By Andrew B. Bindman, Denis Hulett, Isabel Ostrer, and Taewoon Kang
California Health Care Foundation, September 2019
In the 1970s, California was the first state to introduce Medicaid managed care. It is now mandatory in 57 of 58 counties for most Medi-Cal enrollees. In 2018, approximately 10.4 million (80%) of Medi-Cal enrollees received services through one of 22 insurers who provided managed care plans (MCPs) specific to the counties in which they operated.
This report examines the performance of Medi-Cal MCPs over the past decade in quality of care provided to members. In addition to reporting on overall trends in performance, this report also examines differences by type of MCP ownership (public, nonprofit, for-profit) and model of managed care (County Organized Health System, Two-Plan model, and a few different models of competing commercial MCPs).
Key Findings
- From 2009 to 2018, quality of care in Medi-Cal managed care was stagnant at best on most measures. Among 41 quality measures collected in two or more years, more than half (59%) remained unchanged or declined. The picture looks only slightly better when limited to the 31 quality measures still collected by DHCS. Of those, 52% remained unchanged or declined. Specifically, quality of care significantly declined for Medi-Cal enrollees on 4 measures and was unchanged on 12 measures. There was significant quality improvement on 15 measures.
- While declines in quality in some cases were relatively small on a percentage basis, the clinical significance in all cases could be interpreted as substantial, given the size of the impacted population. The same is true for observed improvements in quality.
- Three of the four current measures that declined over time were related to the care of children. Six of the nine quality measures currently in use that are related to children declined or stayed the same; there was improvement in only three of these measures.
- Medi-Cal enrolleesā rating of their experiences with their MCP were consistently below the 50th percentile nationally. The only CAHPS measure that improved significantly over time was the one that asked enrollees to rate how well doctors communicate.
- Medi-Cal MCPsā quality scores varied markedly within and across MCPs by ownership during the past decade. Most striking was the substantially lower quality scores of the for-profit MCPs, on average, relative to the nonprofit and public MCPs. These differences in quality scores by MCP ownership were not explained by observed demographic differences or the physician supply in the counties in which they were operating.
- While there was variation of MCP performance within each of the Medi-Cal managed care models, counties that rely on a single public MCP (County Organized Health Systems) had on average better quality scores than counties that furnish Medi-Cal services through either a Two-Plan or competing commercial model. This remained the case after adjusting county demographics and physician supply, and was even true for the quality measures used as the basis for the enrollment-based āauto-assignmentā incentive in counties with competing MCPs.
Comment:
By Don McCanne, M.D.
California has been a leader in moving Medicaid patients into Medicaid managed care plans. It is now a mature program that can provide us with lessons on the wisdom of such a conversion. So how have these plans performed over the past decade?
One of the main motivations behind this shift was that managed care plans supposedly would improve the quality of care. Yet quality was “stagnant at best on most measures.” “Among 41 quality measures collected in two or more years, more than half (59%) remained unchanged or declined.”
“Six of the nine quality measures currently in use that are related to children declined or stayed the same.”
“Medi-Cal enrolleesā rating of their experiences with their MCP were consistently below the 50th percentile nationally.”
By ownership, “most striking was the substantially lower quality scores of the for-profit MCPs, on average, relative to the nonprofit and public MCPs.”
“Counties that rely on a single public MCP (County Organized Health Systems) had on average better quality scores than counties that furnish Medi-Cal services through either a Two-Plan or competing commercial model.”
We can conclude that for-profit, commercial Medicaid managed care plans often provide lower quality care, and levels of patient satisfaction are low.
More importantly, as stated above, counties that rely on a single public managed care plan (County Organized Health Systems) have better quality scores than counties that rely on competing health plans, belying the claim that health plan competition improves quality. This should speak well for the single payer model of Medicare for All.
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