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Show scholars in the public health and medical communities (Rosenbaum, Hughes, Butler, and Howard 1988; Benjamin, Taliaferro, Bedard, and Kennan 1993; Kotelchuck 1992) all concluded that the provision of low cost quality care under such arrangements is decidedly mixed. Some research indicates that managed care under Medicaid has generated cost savings, generally in the vicinity of 7%, but questions linger as to the extent to which such savings are attributable to selection of healthier Medicaid clients into managed care programs. The preponderance of scholarly research on quality of care shows that patients have not fared any worse under managed care, but they have not fared any better either. Managed care makes little difference in terms of prenatal care and low birthweight for Medicaid beneficiaries (Carey, Weis, and Homer 1991; Krieger, Connell, LoGerfo 1992), and all such beneficiaries continue to receive inadequate care at higher rates than the non-Medicaid population (Krieger, Connell, LoGerfo 1992). One study that focused on maternity care under Medicaid noted that the incentive to do less under managed care, at times, prompted providers to redirect high-risk maternity patients to public clinics (Rosenbaum, Hughes, Butler, and Howard 1988). Utah was cited as a case in point. Serious out-of-plan problems, however, were noted in both Utah and Minnesota. In Utah, where the state incorporates rigorous maternity-risk management and referral standards into its HMO contracts, public health officials noted that plan providers were failing to comply with the standards and instead were informally instructing or encouraging high-risk women to seek care from local health agencies. While the authors noted that the state has apparently acted to clamp down on such practices, it is clear that an underfunded managed care environment acts to create perverse incentives. Furthermore, access to providers does not necessarily improve under managed care. There is a shortage of OB/GYNs in Utah willing to provide services to Medicaid beneficiaries under managed care (Rosenbaum, Hughes, Butler, and Howard 1988). A Medicaid capitation contract with a staff-model health maintenance organization (HMO), such as FHPF, provides some assurance that Medicaid clients will have access to doctors in the panel. But such is not necessarily the case for Independent Practice Associations (IPAs), where physicians have greater discretion over participation and modes of treatment. There is concern that Medicaid patients will continue to have difficulty scheduling appointments with reluctant and perhaps distant practitioners, and that such waits may postpone otherwise appropriate referrals even for emergency care (Benjamin, Taliaferro, Bedard, and Kennan 1993). Managed care is not a panacea for health care cost containment and access problems under Medicaid. Indeed, managed care under Medicaid may exacerbate problems related to access, particularly if the gulf in finance between Medicaid and private pay managed care continues to grow (Rowland and Salganicoff 1994). Misguided Out-of-Pocket Payments The Governor's proposal also seeks to rein in the costs of expanded access by increasing out-of-pocket payments paid by Medicaid beneficiaries. This is a misguided policy, particularly when applied to low-income people, who are most apt to postpone needed care for themselves and their children in the face of even modest cost-sharing (Lohr K. et al. 1986). A 1972 RAND analysis concluded that the introduction of just a $1 co-payment charge on physician Medicaid visits in California promptly reduced ambulatory visits to the physician by 8%, increased hospital utilization by 17%, and did not decrease overall costs (Roemer M. 1993). Conclusions The Governor's proposal relies too heavily on the incantations of free-market principles to the neglect of a growing body of evidence that in order to live up to its promise of increased access at lower cost, Medicaid under managed care must be adequately funded, carefully integrated into mainstream medical care institutions, and diligently monitored to maintain quality of care. Without increased funding, Medicaid beneficiaries and their infants and children are poised to bear a greater health burden because of reduced access, lower quality of care, and higher out-of-pocket costs. Afraid to adequately fund, the Governor has packaged not substantive reform, but a frayed promise. Acknowledgments: The author is grateful to Kim Segal, FHPF Center for Health Care Studies, for her comments on aspects of the Governors health care proposal and for providing relevant material related to the proposal; and to Deborah LaMarche for gathering relevant literature. The views expressed are strictly those of the author. Utah's Health: An Annual Review 1994 121 |