Health Policy Journal Club, Health Policy

Health Policy Journal Club: Medicaid Managed Care Cuts ED Visits

Medicaid managed care reduces disparities in preventable ED visits in Florida.

Discussion about how the publicly insured encounter and use American health care has long dominated conversation around the social safety net. Since the inception and implementation of the Affordable Care Act (ACA) both proponents and opponents of its policies have staked arguments on many state-level Medicaid financing strategies. Mimicking the private managed care model, public Statewide Medicaid Managed Care (SMMC) systems have produced mixed results when it comes to lowering statewide cost burden and in decreasing emergency department (ED) use. Decreased ED usage could signal increased access to the primary care system for affected populations, thereby reducing healthcare disparities.

Managed care systems pay provider networks a flat rate for total patient care, while funding quality control mechanisms that tend to increase access for Medicaid patients. In Florida, the Medicaid managed care strategy has paid dividends in reducing statewide expense and ED visits as healthcare access has increased. In this study, researchers show that Florida’s SMMC also solves another chronic public health challenge: significantly slowing the rate of preventable ED usage in African American and Hispanic enrollees.

When privately insured in Florida, Hispanic and African American populations have 25 and 20 more ED visits every three months, respectively, than White populations for potentially preventable causes. In Medicaid patients, however, these differences drop to 20 and 15 additional visits. The authors suggest that an increase in SMMC-driven primary and preventative care utilization influenced this decrease.

While this effect might seem modest, it presents an early testament to the power of SMMC to provide more equitable access to the primary care system. Recently, policymakers have had appropriately mixed opinions of SMMC studies from California and Massachusetts, where inconclusive results prevented strong endorsement. Now, however, state legislators can see that the SMMC strategy not only reduces costs but also reduces disparities in care.

The upshot is that the managed care model is cost-effective and might increase healthcare access for certain populations. This bodes well for Statewide Medicaid Managed Care as an option for state governments hoping to balance the books while also leveling the health care playing field for disadvantaged residents.

PMID: 29629922

ARTICLE: Hu T, Mortensen K, Chen J. Medicaid Managed Care in Florida and Racial and Ethnic Disparities in Preventable Emergency Department Visits. Advances in pediatrics. https://www.ncbi.nlm.nih.gov/pubmed/29629922. Published June 2018. Accessed September 6, 2018.

Abstract
BACKGROUND: In an effort to address health care spending growth, coordinate care, and improve access to primary care in the Medicaid program, Florida implemented the Statewide Mandatory Managed Care (SMMC) program in May of 2014. 

OBJECTIVES: The objective of this study is to investigate the impact of implementation of mandatory managed care in Medicaid on the preventable emergency department (ED) utilizations, with a focus on racial/ethnic minorities. 

RESEARCH DESIGN: The primary data source is the universe of Florida ED visit and inpatient discharge data from 2010 to 2015, maintained by the Florida Agency for Health Care Administration. We adopt the New York University Billing's ED Classification Algorithm to create measures for preventable ED visits. Using difference-in-differences estimation, we examine preventable ED visits for Florida residents aged 18-64 with a primary payer of Medicaid (treatment group) and private health insurance (control group) pre-SMMC and post-SMMC reform.

RESULTS: Our findings show that SMMC is statistically significantly associated with more reductions in preventable ED visits among non-Hispanic African American (incidence rate ratio=0.81; 95% confidence interval, 0.70-0.94) and Hispanic (incidence rate ratio=0.72; 95% CI, 0.60-0.87) Medicaid enrollees relative to their white counterparts. We also find significant reduction of racial/ethnic disparities only in counties with above median preimplementation Medicaid managed care penetration rate.
CONCLUSIONS: Our findings suggest that implementation of Medicaid mandatory managed care in Florida is associated with reduced racial/ethnic disparities in preventable ED visits.


EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA


As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems.

As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula.

This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.

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