Effectiveness of recipient restriction programs in Medicaid managed care organizations

Jason Michael Beaubien, University of Rhode Island

Abstract

Recipient restriction, defined as the locking-in of Medicaid recipients who tend to doctor or pharmacy "shop" into one specific provider and/or pharmacy, has been utilized by State Medicaid agencies and Medicaid managed care organizations as a measure to not only control misutilization and overutilization of Medicaid services through the reduction of unnecessary or inappropriate services, but also to better manage and improve members' quality of care. The objectives of this research was three-fold: to document the prevalence of recipient restriction programs in State Medicaid agencies and Medicaid managed care organizations (MCO); examine the impact these programs have as a measure to control misutilization and overutilization of Medicaid services; and provide an analysis of recipient restriction in a Northeastern Medicaid Managed Care Organization (NMMCO) through the analysis of both medical and pharmacy claims data and document the effect the program has as a cost-savings measure to the organization. The ultimate goal of this research was to examine recipient restriction at the national level, focusing on Medicaid managed care with a detailed analysis of a single Medicaid MCO. ^

Subject Area

Health Sciences, Pharmacy|Health Sciences, Health Care Management

Recommended Citation

Jason Michael Beaubien, "Effectiveness of recipient restriction programs in Medicaid managed care organizations" (2005). Dissertations and Master's Theses (Campus Access). Paper AAI3206244.
http://digitalcommons.uri.edu/dissertations/AAI3206244

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