The first national study to examine the quality of health care provided by managed care plans serving the Medicaid population finds that while most plans have established guidelines and collected information on quality, most have not been successful yet in improving care. The study, conducted with support from The Commonwealth Fund by Bruce E. Landon, M.D., M.B.A., of Harvard Medical School, and Arnold M. Epstein, M.D., M.A., of the Harvard School of Public Health and Harvard Medical School, appears in the November 10th issue of the Journal of the American Medical Association. The authors surveyed 130 health plans in 11 states and the District of Columbia that are participating in Medicaid managed care. The study is the largest to date examining quality management practices within managed care plans of any type.
"Health plans have focused considerable resources on measuring quality, an important first step toward improving care," said Karen Davis, president of The Commonwealth Fund. "We must still, however, take significant action to improve quality of care for low-income patients, who may have additional barriers to overcome, such as language or literacy problems, or cultural differences."
Medicaid Plans Score Better on Addressing Patients' Special Needs
The authors compare quality management practices in plans defined as "Medicaid" plans (those whose enrollment is more than 75 percent Medicaid beneficiaries) with plans defined as "commercial" (those with fewer than 75 percent Medicaid beneficiaries) caring for the Medicaid population. In the past, managed care plan enrollment was restricted to only 75 percent Medicaid beneficiaries; with passage of the Balanced Budget Act of 1997, however, that restriction was lifted, allowing plans to enroll any percentage of Medicaid beneficiaries. Landon and Epstein studied whether quality of care might suffer from this change by examining differences between commercial plans and Medicaid plans that were already serving Medicaid patients. Although Medicaid plans are generally smaller and newer, the study found no significant difference between these and commercial plans in most quality management practices.
One area where the authors did find a significant difference between Medicaid and commercial health plans was in establishing specific programs to address the special needs of Medicaid beneficiaries. Seven of 10 (71%) Medicaid plans had special programs targeted at six or more of the eight areas analyzed, compared with 43 percent of commercial plans. Of Medicaid plans, 66 percent had programs to assist beneficiaries with literacy problems, compared with 38 percent of commercial plans. Furthermore, 85 percent of Medicaid plans had programs to address transportation problems (such as cab vouchers or van service), compared with 62 percent of commercial plans. "Apparently, in the case of Medicaid managed care plans," said Landon, "those that serve more Medicaid patients are more likely to focus on overcoming barriers to care for these patients than plans that predominantly serve the commercial population."
Among commercial plans, the likelihood of a plan having a program designed to address the special needs of Medicaid enrollees was linked to the proportion of Medicaid enrollees in the plan. Commercial plans with higher numbers of Medicaid enrollees were more likely to have such programs than commercial plans with the smallest proportion (less than 10 percent) of Medicaid enrollees.
Gaps Found Between Health Plan Guidelines and Practice
Landon and Epstein also looked at six measures of quality of care particularly important to Medicaid enrollees. More than 90 percent of both commercial and Medicaid plans collected performance data on rates of childhood immunizations, for example, and more than 80 percent of both types of plans had targeted this area for improvement. Only one in four plans, however, was able to demonstrate improved immunization rates. Similar disparities were found in other areas, including waiting times for specialists and preventive care visits, the proportion of women receiving prenatal care, rates of testing for diabetics, and rates of cervical cancer screening. While 80 percent of plans collected data on how many women patients receive prenatal care in the first trimester of pregnancy, only 40 percent of all plans fed that information back to physicians. And although 70 percent of plans reported they needed to improve rates of prenatal care, only 23 percent had demonstrated improvement.
"This study is the first, to our knowledge, to assess quality management by health plans for Medicaid beneficiaries, and to address the potential impact of the regulatory changes in the Balanced Budget Act of 1997 on health care for millions of low-income Americans," said Epstein. The authors conclude that while in general they did not find much difference in quality management between Medicaid plans and commercial plans serving the Medicaid population, Medicaid plans were more likely to have programs directed toward the special needs of these enrollees. Despite efforts to measure quality, the authors stress, "neither commercial nor Medicaid plans have notably strong records in actual quality improvement."
"Health plans should examine ways to improve health outcomes for all their enrollees," said Karen Scott Collins, M.D., assistant vice president at The Commonwealth Fund. "Some larger, commercially oriented plans, which may not have as much experience with Medicaid beneficiaries, might be able to learn from those with more knowledge of the needs of low-income patients."
