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Medicaid Managed Care Seems to Fall Short

TUESDAY Oct. 9, 2007 -- Medicaid enrollees receive lower quality health care from managed-care programs than do managed-care patients in commercial health plans, a new study found.

This was true regardless of whether the Medicaid enrollee was participating in a Medicaid-only plan or a plan that also accepts commercial patients.

"The policy message is that to the extent that people would be hoping to say that [managed care programs] equalize quality, it has not been the case," said Dr. Bruce Landon, lead author of the study and associate professor of health care policy and medicine at Harvard Medical School. "This would suggest that we have to think of other ways that we can send more resources to Medicaid health plans."

The study is published in the Oct. 10 issue of the Journal of the American Medical Association.

"The findings of this important study affirm that health plan design alone cannot meet the challenge of providing quality of care to Medicaid beneficiaries," added Dr. A. Mark Fendrick, professor of internal medicine at the University of Michigan School of Medicine.

"To ensure that quality benchmarks are met, the multiple stakeholders in the health delivery system must go further and identify/implement interventions that influence Medicaid beneficiaries specifically, regardless of health plan," added Fendrick, who's also a professor of health management and policy at the University of Michigan School of Public Health.

Medicaid is the government-funded program that pays for health care for people who can't afford to finance their own medical expenses.

The proportion of Medicaid beneficiaries enrolling in managed care programs is increasing, unlike the commercially insured population, which is declining. Between 1994 and 2004, enrollment in Medicaid managed care tripled from 7.9 million people (23 percent) to more than 27 million beneficiaries (60 percent).

This trend has been spurred largely by a belief that there are significant cost savings to be had by using managed health-care plans. But the impact on health-care quality has been controversial.

"Part of the main motivation for switching to managed care was cost savings. It also afforded [the Centers for Medicare & Medicaid Services] the ability to get more predictable spending levels year after year, because they were paying premiums rather than paying claims," Landon explained. "Another motivation comes from the quality side. It was thought that a more integrated management approach by managed care might lead to higher quality."

The study authors looked at information on 11 quality measures from all 383 health plans that reported quality-of-care data to the National Committee for Quality Assurance for 2002 and 2003. This included 204 commercial-only plans, 142 mixed Medicaid/commercial plans and 37 Medicaid-only plans.

The 11 indicators covered areas of prevention and screening, chronic disease management and care for pregnant women.

For people on Medicaid, performance on the 11 measures was about the same regardless of whether the person was enrolled in a Medicaid-only plan or a mixed plan.

Similarly, for people with commercial insurance, performance was about the same between commercial-only plans and mixed plans.

But across all three health plan types, performance for the commercial population was better than that for the Medicaid population on all measures except screening for the sexually transmitted disease chlamydia. For this measure, Medicaid enrollees had a coverage rate of 41.8 percent, compared to 25.3 percent in the commercial population.

For the other categories, differences ranged from 4.9 percent for controlling hypertension (58.4 percent of the commercial enrollees versus 53.5 percent for Medicaid) to 24.5 percent for rates of appropriate postpartum care (77.2 percent for commercial versus 52.7 percent for Medicaid).

The findings indicate that the type of health plan was less important than differences in the type of patient population served, local provider networks, access to care and adherence to treatment recommendations, the study authors stated.

Part of the reason for the differences may be in poor reimbursement from Medicaid, said Greg Scandlen, founder for Consumers for Health Care Choices, a nonprofit advocacy group for health-care consumers.

"We also know after dozens of studies that low-income people do less well in health-care programs regardless of what the program is like," Scandlen continued. "It may be as much to do with treatment as it is lifestyle, education, poor nutrition -- a whole laundry list that plagues the lower classes, and I don't think anybody has found a solution to that."

Landon agreed: "These [Medicare patients] are more challenging patients. You might need different resources arrayed in a different way. Even though the health plans have similar care delivery networks, the providers that are seen by Medicaid enrollees might be different from others because of where they live... They might be accessing parts of the delivery system that are not as effective."

In any event, managed care does not seem to be the solution for reducing disparities in the U.S. health-care system, the study authors said.

More information

Visit the U.S. Centers for Medicare & Medicaid Services for more on Medicaid managed care.

Posted: October 2007


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