who had continuous MC (Figure 1). This excluded those who switched from MC to FFS and those who switched insurance products multiple times. Among those who switched once from FFS to MC, we further restricted the sample to those who had a switch date in calendar year 2011 or 2012 (“switchers”), so that we would have 12 months of data before and 12 months of data after the switch date. Note that we use the term “switcher” to refer to a beneficiary who was observed in claims as having changed from FFS to MC; we cannot determine from our data whether the beneficiary or the state initiated the switch. We randomly assigned a date in 2011 or 2012 to serve as a “time zero” (analogous to switch date) for each of the beneficiaries with continuous coverage (FFS or MC).


 
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