Gretchen V. Fleming

Access to office-based physicians under capitation reimbursement and Medicaid case management. Findings from the Children's Medicaid Program.

This study reports the effects of a voluntary Medicaid case-management demonstration on the primary care provided to young children by office-based physicians. The MDs who participated were reimbursed at rates higher than the regular Medicaid fee schedule, either through augmented fees for specific services or through monthly capitation payments. Using the Medicaid Management Information System (MMIS) claims data, we compared the rates at which children in the experimental program and children in the regular Medicaid program were seen by a physician during a one-year period. The majority of experimental children received regular and frequent care from primary care physicians during the demonstration. After controlling for race and prior utilization differences, we found that augmented fee-for-service children received more primary care from office-based physicians than children in the regular Medicaid program. Capitation children received at least the same amount of primary care as children in the regular Medicaid program. We interpret our data to mean that capitation payment, untied to the delivery of services, does not necessarily reduce access to primary care and that higher fees for physicians who treat children may, in fact, increase access.

The Municipal Health Services Program: Improving Access to Primary Care Without Increasing Expenditures

Under the Municipal Health Services Program (MHSP), five city governments created networks of primary care clinics with a goal of serving populations thought to have poor access to primary medical care. A major concern was fragmented care in public hospitals and other public facilities. The new MHSP clinics were expected to provide care at lower cost than the populations alternative sources of care. Medicare and Medicaid waivers were also provided. This evaluation indicates that MHSP did reach most, but not all, of the targeted groups. MHSP may have successfully replaced some outpatient department and emergency room services. However, it failed to realize the program goals of continuity and high patient satisfaction. Per capita expenditures for medical care for MHSP users were no higher than for others, but also were not significantly lower. However, for Medicare eligible MHSP users, expenditures by Medicare were significantly less.

Evaluating the Municipal Health Services Program

MUNICIPAL HOSPITALS have traditionally been a major source of ambulatory as well as inpatient hospital services for inner-city residents, many of whom are low income and minority people. While financial programs such as Medicaid and Medicare and those providing direct services such as OEO-sponsored neighborhood health centers, Children and Youth programs, health maintenance organizations, and the National Health Service Corps have apparently succeeded in reducing the barriers to medical care faced by these groups,l major access problems remain. The literature documents their high rates of illness, receipt of fragmented and poorly coordinated, crisis-oriented care through hospital emergency rooms and outpatient departments, high out-of-pocket outlays relative to income, and the inconvenience they suffer and their dissatisfaction with the care-seeking process.*-6 Further, the current financial crisis and resultant service cutbacks experienced by many municipal hospital systems throughout the country threaten to erode the gains and exacerbate the problems of inner-city populations in obtaining medical The Municipal Health Services Program (MHSP) is an attempt to improve the general medical care in urban communities where municipal health departments and hospitals are principal providers of services. The Robert Wood Johnson Foundation (RWJF) has provided grants of approximately

Health care in the U.S. : equitable for whom?

3,000,000 each to five cities: Baltimore, Cincinnati, St. Louis, Milwaukee, and San Jose. The purpose is to build upon and bring together in a single community location existing categorical programs of public health departments (e.g., clinics for maternal and child health, drug and alcohol abuse, VD, and TB services) and primary medical services tradi-