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Medicaid: Cost Versus Need

Medicaid And Managed Care: A Lasting Relationship?

Abstract

 
The Medicaid program made a major commitment to managed care during the past decade. Following turbulent early years, the marriage matured and stabilized because managed care models responded well to a number of the states’ goals and Medicaid purchasers were willing to make key trade-offs on behalf of their beneficiaries that conformed to the designs of managed care products. The relative tranquility in Medicaid managed care contrasts sharply with turmoil in both the commercial and Medicare sectors. But continuing changes in the managed care marketplace and financial distress in state budgets present new challenges to the strength and durability of this relationship.

By 2002 more than 58 percent of Medicaid’s beneficiaries were enrolled in managed care arrangements, with approximately 40 percent, or more than fifteen million, enrolled in health maintenance organizations (HMOs) and other prepaid health plans.² While managed care in Medicaid encountered considerable turbulence in its early years, its relative tranquility in recent years compares favorably with commercial and Medicare managed care, which have been buffeted by consumer and provider backlash in the private sector and numerous health plan exits from Medicare+Choice (M+C). In general, it appears that Medicaid agencies have been willing to make and sustain the trade-offs associated with managed care in exchange for the value these models provide to beneficiaries and purchasers.

The more stable and durable accommodation with managed care found in Medicaid begs for both more recognition and better understanding. We examine this issue by reviewing the evolution of Medicaid managed care and the challenges it has had to overcome. Contemporary trends in managed care present a new set of developments that underscore that the longevity of the marriage of Medicaid to managed care is not assured, and that significant mutual adjustments will be required to make this a lasting relationship.

In The Beginning . . .

Top In The Beginning .... The Managed Care Rising... Medicaid Managed Care... ‘Endangering The Safety... Managed Care In Transition... Partnership Appears To Pay... A Special Affinity NOTES

 
By the early 1980s ensuring access to a medical home had become a major Medicaid concern, as low payment rates contributed to limited provider participation and increasing reliance on emergency departments as a source of primary care. First-generation Medicaid managed care initiatives sought to contract for medical homes with either prepaid health plans or individual physicians who would be available around the clock and provide primary care and care coordination.³ Ironically, early efforts to achieve this goal often led to conflicts and criticism. Linking beneficiaries with specific providers as their first point of contact for services had the effect of restricting the freedom of choice that beneficiaries ostensibly had under the traditional Medicaid program. When states made enrollment mandatory, this further engendered opposition to managed care.⁴

Early managed care initiatives emerged in a period when there was little experience with state-sponsored experimentation in Medicaid. Their forays were invariably iterative, not always well conceived or crafted, and often subject to considerable criticism.⁵ Also, Medicaid managed care experimentation required states to petition the federal government for waivers of existing Medicaid policies, and they often became entangled in difficult federal-state relationships in a period that predated later interest in Medicaid block grants and devolution. Waiving beneficiaries’ right to free choice of providers became a cause célèbre for many in the advocacy community, who criticized states’ methods and motives and pressured the federal government to slow the movement toward managed care.

Sensitivity about relinquishing freedom of choice seemed overstated, because Medicaid beneficiaries in many states had always found only limited numbers of providers willing to treat them, given low payment rates and other program requirements. The Medicaid eligibility card was, in effect, a license to hunt for providers who would accept it. Managed care pioneers such as Arizona, California, Michigan, and Utah discovered that by embracing managed care, they gained contractually guaranteed access to health plans or primary care physicians. Correspondingly, for the first time many Medicaid agencies developed the capability to monitor compliance with minimum access requirements. Linking beneficiaries with primary care providers also created an opportunity for more care coordination, better access to information and advice for patients, and other benefits of a continuing patient-provider relationship.⁶

Early empirical evidence of managed care impacts was uneven because of program variation, checkered records of implementation, and data availability problems. But in time a credible body of knowledge indicated that a number of states also found that managed care programs achieved the sought-after medical home, accumulated modest savings, and altered patterns of service use.⁷ Dramatic reductions in dependence on expensive emergency departments were reported, suggesting that both cost reductions and better continuity in care were attainable by contractually requiring primary care physicians or health plans to provide round-the-clock availability to beneficiaries.⁸

The Managed Care Rising Tide

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The potential for achieving savings through managed care received intensified interest in the early 1990s as a result of the convergence of two key trends. Medicaid costs began to soar, in large measure because of federally mandated eligibility expansion (the Omnibus Budget Reconciliation Act of 1989, or OBRA-89) as well as medical care inflation and increased service intensity.⁹ A number of states witnessed Medicaid spending increases of more than 20 percent per year during this period and vigorously pursued cost-control mechanisms. Concurrently, evidence from the commercial sector suggested that HMOs were obtaining substantial savings for private purchasers that moved their employees into health plans. Extrapolating from private-sector experience, states saw implementing prepaid managed care models as a promising strategy. What many policymakers overlooked was that private-sector savings were often the result of health plans’ aggressively negotiating large discounts with providers, who had been charging them full price for their services. Furthermore, an ample supply of providers was considered to be a necessary condition for plans to obtain discounts. Likewise, managed care plans appeared to be most successful in reducing inpatient use by shortening stays or diverting care to outpatient settings.

In contrast, most Medicaid agencies were already paying providers well below commercial rates, greatly curtailing savings opportunities. The supply of providers willing to serve Medicaid beneficiaries was also limited, removing an important condition for negotiating further rate discounts. Medicaid was also a major financier of financially stressed safety-net providers that were highly dependent on Medicaid support, making it difficult to extract savings from them without jeopardizing their viability. In terms of utilization changes, effective care management in Medicaid could in fact lead to increased utilization for beneficiaries with substantial unmet need or previously constrained by limited access to certain types of providers. Moreover, at least among low-income women and children in Medicaid, the ability of managed care models to alter use of costly inpatient services was limited, since most inpatient episodes were for obstetrical care.¹⁰

Notwithstanding concerns about uncertain economic payoffs from managed care, a number of venturesome states attempted to parlay anticipated savings from managed care initiatives into support for expanding eligibility to previously uninsured people at about this time. Oregon, closely followed by Tennessee, led this parade, and soon after came Hawaii and Rhode Island.¹¹ These states committed to a course of converting the acute care part of their Medicaid programs into a prepaid health plan strategy. Even if managed care arrangements did not produce major savings—as some clearly realized they could not—they did provide a foundation for enrolling additional populations and guaranteeing them a medical home. Since the programs were based on prepaid rates, they were expected to provide states with some control and predictability over future costs, as long as they could find plans to participate for the rates they could afford to pay.

Embracing managed care was also contentious for Medicaid programs that required important adaptations to make the relationship work.¹² Medicaid funds by this time had become a key revenue stream for supporting a variety of state-level activities and facilities, with constituencies that forcefully challenged a Medicaid agency that tried to act purely as an aggressive purchaser on behalf of its beneficiaries. Direct funding and indirect subsidies for state mental health facilities, academic health centers (AHCs), and public hospitals and health centers could be put at risk if states enrolled beneficiaries in private network-based health plans, since the plans might allocate dollars differently from what state Medicaid agencies had been doing. Thus, as managed care enrollment grew, so too did the concerns of providers of care that had grown dependent on Medicaid financing.

Medicaid Managed Care Everywhere?

Top In The Beginning .... The Managed Care Rising... Medicaid Managed Care... ‘Endangering The Safety... Managed Care In Transition... Partnership Appears To Pay... A Special Affinity NOTES

 
By the mid-1990s the conversion of acute care services in Medicaid programs to managed care was spreading rapidly across the country, as a growing number of states pursued waivers from the federal government to experiment with a variety of models and arrangements.¹³ Prepaid health plans appeared to be the model of choice in many states, and growing numbers of commercial managed care plans chose to enter the Medicaid market at this time, with nearly two out of every three beneficiaries enrolled in predominantly commercial plans by 1998.¹⁴ Several states, including Arizona, Tennessee, and Hawaii, relied exclusively on prepaid plans, while others employed a mix of prepaid plans in urban areas and partial or no-risk models elsewhere in the state.

Other states, because of preference or market-driven necessity, chose to launch or expand primary care case management (PCCM) programs.¹⁵ Typically, in predominantly rural states or those with limited commercial HMO penetration, PCCM was the only possible model. This was not surprising, given the challenges that commercial and Medicare managed care had encountered in non metropolitan areas.¹⁶ Whether PCCM programs could or would have discernible impacts on beneficiaries was unclear at the time. Later research seems to indicate that managed care effects are muted in rural locations, given providers’ limited capacity and inability to alter traditional patterns of care seeking and delivery.¹⁷

More states expanded Medicaid managed care to include additional eligibility groups beyond the populations of low-income women and children targeted in earlier initiatives. States were motivated to try to devise and adapt managed care models for Supplemental Security Income (SSI) beneficiaries because they represented the bulk of expenditures for Medicaid programs—more than 70 percent of all spending in some states.¹⁸ Achievement of substantial savings ultimately had to include some subsets of this population in managed care efforts. But progress was slow in this area, as resistance arose among advocates, consumers, providers, and even plans that were concerned that states were not ready to bring these most challenging groups into managed care arrangements or to pay the plans appropriately for doing so. Early models were very small and narrowly targeted, but they did break new ground in terms of innovations in chronic care management, consumer engagement, and risk-adjustment methodologies.

Another crucial development of the mid-1990s was a widespread awakening among the states to the problems and opportunities associated with negotiating and executing contracts with prepaid health plans. Initial contracts were under-developed and underenforced, as revealed in a series of studies that focused attention on this neglected issue.¹⁹ But in time a growing number of states discovered what a few had already realized: Contracts could be valuable instruments in the hands of sophisticated purchasers. Well-crafted contracts could make participation requirements more explicit, impose unequivocal access and capacity standards, set detailed performance goals, demand more and better data, promote and reward quality improvement, and generally convey to plan vendors a heightened sense of accountability. A number of state Medicaid officials concluded that buying benefits this way was a quantum leap in improvement over the traditional method of fee-for-service (FFS) purchase from individual providers.²⁰

‘Endangering The Safety Net’ Debate

Top In The Beginning .... The Managed Care Rising... Medicaid Managed Care... ‘Endangering The Safety... Managed Care In Transition... Partnership Appears To Pay... A Special Affinity NOTES

 
While the expansion of commercial managed care has spawned a fierce provider backlash in the past decade, Medicaid managed care triggered a particularly perplexing form of provider revolt. Many traditional providers of care to Medicaid beneficiaries, including public hospitals, AHCs, community health centers (CHCs), and high-volume indigenous physicians, came to view enrollment of beneficiaries in prepaid managed care arrangements as threatening. Network-based delivery systems might alter traditional patterns of care seeking among beneficiaries, leading to disruption in provider relationships and revenue streams.

These providers challenged the expansion of managed care in Medicaid on many fronts as articulated most prominently by an Institute of Medicine (IOM) committee that focused directly on this concern.²¹ The fear was that enrollment of safety-net providers’ core customers in managed care plans could increase these customers’ mobility and might enable them to seek care from (mainstream) providers not previously available. This could jeopardize the survival of traditional providers. Aggressive negotiations by plans could suppress providers’ ability to continue to shift costs or cross-subsidize among payers to finance uncompensated care. Many of these providers accused states of being short-sighted and insensitive to maintaining a safety net essential to both the persistently uninsured and those who move back and forth between Medicaid eligibility and uninsured status. Partially in response to these concerns and to federal directives and guidance, state Medicaid programs did compel plans to incorporate safety-net providers into networks and to ensure that their financial requirements were being met. Some states such as California went even further, making explicit accommodations to ensure that Medi-Cal managed care did not put safety-net providers in jeopardy.²² Others, such as Massachusetts and New York, made concerted efforts to anchor managed care initiatives around these providers.

At the same time that some safety-net providers sought to mobilize resistance to expanded managed care, a number of these providers took the opposite tack and sponsored their own plans. Some were built along the lines of early pioneering organizations like the Bronx Health Plan, Neighborhood Health Plan, and United Health Plan of LA, which had been formed by CHCs.²³ Others, like Colorado Access and Johns Hopkins Health Plan, were developed and underwritten by public hospitals or AHCs especially concerned about maintaining Medicaid market shares or adequate payments for care of Medicaid patients, or both.²³ Health center–affiliated plans alone now cover nearly 1.5 million lives.²⁴ The growth in exclusively or predominantly Medicaid plans received a substantial boost in the late 1990s, when commercial plans began to exit the Medicaid market and their enrollees migrated to Medicaid specialized plans.²⁵ Not all of these plans would be provider-sponsored, and a number of investor-owned companies have entered this market, but a common thread was that the plans’ networks include traditional Medicaid providers as core components.

Managed Care In Transition And Under Duress

Top In The Beginning .... The Managed Care Rising... Medicaid Managed Care... ‘Endangering The Safety... Managed Care In Transition... Partnership Appears To Pay... A Special Affinity NOTES

 
By the late 1990s more than half of all Medicaid beneficiaries were in managed care arrangements, which reveals just how dependent Medicaid had become on the managed care marketplace. A number of efforts have been launched in recent years aimed at focusing greater attention to the role of managed care in Medicaid: promoting more systematic collection and reporting of performance data on Medicaid beneficiaries in managed care arrangements; sponsoring quality improvement and best-practice dissemination across health plans; engaging consumers in designing and monitoring their own managed care arrangements; and bolstering the purchasing sophistication of state Medicaid agencies.²⁶ State and federal relationships surrounding Medicaid managed care waivers have become far less contentious and the review and renewal processes more routine.

But heavy dependence of Medicaid on managed has increased the program’s vulnerability to threatening developments in the managed care realm.²⁷ Health plans have suffered an apparent loss of traction in cost control; a profitability downturn in the managed care industry has altered interest in public-sector lines of business; and the twin effects of fierce consumer backlash and provider pushback have shaken the industry to its core. These forces have driven health plans to offer looser products, broader networks, less care management, and more cost sharing to their members—trends that run counter to Medicaid managed care program goals.

Some developments directly affected Medicaid initiatives. Commercial plans began to withdraw from Medicaid as they purged low- and no-margin business lines. The reversal of trends in commercial plans’ entry into Medicaid was first evident in 1998 and has continued to increase since then.²⁸ For some plans, the decision to withdraw was less a reflection on Medicaid than a response to industry profitability trends and the need for retrenchment. But given the administrative demands associated with Medicaid participation, some commercial plans with small Medicaid membership saw the burdens as disproportionate relative to the size of enrollment and the limited upside financial potential. Nearly all plans have pressured states to look more closely at the adequacy and refinement of their rates and the administrative burdens they place on contracting plans to better bring rates and requirements into line with one another.

Other facets of the "changing face of managed care" have indirectly but potentially more momentous long-term implications for Medicaid managed care.²⁹

Network expansion/product diversification. Consumer and provider pressure on plans has largely spelled the demise of restricted network products in the private sector—in particular, the traditional HMO. Multiproduct firms have seen marked migration to broad network products such as preferred provider organizations (PPOs); limited-product firms have had to add these products to their portfolio of offerings. This pattern of change runs counter to Medicaid’s support for tight network products that exchange some choice of providers for better cost control—the traditional trade-off represented by the classic HMO. Commercial health plans may conclude that maintenance of tighter networks solely for a Medicaid product may not be justified by the profitability prospects in this product line. Ultimately, it is not clear who will be selling the product that Medicaid wants to buy in the future if current trends in managed care product transformation continue.

Increased cost participation. Accompanying these changes is greater reliance on consumer cost participation for health plan enrollees in the commercial and Medicare sectors. Multiple-tier drug benefit designs to foster cost-conscious choice of prescription drugs are the most visible version of this trend.³⁰ Health plans may use more demand-side mechanisms to influence consumers’ behavior for other services as well. Medicaid requirements have prohibited or severely curtailed the use of cost sharing, although there are indications that these prohibitions will be relaxed as states avail themselves of increased flexibility.³¹ But beyond regulatory impediments to substantial cost sharing is the inescapable problem that most Medicaid beneficiaries lack the financial resources to meet steeper copayment requirements, and care seeking could be distorted in dangerous ways if these features were to be widely employed in Medicaid managed care arrangements.

Reduced reliance on utilization management and cost-control mechanisms. In efforts to launch kinder and gentler forms of managed care to counteract backlash by providers, many health plans discontinued the use of utilization management techniques that were once associated with reduced inpatient use. In addition, impositions such as prudent layperson laws for emergency departments have diminished plans’ ability to exert control over members’ access to emergency services. Other requirements such as direct access to specialists have the potential for similar adverse impacts on plans’ ability to control costs. Unlike commercial members for whom additional cost sharing (such as copayments on unnecessary emergency department visits) can be used to influence care seeking, plans serving Medicaid beneficiaries may not be able to counteract cost-increasing trends. Medicaid has a long-standing tradition of prior authorization requirements even in FFS, so it may see less value in promoting a weakening of these proven mechanisms.

Higher payments to providers in response to pushback. Evidence indicates that health plans are finding it increasingly difficult to negotiate favorable terms with health care providers, particularly hospitals.³² By successfully engineering market consolidation and negotiating with more resolve and solidarity than evident in the past, hospitals are extracting substantial increases from plans, which in turn are raising premiums sharply in the commercial world. Medicaid agencies that administer payment rates instead of negotiating them may put a number of plans in difficult and at times untenable positions by requiring them to come to terms with key network providers while not permitting them to pass along to purchasers the costs of doing so. Because Medicaid patients are typically concentrated in a limited number of hospitals, these facilities enjoy considerable countervailing leverage with health plans, which they now are unleashing. The safety-net status of many of these providers adds further weight to their claims for increased compensation.

Partnership Appears To Pay Off

Top In The Beginning .... The Managed Care Rising... Medicaid Managed Care... ‘Endangering The Safety... Managed Care In Transition... Partnership Appears To Pay... A Special Affinity NOTES

 
One of the more significant signs of the maturation of Medicaid/State Children’s Health Insurance Program (SCHIP) managed care is the increasing willingness of state purchasers to collaborate with their health plan partners.³³ Instead of tense confrontations with safety-net providers, states such as Massachusetts have made concerted efforts to strengthen their safety-net plans, including assigning beneficiaries who do not select the PCCM option. An increasing number of states, including Arizona, Rhode Island, and Maryland, are working with their plans and major providers to move from simple performance measurement to rewarding high performance with administrative and financial incentives. California is pursuing a series of collaborative opportunities with its plans and relevant consumer groups to design continuous quality improvement projects that focus on specific illnesses such as pediatric asthma or conditions such as emotional disabilities among children.

In states such as Vermont and North Carolina, where the HMO industry made limited inroads, or Arkansas, where it never gained a beachhead in Medicaid, sophisticated mechanisms are being put in place by the states to strengthen and monitor their PCCM programs. These mechanisms include performance measurement and provider profiling, to improve quality. Ultimately, these PCCM programs begin to look like well-crafted, state-run managed care organizations complete with member services, care coordination, quality assurance, and accountability never seen in traditional FFS Medicaid or even earlier forms of PCCM.

Perhaps the most important arena in which this kind of sophisticated collaboration could occur would be in the application of managed care techniques in the design of integrated systems of care for people with chronic illnesses and disabilities. States know that 70–80 percent of Medicaid resources are consumed in caring for these populations. Maryland, Oregon, Oklahoma, Pennsylvania, and others now have substantive experience with large-scale managed care programs for these populations offered through established health plans.

A number of other states, led most notably by Florida, have launched targeted disease management programs for selected conditions, including asthma, diabetes, HIV/AIDS, and hemophilia, that have both high prevalence and high cost in Medicaid. Although the models vary, most of them offer a combination of patient education, care coordination, and aggressive medication management and are typically delivered by specialized organizations selected by state Medicaid agencies. The jury may still be out on Florida’s related cutting-edge experiments with chronic disease and prescription drug management, but they have generated great interest both inside and outside of Medicaid.³⁴ Other states such as Minnesota and South Carolina are joining the early innovators in experimenting with special-needs plans that provide more expert, more flexible, and more consumer-directed care for subsets of the disability population, such as adults with severe physical disabilities and medically fragile children.

In Colorado the structure is in place to demonstrate within a single managed care organization how to integrate physical and behavioral health care for adults with serious and persistent mental illnesses. The promise of increased federal flexibility from the Bush administration has even brought states, plans, and consumers together in states such as Ohio and Michigan to consider new managed care mechanisms for better serving those eligible for both Medicare and Medicaid, the so-called dually eligible population. These states and others who came before them, including Texas, Minnesota, Utah, and Wisconsin, are grappling with the potential of fully capitated systems of managed long-term care services. Their challenge is to reach thousands of beneficiaries statewide, as opposed to the few hundred that participate in more limited site-based programs such as the Program for All-Inclusive Care for the Elderly (PACE).

These examples of managed care–based innovations taking place in Medicaid managed are not meant to be exhaustive. They should, however, convey a sense that states in nearly every region of the country and across the entire continuum of care seem to be deepening their investments in collaborative design and implementation of managed care even as budgetary pressures build for them to make substantial cuts in their programs.

A Special Affinity

Top In The Beginning .... The Managed Care Rising... Medicaid Managed Care... ‘Endangering The Safety... Managed Care In Transition... Partnership Appears To Pay... A Special Affinity NOTES

 
Clearly, there are contemporary risks for an estrangement between Medicaid and managed care caused by severe state financial distress and the transformations afoot in the managed care industry. But the current maneuvering by states to preserve core elements of managed care reveals their intent not to have to return to the not-so-good old days of traditional FFS Medicaid. While troubled by severe financial distress, instability among vendors, and uncertainty about future contracting opportunities, few states have concluded that they have been ill served by managed care. On the contrary, most seem to believe that the conversion of Medicaid to managed care has been a step in the right direction to gain more control and accountability from the health care marketplace where beneficiaries are seeking services. Likewise, states that have invested heavily in developing systems, infrastructure, expertise, and more balanced and constructive relationships with plans and providers are reluctant to relinquish this progress. Those states that have accumulated evidence of the positive impacts of managed care will use it to argue for sustaining the progress made to date.

If conventional prepaid managed care models continue to unravel, look to Medicaid agencies to try to devise customized models to meet their needs. If commercial plans move further away from Medicaid products as they try to adapt to commercial market demands, then states will grow more reliant on predominantly Medicaid plans and try to enhance the performance and bolster the financial viability of these more durable and committed partners. In the final analysis, the peculiar affinity of Medicaid for managed care may best be understood by the fact that a managed care strategy may be most acceptable and, perhaps, successful when resources limitations are clearly recognized, as has always been the case in Medicaid.

Editor's Notes

 
Bob Hurley is an associate professor in the Department of Health Administration, Virginia Commonwealth University, in Richmond. Steve Somers is president of the Center for Health Care Strategies in Princeton.

NOTES

Top In The Beginning .... The Managed Care Rising... Medicaid Managed Care... ‘Endangering The Safety... Managed Care In Transition... Partnership Appears To Pay... A Special Affinity NOTES

 

1. R. Stevens and R. Stevens, Welfare Medicine in America (New York: Free Press, 1974).
2. Centers for Medicare and Medicaid Services, "2001 Medicaid Managed Care Enrollment Report," cms.hhs.gov/medicaid/managedcare/mmcss01.asp (6 November 2002).
3. D. Freund, Medicaid Managed Care: Four Case Studies (Washington: American Enterprise Institute, 1984); and R. Hurley, D. Freund, and J. Paul, Managed Care in Medicaid (Ann Arbor, Mich.: Health Administration Press, 1993).
4. S. Rosenbaum et al., "Incantations in the Dark: Medicaid, Managed Care, and Maternity Care," Milbank Quarterly 66, no. 4 (1988): 661–693; B. Spitz, "When a Solution Is Not a Solution: Medicaid and Health Maintenance Organizations," Journal of Health Politics, Policy and Law 3, no. 4 (1987): 497–519; and W.P. Welch and M. Miller, "Mandatory HMO Enrollment in Medicaid: The Issue of Freedom of Choice," Milbank Quarterly 66, no. 4 (1988): 618–639.
5. U.S. General Accounting Office, Medicaid: Early Problems in Implementing the Philadelphia HealthPASS Program, Pub. no. GAO/HRD-88-37 (Washington: GAO, December 1987); and GAO, Medicaid: Oversight of Health Maintenance Organizations in the Chicago Area, Pub. no. GAO/HRD-90-81 (Washington: GAO, August 1990).
6. Hurley et al., Managed Care in Medicaid.
7. D. Rowland et al., Medicaid and Managed Care: Lessons from the Literature (Washington: Kaiser Commission on the Future of Medicaid, June, 1995).
8. R. Hurley et al., "Emergency Room Use and Primary Care Case Management: Evidence from Four Medicaid Demonstration Programs," American Journal of Public Health 79, no. 7 (1989): 843–847.[Abstract/Free Full Text]
9. Kaiser Commission, The Medicaid Cost Explosion: Causes and Consequences (Washington.: Kaiser Commission, 1993).
10. R. Hurley and S. Wallin, "Adopting and Adapting Managed Care for Medicaid Beneficiaries: An Imperfect Translation," Occasional Paper no. 7 (Washington: Urban Institute, June 1998).
11. J. Holahan et al., "Insuring the Poor through Section 1115 Waivers," Health Affairs (Spring 1995): 199–216.
12. J. Holahan et al., "Medicaid Managed Care in Thirteen States," Health Affairs (May/June 1998): 43–63; and Hurley and Wallin, "Adopting and Adapting Managed Care for Medicaid Beneficiaries:"
13. J.K. Iglehart, "Medicaid and Managed Care," New England Journal of Medicine 332, no. 25 (1995): 1727–1731.[Free Full Text]
14. M. McCue et al., "Reversal of Fortune: Commercial HMOs in the Medicaid Market," HealthAffairs (Jan/Feb 1999): 223–230; and S. Felt-Lisk and S. Yang, "Changes in Health Plans Serving Medicaid, 1993–1996," Health Affairs (Sept/Oct 1997): 125–133.
15. National Academy for State Health Policy, Medicaid Managed Care: A Guide for States, 5th ed. (Portland, Maine: NASHP, 2001).
16. S. Felt-Lisk et al., "Medicaid Managed Care in Rural Areas: A Ten-State Follow-Up Study," Health Affairs (Mar/Apr 1999): 238–245.
17. T. Coughlin and S. Long, "Effects of Medicaid Managed Care on Adults," Medical Care 38, no. 4 (2000): 433–446; and [Medline]S. Long and T. Coughlin, "Impacts of Medicaid Managed Care on Children," Health Services Research 36, no. 1 (2000): 7–23.
18. M. Regenstein and S. Anthony, Medicaid Managed Care for Persons with Disabilities (Washington: Economic and Social Research Institute, August 1998); and S. Payne, "Comparison of Risk-Adjustment Systems for the Medicaid-Eligible Disabled Population," Medical Care 38, no. 4 (2000): 422–432.[Medline]
19. S. Rosenbaum et al., Negotiating the New Health Care System: An Analysis of Contracts between State Medicaid Agencies and Managed Care Organizations (Washington: George Washington University Medical Center, Center for Health Policy Research, 1997).
20. R. Hurley and S. Somers, "Medicaid Managed Care," in The Essentials of Managed Health Care, ed. P. Kongstvedt (Gaithersburg, Md.: Aspen Publishers, 2000); and J. Fossett et al., "Managing Medicaid Managed Care: Are States Becoming Prudent Purchasers?" Health Affairs (July/Aug 2000):36–49.
21. Institute of Medicine, America’s Health Care Safety Net: Intact but Endangered (Washington: National Academy Press, 2000).
22. D. Draper and M. Gold, "Customizing Medicaid Managed Care—California Style," Health Affairs (Sep/Oct 2000): 233–238.
23. B. Gray and C. Rowe, "Safety-Net Health Plans: A Status Report," Health Affairs (Jan/Feb 2000): 185–193; and M. Sparer and L. Brown, "Uneasy Alliances: Managed Care Plans Formed by Safety-Net Providers," Health Affairs (July/Aug 2000): 23–35.
24. A. Zuvekas, "Community Health Center Affiliated Health Plans: A Viable Alternative for Medicaid Managed Care," November 2001, www.ahcahp.org/publications/zuvekas.pdf (6 November 2002).
25. Felt-Lisk and Yang, "Changes in Health Plans Serving Medicaid."
26. Center for Health Care Strategies, "The Medicaid Managed Care Program," www.chcs.org/programs/mmcp.html (24 May 2002); and J. Boehm, "Confronting Health Care Purchasing Challenges within a New Framework," CHCS Brief (Princeton, N.J.: CHCS, August 2001).
27. D. Draper et al., "The Changing Face of Managed Care," Health Affairs (Jan/Feb 2002): 11–23; and L. Benko, "Loosening Their Grip: As HMOs Popularity Continues to Erode, More Plans Turn to Less Restrictive Products, But with Costs Rising, What’s Next?" Modern Healthcare 32, no. 15 (2002): 30–34.[Medline]
28. S. Felt-Lisk et al., Trends in Health Plans Serving Medicaid—2000 Data Update (Washington: Kaiser Commission, November 2001); R. Hurley and M. McCue, Partnership Pays: Making Medicaid Managed Care Work in a Turbulent Environment (Princeton, N.J.: CHCS, February 2000); and T. Coughlin et al., "Commercial Health Plan Participation in Medicaid Managed Care: An Examination of Six Markets," Inquiry 38, no. 1 (2001): 22–34.[Medline]
29. Draper et al., "The Changing Face of Managed Care."
30. G. Mays et al., Consumers Face Higher Costs as Health Plans Seek to Control Drug Spending, Issue Brief no. 45 (Washington: Center for Studying Health System Change, November 2001).
31. NASHP, Medicaid Managed Care; and NASHP, Cost Sharing in CHIP Programs: A Snapshot of Current Practice (Portland, Maine: NASHP, January 2001).
32. B. Strunk et al., Health Plan–Provider Show downs on the Rise, Issue Brief no. 40 (Washington: HSC, June 2001).
33. Hurley and McCue, Partnership Pays; American Association of Health Plans, Innovations in Medicaid Managed Care (Washington: AAHP, January 2002); and CHCS, "Managed Care Best Practices," www.chcs.org/ManagedCare/index.html (24 May 2002).
34. S. Connors et al., Contracting for Chronic Disease Management: The Florida Experience (Princeton, N.J.: CHCS, March 2001).

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				J. C. Robinson The Commercial Health Insurance Industry In An Era Of Eroding Employer Coverage Health Aff., November 1, 2006; 25(6): 1475 - 1486. [Abstract] [Full Text] [PDF]

				J. E. Haberer, B. Garrett, and L. C. Baker Does Medicaid Managed Care Affect Access To Care For The Uninsured? Health Aff., July 1, 2005; 24(4): 1095 - 1105. [Abstract] [Full Text] [PDF]

				B. E. Landon, E. C. Schneider, C. Tobias, and A. M. Epstein The Evolution Of Quality Management In Medicaid Managed Care Health Aff., July 1, 2004; 23(4): 245 - 254. [Abstract] [Full Text] [PDF]

				J. K. Iglehart The Dilemma of Medicaid N. Engl. J. Med., May 22, 2003; 348(21): 2140 - 2148. [Full Text] [PDF]