Quality Found Lacking in Medicaid Managed Care

BOSTON, Oct. 9 -- Patients enrolled in Medicaid managed care plans are less likely to achieve good blood pressure control, receive breast cancer screening, or have timely prenatal care than similar patients enrolled in commercial plans.

The finding emerged from an analysis that compared medical care in 204 commercial only plans, with treatment in 142 Medicaid/ commercial plans, and 37 Medicaid-only plans.

The analysis found that Medicaid patients received worse care on 10 of 11 quality measures, Bruce E. Landon, M.D., M.B.A., of Harvard, and colleagues, reported in the Oct. 11 issue of the Journal of the American Medical Association.

The only instance in which Medicaid patients were more likely to receive recommended care was for Chlamydia screening, with Medicaid plans almost twice as likely to do so.

Lower quality care was observed in both Medicaid-only plans and commercial plans that also serve Medicaid patients, wrote Dr. Landon's team.

Moreover, the problem is not small. Some 27 million Medicaid beneficiaries, 60% of the total Medicaid population, are in enrolled in managed care plans.

"If reducing disparities in care nationally is an important goal of the U.S. health care system, managed care is not a panacea," the investigators concluded. "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 investigators compared 11 Healthcare Effectiveness Data and Information Set (HEDIS) measures reported to the National Committee for Quality Assurance (NCQA) by 383 plans. The HEDIS data from 2002 and 2003 were included in the analysis.

The authors found that while Medicaid enrollees received the same level of substandard care in both the Medicaid-only plans and the mixed-enrollment plans, commercial enrollees likewise received the same level of higher quality care in the commercial only HMOs and the mixed plans. The predictor of poor quality was the income of the patient.

Among the findings:

• Commercial plans achieved blood pressure control for 58.4% of patients, versus 53.5% hypertension control rate in Medicaid plans.
• Timely prenatal care was delivered to 86.9% of patients in commercial plans versus 69.4% of patients in Medicaid plans. For postpartum care the difference was more striking, 77.2% versus 40.7%.
• Recommended breast cancer screening was completed for 52.6% of Medicaid patients versus 75.1% of commercial HMO patients.
• Glycated hemoglobin was tested in 73.4% of Medicaid patients with diabetes and glucose was controlled in 47.4% of Medicaid patients compared with 82.6% and 66.3%, respectively, for diabetic patients enrolled in commercial plans.
• The childhood immunization rate was 54% in the Medicaid plans and 68.7% for commercial plan enrollees.

The authors said their study was subject to a number of limitations, including the fact that Medicaid patients are not only poor, but are also often poorly educated, both factors that are known to influence health status. Also not all managed care plans report quality data to NCQA, so there could be selection bias and the quality measures used may not have reflected a number of additional services offered by managed care plans, services that could impact quality.

Finally, the study reported only on Medicaid managed care plans and "no similar information is available on care provided through traditional fee-for-service Medicaid. For example, it is not known whether enrollees served by Medicaid health plan are receiving better or worse care than Medicaid beneficiaries not enrolled in managed care."