Last October, transparency in Medicaid managed care took a leap forward with the publication of a path-breaking study by Dr. Andrew Bindman and his colleagues at the University of California at San Francisco. The researchers examined the performance of individual managed care organizations (MCOs) participating in the state’s Medicaid program with respect to quality of care for children and adults over the 10-year period 2008-2017. Last month, transparency took another leap forward with the posting of a new report, “Children’s Medi-Cal Managed Care in California Counties: A Landscape,” by the research and advocacy group Children Now. The analysis finds wide variation in the performance of individual MCOs in California on quality of care for children.
To our knowledge, the Children Now analysis is the first independent, publicly available comparison of the performance of individual Medicaid MCOs on child health quality measures. Four measures of child quality (childhood immunizations, well-child visits, adolescent immunizations, and asthma medication) were selected as focus areas because those are measures the state uses for purposes of MCO performance accountability. The report identifies the high-performing and low-performing MCOs on each of these measures for the 2018 reporting year. It also finds that, on a statewide basis, overall MCO performance on children’s quality measures left a lot to be desired. For example, only 70% of two-year-olds in MCOS received all their pediatrician-recommended immunizations, and only 75% of children aged 3 to 6 received a well-child checkup. These averages mask large variations from MCO to MCO and county to county.
This analysis took some doing. Pulling the data together required much more than a review of a pediatric data dashboard or a visit to the state Medicaid agency website, which is not a model of transparency. It meant digging through a variety of quality reports prepared by the state’s External Quality Review Organization to find data specific to children. It also meant making and following through on four different targeted Public Records Act requests for data that the state Medicaid agency had in its possession but was not posting. In the end, the results were well worth the effort, since they confirmed that many MCOs were performing poorly on one or more child quality and access measures, allowing California policymakers and the public to insist upon improvement.
Even though the Children Now analysis focused on California and the variation in its 58 counties, these findings matter for children enrolled in Medicaid MCOs in other states. California is far and away the nation’s largest Medicaid managed care market, with over 10 million beneficiaries, including 4.5 million children – most of whom are enrolled in one of the nearly two dozen Medicaid MCOs offering care in one or more of California’s counties. All of the largest national insurers that compete in the Medicaid managed care market nationally—UnitedHealthcare, Centene, Anthem, Aetna/CVS, and Molina—participate in California’s Medicaid program with a presence in at least one county. The performance of their subsidiaries in California may be indicative of the performance of their subsidiaries in other states. (The Kaiser Family Foundation’s Medicaid MCO Market Tracker is a great resource for identifying individual MCOs and their parent companies in each Medicaid managed care state). This in turn may be of interest to state Medicaid officials, policymakers, advocates, and the public in other states.
State transparency will not, in and of itself, ensure high performance by Medicaid MCOs for children or adults. But without it, there is less of an incentive for MCOs to improve their local performance or for state Medicaid officials responsible for overseeing the MCOs to take measures to ensure that their performance improves. We still have a way to go to ensure that MCO performance data isn’t buried, in California or other managed care states. But the Children Now analysis shows that, with hard work and persistence, it’s possible to open up the black box and begin to get some idea of what’s inside so that states and MCOs can start fixing what’s wrong.