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Pediatric outpatient utilization by differing Medicaid payment models in the United States
Therese L Canares1, Ari Friedman2, Jonathan Rodean3
1Department of Pediatrics, Johns Hopkins University School of Medicine, 1800 Orleans St, Suite G-1509, Baltimore, MD, 21287, USA. Tcanare1@jhmi.edu.
Insights
Children in capitated Medicaid plans had more primary care visits but fewer emergency department visits compared to fee-for-service. Capitated models may improve access to timely, lower-cost acute care for children.
Area of Science:
- Health Services Research
- Pediatric Health Policy
- Managed Care Economics
Background:
- Medicaid managed care aims to control costs through optimized healthcare utilization.
- Adults in capitated plans use primary care providers (PCP) more than emergency departments (ED) versus fee-for-service (FFS).
- Pediatric data on payment model utilization is limited.
Purpose of the Study:
- To determine the association between US capitated and FFS Medicaid payment models and children's outpatient utilization.
- To compare healthcare seeking behaviors in children under different Medicaid payment structures.
- To inform policy on optimizing pediatric care delivery within Medicaid.
Main Methods:
- Retrospective cohort study of US Medicaid enrollees aged 1-18 years using the 2014 Truven Marketscan Medicaid database.
- Included children with >11 months enrollment, excluding those with disabilities, complex conditions, no outpatient utilization, or specific capitation penetration rates.
- Negative binomial and logistic regression analyzed relationships between payment model and visit frequency/odds of utilization.
Main Results:
- Children in capitated plans (90.6%) showed higher odds of visits to urgent care, PCP-acute, and PCP-well-child care compared to FFS (9.4%).
- Capitated plans were associated with lower odds of visits to EDs and specialty care.
- Specific odds ratios (aOR) indicated significant differences in utilization patterns between payment models.
Conclusions:
- The majority of children in US Medicaid have capitated plans, linked to higher acute care utilization but at lower-cost sites like PCP-acute and urgent care.
- Encouraging capitated payment models and PCP-centered care may enhance access to timely, cost-effective acute care for children.
- Findings suggest potential for improved pediatric healthcare delivery and cost management within Medicaid through payment model optimization.
Background:
In the United States (US), Medicaid capitated managed care costs are controlled by optimizing patients' healthcare utilization. Adults in capitated plans utilize primary care providers (PCP) more than emergency departments (ED), compared to fee-for-service (FFS). Pediatric data are lacking. We aim to determine the association between US capitated and FFS Medicaid payment models and children's outpatient utilization.
Methods:
This retrospective cohort compared outpatient utilization between two payment models of US Medicaid enrollees aged 1-18 years using Truven's 2014 Marketscan Medicaid database. Children enrolled > 11 months were included, and were excluded for eligibility due to disability/complex chronic condition, lack of outpatient utilization, or provider capitation penetration rate < 5% or > 95%. Negative binomial and logistic regression assessed relationships between payment model and number of visits or odds of utilization, respectively.
Results:
Of 711,008 children, 66,980(9.4%) had FFS and 644,028(90.6%) had capitated plans. Children in capitated plans had greater odds of visits to urgent care, PCP-acute, and PCP-well-child care (aOR 1.21[95%CI 1.15-1.26]; aOR 2.07[95%CI 2.03-2.13]; aOR 1.86 [95%CI 1.82-1.91], respectively), and had lower odds of visits to EDs and specialty care (aOR 0.82 [95%CI 0.8-0.83]; aOR 0.61 [95%CI 0.59-0.62], respectively), compared to FFS.
Conclusions:
The majority of children in this US Medicaid population had capitated plans associated with higher utilization of acute care, but increased proportion of lower-cost sites, such as PCP-acute visits and UC. Health insurance programs that encourage capitated payment models and care through the PCP may improve access to timely acute care in lower-cost settings for children with non-complex chronic conditions.
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