Although ED use for ACSCs is not the only measure of assessing health care quality, it is an important measure of quality particularly when preventable. These potentially preventable ED visits are associated with ambulatory care sensitive conditions (ACSCs) and are considered to be an indicator of health care quality. Estimates suggest that around 13% to 27% of ED visits in the United States could instead have been managed and taken care of in physician offices, clinics and urgent care centers. Thus, it is reasonable to expect that Medicaid recipients in managed care plans might have fewer ED visits, and have a lower prevalence of ED visits which might have been “potentially preventable,” compared to recipients with conventional Medicaid. Ideally, managed care plans aim to reduce costs, provide preventive services and discourage the overutilization of healthcare resources via care provided by the PCP or the gatekeeper. Outside the U.S., however, managed care models are often described using different terminology, including “integrated care,” “shared care,” “transmural care,” and “comprehensive care”. Several countries with national healthcare systems have also introduced various forms of managed care in their programs, including the United Kingdom, the Netherlands, Germany, Switzerland, Israel, Estonia, Latvia, and Lithuania. Unlike FFS Medicaid, paying for care through capitation might also deter physicians and hospitals from possibly oversupplying services of questionable benefit as a way of enhancing revenue. States have turned to managed care for several reasons, including: (1) achieving greater control and predictability over their spending on Medicaid, (2) improving accountability for program performance, access to services, and care quality, and (3) improving care coordination, reducing duplicate and/or unnecessary services, and promoting greater efficiency in care provision. States pay HMOs’ capitation fees rather than act themselves as health insurers for Medicaid. Because a Medicaid HMO is paid via capitation, it should have incentives to structure its payments to providers and its rules for PCPs and enrollees so that health services are delivered cost-effectively with PCP oversight and continuity of care. These HMOs link each Medicaid enrollee with a primary care physician (PCP) who serves as a care coordinator and gatekeeper for the enrollee’s access to services. Medicaid HMOs, typically, are private-sector HMOs that contract with Medicaid to provide the delivery of health services to Medicaid recipients in exchange for a fixed fee per recipient per month (capitation). The most prevalent forms of Medicaid managed care are Medicaid health maintenance organizations (HMOs) the other two forms of Medicaid managed care are primary care case management (PCCM) and limited-benefits plans. All forms of Medicaid managed care share in common insurance rules for accessing care and the actual provision of health services are more integrated than under conventional fee-for-service (FFS) Medicaid. Managed care within Medicaid encompasses a broad array of contract arrangements between state Medicaid programs and private companies. Yet little is known about whether and how this major change in the structure of Medicaid affects recipients’ use of hospital emergency departments (EDs). Nationwide, the percentage of Medicaid recipients enrolled in some form of managed care has increased more than seven-fold since 1990, up from 11% in 1991 to 82% in 2017. Managed care also appears in other publicly funded health insurance programs in the US like Medicare Advantage and private delivery of subsidized coverage through the marketplace. Since the early 1990s state governments, which administer Medicaid, have increasingly turned to “managed care” as a way to structure Medicaid insurance and provide for the delivery of health services. In the United States (U.S.), Medicaid is a public health insurance program that covers roughly 70 million low-income and financially needy Americans.
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