The California Health Care Foundation has just issued a path-breaking report that marks an important step forward on the road to full transparency about Medicaid managed care. The report, prepared by Dr. Andrew Bindman and his colleagues at the University of California at San Francisco, examines the performance of managed care plans (MCPs) in Medi-Cal (as the state’s Medicaid program is known) on quality for children and adults over a ten-year period, 2008-2017. A preview of the researchers’ findings earlier this year suggested the potential of data transparency to improve the quality of care for Medicaid beneficiaries at under-performing MCPs not just in California but nationally. The report released this week confirms that potential.
The researchers examined data on the quality of care furnished by each participating MCP over the 10-year period 2009 – 2018. (The data are reported the year following the delivery of the care being measured). The researchers used 35 measures from the Healthcare Effectiveness Data and Information Set (HEDIS), and 6 from the Consumer Assessment of Healthcare Providers and Systems (CAPHS). HEDIS measures, established by the National Committee for Quality Assurance (NCQA), are the basis for many of the measures in the Child Core Set. CAHPS is a survey developed by the Agency for Healthcare Research and Quality (AHRQ) designed to measure the patient experience with care from providers and plans. Both measures are standardized, meaning that they provide results that can be compared across MCPs and over time.
The researchers found that, over the 10-year period across all MCPs, more than half of the quality measures either did not improve or declined. Four measures declined significantly; 3 of these related to care of children: “Childhood Immunization Status,” “Childhood Access to Primary Care ages 12 to 24 months,” and “Childhood Access to Primary Care ages 25 months to 6 years.” As the authors note, these data are consistent with the findings of the State Auditor that millions of children in Medi-Cal are not receiving preventive health services. Not good. The researchers also found “marked” variations in quality scores by MCP and by county. Also not good.
California certainly has its work cut out for it. But here’s the thing about transparency. Before this report, the state Medicaid agency knew how the MCPs were performing (it had the data) and the MCPs knew (they supplied the data). It’s not clear whether CMS knew or had the data. Now everyone knows, and the process of holding the MCPs, the state Medicaid agency, and CMS accountable for results can begin.
The researchers make several recommendations for turning things around, as does Christopher Perrone, the Director of CHCF’s Improving Access team. CHCF also commissioned a study of how some of the MCPs improved their quality scores by at least 10 percentage points over the ten-year period, so it’s clear that it can be done.
One additional contribution the researchers could make is to rank each of the MCPs based on their scores on the 9 HEDIS measures related to children. (As discussed below, the researcher ranks each of the MCPs on their quality scores for both children and adults). Without knowing how individual MCPs perform specifically on the measures relating to children, it will not be possible for the state agency or CMS to identify the sources of the decline in scores in the three child health measures over the last 10 years and to improve these scores (or find MCPs with better performance) going forward. The knowledge that such child-specific rankings will be public may also focus the minds of some of MCP managements on improving access to needed services for their child enrollees.
Though the report covers only California, it has significance far beyond the state’s borders. Of the 54 million Medicaid beneficiaries enrolled in MCPs nationwide in 2017, one-fifth, or 10.8 million people, lived in California. Enrollment in MCPs is mandatory for most Medi-Cal beneficiaries, including more than 80% of children, in all but one of California’s 58 counties. There are different models of managed care in different counties, and different types of MCP ownership (for-profit, nonprofit, and public). Of critical importance for transparency purposes, many of the MCPs that cover beneficiaries in California participate in Medicaid managed care systems in other states.
The transparency value of this report nationally is that the researchers did not just look at statewide trends. They also ranked each of the MCPs on average quality measure scores for each of the 10 years, which allows one to see an MCP’s performance relative to itself and its peers over time. The data are MCP- and county-specific; for 2018 (which reflects performance in 2017), 53 MCPs are ranked by name (see Appendix E). The raw scores on each quality measure for each of MCPs for each year are available in a ZIP drive (“Quality Measures by Medi-Cal Managed Care Plan and Year, 2009-2018”) posted on the CHCF website. The scores are helpfully annotated to indicate when they are lower than the 25th percentile nationally.
Here’s what this transparency can do for beneficiary advocates, Medicaid program staff, reporters, and other stakeholders outside of California. Used in conjunction with the plan and parent ownership information in the indispensable KFF Medicaid Managed Care Market Tracker, stakeholders can compare the performance of subsidiaries of national parent companies operating in their states with the subsidiaries of the same parent company operating in California.
For example, Centene Corporation is the parent company of California Health & Wellness (CHW) and Health Net. The researchers ranked each of the MCPs by average quality measure scores (Appendix E). In 2018 (reflecting performance in 2017), CHW plans ranked 12, 38, and 50 out of 53. Health Net plans ranked 13, 29, 36, 36, 41, 49, 51, and 53 out of 53.
Centene Corporation operates MCPs in 19 states other than California. As of March 2019, it owned Medicaid plans operating in AZ, FL, GA, IL, IN, KS, LA, MA, MS, MO, NV, NH, NM, NY, OH, OR, SC, TX, and WA. In the states that collect HEDIS and CAHPS data from their managed care plans, it should be possible to compare the quality scores of the Centene affiliates in those states with the CHW and Health Net plans. (HEDIS and CAHPS measures are standardized nationally and do not vary from state to state). If the performance of the Centene affiliate in, say Texas, is better than that of the Centene affiliate in California, that may be of interest to stakeholders in California. If the performance of the Texas affiliate is worse, or equally bad, that should be of interest to stakeholders in Texas.
The same comparative analysis could be done in the states with plans affiliated with Anthem, whose plans ranked 9, 19, 24, 27, 32, 34, 35, 40, 43, 45, 46, and 48 out of 53 in average quality scores in 2018, and Molina, whose plans ranked 10, 33, 37, and 44. As of March 2019, Anthem owned Medicaid managed care plans in 14 states in addition to California: FL, GA, IN, IA, KY, LA, MD, NV, NJ, NY, TN, TX, VA, and WA. Molina owned plans in eleven other states: FL, IL, MI, MS, NY, OH, SC, TX, UT, WA, and WI.
Of course, this analysis will be even more powerful for child health advocates once rankings of California MCPs based on child quality measures are available. But one step at a time.