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In Brief
CU Review
Determining Utilization & Quality of Care in Managed Care Plans
Findings:
Recommendations
Common Acronyms
Footnotes
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Findings:
Access and Quality of Care
TDH's report to the Legislature presents a rosy view of access to care in managed care areas. It seems obvious that access to a commercial health plan with a network of doctors should increase access to care for Medicaid patients, who have traditionally been rejected by many physicians. This potential benefit significantly increased political support for the shift to managed Medicaid. However, access may still be a problem today.
First, HMOs must incorporate into their networks all the doctors and facilities that have traditionally cared for Medicaid patients. This is a good provision designed to prevent massive disruption in the system and ensure enrollee continuity of care. But it also means that many Medicaid enrollees remain in the same provider networks as before. And like commercial HMOs, not all the doctors in a Medicaid HMO network are taking new Medicaid patients at any given time. Finally, patients who need immediate care-particularly women who become eligible for Medicaid at the time of their pregnancy-must go through a complex, multi-step enrollment process before they can see a doctor. For these patients, access may well have declined, and certainly is delayed at a critical time.
Citing the Texas A&M study, TDH reports, "most providers in traditional Medicaid, PCCM and HMO models perceived that access to and continuity of medical care either increased or was not affected by clients being in managed care." (Summary Report, p. 33) While this statement is true, it obscures the additional fact that a significant minority of physicians in HMOs stated that managed care actually decreased access, and HMO doctors were far more likely to say that managed care decreased access than PCCM or FFS doctors.
[Table 1] Encounter Data Audit finds significant problems tracking services delivered to Medicaid clients from physician office to state administrators
The A&M study found that a significantly greater number of HMO doctors than PCCM doctors in Bexar believed that managed care had decreased access to high quality medical care (14 percent of HMO doctors versus 4 percent of PCCM doctors). HMO doctors were also more likely to report loss of patient continuity of care (27 percent of HMO doctors versus 15 percent of PCCM doctors and 5 percent of FFS doctors. (A&M, p. 4-23) In Travis, HMO providers were more likely to believe that state policies restrict medical services than providers in FFS (34% vs. 17%). (A&M, p. 3-40)
In particular, managed care providers in some areas report problems getting their Medicaid patients in to see specialists. While TDH claims that providers express the same level of satisfaction with ease of pre-certification, whether traditional, PCCM or HMO Medicaid (Summary Report, p. 33), A&M found that HMO (24%) and PCCM (28%) providers were much more likely to report pre-certification to be "difficult" than their FFS counter parts (10%).
"Within the HMOs, concerns about the availability of specialists were evident. Many providers, visited in the field, raised concerns about the numbers of specialists within particular plans being very problematic. They cited difficulty in locating colleagues who could meet with their patients in a timely manner." (A&M, 4-10) HMO providers were more likely (32%) to think it was difficult to make a referral to a specialist, than PCCM providers (24%) or FFS providers (18%).
Researchers detail many new barriers between patients and their care, particularly for pregnant women and their newborn children, who should be seen shortly after their eligibility is established. TDH does not compare prenatal care in managed care with FFS Medicaid. Instead, TDH reports ".access to prenatal care is evident in the HMO model, with more pregnant women receiving a prenatal visit within four weeks of plan enrollment, as compared to PCCM" (Summary Report, p. 4).
This summary statement ignores critical insights about the managed care system as a whole in the underlying study. Texas A&M reported that in Travis, "a gap exists between the time eligibility is established and the time it takes for a participant to appear on an insurer's list...This is of particular concern to obstetricians who believe the lag in the system causes many pregnant women a delay in prenatal care. Physicians at times do not encounter participants until the end of the second trimester of their pregnancy." (A&M, p. 3-44)
This gap in the enrollment process exists for newborns as well as pregnant women. A&M researchers identified "a consistent pattern of concern raised about the cost associated with newborn services" in Bexar, and recommended an evaluation of the billing system for these services. (A&M, p. 4-52) This concern may relate to the period of time right after birth during which a newborn does not officially belong to any plan in the system.
Perhaps related to inadequate prenatal care, researchers also found that newborns cost more under both the Bexar and the Travis pilots, and pregnant women cost significantly less. (A&M, pp. 3-34, 4-39, 4-50) "While the cost analysis indicated a savings in cost for pregnant women, site visits to general practitioners and obstetricians indicate that the savings has been at a risk to pregnant women and the fetus." (A&M, 3-45) While TDH reports no overall increase in the percent of deliveries resulting in "complex" newborns (sick newborns who have to stay in the hospital more than four days or who die) (Summary Report, p. 22) its own graphs show that HMOs report increases in the number of complex newborns in both the Travis and Bexar areas. (Summary Report, p. 26)
In Bexar, among maternity care recipients, fewer HMO enrollees reported receipt of breast feeding instruction, postpartum visits and parenting skills training. Overall, HMO recipients were less likely to rate the medical care they received while pregnant as good or excellent (87 percent) relative to PCCM (92 percent) or FFS (94 percent). (A&M, 4-24)
Access to primary care, obstetrical care and other basic services for women and children were also compromised by the high level of default enrollments in 1997, according to A&M. In the Travis service area, more than a third (37 percent) of Medicaid recipients could not identify the plan they were in, although PCA, the dominant plan, had been operational since 1993. (A&M, p. 3-3) Asked whether they had selected their plan or been defaulted, 46 percent reported they had been defaulted. (A&M, p. 3-10) Researchers also identified high default rates in Bexar county.
It should be noted that NHIC started out as the enrollment broker for the managed care program, but in June 1997 the state switched to a new enrollment broker, Maximus. TDH reports to the Legislature that more than 80 percent of members select their own primary care provider and managed care plan (Summary Report, p. 4), but it is unclear whether this number refers to NHIC or Maximus results. There has been no independent review of enrollment default problems since Maximus took over the program.
Citing NHIC data, TDH categorically states that "managed care has improved access to primary care providers." (Summary Report, p. 33) However, this is based on information from NHIC on the overall capacity of primary care providers in the system to serve Medicaid clients, assuming that each provider now open will take the full 1500 Medicaid patients allowed by TDH. Managed care providers may stop accepting new Medicaid patients at a level far fewer than 1500. Therefore this statistic does not clarify whether the types of providers and care patients need is available when they need it. According to A&M researchers, "Some providers go so far as to say that patients don't really have free choice because at the selection point many are told a particular provider is not taking new enrollments." (A&M, p. 4-9) |
