Monday, March 8, 2010

Health care?

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Health care costs are increasing at rates exceeding inflation. (1) Employer-based health insurance premiums increased 6.1 percent from spring 2006 to spring 2007--in contrast to inflation and wages, which increased 2.6 percent and 3.7 percent, respectively. Medicaid programs face similar cost pressures. (2) For example, the state of Florida estimates that Medicaid expenditures will account for 59 percent of the state's total budget by 2015 if the current system is not changed. (3) In an effort to put some predictability in the rate of growth of their expenditures, states are experimenting with and implementing different forms of delivery and financing. Florida is among several states to enact recent changes to its Medicaid program. (4) Kentucky and South Carolina have also restructured their Medicaid programs. (5)

Florida Medicaid is experimenting with a relatively new form of managed care, the provider-sponsored organization (PSO) to provide care for its beneficiaries. PSOs are provider networks sponsored by a variety of health care organizations such as hospitals, integrated delivery systems (IDSs), or independent practice associations (iPAs), which have reorganized to take on risk-bearing contracts. (6) The basic premise of the PSO is that health care providers can organize and assume insurance risk, thereby eliminating the insurance company, and reducing costs. (7) Health care organizations form PSOs to increase provider autonomy, revenues, and the ability to compete in the managed care environment. (8)

Florida's experimentation with PSOs began with a 1997 waiver program, which lead to the formation of the provider service network (PSN) in 2000. Two additional pilot programs, minority physician networks (MPNs), began operations in 2000 and 2001. An examination of these programs could elucidate the impact of the PSOs on access and quality of care for Medicaid beneficiaries. Using the Consumer Assessments of Healthcare Providers and Systems (CAHPS) survey data, this study examines patient experiences with and self-reported utilization of two different PSOs (PSN and MPN) and MediPass, Florida's Primary Care Case Management (PCCM) program. This study adds to the literature on PSOs by comparing consumer assessments and utilization in PCCM to PSOs.

Florida's Medicaid Demonstration Projects

In 2005, Florida Medicaid was comprised of primarily three distinct programs:

1. The PCCM program or MediPass;

2. The PSOs; and

3. Health maintenance organizations (HMOs).

MediPass was originally established in 1991 as an alternative to Medicaid HMOs aimed at ensuring access to coordinated primary care while decreasing inappropriate utilization of medical services. (9) in MediPass, physicians or groups of physicians contracted directly with Medicaid to provide case management services to patients. PCCM physicians were paid a per member per month case management fee for coordinating care and were reimbursed fee-for-service (FFS) for treatment. (10)

In 1997, the Florida legislature authorized the creation of new, modified versions of MediPass based on the PSO model to serve Florida Medicaid. (11) The PSN was formed in the spring of 2000 through the partnership of three large public health care systems. The delivery network included three safety net hospitals and the physicians who work at each hospital. (12) The PSN was responsible for credentialing network providers, beneficiary services, quality assurance, and disease management.

In 2001, a new variant on the PSO model was adopted within the MediPass program. This new model, known as the minority physician network (MPN), was viewed as a mechanism to increase racial and ethnic minority physician participation in the Medicaid program. (13) A primary aim of the MPN pilot program was to determine if providing local medical management services could improve access while lowering the cost of care. (14) Under the MPN pilot programs, the state contracted with two organizations: an administrative services organization (ASO) and a management services organization (MSO).

Florida requires Medicaid non-disabled participants to choose a managed care program when they enroll. Participants can choose from several models of managed care: (15) HMOs, PCCM, or the MPN/PSN. Some or all of these programs are available to Medicaid beneficiaries, depending on region. In some rural counties the PCCM is the only option. If a beneficiary does not choose a plan, he or she is assigned one.

Patient Assessments of Care for PCCMs and PSOs

Consumer assessment of health plans can be a useful indicator of quality. (16) While there are numerous peer reviewed studies that examine consumer assessment of commercial managed care, and some that compare commercial HMOs or FFS programs to Medicaid HMOs, (17) there have only been a few that included Medicaid PCCM and PSO programs. (18)

Conceptual Framework

The Donabedian (19) structure-process-outcome (SPO) model (see Figure 1) is commonly used as a theoretical framework for research in health care organizations. (20) Structure is defined as the organizational and professional resources that are used to deliver care. Process is the actual process of delivering care. Outcomes are the results of care that has been delivered. This research tests how health plan structure affects processes of care. The relationship between the health plan structure and processes of care is important because processes can affect patient outcomes, such as health status and consumer satisfaction.

The organizational structures examined are PSOs and PCCM in Florida Medicaid (see Figure 2). The PSOs have a greater focus on case and medical management than the PCCM. Additionally, reimbursement and revenue-generating mechanisms provide the PSOs with incentives to manage care. Providers that contract directly with the state, as in the PCCM program, do not have such incentives. As a result of differing incentive and management structures, the processes of care may be different between the PSOs and the PCCM program. As previously indicated, Florida uses two variants of the PSO model, the PSN and MPN, which have slightly different structural features when compared to one another and compared to the PCCM.

As in Florida's PCCM (MediPass), PSN primary care physicians are paid a per member per month (PMPM) case management fee and are reimbursed on a fee-for-service basis. However, the PSN receives monthly PMPM administrative fees. Primary care physicians in the PSN have to obtain prior authorizations for specialty referrals and inpatient utilization. The PSN also has to develop disease management programs for certain chronic diseases such as asthma and diabetes. PSN performance is evaluated based on certain quality targets and cost 'savings' relative to the Medicaid Upper Payment Limit. If these targets are achieved, 'savings' are shared between the PSN and the state.


Similar to the PSN arrangement, the MPNs are paid a PMPM administrative fee and MPN physicians are reimbursed on a fee-for-service basis. The MPNs are expected to achieve cost savings, which if realized, are also shared between the state and the MPNs. unlike the PSN, the MPNs does not have to achieve certain quality standards in order to receive the savings. (21) The MPNs also have to provide certain medical management services such as maintaining comprehensive medical records to document that a continuum of care is provided, adhering to quality of care standards, and assisting with primary care case management activities. unlike the PSN, however, while the MPN primary care providers have to manage referrals, they do not need to obtain prior authorization. Both MPNs place considerable emphasis on using detailed patient data for case management and patient profiling activities.

Process indicators measure the actual process of delivering care. Self-reported emergency department (ED) and physician visits are an indicator of how much care a beneficiary used. CAHPS ratings and reports offer a glimpse of how care is being delivered from the beneficiary's point of view.

Additionally, the process measures need to be adjusted for case-mix. The process measures of the different health plans may be better or worse simply because their beneficiaries may be more or less healthy. Case-mix variables that influence experiences of care and utilization in this study are age, education, gender, and self-reported health status.

Research Objective

The primary objective of this study is to evaluate the effect of PSOs authorized in the 1997 waiver program on patient assessments of care and self-reported utilization by comparing PSOs to PCCM in Florida Medicaid, using CAHPS data and self-reported utilization. There are two main research questions:

1. Are there differences in patient assessments of care in the PSOs compared to the PCCM?

2. Are there differences in utilization in the PSOs compared to the PCCM?

Previous research gives some indication of how health plan structure may impact the process of care. Within the private sector, health plans with higher levels of management have more primary care visits, fewer specialist visits, and worse beneficiary ratings. (22) Since the PSOs are more heavily managed than the PCCM, it is expected that they will receive lower ratings and reports of care. Furthermore, it is expected that beneficiaries in the PSOs will also have more primary care visits, fewer specialist visits, and fewer ED visits.




This study concentrated on adult non-HMO Florida Medicaid participants in counties where both PCCM and PSO were available. Children and people over 65 years old were excluded from the analysis because they are both special populations.


This study used data gathered from a cross sectional survey of Florida Medicaid beneficiaries. The survey included the CAHPS 2.0 survey instrument and was conducted from March 1 to April 30, 2005, using a computer-assisted telephone interview system. The CAHPS surveys were designed to provide information that would allow consumers to compare health care plans and select the plan and services that are most appropriate to their needs. (23) These survey responses were used to construct the ratings and reports in the analysis. Telephone surveys were administered to a random sample of non-elderly adults within each PSO and MediPass. There was a 49.5 percent response rate and a total of 1,879 completed surveys. The final study population was limited to the 1,257 beneficiaries located in counties with a choice of plan (PCCM and PSO).


The dependent variables consisted of CAHPS reports and ratings of care and vutilization. The CAHPS 2.0 survey is divided into four global ratings and 17 items that are combined into five reports. (24) The five CAHPS reports are:

* Getting needed care;

* Timeliness of care;

* Provider communication;

* Staff helpfulness; and

* Plan service.

The items in the "Getting needed care" and "Plan service" reports are scored as "A big problem," "A small problem," or "Not a problem." The items in the "Timeliness of care," "Provider Communication," and "Staff helpfulness" reports are scored as "Never," "Sometimes," "usually," and "Always." The global ratings in the CAHPS instrument are: "Personal doctor/nurse," "Specialist," "Overall care," and "Plan." The global ratings are reported on a scale from zero to 10, with 10 being the highest. The global ratings were transformed linearly to a 0 to 100 scale. The reports were calculated in two steps. First, the items were transformed linearly to a 0 to 100 scale, and then a mean score of items within the report was calculated.

Utilization measures were self-reported ED, physician, and specialist visits. Self-reported utilization is a categorical measure with five levels: one, two, three, four, five to nine, and ten or more visits.

The main independent variable of interest was the Medicaid managed care plan type, which consisted of indicator variables for the MPN, the PSN, and the PCCM (reference group). Additionally, age, education, gender, and self-reported health status were used as case-mix variables. (25) Age was categorized into five ranges: 18-24, 25-34, 35-44, 45-54, and 55-64. Education was categorized into six groups: eighth grade or less, some high school, high school graduate or GED, some college or two-year degree, four-year college graduate, and more than four-year college degree. Gender was female or male. Self-reported health status was ranked as excellent, very good, good, fair, or poor.

Two control variables were included in the analysis: race/ethnicity and survey language. Race/ethnicity was categorized into four groups: non-Hispanic White, non-Hispanic Black, Hispanic, and Other. The survey was administered in either English or Spanish. An indicator variable for the Spanish language survey was included to control for potential instrumentation differences.


Linear regression with Huber-White heteroskedasticity consistent (26) standard errors was used to determine differences in CAHPS scores between the MPNs, the PSN, and PCCM. Ordered logits were used to analyze differences in ED specialist, and physician visits since the dependent variables were categorized into ascending groups.

Beneficiaries are asked to choose a health plan when they enroll in Medicaid. If they do not choose a plan, they are assigned to one. This creates self-selection bias that will result in inconsistent estimates of effects if it is not accounted for. Potential self-selection bias was controlled for with propensity scores. (27) A logit was used to estimate an individual's propensity to belong to a PSO based on Florida Department of Health region and primary language spoken at home. There are five Department of Health regions in Florida, two of which offer a PSO option. Primary language spoken at home was reported as English, Spanish, or other. The probability of belonging to a PSO was predicted from the logit and used in the regressions as a covariate.


Of the 1,257 survey respondents, 638 were in an MPN, 327 were in PCCM, and 292 were in the PSN (see Figure 3). There were differences across plans in age, general health, Spanish language surveys, and racial/ ethnic makeup of plan members.

Figures 4 to 6 present the regression results for the study. For the most part, the PSOs did not have a significant impact on CAHPS reports compared to the PCCM (see Figure 4). The only difference in CAHPS reports was the PSN's score for staff helpfulness ([beta] = -4.47), which was lower than PCCM. Likewise, the only rating where the PSOs differed significantly from PCCM was in the specialist rating (see Figure 5). Compared to beneficiaries in PCCM, beneficiaries in the MPN ([beta] = -4.98), and PSN ([beta] = -5.05) gave lower ratings for specialists. Beneficiaries in the PSOs did not rate their personal doctor, health care, or the plan differently from beneficiaries in the PCCM.

Both the MPNs and the PSN had significantly lower odds of physician visits than the PCCM (see Figure 6). The MPN had 23 percent lower odds of physician visits than the PCCM (odds ratio (OR) 0.81, 95 percent confidence interval (CI) 0.63, 1.03) while the odds for the PSN were 32 percent lower than the PCCM (OR 0.76, 95 percent CI 0.57, 1.02). There were no differences in specialist or ED visits between the PSOs and the PCCM.


Using the Donabedian (28) SPO model, this research tested how health plan structure affects processes of care. As expected, PSOs received worse ratings and reports than the PCCM for some aspects of care. Specialist ratings for the PSOs were below PCCM. This may relate to differences between the PCCM and PSO plans in the degree of managed care, where the PSO plans exercise greater control on specialist care. (29) However, a sub-analysis of one item from the "Getting needed care" composite, PSO beneficiaries did not report any more problems seeing a specialist than PCCM beneficiaries.

Reports of staff helpfulness in the PSN were below PCCM, but the MPN was not significantly different than the PCCM on this dimension. Staff helpfulness reports patient perceptions with respect to courtesy, respect, and helpfulness of clinic's staff. As such, this suggests a potential area for PSN's quality improvement.

The Medicaid PSOs did not behave like the private plans studied by Reschovsky, Kemper, and Tu. (30) PSOs had lower odds of using physician services and the same odds of seeing a specialist or using the ER compared to PCCM beneficiaries, indicating potential barriers to primary care access.

There are a number of limitations to this study. First, this study excluded HMOs. Further research into the differences in experiences in HMOs and PSOs is needed to judge the impact of Medicaid beneficiaries switching from HMOs to PSOs. Second, the study relies on self-reported survey data. Respondents may not accurately recall their health care utilization.

In summary, the PSOs did not demonstrate better processes of care than the PCCM. Beneficiaries in the PSOs had similar ratings and reports of care to those in the PCCM. However, PSOs had lower physician visits compared to the PCCM, indicating potential access barriers to primary care. The PSO's impact on ER utilization and specialist utilization was similar to that of the PCCM. The PSOs may lower costs, but the savings may be due to lower physician utilization rather than better case management. This is important since states that are experimenting with PSOs in their Medicaid programs are looking to these vorganizations to improve beneficiary care while lowering costs.

Acknowledgements: This project was supported in part by the Florida Agency for Health Care Administration (AHCA), Contract No. MED054. The authors also wish to acknowledge the feedback received from Dr. Paul Duncan at the University of Florida on earlier drafts of this article.


(1.) Claxton, G, et al., "Health Benefits in 2007: Premium Increases Fall to an Eight-Year Low, While Offer Rates and Enrollment Remain Stable," Health Aff, 26, 5 (2007): 1407-1416.

(2.) Borger, C, et al., "Health Spending Projections Through 2015: Changes on the Horizon," Health Aff, 25, 2 (2006): w61-73.

(3.) Arnold, TW, "Florida Medicaid Program: An Overview," Agency for Health Care Administration (AHCA), State of Florida, 2007, recent_presentations/hh_innovation_medicaid_program_overview_010907.pdf.

(4.) Agency for Health Care Administration (AHCA), "Florida Medicaid Reform Application for 1115 Research and Demonstration Waiver," medicaid_reform/waiver/pdfs/medicaid_ reform_waiver_final_101905.pdf.

(5.) Centers for Medicare & Medicaid Services (CMS), "Kentucky Health Choices 1115 Waiver Proposal," MedicaidStWaivProgDemoPGI/downloads/; Centers for Medicare & Medicaid Services (CMS), "South Carolina Healthy Connections 1115 Waiver," ProgDemoPGI/downloads/South%20Caroli

(6.) Bazzoli, GJ, et al., "Managed Care Arrangements of Health Networks and Systems: A Review of the 1999 Experience," J Ambul Care Manage, 26, 3 (2003): 217-228.

(7.) Alden, S, "The Market Made Them Do It," Hospitals & Health Networks, 71, 13 (1997): 32.

(8.) Sharar, DA, and Weinstein, M, "Provider-Sponsored Networks in Public Sector Behavioral Health," Adm Policy Ment Health, 29, 1 (2001): 3-20; Rosenthal, MB, et al., "Transmission of Financial Incentives to Physicians by Intermediary Organizations in California," Health Aff (Millwood), 21, 4 (2002): 197-205; Grossman, JM, "Health Plan Competition in Local Markets," Health Serv Res, 35, 1 Pt 1 (2000): 17-35.

(9.) Lieu, TA, et al., "Cultural Competence Policies and Other Predictors of Asthma Care Quality for Medicaid-Insured Children," Pediatrics, 114, 1 (2004): e102-110.

(10.) Rawlings-Sekunda, J, et al., "Emerging Practices in Medicaid Primary Care Case Management Programs," health/reports/PCCM/index.htm.


(11.) Duncan, RP, et al., "Evaluating Florida's Medicaid Provider Service Network Demonstration Project," (Florida Agency for Health Care Administration, 2004); Duncan, RP, et al., "Evaluating Florida's Medicaid Provider Services Network Demonstration," Health Services Research 43, 1 Pt 2 (2008) 384-400.

(12.) Duncan, RP, et al., "Evaluating Florida's Medicaid Provider Services Network Demonstration," Health Services Research 43, 1 Pt 2 (2008) 384-400; Lemak, CH, et al., "Evaluation of Florida's Minority Physician Network (MPN) Program," (AHCA, 2004).

(13.) Lemak, CH, et al., "Evaluation of Florida's Minority Physician Network (MPN) Program," (AHCA, 2004).

(14.) Id.

(15.) Lavizzo-Mourey, R, Lumpkin, JR, "From Unequal Treatment to Quality Care," Ann Intern Med, 141, 3 (2004): 221.

(16.) Weech-Maldonado, R, et al., "Health Plan Effects on Patient Assessments of Medicaid Managed Care among Racial/Ethnic Minorities," J Gen Intern Med, 19, 2 (2004): 136.

(17.) Roohan, PJ, et al., "Do Commercial Managed Care Members Rate Their Health Plans Differently Than Medicaid Managed Care Members?" Health Serv Res, 38, 4 (2003): 1121; Bovbjerg, VE, et al., "Assessing Medicaid Recipient Access and Satisfaction: Fee-for-Service, Case Management, and Capitation," Eval Health Prof, 23, 4 (2000): 422-440; Garrett, B, et al., "Effects of Medicaid Managed Care Programs on Health Services Access and Use," Health Serv Res, 38, 2 (2003): 575.

(18.) Garrett, B, et al., "Effects of Medicaid Managed Care Programs on Health Services Access and Use," Health Serv. Res., 38, 2 (2003): 575; Johnson, CE, et al., "Outsourcing Administrative Functions: Service Organization Demonstrations and Florida Medicaid PCCM Program Costs," University of Florida, 2005; Hu, HM, et al., "Enrollee Satisfaction with Three Florida Medicaid Managed Care Programs," Managed Care Interface, 5, (2003): 22.

(19.) Donabedian, A, "The Quality of Care: How Can It Be Assessed?" JAMA, 260, 12 (1988): 1743-1748.


(20.) Burns, LR, "Medical Organization Structures That Promote Quality and Efficiency: Past Research and Future Considerations," Qual Manag Health Care, 3, 4 (1995): 10-18; Zinn, JS, Mor, V, "Organizational Structure and the Delivery of Primary Care to Older Americans," Health Serv Res, 33, 2 Pt li (1998): 354-380.

(21.) Supra, n.12.

(22.) Reschovsky, JD, et al., "Does Type of Health Insurance Affect Health Care Use and Assessments of Care among the Privately Insured?" Health Serv Res, 35, 1 Pt 2 (2000): 219-237; Kemper, P, et al., "Insurance Product Design and Its Effects: Trade-Offs Along the Managed Care Continuum," Inquiry, 39, 2 (2002): 101-117.

(23.) Crofton, C, et al., "Forward," Medical Care, 37, Supp. (1999): MS1.

(24.) Weech-Maldonado, R, et al., "Race/Ethnicity, Language, and Patients' Assessments of Care in Medicaid Managed Care," Health Serv Res, 38, 3 (2003): 789.


(25.) Elliott, MN, et al., "Case-Mix Adjustment of the National CAHPS Benchmarking Data 1.0: A Violation of Model Assumptions?" Health Serv Res, 36, 3 (2001): 555-573.

(26.) White, H, "A Heteroskedasticity-Consistent Covariance Matrix Estimator and a Direct Test for Heteroskedasticity," Econometrica, 48, (1980): 817-830.

(27.) D'agostino, RB, "Tutorial in Biostatistics: Propensity Score Methods for Bias Reduction in the Comparison of a Treatment to a Non-Randomized Control Group," Statist Med, 17, (1998): 2265-2281.

(28.) Supra, n.19.

(29.) Supra, n.22.


(30.) Reschovsky, JD, et al., "Does Type of Health Insurance Affect Health Care Use and Assessments of Care among the Privately Insured?" Health Serv Res, 35, 1 Pt 2 (2000): 219-237.

K. Cameron Schiller, MS, is a health care consultant. Robert Weech-Maldonado, PhD, is Professor & L.R. Jordan Endowed Chair, University of Alabama at Birmingham.

Allyson G. Hall, PhD, is Associate Professor at the University of Florida and Associate Director for the Florida Center for Medicaid and the Uninsured.

Figure 2. Structural Differences in Florida Medicaid Plans in 2004


Ownership/ State of Florida Administrative services
Management organization or
management services

Payment $3 PMPM case $3 PMPM case management
management fee, fee, $9 PMPM
fee-for-service administrative fee,
reimbursement fee-for-service
reimbursement, and a
payment based on the
difference between
Medicaid HMO upper
payment limits and
actual expenditures
("shared savings")

Quality Incentives None Must conform to some
HEDIS standards

Specialist Referral Prior authorization Self-managed

Medical No Yes

Inpatient Services Prior authorization Prior authorization


Ownership/ Safety-Net Hospital Network

Payment $3 PMPM case management
fee, $9 PMPM administrative
fee, fee-for-service
reimbursement, and a
payment based on the
difference between Medicaid
HMO upper payment limits
and actual expenditures
("shared savings")

Quality Incentives Bonus partially based on
meeting HEDIS standards.
Disease management
required for certain diseases.

Specialist Referral Prior authorization

Medical No

Inpatient Services Prior authorization

Figure 3. Demographics of Survey Respondents


N 327 638 292


18-24 4.6% 12.5% 5.5% 68 (8) <.0001
25-34 19.6% 24.6% 12.0%
35-44 21.4% 218% 17.8%
45-54 29.4% 22.9% 28.8%
55-64 28.1% 18.2% 36.0%


Eighth grade or less 15.6% 16.0% 15.4% 5 (8) 0.745
Some high school 26.0% 23.5% 26.4%
High school graduate or
GED 34.9% 34.6% 37.0%
Some college or 2-year
degree 18.7% 18.3% 15.0%
4-year college graduate
or more 4.9% 7.5% 6.2%


White 41.6% 39.0% 4.8% 156 (6) <.0001
Black 23.9% 22.6% 51.4%
Hispanic 30.9% 35.6% 42.1%
Other 3.7% 2.8% 1.7%


Female 75.9% 70.7% 68.8% 4 (2) 0.119
Male 24.2% 29.3% 31.2%

Spanish Language Survey 16.5% 4.9% 28.1% 11 (2) 0.004

General Health

Excellent 5.2% 11.1% 6.2% 26 (10) 0.003
Very Good 8.6% 11.6% 6.9%
Good 17.7% 21.0% 24.3%
Fair 37.0% 31.2% 34.9%
Poor 30.3% 23.5% 26.4%
Missing 1.2% 1.6% 1.4%

Figure 4. Linear Regression on CAHPS Report Scores

Getting Timeliness Provider Staff Plan
Needed Care of Care Communication Helpfulness Service

N 1,164 1,071 954 955 573
B (SE) B (SE) B (SE) B (SE) B (SE)
MPN 0.00 -1.27 -0.26 0.74 -3.54
(2.46) (2.32) (1.95) (1.97) (3.98)
PSN -1.95 -3.60 -0.87 -4.47 * -4.85
(3.02) (3.07) (2.37) (2.60) (4.99)

Plan reference: PCCM

* p < 0.10; ** p < 0.05; *** p < 0.001

Figure 5. Linear Regression on CAHPS Ratings

Doctor Specialist Overall Care Plan

N 904 588 1198 1124
B (SE) B (SE) B (SE) B (SE)
MPN -1.79 -4.98 ** -1.58 -1.06
(1.60) (1.84) (1.66) (1.66)
PSN 2.09 -5.05 ** -1.42 -0.81
(1.84) (2.39) (2.10) (2.02)

Plan reference: PCCM

* p < 0.10; ** p < 0.05; *** p < 0.001

Figure 6. Odds Ratios of Increasing Utilization

Physician Visits Specialist Visits ED Visits

N 1, 239 1,239 1,239
OR (95% CI) OR (95% CI) OR (95% CI)
MPN 0.81 * (0.63, 1.03) 1.26 (0.94, 1.69) 1.13 (0.85, 1.51)
PSN 0.76 * (0.57, 1.02) 1.09 (0.77, 1.54) 1.16 (0.81, 1.67)

Plan reference: PCCM

* p < 0.10; ** p < 0.05; *** p < 0.001Source Citation
Schiller, K. Cameron, Robert Weech-Maldonado, and Allyson G. Hall. "Patient assessments of care and utilization in medicaid managed care: PCCMs vs. PSOs." Journal of Health Care Finance 36.3 (2010): 13+. Academic OneFile. Web. 8 Mar. 2010.
Document URL

Gale Document Number:A220468402

Disclaimer:This information is not a tool for self-diagnosis or a substitute for professional care. USA, LLCget the best of the bestPersonalized MY M&M'S® Candies(Web-Page) (Album / Profile)
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