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An academic medical center's experience with mandatory managed care for Medicaid recipients
A L Hillman1, N Goldfarb, J M Eisenberg
1School of Medicine, Leonard Davis Institute of Health Economics, Philadelphia, PA.
Abstract:
This paper reports on The Hospital of the University of Pennsylvania's experience and concerns as a participating primary care site in a Medicaid managed care program (HealthPASS), which was established in 1986. Enrollment is mandatory for approximately half of Philadelphia's medical assistance population. Participating primary care sites receive monthly capitation for enrollees and serve as "gatekeepers" for specialty and inpatient services. The report discusses why the academic medical center chose to participate in the program and how existing activities were modified to meet both increased demand for primary care and increased administrative requirements. It also identifies characteristics of the HealthPASS program and of the medical center that have impeded effective case management of care for the urban poor population that the program serves. Improving the quality of care for the medically indigent while controlling costs is essential, but political realities and the special needs of the Medicaid population must be acknowledged. Increased attention must be given to the impact that political compromises have on the design and effectiveness of a managed care program.
Insights
The Hospital of the University of Pennsylvania's participation in the HealthPASS Medicaid managed care program faced challenges in managing care for the urban poor. Political compromises impacted the program's effectiveness and the quality of care for the medically indigent.
Area of Science:
- Health Services Research
- Public Health Policy
- Academic Medicine
Background:
- The HealthPASS program, a Medicaid managed care initiative, mandated enrollment for a significant portion of Philadelphia's medical assistance population.
- Participating primary care sites, like the Hospital of the University of Pennsylvania, acted as gatekeepers for specialty and inpatient services, receiving monthly capitation payments.
Purpose of the Study:
- To report on the experience and concerns of a major academic medical center participating as a primary care site in the HealthPASS program.
- To identify factors within the HealthPASS program and the medical center that hindered effective case management for the urban poor.
Main Methods:
- Qualitative analysis of the academic medical center's experience within the HealthPASS program.
- Review of modifications to existing activities to meet program demands.
- Identification of challenges in case management for the urban poor population.
Main Results:
- The academic medical center modified its operations to address increased primary care demand and administrative burdens.
- Specific program and institutional characteristics impeded effective case management for the urban poor.
- Political realities and compromises influenced program design and effectiveness.
Conclusions:
- Improving care quality for the medically indigent while controlling costs requires acknowledging the unique needs of the Medicaid population.
- Political compromises in managed care program design can negatively impact effectiveness.
- Further attention is needed on the interplay between political factors and managed care program outcomes for vulnerable populations.