Researchers find lower-quality care in Medicaid plans in controversial study

Harvard University researchers say Medicaid managed care enrollees receive lower quality care than that received by commercial managed care enrollees. But a spokesman for Medicaid managed care plans questions the study results, saying it's not fair to compare Medicaid and commercial populations.

According to research by Harvard Medical School Department of Health Care Policy professor Bruce Landon, MD, MBA, MSc, and colleagues, enrollment in Medicaid managed care more than tripled between 1994 and 2004, from 7.9 million beneficiaries to more than 27 million beneficiaries. The proportion of Medicaid beneficiaries in managed care increased from 23% to more than 60% in that decade.

With so many Medicaid recipients in managed care, it's important to evaluate the quality of the care they receive. Dr. Landon says managed care's impact on quality for the Medicaid population has been controversial. "HMOs may incorporate prevention and routine care to prevent serious and costly downstream complications and use population-management techniques to improve the delivery of service to their enrollees," he says. "These techniques may be especially helpful to Medicaid recipients. State Medicaid programs also have adopted a variety of value-based purchasing techniques that require Medicaid managed care plans to measure and report on performance on core quality indicators and to undertake efforts to improve performance. Nevertheless, health plans may institute programs or procedures that limit access to necessary medical services. The poorly educated, low-income, and immigrant populations often served by Medicaid health plans likely have less ability to negotiate the sometimes complex requirements of managed care systems."

The researchers say that while Medicaid-only managed care plans may be able to provide superior care compared with commercial plans that also cover Medicaid populations but do not solely tailor services to that population, concerns have been raised about the quality of care delivered in Medicaid-only plans.

There is a concern, they say, that because many Medicaid health plans are regional plans, they may be undercapitalized, inexperienced in quality management, or rely on networks of lower-quality providers.

Dearth of peer-reviewed research

And despite considerable interest from state and national policy- makers and advocates, there has been almost no information in peer-reviewed journals on the quality of care delivered within health plans to Medicaid enrollees, how that quality compares with that received by their commercial enrollee counterparts, and how the type of plan (Medicaid-only or Medicaid/commercial) makes a difference.

For their evaluation, the researchers examined performance on Healthcare Effectiveness Data and Information Set (HEDIS) quality indicators in three types of managed care plans—Medicaid-only plans, commercial-only plans, and Medicaid/commercial plans. They compared quality performance for the Medicaid and commercial populations by comparing plans that focused exclusively on one or the other population with plans that provided care for both populations.

Services evaluated included childhood immunizations, adolescent immunizations, breast cancer screening, cervical cancer screening, chlamydia screening, controlling high blood pressure, glycated hemoglobin testing in diabetes, glycated hemoglobin control to under 9%, use of appropriate medications for asthma, timeliness of prenatal care, and appropriate postpartum care.

Among the 383 health plans included in the study, 326 plans contributed commercial data and 137 contributed Medicaid data. The commercial-only population was served by 204 health plans, 37 plans served only the Medicaid population, and 142 served both commercial and Medicaid clients.

Most health plans serving only the commercial market were for-profit (77.9%); whereas 51.4% of the health plans serving only the Medicaid market were for-profit. Plans studied were well distributed around the country. A higher proportion of Medicaid and Medicaid/commercial plans were independent local plans (62.2% and 52.8%) as compared with 27.5% of commercial-only health plans. Most plans serving the commercial population (including those also serving Medicaid clients) had been in operation for more than 10 years, while most Medicaid-only plans were less than 5 years old.

Similarities and a glaring difference

The researchers say they found little difference in the quality of care provided to the Medicaid population served by Medicaid-only plans compared with the quality of care provided to the Medicaid population served by commercial plans that also served Medicaid enrollees. Similarly, they say, there was very little difference in quality provided to commercial populations served by commercial-only plans compared with that provided to commercial populations served by Medicaid/commercial plans.

"In contrast," they say, "compared with the commercial population, the quality of care was substantially lower for the Medicaid population, regardless of plan type (with the exception of chlamydia screening). These findings suggest that the type of health plan enrolling the population is a less important determinant of the quality of care than differences in the characteristics of the population being served, the local provider networks in which they receive care, access to care, patterns of care-seeking, and adherence to treatment recommendations."

The researchers say the differences they observed between the quality performance for commercial and Medicaid enrollees both were statistically and clinically significant. Thus, cervical cancer screening rates and rates of diabetes control were more than 15 percentage points higher for commercial populations. They say further that analyses completed by the National Committee for Quality Assurance (NCQA) suggest that differences in hemoglobin A1C control of an even smaller magnitude within commercial health plans could result in up to 15,000 fewer deaths per year nationally. "Thus," they contend, "there is a clear opportunity for improving the health care and health of individuals cared for in Medicaid managed care."

Interestingly, they say, chlamydia screening is the only measure showing higher performance in the Medicaid population vs. the commercial population. Factors affecting performance on this measure include physicians' perceptions about the prevalence of infection in their patient populations and outreach efforts to teenagers and young adults who may be covered under their parents' insurance policies. Higher performance in Medicaid programs, they say, may be a result of Medicaid recipients being more likely to be treated in clinics where sexually transmitted disease screening is routinely implemented or where clinicians have more accurate understanding of the prevalence in that particular population.

Socioeconomic challenges

"These differences in quality performance also underscore the challenge of delivering high-quality care to the Medicaid population," the researchers say. "Patients enrolled in Medicaid are socioeconomically disadvantaged and may face additional competing needs that make adhering to treatment recommendations difficult. Our findings suggest that mainstreaming Medicaid beneficiaries by enrolling them in health plans that also offer commercial insurance products does not appear better or worse than enrolling them in Medicaid-only health plans. While we found that performance in Medicaid/commercial plans was marginally higher than that for Medicaid-only plans on 10 of the 11 measures, those results were not statistically significant. In our previous research, we found that health plans that focus predominantly on the Medicaid population have additional outreach services aimed at the special needs of the Medicaid population. Our data here suggest that these additional services might not be sufficient to bring the quality of care for the Medicaid population up to the level received by commercial populations for routine quality indicators such as those in HEDIS, although we were not able to assess the specific outreach programs of the plans in our study."

According to the researchers, while HEDIS performance was similar across different types of health plans, the patterns observed might be explained in some part by the settings in which patients obtain care. Thus, disadvantaged patients covered through Medicaid might receive care from doctors or hospitals of generally lower quality. Presumably, the researchers say, these physicians would be included in both Medicaid-only plans and those that serve the Medicaid and commercial populations, since performance was similar across those types of plans.

Thus, even to the extent that delivery systems overlap, enrollees may still see different clinicians based on segregation of residence by socioeconomic factors. Also, many physicians refuse to participate in health plans that serve the Medicaid population, so the delivery networks might not always overlap.

A few matters of contention

Study limitations cited by the authors are important to those who disagree with the study conclusions. First, the researchers say, socioeconomic characteristics of enrolled populations are known to be associated with the quality of care and therefore could be an important confounder since commercial and Medicaid health plans enroll populations that differ on those characteristics.

At the least, they say, the results show that the alternate types of managed care plans do not make a difference in the quality of care for Medicaid enrollees, who seem to be at risk for receiving lower-quality care than the commercial populations.

Second, not all health plans in the country report data to NCQA, although the study plan sample included the vast majority of health plan enrollees nationally.

Third, not all health plans could be linked immediately to the health plan characteristics obtained from the Interstudy Competitive Edge 8.2 2002 release that reflected data from 2001 and contained additionally updated information on HMOs in the U.S. The researchers say they did additional Internet and telephone call follow-up but were not able to obtain all relevant variables for each plan.

Fourth, although quality indicators from several care domains were included, the data include a limited number of process measures of quality and may not represent many of the dimensions of quality of care provided by health plans.

Finally, while the analyses document performance problems in Medicaid managed care, no similar information is available on care provided through traditional fee-for-service Medicaid. Thus, it is not known whether enrollees served by Medicaid health plans are receiving better or worse care than Medicaid beneficiaries not enrolled in Medicaid managed care.

The researchers conclude that if reducing disparities in health care nationally is an important goal of the U.S. health care system, "managed care is not a panacea. Additional resources will need to be devoted to designing and implementing specific interventions to improve the quality of care for Medicaid beneficiaries enrolled in managed care."

The study limitation cited by the researchers in terms of not always accounting for population socioeconomic differences resonates with America's Health Insurance Plans (AHIP) spokesman Mohit Ghose. "It's clear that the Medicaid population is one of the most difficult populations to serve," he tells State Health Watch. "But Medicaid managed care plans have never shrunk from taking on that challenge. We enroll members in needed health services and see improvements in health status."

An inappropriate comparison?

Ghose says it's inappropriate to compare the Medicaid population with a commercially insured population. He says a more appropriate analysis would be to compare Medicaid managed care with Medicaid fee-for-service, but that comparison has never been made.

"Our members are doing the work," Mr. Ghose declares. "We can show improvement in Medicaid managed care, with some years better and some worse and some measures better and some worse. It varies with the population being served until you hit a plateau."

He cites a March 2006 study in Maryland that found that Medicaid beneficiary access to ambulatory care was 20% higher through managed care than fee-for-service. In addition, he says, there were 36% more well-child services provided.

And a March 2006 New York State study found that Medicaid managed care beneficiaries were more likely to receive several critical preventive services.

Mr. Ghose says in the latest NCQA survey, Medicaid managed care plans made gains in 34 of 43 quality measures compared with last year.

His final example is Kentucky, which has seen a 247% increase in EPSDT (Early Periodic Screening Diagnosis and Testing) since Medicaid managed care began and a 162% increase in childhood immunization rates.

"You find that almost across the board Medicaid managed care is providing higher quality care than Medicaid fee-for-service," Mr. Ghose concludes.

The Harvard study appeared in the Oct. 10, 2007, issue of the Journal of the American Medical Association. E-mail Dr. Landon at Landon@hcp.med.harvard.edu. Telephone Mr. Ghose at (202) 778-8494.