Investigating the Drivers of Increased Specialty Utilization for a Managed Care Organization

Health Plus is a managed care organization that covers over 323,000 low-income and underserved individuals in New York City and Nassau County through the Medicaid, Child Health Plus, and Family Health Plus state-sponsored health programs and through federal Medicare Advantage programs. The Capstone team worked to understand the underlying reasons for growth in specialty physician outpatient utilization in its state sponsored programs. The team conducted a literature review to understand national trends and drivers of specialist utilization. Using hypotheses from the literature review, the team tested them using the organization’s internal data. Finally, the team conducted surveys of primary and specialty care providers within the Health Plus network to better understand referral patterns and usage patterns of primary care and specialists. Finally, the team made recommendations and created metrics for managing the use of outpatient specialty services without detriment to quality care and provider satisfaction.