Medicaid Pay-For-Performance (P4P) Programs and the Use of Preventive Care Services

We estimated the effect of Medicaid P4P programs on the use of preventive care services and the relative effects of different P4P incentive designs. Medicaid managed care plans in states with P4P programs are reimbursed based on specific performance criteria, including some relating to the receipt of preventive care among Medicaid enrollees. Over the past ten years, the number of state Medicaid P4P programs has dramatically increased – to 20 states by 2010.   However, limited literature studies the effects of these programs.

We used data from the National Health Interview Survey (NHIS) 1998-2000, 2003, 2005, 2008 and 2010, and the National Immunization Survey (NIS) 1999-2010.   We consider the use of several different preventive care services for nonelderly adults in the NHIS who are on Medicaid and not Medicare.  For these analyses, we consider different age ranges according to the recommended age range for each preventive care service examined.  We also consider immunization rates for children on Medicaid aged 19 to 35 months in the NIS. Sample weights were used and standard errors accounted for the complex design of the surveys.

Among those on Medicaid, state adoption of a P4P program is positively associated with the likelihood that adults have received several preventive care services, including mammograms, blood pressure checks and Pap smears. P4P adoption is also associated with small but significant increase in the probability that children on Medicaid are up-to-date on the vaccine series.  These average effect sizes are larger in states with higher Medicaid managed care penetration rates and in states that use negative financial incentives, such as withholds and penalties, rather than states with positive financial incentives and non-financial incentives.

With expansions in Medicaid eligibility possible, Medicaid managed care programs may cover more individuals.  In the past, states have attempted to use P4P programs as a way to link health care spending to quality and efficiency of care. Results in this paper provide evidence that P4P programs are associated with increases in the use of preventive care services among Medicaid enrollees, especially for states with higher Medicaid managed care penetration rates. The incentive design of the program also matters since there are significant associations between different incentive types and the magnitude of increases in preventive care use.