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HEALTHECONOMICSRESEARCH,INC. 4W1al1tWhaavme,rlMeAy0O2a4k5s2-R8o4a1d,4Suite330 (781)788-8100 (781)788-8101-FAX 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 oreg/provider/toc.wpd/nd 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 oreg/provider/toc.wpd/nd 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 Oreg/provider/exccsum.wpd/lmt 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 Oreg/provider/execsum.wpd/lmt 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 Oreg/providcr/execsum.wpd/lmt 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 Oreg/provider/execsum.wpdyiml 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 Oreg/provider/execsum.wpd/lmt 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 Oreg/provider/chapI.wpd/lmt Chapter1 Introduction aboutthequalityofOHPplansoverallandcomparedtocommercialproducts. Physician opinionofpatientunderstandingandinteractionwithpatientswillhelptoaddressthe appropriatenessofmanagedcareforthesepopulations. Wesurveyedoffice-basedphysiciansinOregonandwilluseresponsestoanswer severalspecificpolicyquestions. HowisOHPdoing? WhydophysiciansparticipateinMedicaid? TowhatextentdophysiciansparticipateinMedicaid? HowarephysiciansmostlikelytocontractwithMedicaid? Dophysiciansliketheprioritylist? HowdophysiciansfeelthatpeoplewithdisabilitiesfareunderOHP? Howdophysiciansseethelocalmanagedcareplans? Dophysiciansreportthat managedcareworksfortheMedicaidpatient population? HealthEconomicsResearch,Inc. ProviderParticipationinOHP: 1-2 Oreg/provider/chap1.wpd/lmt