AN EMPIRICAL ANALYSIS OF THE IMPACT OF A MEDICAID PRIMARY CARE CASE MANAGEMENT PROGRAM ON EMERGENCY DEPARTMENT AND SPECIALTY PHYSICIAN UTILIZATION IN GEORGIA

摘要

Beginning in the early 1980's, and accelerating through the 1990's, the primary funding mechanism for medical care in the United States shifted from the traditional "fee for service" paradigm to some form of "managed care" model. In the least restrictive form of managed care, an independent primary care physician assumes overall responsibility for the management of a patient's medical affairs, and acts as a "gatekeeper" for access to more specialized care.The driving force behind managed care programs has clearly been cost control, and the evaluation of such funding arrangements has tended to focus on expenditure and utilization measures. This study departed from more traditional methodologies and focused on the underlying decision processes that drive the demand for emergency department and specialty physician services by Medicaid recipients in the state of Georgia.Separate non-linear count regression models were developed for the decision to seek treatment - presumably made by the patient - and for the decision concerning the extent of treatment provided - presumably made by the physician. This methodology allowed the separate evaluation of the decisions made by patients and physicians, and avoided certain statistical problems that arise when using Gaussian models to analyze data that are highly skewed and consist of non-negative low-valued integers.This research found that Medicaid recipients in the managed care program sought treatment from emergency departments and specialty physicians less frequently than those enrolled in the traditional Medicaid fee for service plan. However, once a recipient contacted an emergency department or specialty physician, no statistically significant differences were detected between those recipients in the managed care program and those receiving benefits under the traditional Medicaid plan.