Association for Public Policy Analysis & Management

Background: Medicaid Managed Care (MMC) plans employ cost containment tools, such as prior authorization, preferred drug lists, and restrictive provider networks, to achieve savings relative to traditional, state-run Medicaid programs. Because these tools may affect clinicians’ therapeutic recommendations and Medicaid patients’ adherence to treatment, beneficiaries’ quality of care may be reduced. We know little about the effects of MMC cost containment tools because information about their implementation is often proprietary.

Setting: The 33 federally qualified health center (FQHC) organizations in Georgia, most of which regularly see patients enrolled in the state’s three (through September 2017) MMC plans

Data: A survey of FQHC-based physicians and nurse practitioners regularly treating children and adolescents with asthma or attention deficit hyperactivity disorder (ADHD). The survey captures information on: difficulties encountered when making referrals and prescribing medications due to MMC plans’ tools; the quality of care MMC beneficiaries receive; how effectively FQHCs manage MMC plans’ administrative requirements; and other FQHC and clinician characteristics. Data are gathered for MMC patients overall and for each MMC plan separately.

Results: We received 63 completed surveys (estimated 68% response rate), representing 19 (58%) of Georgia’s FQHC organizations. Across multiple measures, between one-fifth and one-half of respondents indicated they had experienced difficulties with prior authorization, preferred medication prescribing, or specialist referrals often or very often when caring for their asthma and ADHD patients. Only 57.1% identified one or more differences between the MMC plans in any of the survey’s 12 items about such difficulties. Greater difficulties with referrals to certain specialists and prior authorization request denials were associated with perceptions of poorer patient care quality overall among clinicians. Whether respondents’ perceptions of effective administrative efforts by FQHCs to manage MMC plans’ cost containment tools were associated with either difficulties due to these cost containment tools or overall quality was inconclusive.

Conclusion: In Georgia, FQHC clinicians’ expressed difficulties with denied prior authorization requests and obtaining referrals when providing preferred treatments to Medicaid-enrolled, chronically ill children and adolescents was associated with their perceptions of their patients’ overall quality of care.