Physician participation in the Oregon Health Plan : final report

108 Pages·2001·3.8 MB·English

by  Kulas, Elizabeth

HEALTHECONOMICSRESEARCH,INC.
4W1al1tWhaavme,rlMeAy0O2a4k5s2-R8o4a1d,4Suite330
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Physician Participation in the Oregon Health
Plan
CMSLibrary
FinalReport 7500CS2e-c0u7ri-t1y3Blvd.
Baltimore,MD21244
Preparedby:
ElizabethKulas,Ph.D.
GalinaKhatutsky,M.S.
HealthEconomicsResearch,Inc.
411WWaavletrhlaemy,OMaAks0R2o4a5d2,-8Su4i1t4e330
September25,2001
ProjectDirector ScientificReviewer
TBhobeerne,seParrocjhecptreOfsfeincteerd.inThtheisstraetpeomretnwtasscopnetrafionremdedinutnhdiserreHpeoarlttahrCeasroeleFliyntahnocsienogfAtdhmeinaiusthtorrastiaonnd(nHoCFenAd)orCsoentmreancttbNyo.HC50F0A-9o4r-0A0S5P6E,Psahuoluldbe
inferredorimplied.
TableofContents
Page
ExecutiveSummary ES-1
Chapter1 Introduction 1-1
Chapter2 BackgroundIssues 2-1
2.1 TheOregonHealthPlan 2-1
2.2 PreviousStudies 2-6
Chapters MethodsandData 3-1
3.1 Methods 3-1
3.2 Data 3-5
3.3 Validation 3-12
Chapter4 PhysicianOpinionsConcerningOHP 4-1
4.1 ComparisonstotheBaselineSurvey 4-1
4.2 PhysicianParticipationinMedicaid 4-8
4.3 PhysicianOpinionofthePriorityList 4-21
4.4 PatientUnderstanding 4-28
4.5 PhysicianOpinionofIndividualOHPPlans 4-40
4.6 TreatingOHPMemberswithDisabilities 4-49
4.7 HowisOHPdoing? 4-61
References R-1
AppendixA ClassificationofHMOsintoGroups A-1
HealthEconomicsResearch,Inc. ProviderParticipationinOHP: i
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TableofTables
Chapter3
Table3-1 SampleStrata 3-4
Table3-2 UnweightedCharacteristicsofPhysicianRespondents 3-6
Table3-3 PracticeCharacteristicsofPhysiciansCompletingOHPPSUnweighted,
participantsandnon-participants 3-8
Table3-4 DoPracticeCharacteristicsVarybySpecialty? 3-10
Table3-5 ValidationofRespondentCharacteristicswithOMASurvey 3-13
Chapter4
Table4-1 CompareResponsestoBaselineSurvey 4-3
Table4-2 PercentofOregonianswithoutHealthInsurance1993:1997
USStatisticalAbstract 4-6
Table4-3 WeightedMeanCharacteristicsofMDsWhoParticipateinOHPv.
MDsWhoDoNotParticipateinOHP 4-10
Table4-4 ReasonsforParticipationDecision 4-13
Table4-5 ExtentofParticipationHowManyPlansinaCountyDoesaPhysician
ContractWith? 4-16
Table4-6 OLSRegressionsforNumberofPlans 4-18
Table4-7 PhysicianOpinionofthePriorityList 4-22
Table4-8 HowHasthePriorityListAffectedAspectsofTreatmentorCare .... 4-27
Table4-9 OHPPatients'UnderstandingofManagedCareWeighted 4-30
Table4-10 LogisticRegressionResultsforFairorPoorPatientUnderstandingof
FourAspectsofManagedCareOddsRatiosandSignificance 4-32
Table4-11 LogisticRegressionResultsforPatientUnderstandingWorsethan
OtherPatientsOddsRatiosandSignificance 4-36
Table4-12 ContractingandAdministrativeDealingswithPlans 4-41
Table4-13 OHPPlanRatingsWeighted 4-44
Table4-14 LogisticRegressionResultsforFairorPoorPlanhiteractionsOdds
RatiosandSignificance 4-46
Table4-15 LogisticRegressionResultsforPlanhiteractionWorsethanOtherPlans
OddsRatiosandSignificance 4-50
Table4-16 TreatingOHPMemberswithDisabilities 4-52
Table4-17 HowGoodisOHPatMeetingtheFoUowdngNeedsofPeoplewith
Disabilities? 4-54
Table4-18 HowdoOHPMemberswithDisabilitiesFare? 4-60
Table4-19 ParticipantRelationtoOHP/Medicaid 4-62
Table4-20 SummaryofOpen-EndedOpinionsofOHP 4-66
HealthEconomicsResearch,Inc. ProviderParticipationinOHP: ii
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Executive Summary
TheOregonHealthPlan(OHP),Oregon'sMedicaidprogram,isavailable(sometimes
withapremium) to Oregoniansat 100 percentofpovertyorbelowwho meetasset
requirements. OHPisavailabletochildrenandpregnantwomenupto 170percentof
povertyinpartduetotheSCHIPexpansions,manyofwhichareorganizedthroughMedicaid
inOregon. Aspartofthestate'sstrategytofundMedicaidservicestoanexpanded
population,OHPrequiresahnostallbeneficiariestoenrollmmanagedcareplansandrations
carethroughapriorityUstofcondition/treatmentpairs. OHPwasfirstimplementedm1994
fortheTANFandexpansionpopulations,andin1995forSSIbeneficiariesbothoverand
under65(includingMedicare/Medicaiddualeligibles),andchildreninfostercare.
Thispaperreportsphysicians'perceptionsoftheOregonHealthPlanasidentified
inamailedsurveyof1329physicians. ThesurveywasconductedbyHealthEconomics
Research,Inc.(HER)andResearchTriangleInstitute(RTI)in1998,andsampledphysicians
whowerelikelytobeinoffice-basedspeciaUiesandover-sampledphysiciansinfieldsthat
careformanypeoplewithdisabilities. Weaskedphysicianstoreporttheirviewofthe
conceptofOHP,theirreasonsforparticipation,andtocommentonspecificoperationaland
accesstocareissues. Oursampleincludes794physicians(60percentofthesample
respondedandworkedfull-time). Thesampleincludedbothparticipatingphysicians(91
percentoftheweightedrespondents)andnonparticipatingphysicians(9percent).
HealthEconomicsResearch,Inc. ProviderParticipationinOregonhealthPlan:ES-1
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ExecutiveSummary
PhysiciansgenerallylikedtheconceptoftheOregonHealthPlanandcommented
favorablyaboutseveralaspectsoftheprogram.Theyreportedthatfeweroftheirpatientsare
uninsiaredsincetheprogram'sinception,thatqualityhadnotsubstantiallydeclined,andthat
peoplewithdisabilitieswerenotmoreadverselyaffectedthanothersasaresultofmanaged
careenrollmentorbecauseofthepriorityUst. Moreprimarycarephysiciansreportthatthey
areseemgpersonswithdisabilitiesthanbeforeOHP. Manyphysiciansreportedproviding
careregardlessoftheprioritylistrestrictions.
PhysicianswerecriticaloftheOHPreimbursementrates,administrativehasslesof
dealingwithmanagedcareplansgenerally,andreportconfusionaboutwhatiscoveredby
theprioritylist. TheyalsoreportthattheirMedicaidpatientshavelessimderstandingof
managedcareprocessesthantheirotherpatientsenrolledinmanagedcareplans. Mental
healthand substance abusetreatmentstand outas areas inwhichtheybelieve OHP
restrictionsareproblematic.
TreatingtheUninsured
• Physiciansaretreatingfeweruninsuredpatients. 56percentofphysicians
respondedthatthenumberofuninsuredpatientstheyseehasdecreased
andonly5percentreportedanincrease.Therestsaiditwasaboutthe
same. ThebaselinestudybyOMAPfoundthatmanyphysiciansfeh
therewasariseinthenumberofuninsuredpatienttheysawintheyears
priortoOHP. Thereisclearlyachangeinphysicianopinionbeforeand
afterOHP.
HealthEconomicsResearch,Inc. ProviderParticipationinOregonhealthPlan:ES-2
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1
ExecutiveSummary
ParticipationandExtentofParticipationinOHP
• OursurveyindicateshighparticipationamongphysiciansinMedicaid.9
percentofphysiciansparticipate,confirmingpreviousstudiesthatfind
highparticipationinOregon. Accessproblemsarisingfiromphysician
availabiUtyarenomoreofaproblemforMedicaidpatientsthanforother
patientsinthestate.
• Accesstopsychiatristsisapotentialproblembecausepsychiatristsare
leastlikelytoparticipateinMedicaid.
• Therehasbeenan11percentnetgainofphysiciansservingMedicaid
patientsafterimplementationofOHP.
• VeryfewrespondentsreportparticipatinginMedicaidmanagedcareto
accessnon-Medicaidpatients. Only16percentofphysiciansanswerthat
accesstoamanagedcareplan'scommercialclientswasaveryimportant
reasonwhytheyparticipateinMedicaidand22percentanswerthatitis
somewhat important. Three quarters ofphysicians participate in
Medicaidforaltruisticreasons. Whilethereisasurveybiastogivingthe
sociallycorrectanswer,itisstillinterestingthatsomanydocitethis
answerasaveryimportantreasonwhytheyparticipate.
• Physicianswhodonotparticipatecitelowreimbursement,administrative
hasslesandhavingenoughpatientsasthemostimportantreasonswhy
theydonotparticipateinMedicaid. Inaddition,21 percentofnon-
participatingphysiciansindicatethattheywerede-selectedbyanOHP
healthplanand29percentofnon-particpantshavenomanagedcare
contractsatall. Thesefindingsindicatethatwhilereimbursementrates
areveryimportanttophysicians,raisingratesalonewillnotgreatly
increasethenumberofphysicianswhoserveMedicaid.
• Physicianscontractwithanaverageof1.7plansinruralareasandover
3plansinurbanareas. Inruralareas,thisresultsinsomephysicians
contractingwithplansoutsidetheircountyofservice.Inurbanareasother
thanPortland,physiciansoftencontractwithallavailableplans. Portland
physicianscontractwithabout50percentoftheplansavailabletothem.
Thisindicatessignificantoverlapinphysiciannetworksinallareasofthe
state.
• Factors otherthangeographythatexplainthe extentofcontracting
includebeingaspecialistratherthanaprimarycarephysician,beingin
asinglespecialtypractice,andbeinginaforprofitpractice.
HealthEconomicsResearch,Inc. ProviderParticipationinOregonhealthPlan:ES-3
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ExecutiveSummary
PhysicianOpinionofthePriorityList
• Physiciansareconcernedaboutknowingwhatiscoveredunderthe
prioritylistandtwo-thirdsreportdifficultyknowingwhatiscovered.
Whilethisisasourceofstressforphysicians,manyaredelivering
uncoveredcareanyway. Whenphysiciansdonotprovidetheuncovered
care, only 11 percent think the patient usually or always suffers
significantly.
• Mostphysicianswereneutral,andsomewerenegativeabouttheeffects
oftheprioritylistonvariousfeaturesoftheirpractice. Mostwere
unhappyabouttheadministrativeburden. Itwasnotclearfromthe
additionalcommentswhatburdenthelistitselfcreatesinadditionto
Medicaidmanagedcaremoregenerally.
PatientUnderstandingofOHP
• PhysiciansareconcernedthatMedicaidpatientunderstandingofmanaged
careispoor.ThemajorityanswerthatMedicaidpatientsunderstandless
than otherpatients enrolledinmanaged careplans. Despitethese
responses to our questions, there was no physician comment that
managedcareisinappropriatefortheMedicaidpopulation.
• Theexperiencereportedbyphysiciansvariedmorewithtypeofspecialty
than along the lines of primary care physician and specialist.
PediatriciansinOregonaremorelikelytofeeltheirpatientshaveagood
imderstandingofmanagedcarethanotherphysicians.
PhysicianOpinionofInteractionwiththeMedicaidPlansandOMAP
• Interaction with Medicaid plans compares well to the interaction
physicianshavewithotherplans. Reimbursementratesweretheonly
areawhereMedicaidplansfellsubstantiallyshortofothermanagedcare
plansintheeyesofphysicians. Theseresultsheldbothforplanswith
otherlinesofbusinessandthosethatfocusonMedicaid. Inparticular,
physiciansperceivenodifferenceinaccesstoreferralsandtheabilityto
provideneededcarebetweenMedicaidandnon-Medicaidplans.
• Pediatriciansaremorelikelythanotherphysicianstosaythatfeaturesof
planinteractionaregood.
• CommunicationbetweenphysiciansandOMAPcouldbeimproved. 60
percentfeltthatcommunicationaboutchangesinOHPwasfairorpoor.
HealthEconomicsResearch,Inc. ProviderParticipationinOregonhealthPlan:ES-4
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ExecutiveSummary
Thiscomplaintislikelyrelatedtothefactthatphysiciansareconfused
aboutwhatiscoveredanduncoveredundertheprioritylist. Thepoint
maybemootbecausethelistprobablywillnotchangeinthefuture.
TreatingMemberswithDisabilities
• Themajorityofparticipatingphysicianstreatmemberswithdisabilities,
thoughformost,memberswithdisabilitiesmakeupasmallpercentage
ofthepractice. Psychiatristsarethemostlikelytohaveahighpercentage
ofpatientswhoaredisabled.
• Alargeminority(34percent)ofprimarycarephysiciansfeeltheysee
morepatientswithdisabilitiessincethestartofOHP. Only15percentof
specialistssaytheynowseemoreOHPpatientswithdisabilities. This
couldimplypeoplewithchronicconditionsarenowmorelikelytobe
managedbyaprimarycarephysicianthanbeforeOHP.
• Surveyed physicians who treat the disabled feel that persons with
disabilitiesfaresimilarlytoothersunderMedicaidmanagedcare.
• Physiciansexpressedconcernsaboutrestrictionsinmentalhealthand
substanceabusetreatmentandthereforethesepatientsinparticulardo
worseundermanagedcare. This istheonlyareaidentifiedwhere
physiciansfeelqualityhasnotablydeclined.Again,thisisinterestingin
lightoftheexpandednumberofconditionscoveredunderOHPandthe
expandedpopulationthatisnoweligibleformentalhealthbenefits.
HealthEconomicsResearch,Inc. ProviderParticipationinOregonhealthPlan:ES-5
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1
Introduction
Inthispaperweaddresshowphysiciansinteractwithandviewthreetypesof
MedicaidmanagedcareplayersinOregon. TheseplayersaretheState,plansinthesystem
andclientsinthesystem. TheOregonHealthPlan(OHP)isthestateMedicaidmanaged
careprogram;theofficethatrunstheOHPistheOfficeofMedicaidAssistancePrograms
(OMAP). Plansincludeavarietyoftraditionallycommercialplansand'homegrown'plans
thatonlyservetheMedicaidpopulation. Someoftheseplanswereformedbytraditional
Medicaidproviders,atraitthatiscommoninmanyoftheplansservingMedicaidinother
statesasmanagedcaregrows. ClientsinmanagedcareinOregonareamorecomplexgroup
thanthoseinmanyotherstatesbecausetheyincludedualeligible,disabledandelderly
peopleaswellasanexpansionpopulationthatisrelativelynewtoMedicaid.
TheOHPisinnovativeandimiquelyfeaturesa'prioritylist'meaningthereare
specifictreatment/conditioncategoriesthatMedicaiddoesnotpayfor. Partoftherationale
forthelististoallowOregontoexpandthepopulationservedbyMedicaid. Development
oftheplanwasaninclusiveprocess,drawingontheopinionsofpolicymakers,managed
careplans,physicians,recipients,advocatesandmanyothers.
PhysicianopinionandinteractionswithOHPandOMAPwillillustratelessons
learnedaboutimplementingamajorMedicaidoverhaul.Westudyphysicianopinionof
OHP,participationinOHPandcontractingwithOHPplans. Physiciansprovideinsight
HealthEconomicsResearch,Inc. ProviderParticipationinOHP: 1-1
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Chapter1 Introduction
aboutthequalityofOHPplansoverallandcomparedtocommercialproducts. Physician
opinionofpatientunderstandingandinteractionwithpatientswillhelptoaddressthe
appropriatenessofmanagedcareforthesepopulations.
Wesurveyedoffice-basedphysiciansinOregonandwilluseresponsestoanswer
severalspecificpolicyquestions.
HowisOHPdoing?
WhydophysiciansparticipateinMedicaid?
TowhatextentdophysiciansparticipateinMedicaid?
HowarephysiciansmostlikelytocontractwithMedicaid?
Dophysiciansliketheprioritylist?
HowdophysiciansfeelthatpeoplewithdisabilitiesfareunderOHP?
Howdophysiciansseethelocalmanagedcareplans?
Dophysiciansreportthat managedcareworksfortheMedicaidpatient
population?
HealthEconomicsResearch,Inc. ProviderParticipationinOHP: 1-2
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