Evaluation of the Arkansas Medicaid Primary Care Physician Management Program

Article excerpt

INTRODUCTION

Since 1981, many States have experimented with various forms of managed care to control rising Medicaid expenditures and improve access to medical services for recipients. In early 1993, the Arkansas Department of Human Services submitted a waiver request (section 1915(b)(1)) to HCFA to establish a primary-care case-management program called the Arkansas Medicaid Primary Care Physician (PCP) Management program. HCFA approved the application with the requirement that the program be evaluated by September 30, 1995. This article describes the important features of this program and reports on its effectiveness in the first 1 1/2 years of operation.

The effectiveness of the Arkansas PCP program is determined by a cross-sectional pooled time series analysis of quarterly data routinely collected by State Medicaid agencies participating in the Medicaid Statistical Information System (MSIS). The adjudicated claims data permit estimating the impact of managed care programs by expenditure classes and by recipients' maintenance assistance, or eligibility group. The time series analysis design can, with appropriate modifications, be replicated in other States participating in the MSIS data base project. The Arkansas PCP evaluation examines two critical questions: (1) Has the program been effective in controlling the State's Medicaid expenditures? (2) Has the program changed Medicaid recipients' health care utilization patterns consistent with managed care goals?

Features and Implementation of the Arkansas PCP Program

The Arkansas Medicaid PCP Management Program was patterned after Kentucky's KenPAC program (Beaulieu, 1991) and is a fee-for-service (FFS) primary-care gatekeeper enrollment program (Hurley, Freund, and Paul, 1993). Under this type of managed care, the Arkansas Department of Human Services contracts with five primary-care physician. specialties (family practice, general practice, internal medicine, obstetrics/gynecology, and pediatrics) who, in exchange for a $3 per person per month fee, assume certain patient management responsibilities, including the provision of comprehensive primary care, referral to specialists when medically necessary, and 24-hour per day live-voice access for referral to a physician on call. Medicaid eligibles are required to sign up with a primary-care provider and use this provider first, except for true medical emergencies.

The Arkansas Department of Human Services began recruiting primary-care physicians in October of 1993; by September 1995, 1,287 primary-care physicians had agreed to participate in the Medicaid PCP provider network. Each network provider was allowed to enroll up to 1,000 persons. However, some providers were permitted to enroll more Medicaid eligibles, if they had a large Medicaid patient load prior to program implementation or no other participating providers were located within reasonable distance of the Medicaid eligible.

The Arkansas Medicaid PCP program exempts 30 percent of all Medicaid-eligible persons from participation. The exempted groups are Medicaid eligibles who: (1) have Medicare as their main insurance, (2) reside in nursing homes, (3) reside in intermediate care facilities for the mentally retarded, (4) are eligible for Medicaid as a result of medically needy spend-down, (5) receive children's medical services, (6) are temporary residents outside Arkansas State boundaries, or (7) are retroactively eligible.

The Arkansas Medicaid PCP program was implemented statewide with enrollment that was supposed to be staggered by Medicaid eligibility group. Enrollment of Medicaid eligibles began with Aid to Families with Dependent Children (AFDC) recipients on February 1, 1994, followed by `other Medicaid' recipients on May 1, and Supplemental Security Income (SSI) recipients on August 1, 1994. The actual enrollment of the three Arkansas Medicaid Aid classes is shown in Figure 1 and the composition of the three aid classes is cross- referenced in Table 1. …