Quality of Care Unknown for More than Half of Young Children in Medicaid Managed Care Due to Short Stays in Health Plans

NEW YORK CITY, Feb. 25 ??? The government has no way of knowing whether up to 60 percent of young children in Medicaid managed care plans are receiving adequate care because these children???s care is not being ???measured??? by the national performance reporting system, according to a new study by The New York Academy of Medicine. The findings appear in the current (February, 2004) issue of the Journal of Health Care for the Poor and Underserved.

Medicaid plans are required to submit data only on services provided to children who have been continuously enrolled for 12 months with no more than a month break. Most children are not in plans that long. Academy scientists found that only 39 percent of two-year-olds remained enrolled in a single Medicaid managed care plan for 12 months. If children are not included in the national quality monitoring system, the government cannot ensure they are being adequately served, nor can Medicaid insurance plans be held accountable for services. Patients without continuous health plan enrollment lack a long-term medical home and may receive less-than-optimum care.

???We don???t know anything about the health care of more than 60 percent of the children enrolled in Medicaid managed care because they are left out of the quality monitoring system,??? said lead author Gerry Fairbrother, Ph.D., a Senior Scientist in the Academy???s Division of Health and Science Policy, and an Associate Professor in the Department of Epidemiology and Social Medicine at the Albert Einstein College of Medicine/Montefiore Medical Center. Managed care is Medicaid???s dominant form of service delivery, and its major advantage over the usual system of care is that plans can be held accountable for meeting enrollees??? needs. Yet because of the way Medicaid managed care operates, much of this advantage is lost for young children.

Researchers examined Medicaid data from the Centers for Medicaid and Medicare Services and from 12 states. They found that while 78 percent of young children were continuously enrolled in Medicaid for 12 months, only 39 percent were continuously enrolled in the same Medicaid managed care plan and thereby included in the performance tracking system for health plans. Many such children fall out of the Medicaid managed care system at the end of an enrollment period, only to re-enter it after a short break???a situation known as ???churning.???

A somewhat higher percentage of two-year-olds ??? 60 percent ??? were continuously enrolled in a single Medicaid managed care plan for six months with no more than a one-month break. At first glance, this suggests that the ???continuous enrollment??? requirement for data-reporting should be changed from 12 months to six, as had been proposed in 2000 by a committee convened by the Centers for Disease Control and Prevention (CDC) and the National Committee for Quality Assurance. But the authors caution that this would not correct the fundamental problem: that children are staying in managed care plans for a short period of time.

The reasons why many children are not in a health plan for long are poorly understood, the authors wrote. ???We need to determine why so many children fail to remain enrolled in a given plan for six and twelve months and we need to develop recommendations for improvement,??? Fairbrother said.

Co-authors of the study are: Aparna Jain, M.P.H., Heidi L. Park, Ph.D., Arfana Haidery, M.P.H. and Bradford H. Gray, Ph.D., all of the Academy???s Division of Health and Science Policy; and Mehran S. Massoudi, Ph.D., M.P.H., of the Health Services Research and Evaluation Branch of the CDC???s National Immunization Program. The project was supported by the CDC.

The Journal of Health Care for the Poor and Underserved is the only professional journal in the U.S. focusing exclusively on contemporary health care issues of low-income, under-represented and medically underserved communities. It is the official journal of the Association of Clinicians for the Underserved. The New York Academy of Medicine is a non-profit institution founded in 1847 that is dedicated to enhancing the health of the public through research, education and advocacy, with a particular focus on urban populations, especially the disadvantaged.

View the full study.

Posted on February 25, 2004

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