As frequent (or even infrequent) readers of Say Ahhh! have heard us say, the world of Medicaid managed care is complex. But because over 70 percent of all Medicaid beneficiaries (and over 80 percent of child beneficiaries) are enrolled in a Managed Care Organization (MCO), those of us who are invested in keeping track of exactly how well these MCOs are working for children and families are in it for the long haul. Peer reviewed and other systematically gathered research are necessary for knowing what is working (or not working) in Medicaid managed care, especially considering the general lack of transparency. Here are some significant research findings published so far during 2022:
Researchers from Yale and the University of California, San Francisco found that there were significant differences in health care spending and utilization among Black and White enrollees in three managed care states in the South and Midwest. The authors of the study found that annual spending among Black adult Medicaid enrollees was 6 percent lower ($317) than White adults. Black adults also had fewer primary care visits, filled fewer prescriptions, and were less likely to receive treatment with pharmacotherapy for opioid use disorder than White adults. And results were even more pronounced for children. The study found that spending on health care for Black children was 14 percent less than White children and they had fewer primary care visits, and had fewer prescriptions filled (including those for asthma and diabetes) than White children per year. The authors make the point that because current spending is used to set risk scores, these disparities could lower future capitation payments to MCOs
Similarly, researchers at Brown University and the University of Vermont found racial and ethnic disparities in patient experience of care among Medicaid managed care enrollees. Compared to White patients, Hispanic/Latino and Black patients reported significantly worse outcomes across access to care, access to a personal doctor, timely access to a checkup/routine care, and timely access to specialty care. But the largest disparities on these measures were between White patients and Asian American, Native Hawaiian, or Pacific Islander patients.
Another element of health equity, that we often see play out in the form of racial and ethnic disparities, is network adequacy and access to services. There are many ways to measure network adequacy, and since the 2020 Medicaid managed care final rule, states have a lot more leeway in how they want to do so. In a study published in the American Journal of Managed Care, researchers surveyed managed care network adequacy standards in 39 states (of 40 total managed care states plus DC). Of the 39 states, 35 used time and distance standards. Of the other 4 states, 1 used only provider-to-enrollee ratios and the other 3 used qualitative access standards.
COVID-19 & The PHE Unwinding
Medicaid managed care enrollment, like Medicaid enrollment generally, has grown during the COVID-19 pandemic, mainly due to economic instability and the continuous coverage provisions of the Families First Coronavirus Recovery Act. With more people relying on MCOs for their health care during the pandemic, many MCOs had to switch up business as usual regarding how they responded to their members’ needs. In their expansive compendium entitled Medicaid Managed Care’s Pandemic Pivot: Addressing Social Determinants of Health to Improve Health Equity, the Institute for Medicaid Innovation (IMI) highlights 33 Medicaid MCO initiatives to: (1) Capture the unique changes and programs created by Medicaid MCOs in response to the pandemic; (2) Better understand innovation focused on meeting health and social needs of members with an emphasis on programs addressing inequities exacerbated by the pandemic; and (3) Identify initiatives across the country, with a targeted scan in Texas.
The enrollment growth in Medicaid MCOs due to the continuous eligibility provisions means that these MCOs will hold some responsibility for how smoothly (or not) the renewal and redetermination process goes for more than two-thirds of Medicaid beneficiaries nationwide once the PHE ends. This brief from researchers at the Kaiser Family Foundation outlines the ways MCOs can help mitigate potential catastrophic coverage loss as the PHE unwinds.
Navigating a Post-Dobbs World
The second part of a two-part study (part one here and part two here) by researchers at the Milken Institute School of Public Health at George Washington University took a deep dive into Medicaid managed care contracts and interviews with state officials, health plans, and providers to understand the current state of family planning coverage and opportunities available through managed care. Although the study was conducted before the Supreme Court reversed and remanded its decision in Dobbs v. Jackson Women’s Health Center, it has some important implications for a Post-Dobbs world. Some of their most notable findings are: (1) MCOs overwhelmingly prefer inclusion of providers of family planning services in provider networks; (2) Enrollee understanding of the freedom of choice guarantee is limited; (3) MCOs perceive family planning as a key element of primary care; and (4) CMS’s arbitrary distinction between family planning and family planning-related services is confusing for enrollees and increases the risk that patients will not receive treatment when they seek care from out-of-network providers, which goes against the freedom of choice guarantee.
This is certainly not an exhaustive list of research on Medicaid managed care that has been published this year (for more reading, see this report on Medicaid MCO financials in 2021 and this report from the Urban Institute on the collection of race and ethnicity data). In the future (read: fingers crossed for 2023), the new standardized reporting templates, which will allow state-level and MCO-level comparisons on quality, network adequacy and access, and MLRs (and will supposedly be available to the public) could be the basis for great managed care research.