The Impact of Medicaid Primary Care Case Management on Office-Based Physician Supply in Alabama and Georgia

Abstract

The success of the ''primary care case management (PCCM)'' form of managed care implemented in many state Medicaid programs over the past several years depends in part on the expanded availability of primary care physician sites to substitute for hospital-based outpatient care and to provide a medical home for enrollees. However, the PCCM requirement for physicians to accept assignment of a caseload of patients and to provide all of their primary care likely conflicts with the approach of limited Medicaid participation favored by many Medicaid physician participants. This study examines the early impact of PCCM implementation, in the absence of physician reimbursement level increases, on the patterns of Medicaid participation by physicians in communities in Georgia and Alabama. We find that the implementation of PCCM under these conditions often was associated with reductions in the proportion of physicians participating in Medicaid, reductions in the number of very small Medicaid practices, and declines in Medicaid visit volumes across all participating physicians. We also find evidence of an overall reduction in the number of primary care visits per Medicaid enrollee, but an increase in the proportion of these visits that were for preventive care services associated with initial PCCM implementation.

Effects of Primary Care Case Management (PCCM) on Medicaid Children in Alabama and Georgia: Provider Availability and Race/Ethnicity

“…Our work extends earlier analysis of the effects of PCCM on participating providers in the two study states (Adams, Bronstein, and Florence 2003); this work found reductions in the proportion of participating physicians, reductions in small Medicaid practices, and declines in Medicaid visit volume among those still participating. We make methodological contributions by controlling for these changes in the availability of participating providers in the child's community and using fixed effects to control for time-invariant characteristics of the children as we follow them over the pre/post-PCCM implementation period.…”

“…Indirect effects are those that may occur with changes in the availability-the number and relative proximity-of Medicaid participating physicians and clinics. Earlier work found that PCCM implementation was associated with reductions in participating physicians, the number of small Medicaid practices, and participating physicians' volume, but effects differed across Georgia and Alabama and urban/rural areas (Adams, Bronstein, and Florence 2003).…”

“…In earlier work (Adams, Bronstein, and Florence 2003;Bronstein, Adams, and Florence 2004), we defined markets for physicians in a given community by clustering the zip codes from which 80 percent or more of their Medicaid patients came. Together, these provider measures are intended to reflect distance, and hence "time price," to Medicaid providers and the overall supply of office-based physician services relative to Medicaid demand in their market area.…”

“…We also combine the multivariate coefficients with actual changes in the provider system over the study period to summarize the "net effect" of PCCM-direct plus potential indirect effects through provider availability in the child's community-on children's use of care in these two Medicaid programs. We note that the indirect effect, as measured here, reflects all changes in provider availability over time, although only some of these changes are associated with PCCM implementation (Adams, Bronstein, and Florence 2003).…”

Nonurgent Care in the Emergency Department: Can We Save by Shifting the Site of Care?

“…In the past decade, several states have implemented primary care case management in their Medicaid programs. 8 One of the main rationales for primary care case management was to provide a primary care physician to Medicaid beneficiaries to improve the continuity of care and to reduce reliance on the ED for nonurgent care. Private health plans have also attempted to reduce ED use in recent years by increasing copayments for ED visits.…”