Piwnica-Worms Katherine, Wallace Jacob, Lollo Anthony, Ndumele Chima D
National Clinician Scholars Program, Yale School of Medicine, 333 Cedar Avenue, SHM I-456, PO Box 208088, New Haven, CT, 06510, USA.
Yale School of Public Health, New Haven, CT, USA.
J Gen Intern Med. 2020 Jul;35(7):1997-2002. doi: 10.1007/s11606-020-05784-4. Epub 2020 May 6.
Medicaid managed care plans change provider networks frequently, yet there is no evidence about the performance of exiting providers relative to those that remain.
To investigate the association between provider cost and quality and network exit.
Observational study with provider network directory data linked to administrative claims from managed care plans in Tennessee's Medicaid program during the period 2010-2016.
1,966,022 recipients assigned to 9593 unique providers.
Exposures were risk-adjusted total costs of care and nine measures from the Healthcare Effectiveness Data and Information Set (HEDIS) were used to construct a composite annual indicators of provider performance on quality. Outcome was provider exit from a Medicaid managed care plan. Differences in quality and cost between providers that exited and remained in managed care networks were estimated using a propensity score model to match exiting to nonexiting providers.
Over our study period, we found that 21% of participating providers exited at least one of the Medicaid managed care plans in Tennessee. As compared with providers that remained in networks, those that exited performed 3.8 percentage points [95% CI, 2.3, 5.3] worse on quality as measured by a composite of the nine HEDIS quality metrics. However, 22% of exiting providers performed above average in quality and cost and only 29% of exiting providers had lower than average quality scores and higher than average costs. Overall, exiting providers had lower aggregate costs in terms of the annual unadjusted cost of care per-member-month - $21.57 [95% CI, - $41.02, - $2.13], though difference in annual risk-adjusted cost per-member-month was nonsignificant.
Providers exiting Medicaid managed care plans appear to have lower quality scores in the year prior to their exit than the providers who remain in network. Our study did not show that managed care plans disproportionately drop high-cost providers.
医疗补助管理式医疗计划频繁变更供应商网络，但尚无证据表明退出的供应商与仍留在网络中的供应商相比表现如何。
研究供应商成本、质量与网络退出之间的关联。
一项观察性研究，将供应商网络目录数据与田纳西州医疗补助计划2010 - 2016年期间管理式医疗计划的行政索赔数据相链接。
1966022名受助者，分配给9593个不同的供应商。
暴露因素为风险调整后的总护理成本，使用医疗保健有效性数据和信息集（HEDIS）中的九项指标构建供应商质量表现的综合年度指标。结果是供应商退出医疗补助管理式医疗计划。使用倾向得分模型将退出的供应商与未退出的供应商进行匹配，以估计退出和仍留在管理式医疗网络中的供应商在质量和成本上的差异。
在我们的研究期间，我们发现21%的参与供应商至少退出了田纳西州的一项医疗补助管理式医疗计划。与仍留在网络中的供应商相比，退出的供应商在由九项HEDIS质量指标综合衡量的质量方面表现更差，相差3.8个百分点[95%置信区间，2.3，5.3]。然而，22%的退出供应商在质量和成本方面表现高于平均水平，只有29%的退出供应商质量得分低于平均水平且成本高于平均水平。总体而言，就每月每位成员的年度未调整护理成本而言，退出的供应商总成本较低——为21.57美元[95%置信区间，-41.02美元，-2.13美元]，尽管每位成员每月的年度风险调整成本差异不显著。
退出医疗补助管理式医疗计划的供应商在退出前一年的质量得分似乎低于仍留在网络中的供应商。我们的研究并未表明管理式医疗计划不成比例地淘汰高成本供应商。
