Medicaid Managed Care: The Challenge of
January 1998 - Number Six
By Julianna S. Gonen, PhD
Managed care has made substantial and increasing inroads in enrolling the nation's Medicaid population, as more and more states turn to prepaid care models to rein in health care costs for the poor and disabled, and also to enhance access to services. Nearly 40 percent of the Medicaid population, primarily low-income women and children, are enrolled in managed care plans. Because of the high number of low-income women in these plans and their particular vulnerabilities, it is important to assess how well Medicaid managed care plans are caring for these women.
The Role of Medicaid in Ensuring Access to Care for Low-Income Women
As of 1995, the Medicaid population was distributed among the following categories: children (17.5 million), adults in families (8 million), elderly (3.9 million), and blind and disabled persons (5.8 million). The numerical distribution does not parallel the distribution of expenditures; while adults and children in low-income families constitute nearly 75 percent of beneficiaries, they account for only 28 percent of spending. The elderly and disabled account for 60 percent of spending because of their intensive use of acute and long-term care services. Federally mandated services covered by Medicaid include inpatient and outpatient hospital care; physician, midwife, and certified nurse practitioner services; laboratory and x-ray services; nursing home and home health care; early and periodic screening, diagnosis, and treatment services for children under 21; family planning services; and services provided in rural health clinics or federally qualified health centers. States may opt to cover additional services such as prescription drugs, clinic services, prosthetics, hearing aids, dental care, and intermediate care facilities for the mentally retarded.1
Traditionally, women who are not elderly have qualified for Medicaid through links to welfare programs such as Aid to Families with Dependent Children (AFDC) or Supplemental Security Income (SSI), or because they have low income and are pregnant. Eligibility expansions in the past few years, such as higher maximum income levels, have led to greatly increased enrollment. New welfare legislation passed recently, however, eliminates the automatic link between AFDC and Medicaid and will significantly affect Medicaid eligibility. In particular, the requirement for a separate application process for Medicaid may depress enrollment. Women who lose their access to Medicaid will likely remain uninsured; indeed previous studies have shown that nearly two thirds of women who leave Medicaid become uninsured.2
Since pregnancy is one means of qualifying for Medicaid coverage, Medicaid plays a particularly important role in financing maternity care, paying for approximately 40 percent of births in the United States.3 Coverage for the mother ends 60 days after childbirth unless she meets AFDC eligibility criteria. Approximately half of adult women on Medicaid become eligible through AFDC qualification, one quarter of them by virtue of being both low-income and pregnant.2 This group of women in their peak childbearing years is at risk for unintended pregnancy and sexually transmitted diseases (STDs), both of which carry significant morbidity and mortality.4 Many rely on traditional publicly funded family planning clinics for contraceptive and STD care; these clinics are in fact the major providers of reproductive care for Medicaid beneficiaries. Medicaid funds nearly half of all publicly supported contraceptive services, even more than family planning-specific funding in Title X, which provides categoric federal funding for nearly 4,000 family planning providers serving low-income populations.5
Medicaid has made health care more accessible for many low-income Americans, providing coverage to many who would otherwise have none. It has helped to reduce access barriers for low-income women, so that today low-income women with Medicaid coverage are just as likely as privately insured women to have a usual source of care, to have seen a physician in the past year, and to receive preventive care.6 It has not, however, been a panacea for the underserved. A number of nonfinancial barriers have persisted in the traditional fee-for-service Medicaid system, including low physician participation due to inadequate payment levels, a dearth of physicians in the disadvantaged communities in which many Medicaid beneficiaries reside, and fragmented care provided largely through overburdened hospitals.
Medicaid Managed Care
A major change in states' ability to mandate managed care took place in 1997, as part of the Balanced Budget Act; states no longer need federal waivers to implement mandatory managed care for most categories of beneficiaries.7 The new law also permits the establishment of Medicaid-only health plans by rescinding the 75/25 rule (having at least 25 percent commercial enrollment had previously been considered a proxy for quality), and establishes new consumer protections. This will probably result in continued increases in mandatory Medicaid managed care enrollment, as today all states except Alaska are pursuing managed care initiatives.8
There are three primary forms of Medicaid managed care arrangements: full-risk plans (health maintenance organizations or health insuring organizations); limited-risk prepaid health plans; and fee-for-service primary care case management (PCCM). Approximately two thirds of enrollees are in full-risk or prepaid health plans, while the other third are found in PCCM programs, which use gatekeepers reimbursed through discounted fee-for-service.9 Nearly half of Medicaid enrollees in fully capitated managed care arrangements as of 1996 were in plans with at least 75 percent Medicaid enrollment; the number of Medicaid-only plans has more than doubled since 1993 to almost 150. The participation of commercial managed care organizations (MCOs) in Medicaid has steadily increased, but more than half of the plans entering the Medicaid managed care market during the period from 1993 to 1996 were newly formed, and most of these were Medicaid-only plans. Tracking the number and composition of full-risk plans serving Medicaid is important since these are the plans that will experience the strongest financial incentives to limit service utilization.10
Most state efforts to roll Medicaid beneficiaries into managed care have focused on low-income women and their children. By encouraging the use of preventive services and assigning enrollees to primary care providers, Medicaid managed care has the potential to provide better overall care and reduce inappropriate care and also reduce costs. But the evidence of managed care's ability to lower costs and increase access has been inconclusive.11 Furthermore, the minimal impact on states' overall Medicaid costs derives largely from the fact that the populations enrolled in managed care (low-income families) account for only about one quarter of Medicaid expenditures. It is the costs of acute and long-term care for the disabled and the elderly that account for the bulk of Medicaid expenditures.
More importantly from the perspective of the enrolled population are the potential risks that may come with the shift to managed care. One problem has been that some plans have engaged in fraudulent or discriminatory enrollment practices. But there is a broader concern that the managed care industry has taken on a market for which it was not ready. There is significant diversity among the types of MCOs serving the Medicaid population. Some developed out of federally qualified health centers with years of experience serving low-income populations, but others are commercial MCOs that have developed a Medicaid product as a new line of business. Some of these plans with little experience serving the Medicaid population have experienced difficulty in addressing its unique health care needs adequately, and many commercial plans are now pulling out of the Medicaid market. There may be financial incentives for plans to undertreat in a capitated environment with a population that tends to need more services. This population is also more vulnerable in that if the plan does not provide services they are less able to "vote with their feet" and exercise other options or pay for extra care out of pocket. Other risks include disruptions in the physician-patient relationship, barriers to specialty care, and uncertain state capacity to monitor quality of care sufficiently.9 Ensuring the success of Medicaid managed care will depend in part on the adequacy of the capitation rates paid to health plans and on the monitoring of access and quality by the states and the federal government.8
Women's Preventive Health Care. Research results on the delivery of preventive health services to women in Medicaid managed care plans have been positive.11 A study of Medicaid managed care demonstration projects in specific counties in California and Missouri showed that women in Medicaid MCOs were more likely than those in Medicaid fee-for-service (FFS) programs to receive clinical breast exams and to learn how to perform a breast self-exam. In the California project, there was no difference in pap test frequency between women in managed care and those in FFS, but those in managed care in Missouri had a much higher rate than those in FFS.12 A similar study in Arizona found women in Medicaid managed care and FFS equally likely to receive both Pap tests and mammograms.13 Site visits to 14 HMOs serving Medicaid beneficiaries and the safety net providers in those plans' service areas revealed that Medicaid managed care programs have increased the availability of primary care services for enrollees in those states.14 This study also found that safety net providers play a significant role in many plans' strategies to serve their Medicaid populations, and that most of these providers, with the exception of public health departments, are faring reasonably well. Concerns were raised, however, that enabling services that support access to care, such as case management and transportation, may be vulnerable to cuts without demonstrable evidence of their cost-effectiveness. Plans whose central mission was to serve Medicaid beneficiaries were found to offer more such enabling services than commercial-based plans.
Reproductive Health Services. Reproductive health care is critical for a major proportion of the Medicaid population. Following the implementation of managed care programs in the early 1980s, enrollees in many Medicaid managed care plans continued to access public family planning clinics for reproductive health care, rather than obtaining these services through their new health plans. These clinics, not being part of the enrollees' managed care networks, were prevented from obtaining reimbursement for these services because they were supposed to be provided by the managed care plan and thus had already been paid for in the capitation amount given to the health plan by the state. This led to a large increase in the amount of uncompensated care being provided at family planning clinics, prompting a federal legislative response. Congress mandated in 1986 that enrollees in Medicaid managed care plans must be allowed to retain the freedom to access any family planning provider, regardless of whether the provider is part of the plan's network. This did not fully solve the problem, however, as clinics have experienced difficulty obtaining reimbursement from the health plans. The lack of a uniform and comprehensive definition of family planning services further complicates the situation.15 The exemption has also enabled community-based family planning providers to avoid developing strong relationships with managed care plans, which has implications for the quality of care received by Medicaid managed care enrollees and for the economic survival of Medicaid-dependent providers.
In some instances, however, Medicaid managed care plans have been able to increase access to services. A study of Arizona's Medicaid managed care program, the Arizona Health Care Cost Containment System, concluded that the program's inclusion of family planning services had a positive impact on utilization of these services statewide.16 Low-income women in Arizona were more than twice as likely to receive family planning services in 1989 than they were in 1984.
Maternal and child health (MCH) agencies also have a long history of serving low-income and special needs families, and officials of these programs have expressed concerns about the ability of managed care plans to assume this responsibility. In a 1993 report, the Association of Maternal and Child Health Programs recommended that MCH agencies undertake greater involvement in managed care plans as these plans develop services for Medicaid beneficiaries.17 Particular areas in which MCH agency expertise is needed include provider recruitment, certification, training, and technical assistance. The report also recommended that MCH programs serve as primary contractors or subcontractors within managed care networks when needed, and that they develop standards, contracts, and data systems to monitor quality of care.
Medicaid's role as the leading financier of births in the United States has made prenatal care a key priority for Medicaid managed care plans. In 1986, Congress expanded Medicaid eligibility for prenatal care for low-income women, and since then many states have used Medicaid to improve access and enhance prenatal care services.18 By January 1994, 34 states had increased Medicaid eligibility to pregnant women with incomes over 133 percent of the federal poverty level, and 45 states eliminated asset tests. North Carolina and Washington provided the most extensive enhanced services, and both had evidence suggesting positive effects on birth outcomes. Providing prenatal care to Medicaid enrollees presents health plans with a whole new set of challenges, as the women in need of the services face numerous barriers to access, both financial and logistical. Poor single women may lack social support networks, rely on public transportation, live in inadequate housing in unsafe neighborhoods, and lack telephones.9 Low literacy may also present an access barrier. Women living in these conditions are likely to have poorer overall health already and have difficulty accessing prenatal care services when pregnant. If their managed care plans are not cognizant of and sensitive to these contextual factors they are unlikely to be successful in delivering services and improving birth outcomes. Some states have used their section 1915(b) waivers to develop innovative managed care programs that have increased access to prenatal care and produced cost savings in the process.19 But while capitation payments may provide plans some flexibility to provide some enabling services that go beyond the medically necessary care covered by Medicaid, the research evaluating Medicaid managed care prenatal services has not found improvements in outcomes over Medicaid fee-for-service programs.11
In Iowa, for example, women enrolled in the state's PCCM program received less prenatal care than those in Medicaid fee-for-service.20 Between 1989 and 1992, there was a 20 percent increase in the number of women who received adequate prenatal care in fee-for-service counties, and only a 5 percent increase in the PCCM counties. Women in the FFS counties who initiated prenatal care in the first trimester increased 17 percent, compared with 6 percent in the PCCM counties. And the increase in the number of women who received enhanced prenatal services in the FFS counties was nearly double the increase in the PCCM counties. There were no differences between the two programs in mean gestational age or birthweight, but there was an increase in very-low-birthweight births in both groups. Other studies of managed Medicaid in Missouri, California, and Philadelphia have found no difference between FFS and managed care programs in the early receipt of prenatal care.21 A neutral or small beneficial effect on prenatal care was found among Medicaid managed care enrollees in Washington, but the study authors also found that the amount of prenatal care received by Medicaid enrollees was less than that received by commercial enrollees in the same plan, and that Medicaid recipients also had poorer birth outcomes.22 A study of a random sample of women enrolled in the Illinois Medicaid program compared those in fee-for-service and those in the Prepaid Plan, and found that while birth outcomes and infant health status were similar in the two groups, mothers in the prepaid plan reported more untreated infant problems and shorter postpartum hospital stays.23 Mothers in the prepaid plan also reported more perceived barriers to pediatric care.
Chronic Illness. Reproductive health services are not, of course, the only concern of low-income women enrolled in Medicaid. These women also experience high rates of chronic illnesses such as arthritis, hypertension and diabetes, limitations in activities, and other disabilities.24 The high rates of disability and chronic illness in this population make access to specialists and experimental treatments particularly important, especially as Medicaid managed care expands beyond predominantly low-income families to include people with disabilities as well.9 Medicaid also plays an important role for low-income older women, covering Medicare copayments and deductibles and services not covered by Medicare, such as prescription drugs and long-term care. Medicaid pays for approximately half of all nursing home care.
Mental Health Issues. Many states are now moving beyond enrolling only low-income women and children in Medicaid managed care and including individuals with disabilities and significant mental health needs. States implementing managed behavioral health care for their Medicaid populations vary in the degree to which they have integrated these services with physical health services, with some carving them out entirely and others using a partial carve-out approach that leaves those with more limited mental health needs in the regular managed care plans while providing a specialty plan to those with more acute needs. No states have adopted a fully integrated approach, out of a fear that in competitive markets, a fully integrated plan would have an incentive to avoid adverse selection by making its plan unattractive to those with mental health and substance abuse problems.25
Women in general suffer disproportionately from disorders such as depression, and the financial and social difficulties faced by poor women increase their susceptibility to certain mental health problems. Low-income women are more likely to suffer from anxiety and depression, suicidal thoughts, low self-esteem, and dissatisfaction with their lives than more affluent women. The comorbidities of mental and physical health problems are by now well documented, and so the prevalence of these disorders among women on Medicaid warrants significant attention by health plans enrolling this population.26
One State's Experience: California
The two-plan model, devised in 1993 to expand Medi-Cal managed care, has been implemented in 12 California counties and is thus the most prominent model. It was designed specifically to allow enrollees access to certain services outside MCO networks. Clinical services covered under the model for which health plans must reimburse out-of-network providers include family planning, STD treatment, HIV testing, nurse midwife services, and immunizations. Health plans are required to contact new enrollees within 120 days to offer health assessments and preventive care.27
County-organized health systems are another Medi-Cal managed care model, as exemplified by CalOPTIMA in Orange County. CalOPTIMA began operations in October 1995 and currently has a membership of approximately 218,000 beneficiaries. The delivery system is a combination model, with 5 HMOs, 13 hospital-physician consortia (created specifically for CalOPTIMA to serve Medi-Cal beneficiaries, with mandated inclusion of traditional providers and community clinics), and CalOPTIMA Direct, a modified fee-for-service program administered directly by the agency. Some unique features of CalOPTIMA have proven beneficial for women's health and good for essential community providers such as Planned Parenthood, largely due to a commitment to ensuring the continuation of the public health safety net. The system's best successes are better access to preventive care and reproductive health services as a result of state mandates, more coordination and integration of services (due in part to new cooperation between hospitals and safety net providers), more choice of providers, and improved relations between hospitals and family planning providers. There are several lessons that private payers and health plans can learn from the experience of Medi-Cal and CalOPTIMA, including allowing out-of-plan access for certain services (especially family planning), instituting linguistic and cultural competency requirements, clarifying and standardizing the scope of family planning services, establishing comprehensive perinatal support services programs, and providing coverage for every form of FDA-approved contraception.28
Healthy San Diego is one of two geographic managed care models in the state; it comprises several health plans designated by the county as eligible for serving Medi-Cal beneficiaries. Although enrollment in managed care is voluntary, it is the default option if a beneficiary does not select a plan. Healthy San Diego includes four licensed MCOs, each of which provides slightly different benefits (both inpatient and outpatient), and two PCCM plans. The geographic managed care model has increased choice for beneficiaries but problems with delivery remain. Although the managed care plans are ostensibly integrated delivery systems, most are in fact "contract networks" which require complex referrals and authorizations for the provision of care. These networks also engender a large amount of administrative overhead as a byproduct. While Medi-Cal has been good for pregnant women, there is concern about women who are not pregnant or do not have children and therefore have less access to services, as well as undocumented women for whom prenatal care benefits will be terminated shortly following the passage of recent legislation. These women will likely be absorbed by other safety net providers or be seen in emergency rooms.29
Lessons drawn from the seminar include: it is important to obtain public/community/local input when devising systems and to allow for out-of-network access for some services; the downside to increased choice is often bewildering complexity for beneficiaries who are not sophisticated health care consumers; health plan programs and standards must be tailored to reflect the diversity of needs of public beneficiaries; and little is known about the outcomes of various delivery models or even specific services.
Assessing Quality of Care
One of the most widely used quality assessment initiatives in the commercial health care market is NCQA's Health Plan Employer Data and Information Set (HEDIS). The first set of HEDIS measures for the privately insured was promulgated in 1991, and in 1995 NCQA issued its first draft set of HEDIS measures designed specifically for Medicaid managed care. The set of measures crafted for Medicaid managed care enrollees was designed to reflect the different health needs of the population as well as structural differences between commercial and Medicaid insurance products. For example, in the commercial market HEDIS measurements generally are calculated only for members continuously enrolled in the health plan for at least two years. Because of the complex eligibility rules for Medicaid, and in particular the fact that a primary means of eligibility for low-income women is pregnancy, such continuous enrollment requirements for Medicaid managed care enrollees would in effect preclude most enrollees from measurement, rendering the values meaningless. Thus the continuous enrollment requirement was relaxed for Medicaid HEDIS measures. Other difficulties encountered when developing standard quality measures for Medicaid managed care plans are variations between states in the demographics and needs of their Medicaid populations, the more comprehensive nature of the Medicaid benefits package, the problem of validity when measuring services for particularly small sub-groups (such as special needs children), and the overall poorer health status of the Medicaid population.31
Medicaid HEDIS was released in 1996, containing measures of enrollee stage of pregnancy at time of enrollment (a form of risk adjuster and a baseline for prenatal care measures), proportion of low-birthweight deliveries, several behavioral health measures, and descriptive measures of high-priority programs such as family planning services and linkages to public health and social services agencies. The Medicaid HEDIS measures were then incorporated into commercial HEDIS when iteration 3.0 was released in early 1997.
But whether quality measurement initiatives are undertaken in the public sector or the private, it is the ultimate use of such data that is of importance. During this transition to Medicaid managed care, many states have lacked the capacity to monitor effectively the quality of care being delivered to enrollees in Medicaid plans. When data have been generated by the plans, states often collect the data but then do little with the information. As Medicaid managed care continues to grow, it will be essential not only to develop and implement quality measures relevant to women's health, but also to ensure that the information generated through such measures is used for genuine oversight and quality improvement.
Outstanding Issues and Questions