Challenging the Cost Effectiveness of Medi-Cal Managed Care

Some researchers and consulting groups have promoted managed care as a way to provide cost-effective quality care to Medicaid patients, based on assertions that are often poorly substantiated. Unfortunately, politicians and policy makers in California and other states have adopted the presumption of the cost-effectiveness of Medicaid Managed Care as a rationale for expanding the use of managed care programs to include a larger share of more Medicaid eligible enrollees, and expand coverage and services to the currently uninsured. This paper challenges the assertion that Medi-Cal Managed Care is cost effective, by demonstrating that the unique and idiosyncratic manner in which Medi-Cal managed care has been implemented in California (and other states) creates perverse incentives leading to cost-shifting and selective enrollment and dis-enrollment of costly beneficiaries. This places an unfair burden on fee-for-service Medi-Cal providers, who are expected to provide more services for less reimbursement. Administrators of Medicaid Managed Care programs need to consider risk adjusted rates for beneficiaries enrolled in plans in order to align incentives with program objectives. [WestJEM. 2009;10:124-129.

Categorization, Designation, and Regionalization of Emergency Care: Definitions, a Conceptual Framework, and Future Challenges

This article reflects the proceedings of a breakout session, “Beyond ED Categorization—Matching Networks to Patient Needs,” at the 2010 Academic Emergency Medicine consensus conference, “Beyond Regionalization: Integrated Networks of Emergency Care.” It is based on concepts and areas of priority identified and developed by the authors and participants at the conference. The paper first describes definitions fundamental to understanding the categorization, designation, and regionalization of emergency care and then considers a conceptual framework for this process. It also provides a justification for a categorization system being integrated into a regionalized emergency care system. Finally, it discusses potential challenges and barriers to the adoption of a categorization and designation system for emergency care and the opportunities for researchers to study the many issues associated with the implementation of such a system.ACADEMIC EMERGENCY MEDICINE 2010; 17:1306–1311 © 2010 by the Society for Academic Emergency MedicinePeer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79324/1/j.1553-2712.2010.00932.x.pd

Important Historical Efforts at Emergency Department Categorization in the United States and Implications for Regionalization

This article is drawn from a report created for the American College of Emergency Physicians (ACEP) Emergency Department (ED) Categorization Task Force and also reflects the proceedings of a breakout session, “Beyond ED Categorization—Matching Networks to Patient Needs,” at the 2010 Academic Emergency Medicine consensus conference, “Beyond Regionalization: Integrated Networks of Emergency Care.” The authors describe a brief history of the significant national and state efforts at categorization and suggest reasons why many of these efforts failed to persevere or gain wider implementation. The history of efforts to categorize hospital (and ED) emergency services demonstrates recognition of the potential benefits of categorization, but reflects repeated failures to implement full categorization systems or limited excursions into categorization through licensing of EDs or designation of receiving and referral facilities. An understanding of the history of hospital and ED categorization could better inform current efforts to develop categorization schemes and processes.ACADEMIC EMERGENCY MEDICINE 2010; 17:e154–e160 © 2010 by the Society for Academic Emergency MedicinePeer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79214/1/j.1553-2712.2010.00931.x.pd

Challenging the Cost Effectiveness of Medi-Cal Managed Care

Some researchers and consulting groups have promoted managed care as a way to provide cost-effective quality care to Medicaid patients, based on assertions that are often poorly substantiated. Unfortunately, politicians and policy makers in California and other states have adopted the presumption of the cost-effectiveness of Medicaid Managed Care as a rationale for expanding the use of managed care programs to include a larger share of more Medicaid eligible enrollees, and expand coverage and services to the currently uninsured. This paper challenges the assertion that Medi-Cal Managed Care is cost effective, by demonstrating that the unique and idiosyncratic manner in which Medi-Cal managed care has been implemented in California (and other states) creates perverse incentives leading to cost-shifting and selective enrollment and dis-enrollment of costly beneficiaries. This places an unfair burden on fee-for-service Medi-Cal providers, who are expected to provide more services for less reimbursement. Administrators of Medicaid Managed Care programs need to consider risk adjusted rates for beneficiaries enrolled in plans in order to align incentives with program objectives. [WestJEM. 2009;10:124-129.

Are Usual and Customary Charges Reasonable?

An editorial about the use of usual and customary charges for out-of-network benefit determinations

Are Usual and Customary Charges Reasonable?

An editorial about the use of usual and customary charges for out-of-network benefit determinations