As public policy advocates for children, pediatric providers should have awareness of whether capitated payment models are associated with children’s use of cost-effective locations, such as the PCP. Children in FFS Medicaid plans are associated with greater expenditures and in concordance with this, the portion of children enrolled in capitated MCOs are rising and FFS plans declining. The enrollment of children into a MCO or fee-for-service (FFS) plan is varied by state policies, and includes factors such as plan availability, geography, disability or complex care needs, or enrollee choice. Providers are encouraged to control costs by limiting low-value tests and treatments, advocating for prevention, and promoting children to seek care at cost-effective venues, preferably coordinated through the primary care provider (PCP). The MCO then pays providers on either a capitated or FFS basis. Under capitated payment models, state Medicaid agencies and MCOs agree to a fixed payment, per member, per month, to control health costs and coordinate care. Most newly insured children are covered under comprehensive managed care organizations (MCO), which utilize capitated payment models. Since the United States’ (US) Affordable Care Act (ACA) of 2010 and Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act (MACRA) of 2015, enrollment of children in Medicaid or CHIP has grown to historically high rates. Health insurance programs that encourage capitated payment models and care through the PCP may improve access to timely acute care in lower-cost settings for children with non-complex chronic conditions. The majority of children in this US Medicaid population had capitated plans associated with higher utilization of acute care, but increased proportion of lower-cost sites, such as PCP-acute visits and UC. Children in capitated plans had greater odds of visits to urgent care, PCP-acute, and PCP-well-child care (aOR 1.21 aOR 2.07 aOR 1.86, respectively), and had lower odds of visits to EDs and specialty care (aOR 0.82 aOR 0.61, respectively), compared to FFS. Negative binomial and logistic regression assessed relationships between payment model and number of visits or odds of utilization, respectively. Children enrolled > 11 months were included, and were excluded for eligibility due to disability/complex chronic condition, lack of outpatient utilization, or provider capitation penetration rate 95%. This retrospective cohort compared outpatient utilization between two payment models of US Medicaid enrollees aged 1–18 years using Truven’s 2014 Marketscan Medicaid database. We aim to determine the association between US capitated and FFS Medicaid payment models and children’s outpatient utilization. Adults in capitated plans utilize primary care providers (PCP) more than emergency departments (ED), compared to fee-for-service (FFS). In the United States (US), Medicaid capitated managed care costs are controlled by optimizing patients’ healthcare utilization.
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