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Aspects of XXXXXXXX managed XXXX XXXX may XXXXXX XXXXXX to and quality of care
Economic incentives.XXXXX XXX FFS model, XXX XXXXX XXXX providers directly XXX each XXXXXXX service received by a XXXXXXXX enrollee. Under XXXXXXX care, XXX XXXXX XXXX a XXXXXXX XXXX XXXX a XXXXXXXXXX rate—a fixed XXXXXX XXXXXXXXX member per XXXXX&XXXXX;to XXXXX a defined set of XXXXXXXX for XXXX XXXXXX XXXXXXXX in the XXXX. XX turn, XXX XXXX XXXX providers XXX all of XXX XXXXXXXX XXXXXXXX an enrollee XXX XXXXXXX that XXX included in XXX XXXX’s XXXXXXXX XXXX the state. XXXX are at financial risk if spending on XXXXXXXX and XXXXXXXXXXXXXX XXXXXXX XXXXXXXX; conversely, XXXX XXX XXXXXXXXX XX XXXXXX any portion XX XXXXXXXX XXX XXXXXXXX XXX XXXXXXX services and other XXXXXXXXXXXXX XXXXXXXX activities.
XXXX suggest XXXX capitation XXXX not provide incentives to overtreat XXXXXXXX as in FFS. Instead, managed XXXX encourages XXXXXXXXX to keep enrollees XXXXXXX in order to XXXX costs XXXXXX the XXXXXXXXXX XXXX, XXXXXXX preventive and XXXXXXXXXXX care to avoid expensive XXXXXXXX stays and emergency XXXXXXXXXX XXXXXX. Capitation XXXX XXXXXXXX more XXXXXXXXX when budgeting XXX encourages the XXXXXXXXX XXX of XXXXXXXX.
XXXXXX argue XXXX a capitated payment system XXXX XXXX MCOs a XXX amount per enrollee and XXX XX how XXXX treatment XX XXXXXXXX may XXXXXX XXXXXXXXXX to undertreat patients to minimize treatment XXXXX (Green XXXX;Sparer XXXX;Duggan XXX XXXXXXX 2013;XXXXXXXX XXX XXXX XXXX). Capitated plans may XXXX XXXX to enroll as many healthy XXXXXXXX as possible XXX discourage participation XX XXXXXXXX or high utilizing enrollees (XXXXXXXX XX al. 2015;Glazer and XXXXXXX 2000).
XXXXXXXXXX XXX also be XXXXXXXXXX by XXXXXXXXXX XXXXXXX XXXXX. XXX example, adequate payments XXXXXX XX able to XXXXXXX XXXXXX XX coordinated and XXXXXXXXX care XXXXX XXXXXXXXXX savings that XXX XXXXXXX XXXXXXXXXX XXXXXXXXX XXXXXXXXX XXXXXXXX. XX XXX other hand, if capitation rates are XXX too low, they may create XXXXXXXXXX to XXXXXXXX services through use of gatekeepers, preauthorization policies, or XXXXXX XX XXXXXXXX.
XXX XXXXX may XXXX XXXXXXXX plans XX XXX XXXX XXX services, XXXXX in XXXX may reduce XXX number XX providers willing to XXXXX enrollees thus XXXXXXXX XXXXX XXXXXX XX XXXX. In Illinois, for example, XXXX of the traditional XXXXXX-XXX provider XXXXXXXXX boycotted XXX state’s XXXXXXX care XXXXXXXXXX when it XXX implemented, XXXXXXX XXXX XXX XXXXXXX rates were XXX XXX XXX the bureaucratic XXXXXXXXXXXXXXX XXX XXX XXXX (XXXXXX 2012). Providers XXXX also XXXXX low XXXXXXX rates in XXX XXXXXXXXXX Medicaid managed care program XX a XXXXXXX to XXXXX XXXXXXXXXXXXX (Tater et XX. 2016).
Network composition.FFS XXXXXXXX programs XXXXXXXXX contract XXXX XXX qualified provider willing to accept XXXXXXXX XXXXXXX rates, and Medicaid beneficiaries who receive XXXXXXXX through FFS XXX XXXXXXXX XX freedom of choice XXXXX XXXXXXXX providers. Managed care plans XXX XXXXXXXXX XXXXX own provider network qualifications, XXXXXXXX terms, and payment rates (XXXXXX XXXXXXXXXX XXXXXXXX by the terms of the contract XXXX the state). They XXXXXXXXX XXXXX XXX enrollees XX a network of XXXXXXXXX. XXX provider XXXXXXXX XXXX XX XXXXXXXXXX to provide adequate XXXXXX XX XXX XXXXXXX services, XXXXXX XXXX XXXXXXX the XXXXXX, XXXX, XXX XXXXXXXXXX XXXXXXXXXXXX of XXXXXXXXX, among other factors, XXX there XXX XX universal XXXXXXX to determine sufficiency.
XXX XXXX and scope XX XXX network XXXX XXXXXX XXX types, XXXXXXXXXXXX, XXX quality XX services available to enrollees XXX access XXX XXXX XXXXXXXXXXXXX XXXXXX a state, XXXXXXX urban XXX XXXXX areas, and XXXXXX states. XXXXXXXX with a sufficient XXXXXX XX participating providers may help XXXXXX access XX XXXXXXXX XXXXXXX XXXXX the XXXXXXXX XXXXX XXXXXX XXXXXXXX may XXXXX XXXXXXXXX care or XXXXX referrals and inhibit beneficiary XXXXXX XXX XXXXXX to XXXX XXXXXXX XXXX. Consumer XXXXXXXX XXXXXXXXXXXXX worry XXXXX XXXXXXXXXX XXXXXXXX XXXXXXXX XXX XXXXXX in long-XXXXXXXX XXXXXXX-provider relationships, especially XXX the high-cost populations XXXX have XXX most XXXXXXXXXX XXXXXX XXXXXX (XXXXXX XXXX;Corlette et al. XXXX;AcademyHealth 2014). XXXXXXXXXX variation in XXXXXXXX access, which can XX driven XX both XXX XXXXXXX of an XXX’s network XXX the XXXXXXXXXXXX XX providers in a given XXXXXXXXXX area, XXX also affect XXX XXXX, XXXXXXX, and XXXXXX of services XXXX by beneficiaries (GAO 2015).
Covered XXXXXXXX.Contracts between XXX state XXX MCOs XXXXXXXX XXXXX state plan XXXXXXXX are XXX responsibility XX the XXX, XXXXX (if XXX) remain XXXXXXX by the state, XXX which (if any) are XXXXXXXX XX other XXXXXXX or through other delivery systems. XX XXXX cases, XXXXXXXX that are unique to Medicaid XXX have XXX been XXXXXXXXXXXXX XXXXXXXXX through XXXXXXX care, XXXX XX XXXX XXXX XXXXXXXX and XXXXXXXX or non-emergency XXXXXXXXXXXXXX XXX XXXXXX out of XXX capitated benefit package in order to XXXXXXXX access to these XXXXXXXX. XXXXXXX, XXX provision of benefits XXXXXXX XXXXXXXX XXXXXXXX XXXXXXX can introduce XXX challenges in coordination of XXXX.
MCOs must XXXXXXX XXX XXXXXXXX offered under the state XXXX, XXX they XXX provide benefits XXXXXXXXXX to XXX using the so-XXXXXX in lieu of policy. Under XXXX XXXXXX, XXXX XXXXXXXXX may XXXXX, XXX enrollees, cost-XXXXXXXXX XXXXXXXX XXXX XXX in XXXXXXXX XX those covered XXXXX the state XXXX, XXXXXXXX the cost of these services XXXXXX XX XXXXXXXX when determining XXX payment rates (42 CFR XXX.X(c)). Because MCOs can XXXXXXX XXXXXXXX in XXXXXXXX to XXXXX XXXXXXX under XXX state XXXX, access XX them XXX XX enhanced XXX their XXXXXXXXX. These services are XXXXX XXXXXXXX XXXXXXXX that may XXXXXXXXXX XX XXXX XX XXXXXXXXX XXXX such XX, XXXX management or transportation XXXXXXXX XXX covered XXXXX XXX state plan, long-XXXX services XXX supports, or social interventions XXXX as XXXXXXXXX, equipment, or services XXXXXXXX with partnerships with other XXXXXXXXXXXXX.
Contracting specifications and XXXXXXXXX. Medicaid managed XXXX plans are required to XXXX XXXXXX and quality standards that XX not XXXXX to other XXXXXXXX XXXXXXXX systems. As XXXXXXXXX in greater XXXXXX in the XXXXXXXXX section, there are XXXXXXX statutory XXX XXXXXXXXXX requirements, such as standards for XXXXXX and capacity XXX a XXXXXXXXXXX for periodic XXXXXXXX XXXXXXX XXXXXX, XXXX XXXX apply to MCOs. XXXXXXX, states XXX XXXXXX additional access and quality requirements XX XXXXXXXX MCOs XXXXXXX the XXXXXXXXXXX and contracting XXXXXXX. States XXX require plans XX XXXX XXXXXXX standards (e.g., XXXXXXXXXXXXX) in order XX XXXXXXXXXXX, XXXXXXX payment or enrollment XXXXXXX for the XXXXXXXXXXX of XXXXXXX quality or access goals, XXX require MCOs XX XXXXXXXXXXX in quality XXXXXXXXXXX activities.
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XXXXXXX
XXXXXXXXXXXXXX
provider XXXXXXX relationship. XXXX XXXXXXXXXXXX is con-
tractual in nature XXX XX XXXXX on XXXXXXXXXXXXXXX, XXXXX,
XXXXXX XXXX a pretreatment conference XX outline medical
XXXX cases XXX orthopedic surgeons.
XXXXXX will generate XXXXXXXX XXXX-XX-XXXX ethical
dilemmas for orthopedists.
* XXXXXXXXXX XXXXXXXX the orthopedic XXXXXXXX as XXXX.
XXX limitation of diagnostic XXXX-XX XXX XXXXXXXXXX
XXXX XXXXXX to treatment protocol. A XXXX in point XX the
XX worse in these situations, XXX XXXX considerations XXX-
vail. There XXXX can XX a XXXXXXXXXXXX XXX the XXXXXXXXXX
surgeon in certain XXXXXXX care plans XX refer a patient
important XXXX XXX managed care plan be XXXXXXX in such
* When the XXXXXXXXX or XXXXXXXX between the patient
XXX XXX XXXXXXX XXXX XXXXXXXXXXXX prohibits XXX ortho-
XXXXX XXXXXXX XXXX providing XXX XXXXX and customary
by XXX XXXX and to XXXXXXXX XXXXX alternatives XXX care. XX
plan's appeal process.
XXXXX. X XXXXXXX XXXXXXX XX XXXX of inappropriate or
excessive XXXXXXXXX XXXX primary XXXX XXXXXXXXXX. This,
XX XXXXXX, XX the XXXXXXXX XX XXXX XXXXXX in the HMO
XXXXXX XXXXXXXXX, XXXXXXXX XXXXXXX, durable medical equip-
pedic surgeons XXXXXXX XXX XXXXXXXXX:
* joint venture versus XXXXXXXXX XXXXXXXX XX a group
or conglomerate,
* XXXXX XXXXXXXXXXXXX that may XXXXXXX the public, XXX
* XXXXXXX XX XXX XXXXXXXXX XXX XXXXXXX XXXXXXXXXXX with
nonbusiness XXXXXXXX.