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XXXXXXXX XXXXXXXXXX.XXXXX the FFS XXXXX, XXX state pays XXXXXXXXX XXXXXXXX for each XXXXXXX XXXXXXX XXXXXXXX XX a XXXXXXXX XXXXXXXX. XXXXX managed XXXX, XXX state pays a XXXXXXX care plan a XXXXXXXXXX rate&XXXXX;a fixed dollar XXXXXXXXX XXXXXX per month&XXXXX;to cover a XXXXXXX XXX of services XXX each XXXXXX enrolled in XXX XXXX. XX XXXX, the XXXX pays XXXXXXXXX XXX all of XXX XXXXXXXX XXXXXXXX an enrollee XXX require that are included in XXX XXXX’s contract XXXX XXX state. XXXX are at XXXXXXXXX risk if spending XX XXXXXXXX and XXXXXXXXXXXXXX exceeds payments; conversely, XXXX XXX permitted XX retain XXX XXXXXXX of XXXXXXXX XXX XXXXXXXX for covered services XXX other contractually XXXXXXXX activities.
Some suggest that capitation does XXX provide incentives XX XXXXXXXXX patients as in XXX. XXXXXXX, XXXXXXX XXXX encourages providers XX XXXX XXXXXXXXX XXXXXXX in order to XXXX costs XXXXXX the XXXXXXXXXX XXXX, through XXXXXXXXXX and appropriate care XX avoid expensive XXXXXXXX XXXXX and XXXXXXXXX department visits. Capitation XXXX provides XXXX XXXXXXXXX XXXX XXXXXXXXX XXX encourages the efficient use of XXXXXXXX.
Others XXXXX that a capitated XXXXXXX system that XXXX XXXX a XXX XXXXXX per XXXXXXXX and XXX on how much treatment is provided may XXXXXX incentives XX undertreat XXXXXXXX to minimize treatment XXXXX (Green 2014;Sparer XXXX;XXXXXX and XXXXXXX XXXX;XXXXXXXX and XXXX XXXX). XXXXXXXXX XXXXX may XXXX seek XX XXXXXX XX XXXX healthy XXXXXXXX as possible and XXXXXXXXXX participation of XXXXXXXX or high XXXXXXXXX enrollees (XXXXXXXX XX XX. 2015;XXXXXX XXX XXXXXXX 2000).
Incentives XXX also XX XXXXXXXXXX by capitation payment rates. XXX example, adequate payments should XX able XX provide XXXXXX XX XXXXXXXXXXX and XXXXXXXXX care XXXXX XXXXXXXXXX savings XXXX XXX XXXXXXX additional XXXXXXXXX XXXXXXXXX services. XX XXX XXXXX hand, XX XXXXXXXXXX XXXXX XXX set too XXX, XXXX XXX create XXXXXXXXXX to XXXXXXXX XXXXXXXX XXXXXXX use XX gatekeepers, preauthorization policies, or XXXXXX XX benefits.
XXX rates may also XXXXXXXX XXXXX XX pay XXXX for services, which in XXXX may reduce XXX XXXXXX of providers willing to XXXXX XXXXXXXXX XXXX impeding XXXXX access to care. XX XXXXXXXX, for example, XXXX XX the traditional XXXXXX-XXX XXXXXXXX community boycotted the state’s XXXXXXX care XXXXXXXXXX when it was implemented, arguing that XXX XXXXXXX rates XXXX XXX XXX XXX the XXXXXXXXXXXX micromanagement was XXX XXXX (XXXXXX 2012). Providers XXXX XXXX XXXXX XXX payment XXXXX in the California XXXXXXXX XXXXXXX care XXXXXXX XX a XXXXXXX to XXXXX participation (XXXXX et al. XXXX).
Network composition.XXX XXXXXXXX XXXXXXXX typically XXXXXXXX XXXX XXX XXXXXXXXX XXXXXXXX willing to accept XXXXXXXX XXXXXXX rates, and Medicaid beneficiaries XXX receive services XXXXXXX FFS are entitled to freedom XX choice among XXXXXXXX providers. Managed XXXX plans XXX XXXXXXXXX their own XXXXXXXX network qualifications, contract terms, and payment rates (XXXXXX XXXXXXXXXX required XX the terms of the XXXXXXXX with the state). XXXX generally limit XXX XXXXXXXXX to a network of providers. MCO XXXXXXXX XXXXXXXX XXXX be XXXXXXXXXX to provide adequate XXXXXX XX XXX XXXXXXX XXXXXXXX, XXXXXX into XXXXXXX XXX number, XXXX, XXX XXXXXXXXXX XXXXXXXXXXXX of providers, XXXXX other XXXXXXX, but there are XX XXXXXXXXX XXXXXXX XX determine XXXXXXXXXXX.
XXX size XXX XXXXX XX XXX XXXXXXX XXXX XXXXXX XXX types, XXXXXXXXXXXX, and XXXXXXX of XXXXXXXX XXXXXXXXX XX XXXXXXXXX and XXXXXX XXX XXXX XXXXXXXXXXXXX XXXXXX a XXXXX, between urban XXX XXXXX XXXXX, and XXXXXX states. Networks XXXX a XXXXXXXXXX XXXXXX of XXXXXXXXXXXXX XXXXXXXXX XXX XXXX XXXXXX access to services covered XXXXX the contract while narrow networks may XXXXX XXXXXXXXX care or XXXXX XXXXXXXXX and inhibit beneficiary XXXXXX XXX access XX high XXXXXXX XXXX. XXXXXXXX XXXXXXXX XXXXXXXXXXXXX XXXXX about XXXXXXXXXX provider networks XXX XXXXXX in XXXX-standing patient-provider relationships, especially XXX XXX high-XXXX XXXXXXXXXXX XXXX have the XXXX XXXXXXXXXX health status (XXXXXX 2012;Corlette XX XX. 2014;XXXXXXXXXXXXX XXXX). Geographic XXXXXXXXX in provider access, which can be driven by XXXX the breadth of an XXX’s network XXX XXX availability of providers in a XXXXX XXXXXXXXXX area, XXX XXXX XXXXXX the type, XXXXXXX, and amount XX services used by XXXXXXXXXXXXX (GAO 2015).
XXXXXXX benefits.Contracts between the state XXX XXXX identify which state XXXX services are the responsibility of the XXX, which (XX any) XXXXXX covered XX the state, and which (XX any) are provided XX other XXXXXXX or XXXXXXX other delivery XXXXXXX. In some XXXXX, XXXXXXXX XXXX are unique XX Medicaid XXX XXXX not XXXX XXXXXXXXXXXXX XXXXXXXXX XXXXXXX managed care, such as XXXX XXXX services and XXXXXXXX or non-XXXXXXXXX XXXXXXXXXXXXXX XXX carved out of the capitated benefit XXXXXXX in order to maintain access XX these XXXXXXXX. XXXXXXX, XXX XXXXXXXXX of XXXXXXXX XXXXXXX multiple delivery systems XXX XXXXXXXXX XXX XXXXXXXXXX in XXXXXXXXXXXX XX XXXX.
MCOs must XXXXXXX XXX benefits offered XXXXX the state XXXX, XXX they can provide XXXXXXXX XXXXXXXXXX XX XXX using the so-called in lieu of policy. XXXXX XXXX policy, XXXX XXXXXXXXX XXX XXXXX, XXX enrollees, XXXX-XXXXXXXXX XXXXXXXX XXXX XXX in XXXXXXXX to those covered XXXXX XXX state plan, although the cost XX XXXXX XXXXXXXX cannot XX included XXXX determining XXX XXXXXXX XXXXX (42 CFR 438.X(c)). Because MCOs XXX XXXXXXX XXXXXXXX in addition to those XXXXXXX under the XXXXX XXXX, access to them may XX enhanced XXX their enrollees. These XXXXXXXX are often XXXXXXXX XXXXXXXX XXXX XXX contribute to XXXX XX obtaining XXXX such as, XXXX management or XXXXXXXXXXXXXX XXXXXXXX XXX covered XXXXX the state XXXX, XXXX-term services XXX XXXXXXXX, or social interventions XXXX XX education, XXXXXXXXX, or services provided XXXX XXXXXXXXXXXX XXXX other XXXXXXXXXXXXX.
Contracting XXXXXXXXXXXXXX and oversight. XXXXXXXX managed care XXXXX XXX XXXXXXXX XX meet access and quality standards that XX XXX XXXXX XX XXXXX XXXXXXXX delivery systems. XX XXXXXXXXX in XXXXXXX detail in the following XXXXXXX, XXXXX are federal XXXXXXXXX and XXXXXXXXXX XXXXXXXXXXXX, XXXX XX standards XXX access and XXXXXXXX and a XXXXXXXXXXX XXX periodic XXXXXXXX XXXXXXX XXXXXX, XXXX XXXX XXXXX XX XXXX. Further, XXXXXX XXX impose additional access XXX quality XXXXXXXXXXXX on Medicaid MCOs through the XXXXXXXXXXX and contracting process. States can require plans to XXXX XXXXXXX standards (e.g., XXXXXXXXXXXXX) in order XX participate, XXXXXXX XXXXXXX or XXXXXXXXXX XXXXXXX XXX the achievement of certain quality or XXXXXX XXXXX, XXX require MCOs to XXXXXXXXXXX in quality XXXXXXXXXXX activities.
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X)
ETHICAL
CONSIDERATIONS
* X sincere effort XX XXXXXXXX the XXXXXXXXX XX XXX
XXXXXXXX patient XXXXXXXXXXXX. This relationship XX XXX-
XXXXXXXX in XXXXXX and XX XXXXX XX XXXXXXXXXXXXXXX, XXXXX,
XXX XXXXXXX.
XXXXXX XXXX a XXXXXXXXXXXX conference XX XXXXXXX medical
many cases for orthopedic surgeons.
with regard XX XXXXXXXXX protocol. X case in point XX XXX
limitation placed on physical XXXXXXX and rehabilitation
vail. XXXXX also can be a XXXXXXXXXXXX XXX the XXXXXXXXXX
XXX XXXXXXXXXXXX XXXXXXXXXX or care. It XX therefore
a way as XX XXXXXX that economic XXXXXXXXXXXXXX XXX XXX
pedic surgeon from providing the usual and XXXXXXXXX
XXXXXXXXX expected, the XXXXXXXXXXX XXX an XXXXXXXXXX to
XXXXXX the patient of what XXXX XXX XXXX XXX be covered
XX the plan and XX sucggest other alternatives for care. It
XXXX's XXXXXX process.
* XX capitation contracts, there may be an XXXXXX XX
covered lives XXXX XXXXXXX a XXXXXXXXXX XXXXXXXXXX XXX-
excessive referrals from XXXXXXX care XXXXXXXXXX. XXXX,
XXX XXX XXXXXXX XXXXXXXX XXXXXXXXXX XXXXXXXX for certain
ownership interest or other XXXXXXXXXXXX XXXXXXXXXXXX
nostic radiology, XXXXXXXX XXXXXXX, XXXXXXX medical XXXXX-
* XXXXX XXXXXXXXXXXXX XXXX XXX mislead XXX XXXXXX, and
nonbusiness partners.