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particularly difficult to predict the effect of health industry consolidation on quality in Medicaid managed LTSS programs. On one hand, because of the enormous size and reach of their Medicaid programs,173 states exercise near- monopsony, de facto single-payer174 purchasing power for LTSS. Thus, a provider who wants to become or remain part of the managed Medicaid LTSS network (low reimbursement being better than zero market share) in some states with multiple competing providers may have an incentive—bordering on coercion175—to be attractive to the state by achieving and maintaining positive ratings and reputation for quality and consumer satisfaction.176 On the other hand, despite their near-monopsony power, some states may have so few LTSS providers competing to be included in their inadequately compensated, managed Medicaid LTSS provider networks that those states find it necessary to tolerate the inclusion of providers exhibiting a somewhat less than stellar quality of care record. Researchers should investigate which of these hypotheses ultimately gets borne out by the evidence.177
Evaluation of Illinois’ Medicaid Primary Care Case Management Program, 12 ANNALS FAM. MED. 408, 412 (2014) (reporting positive findings concerning impact on quality), with Kyle J. Caswell & Sharon K. Long, The Expanding Role of Managed Care in the Medicaid Program: Implications for Health Care Access, Use, and Expenditures for Nonelderly Adults, 52 INQUIRY 1, 9 (2015) (reporting negative findings regarding quality); see also Diana D. McDonnell & Carrie L. Graham, Medicaid Beneficiaries in California Reported Less Positive Experiences When Assigned to a Managed Care Plan, 34 HEALTH AFF. 447, 447 (2015) (reaching the same conclusion). 173. See John K. Iglehart & Benjamin D. Sommers, Medicaid at 50—From Welfare Program to Nation’s Largest Health Insurer, 372 NEW ENG. J. MED. 2152, 2152–2154 (2015) (examining the evolution of the Medicaid program since its creation under the Social Security Amendments of 1965). 174. See Kristin Peterson, State Medicaid Agencies as Single Payers: An Innovative Approach to Medicaid Expansion Obligations Under the Patient Protection and Affordable Care Act, 21 ANNALS HEALTH L. ADVANCE DIRECTIVE 35, 47–48 (2011) (stating that Vermont applied to CMS to become its own public managed care entity for Medicaid, and if it is approved, Vermont will be a single payer). Regarding the single-payer concept, see generally Kenneth Shuster, Because of History, Philosophy, the Constitution, Fairness & Need: Why Americans Have a Right to National Health Care, 10 IND. HEALTH L. REV. 75 (2013). Cf. Ann Marie Marciarille, The Medicaid Gamble, 17 J. HEALTH CARE L. & POL’Y 55, 55 (2014) (“As passed, the ACA transformed Medicaid from an unevenly and underfunded program for the poor and disabled to a program to offer those priced out of commercial insurance markets government-funded health insurance similar to Medicare, the single-payer system for seniors and the disabled.”). 175. Cf. Nat’l Fed’n of Indep. Bus. v. Sebelius, 132 S. Ct. 2566, 2604–2605 (2012) (plurality holding that Medicaid is such a large portion of state budgets that the federal government’s threat to withhold Medicaid funds from a state amounts to unconstitutional coercion). 176. See FLA. STAT. ANN. § 409.982( 1) (West 2015) (“Managed care plans may limit the providers in their networks based on credentials, quality indicators, and price.”). 177. See Evaluation Contract, supra note 171.