Quality management practices in Medicaid managed care: a national survey of Medicaid and commercial health plans participating in the Medicaid program.

CONTEXT

Rapid expansion of Medicaid managed care has raised concerns about the capacity and willingness of health plans enrolling Medicaid beneficiaries to provide high-quality care. Recently, legislation has facilitated market entry of Medicaid plans, health plans that draw most of their enrollment from the Medicaid population.

OBJECTIVE

To characterize and compare the organizational characteristics and programs related to quality of care of commercial and Medicaid health plans that participate in the Medicaid program.

DESIGN

Cross-sectional survey conducted September 1997 to April 1998.

SETTING

The Medicaid program in 11 states and the District of Columbia.

PARTICIPANTS

All 154 health plans in these localities that provided prepaid general medical care to Medicaid beneficiaries during June 1997, of which 130 (84%) responded to the survey.

MAIN OUTCOME MEASURES

Health plan reports of structural characteristics, services offered, performance measurement and feedback, disease management programs, information systems capabilities, and provider network composition and relationships.

RESULTS

Half of the respondents were Medicaid plans, with 75% or more of enrollees drawn from the Medicaid population. Medicaid plans tended to be smaller and newer than commercial plans that also served the Medicaid population and had more enabling programs targeting the special needs of the Medicaid population, such as inadequate transportation (85% of Medicaid plans vs 62% of commercial plans; P = .003) and illiteracy (66% vs 38%, respectively; P = .002). Overall, 71% of Medicaid plans vs 43% of commercial plans had enabling programs targeted at 6 or more of the 8 special needs we specified (P = .001). While commercial plans had a higher proportion of board-certified primary care physicians (81% vs 73%; P = .01), we found no major differences between Medicaid plans and commercial plans in collection and dissemination of performance measures, designation of specific areas for quality improvement, or use of disease management programs targeted at conditions prevalent in the Medicaid population. Neither commercial nor Medicaid plans reported high success in improving quality of care.

CONCLUSIONS

Based on our survey, while Medicaid plans resemble commercial plans serving the Medicaid population in many aspects of quality management, they are more likely to target programs directed to the specific needs of the Medicaid population. Neither commercial nor Medicaid plans have notably strong records in actual quality improvement.