Leveraging Evidence for Access and Development, Krea University, Sricity, India.
Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island.
JAMA Intern Med. 2020 Dec 1;180(12):1672-1679. doi: 10.1001/jamainternmed.2020.5408.
Enrollment in Medicaid managed care plans has increased rapidly, particularly in national commercial insurance plans. Whether the type of managed care plan is associated with the use of health services for Medicaid beneficiaries is unknown.
To compare the use of outpatient and acute care between Medicaid enrollees randomly assigned to a national commercial managed care plan or a local Medicaid-focused managed care plan.
DESIGN, SETTING, AND PARTICIPANTS: This natural experiment of a cohort of Medicaid enrollees randomly assigned to 2 managed care plans in a Northeastern US state was conducted from June 30, 2009, to June 30, 2013. Statistical analysis was performed from September 1, 2019, to August 30, 2020.
Assignment to a Medicaid-focused insurance plan or a commercial managed care plan.
Outpatient visits, emergency department visits, and total inpatient and ambulatory care-sensitive hospitalizations.
A total of 8010 patients were included in the analysis: 4737 were assigned to a Medicaid-focused plan (2795 female [59.0%]; mean [SD] age, 17.8 [3.2] years) and 3273 to a commercial managed care plan (1915 female [58.5%]; mean [SD] age, 17.9 [3.3] years). Those randomly assigned to the Medicaid-focused plan had a mean (SD) of 6.67 (9.18) annual outpatient visits per person, and those assigned to the commercial plan had a mean (SD) of 8.36 (11.77) annual outpatient visits per person (adjusted absolute difference, 1.72 [95% CI, 1.31-2.13]; 22% relative difference). The increased use of outpatient visits in the commercial plan was associated with an increase in specialty care visits (mean [SD], 2.34 [6.31] visits in Medicaid-focused plan vs 3.75 [9.32] visits in commerical plan; adjusted absolute difference, 1.43 visits [95% CI, 1.25-1.56 visits]; 61% relative difference). Mean (SD) annual emergency department visits were 0.49 (1.39) per person in the Medicaid-focused plan and 0.51 (1.40) in the commercial plan (adjusted absolute difference, 0.02 [95% CI, -0.02 to 0.05]). Mean (SD) annual inpatient admissions were 0.067 (0.45) per person in the Medicaid-focused plan and 0.069 (0.53) in the commercial plan (adjusted absolute difference, 0.003 [95% CI, -0.01 to 0.02]). Plan assignment was not significantly associated with ambulatory care-sensitive admissions. Results were consistent in instrumental variables analyses that accounted for disenrollment and switching.
Compared with Medicaid managed care enrollees assigned to a Medicaid-focused plan, those assigned to a commercial plan had more outpatient visits, particularly for specialty care, but had similar rates of emergency department visits and hospitalizations. These findings suggest that the type of managed care plan may be associated with health services use and spending among Medicaid beneficiaries and that random assignment may help states understand how well different plans perform for enrollees.
医疗补助管理式医疗计划的参保人数迅速增加，尤其是在全国商业保险计划中。目前尚不清楚管理式医疗计划的类型是否与医疗补助受益人的医疗服务使用情况有关。
比较随机分配到全国商业管理式医疗计划或当地以医疗补助为重点的管理式医疗计划的医疗补助参保者的门诊和急性护理使用情况。
设计、地点和参与者：这是在美国东北部一个州的医疗补助参保者随机分配到 2 种管理式医疗计划的自然实验队列研究，于 2009 年 6 月 30 日至 2013 年 6 月 30 日进行。统计分析于 2019 年 9 月 1 日至 2020 年 8 月 30 日进行。
分配到以医疗补助为重点的保险计划或商业管理式医疗计划。
门诊就诊、急诊就诊以及总住院和门诊医疗敏感住院。
共纳入 8010 例患者进行分析：4737 例被分配到以医疗补助为重点的计划（2795 例女性[59.0%]；平均[标准差]年龄，17.8[3.2]岁），3273 例被分配到商业管理式医疗计划（1915 例女性[58.5%]；平均[标准差]年龄，17.9[3.3]岁）。随机分配到以医疗补助为重点的计划的患者每人平均（标准差）有 6.67（9.18）次年度门诊就诊，而随机分配到商业计划的患者每人平均（标准差）有 8.36（11.77）次年度门诊就诊（调整后的绝对差异，1.72[95%置信区间，1.31-2.13]；22%相对差异）。商业计划中门诊就诊的增加与专科就诊就诊的增加相关（平均[标准差]，以医疗补助为重点的计划为 2.34[6.31]就诊；商业计划为 3.75[9.32]就诊；调整后的绝对差异，1.43就诊[95%置信区间，1.25-1.56 就诊]；61%相对差异）。以医疗补助为重点的计划中，每人平均（标准差）每年急诊就诊 0.49（1.39）次，商业计划中为 0.51（1.40）次（调整后的绝对差异，0.02[95%置信区间，-0.02 至 0.05]）。以医疗补助为重点的计划中，每人平均（标准差）每年住院 0.067（0.45）次，商业计划中为 0.069（0.53）次（调整后的绝对差异，0.003[95%置信区间，-0.01 至 0.02]）。计划分配与门诊医疗敏感入院无显著相关性。在考虑到退保和转换的工具变量分析中，结果一致。
与被分配到以医疗补助为重点的计划的医疗补助管理式医疗计划参保者相比，被分配到商业计划的参保者门诊就诊次数更多，尤其是专科就诊，但急诊就诊和住院率相似。这些发现表明，管理式医疗计划的类型可能与医疗补助受益人的医疗服务使用和支出有关，随机分配可能有助于各州了解不同计划对参保者的表现。
