Medicaid Managed Care: Transparency of Performance on Maternal Health

Our nation is in the midst of an ongoing maternal health crisis, one that particularly affects Black women.  The causes are complex, the need to address them is urgent, and there is no single solution.  One of many potential solutions that has not received enough attention is Medicaid managed care.  Medicaid, the nation’s largest health insurer by enrollment, pays for over 40 percent of the nation’s births; it covers prenatal care, birthing services, and postpartum care.  In most states, for most pregnant women and other beneficiaries, Medicaid means enrollment in managed care organizations (MCOs), which contract with the state Medicaid agency to deliver covered services through networks of providers that they select and oversee.  The MCO in which a pregnant woman is enrolled determines the accessibility and quality of the care she receives, which in turn affects her maternal health outcomes.

Currently, there are about 280 MCOs contracting with 41 state Medicaid programs (including D.C.).  We looked at 52 of them operating in 12 states (Georgia, Illinois, Iowa, Kansas, Kentucky, Michigan, Mississippi, Nevada, New Jersey, New Mexico, Tennessee, and Washington).  We wanted to see if we could tell from publicly-available data how each of these MCOs was performing on maternal health, and whether it was possible for beneficiaries and the public to identify high-performing as well as low-performing plans.  We scoured state Medicaid websites, state public health agency websites, and each MCO’s website for data on maternal health performance during calendar years 2021-2022. (If you’re counting, that’s at least 76 websites; not all of them were models of accessibility).

Based on prior work at CCF, we did not have high expectations that there would be much transparency on individual MCO performance.  Our expectations were not exceeded.  Based on the limited data that was publicly available, we were unable to assess, with any degree of confidence, the maternal health performance of any of the 52 MCOs.  Among the findings in our report:

  • Only three states—Illinois, New Mexico, and Washington—posted the number of pregnant enrollees in each Medicaid MCO, and only two of those states—New Mexico and Washington—disaggregated MCO enrollment by race and ethnicity. It’s very hard to begin a conversation about an MCO’s maternal health performance if you don’t know how many pregnant women it enrolls.
  • The CMS Maternity Core Set consists of nine separate measures. We searched for six of them. Only two of those six measures—Timeliness of Prenatal Care, and Timeliness of Postpartum Care—were posted by all 12 states for each of their MCOs.  (Each of these measures has limitations in capturing quality in maternity care).  None of the states posted MCO-specific performance results on two of the other measures, Live Births < 2,500 Grams or Low-Risk Cesarean Deliveries.
  • Eight of the 12 state Medicaid agencies posted consumer-facing tools on their websites to help enrollees make informed choices among MCOs. All of these report cards/scorecards rated individual MCOs based on maternal health performance, but the grades/scores varied considerably in usefulness to pregnant women trying to decide whether to enroll in a particular MCO.
  • All 12 states operate Maternal Mortality Review Committees (MMRCs) that review the causes and contributing factors of death among pregnant women and new mothers and issue reports on their findings. None of the MMRC reports we scanned examined the role of individual Medicaid MCOs in managing pregnant or postpartum enrollees.  Five of the states did not have a representative from the state Medicaid agency on their MMRC.

There’s much in this report that simply will not fit into a 920-word blog.  The Executive Summary offers a good overview, but even that can’t do it justice.  The data we collected, along with the sources we collected them from, will be of value not only to advocates in the 12 study states but also to advocates in the remaining managed care states, as a roadmap for their own transparency analyses.  For those who prefer live briefings, we will be presenting our report at a webinar on Thursday, November 2, at 1:00PM ET, where our colleague Sara Rosenbaum, Professor Emerita at the George Washington University School of Public Health, will respond. (This bookends our joint webinar on Medicaid MCO contracts and maternal health on July 19).

Medicaid by itself can’t solve the nation’s maternal health crisis.  Similarly, transparency about the performance of individual Medicaid MCOs on maternal health won’t, by itself, solve the crisis. But transparency holds the promise of improving the performance of individual MCOs, which in turn is likely to improve maternal health outcomes.  If MCOs, and the state agencies that contract with them, know that data about their performance will be public, the MCOs will have an additional incentive to ensure that they can achieve high performance, and the state agencies will have an additional incentive to address any low-performing MCOs.

To state the obvious, transparency costs almost nothing.  It simply requires the agency to post the performance data that it is already paying the MCOs to collect and report.  Transparency does not require an increase in Medicaid benefits, eligibility, or payment rates.  It does not impose significant new administrative burdens on Medicaid agencies or the MCOs; the data are already being collected and reported. And it does not create the litigation and political risk for the agencies that comes with imposing sanctions on poor-performing MCOs.

Greater transparency could one day give the public enough information to identify high-performing MCOs and showcase their best practices in addressing the maternal health crisis.  Low cost, high potential payoff.