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NEWS ALERT
Harvard Medical School Office of Public Affairs

HMOs FAIL TO BRIDGE THE GAP BETWEEN MEDICAID AND COMMERCIAL PATIENTS

FINDINGS:
Medicaid patients in HMOs fare worse than commercial patients in HMOs. This is the case for both HMOs serving only the Medicaid population and HMOs serving both the Medicaid and the commercial populations.

RELEVANCE:
In the early 1990s, many policy makers viewed managed care as a panacea to the nation’s health care problems. They reasoned that HMOs could provide high quality yet efficient care for more people by more tightly managing care processes. They also believed that HMOs might eliminate the quality of care gap between the Medicaid and commercial populations, encouraging them to move Medicaid beneficiaries into managed care. This study suggests their strategy didn’t eliminate disparities in quality of care between Medicaid and commercial populations, implying that additional interventions are needed.

BOSTON, Mass. (October 9, 2007)—Once viewed as a panacea to the nation’s health care problems, HMOs have fallen out of favor. Commercially insured patients who flooded into HMOs, or managed care, in the early 1990s left in droves by the end of the decade. Medicaid patients, however, don’t always have the luxury of choosing their health plans, and the proportion of Medicaid beneficiaries enrolling in HMOs continues to increase.

A new study by researchers at Harvard Medical School and Harvard School of Public Health shows that under HMOs, Medicaid patients fare worse than commercial HMO patients on 10 of 11 quality measures. Though policy makers once hoped that HMOs would eliminate the quality of care gap between the Medicaid and commercial populations, this clearly hasn’t happened.

“There was a lot of hope that managed care would eliminate disparities between the Medicaid population and the commercial population,” says Bruce Landon, an associate professor at Harvard Medical School and first author on the paper, which appears in the Journal of the American Medical Association on Oct. 10. “HMOs may have moved care in that direction, but there is still a gap in the care that Medicaid and commercial patients receive.”

Using data from 383 health plans, the researchers looked at four groups:

* Medicaid beneficiaries enrolled in HMOs that serve only the Medicaid population.
* Medicaid beneficiaries enrolled in HMOs that serve both the Medicaid population and the commercial population.
* Commercial patients enrolled in HMOs that serve both the Medicaid population and the commercial population.
* Commercial patients enrolled in HMOs that serve only the commercial population.

HMOs serving only the Medicaid population and HMOs serving both the Medicaid and the commercial populations appear to provide about the same quality of care to Medicaid patients. But the care falls short of that provided to commercial patients in HMOs. Even within the same health plan, commercial enrollees received higher quality of care on almost all of the measures examined.

“Across the 10 measures, we saw quality of care differences ranging from 5 to 25 percent, a difference that has substantial clinical implications for patients with chronic conditions such as diabetes,” says senior author Arnold Epstein, who is a professor at the Harvard School of Public Health. “Medicaid patients received better care than commercial patients in only one area—Chlamydia screening.”

The study did not include Medicaid patients who are not enrolled in managed care, so it is certainly possible that HMOs serve the Medicaid population better than traditional Medicaid. But HMOs do not eliminate the quality of care gap between Medicaid patients and the commercial population.

The researchers measured care in three main areas—prevention and screening, chronic disease management, and care for pregnant women—and discovered striking differences. For example, female Medicaid beneficiaries receive 25 percent less postpartum care than their commercial counterparts, and Medicaid patients with diabetes were 15 percent more likely to have unacceptable blood sugar levels than their commercial counterparts.

“Part of the gap might be explained by the patients themselves, for it’s possible that the Medicaid population is less able to adhere to doctors’ recommendations than the commercial population,” says Landon, who is also an associate professor of medicine at the Beth Israel Deaconess Medical Center. “But I suspect Medicaid patients may also fare worse because they visit doctors and hospitals of lower quality.”

“This study suggests that policy makers must develop new, novel strategies if we are going to eliminate the quality of care gap between the Medicaid and commercial populations,” adds Epstein, who is also a professor of medicine at Brigham and Women’s Hospital.

This research was supported by a grant from the Robert Wood Johnson Foundation.

Written by Alyssa Kneller

CITATION:
The Journal of the American Medical Association, October 10, 2007
“Quality of care in Medicaid managed care and commercial health plans: a national study”
Bruce E. Landon, MD, MBA (1,2); Eric C. Schneider MD, MSc (3,5); Sharon-Lise Normand, PhD (1,4); Sarah Hudson Scholle, MPH, DrPH (6); L. Gregory Pawlson, MD, MPH (6), and Arnold M. Epstein, MD, MA (3,5)

(1) Department of Health Care Policy, Harvard Medical School, Boston, MA
(2) Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA
(3) Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
(4) Department of Biostatistics, Harvard School of Public Health, Boston, MA
(5) Section of Health Services and Policy Research, Division of General Medicine, Brigham and Women’s Hospital, Boston, MA
(6) National Committee on Quality Assurance, Washington, DC

 

CONTACTS:
HARVARD MEDICAL SCHOOL
Alyssa Kneller
public_affairs@hms.harvard.edu
617.432.0442

HARVARD SCHOOL OF PUBLIC HEALTH
Todd Datz
tdatz@hsph.harvard.edu
617.432.3952

Harvard Medical School has more than 7,000 full-time faculty working in eight academic departments based at the School's Boston quadrangle or in one of 47 academic departments at 17 Harvard teaching hospitals and research institutes. Those Harvard hospitals and research institutions include Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Cambridge Health Alliance, The CBR Institute for Biomedical Research, Children's Hospital Boston, Dana-Farber Cancer Institute, Forsyth Institute, Harvard Pilgrim Health Care, Joslin Diabetes Center, Judge Baker Children's Center, Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, McLean Hospital, Mount Auburn Hospital, Schepens Eye Research Institute, Spaulding Rehabilitation Hospital, VA Boston Healthcare System.

Harvard School of Public Health is dedicated to advancing the public's health through learning, discovery, and communication. More than 300 faculty members are engaged in teaching and training the 900-plus student body in a broad spectrum of disciplines crucial to the health and well being of individuals and populations around the world. Programs and projects range from the molecular biology of AIDS vaccines to the epidemiology of cancer; from risk analysis to violence prevention; from maternal and children's health to quality of care measurement; from health care management to international health and human rights.