Quality of care in Medicaid managed care and commercial health plans

Context  In contrast to the commercially insured population, the proportion of Medicaid beneficiaries enrolling in health maintenance organizations continues to increase. Objective  To compare quality of care within and between the Medicaid and commercial populations in 3 types of managed care plans: Medicaid-only plans (serving predominantly Medicaid enrollees), commercial-only plans (serving predominantly commercial enrollees), and Medicaid/commercial plans (serving substantial numbers of both types of enrollees). Design, Setting, and Participants  All 383 health plans that reported quality-of-care data to the National Committee for Quality Assurance for 2002 and 2003, including 204 commercial-only plans, 142 Medicaid/commercial plans (plans reported data for the Medicaid and commercial populations separately); and 37 Medicaid-only plans. Main Outcome Measures  Eleven quality indicators from the Healthcare Effectiveness Data and Information Set (HEDIS) applicable to the Medicaid population. Results  Among Medicaid enrollees, performance on the 11 measures observed in this study were comparable for Medicaid-only plans and Medicaid/commercial plans. Similarly, among commercial enrollees, there was virtually no difference in performance between health plans that served only the commercial population and those that also served the Medicaid population. Overall across all health plan types, the performance for the commercial population exceeded the performance for the Medicaid population on all measures except 1, ranging from a difference of 4.9% for controlling hypertension (58.4% for commercial vs 53.5% for Medicaid; P = .002) to 24.5% for rates of appropriate postpartum care (77.2% for commercial vs 52.7% for Medicaid; P = .001). Differences of similar magnitude were observed for commercial and Medicaid populations treated within the same health plan. Conclusions  Medicaid managed care enrollees receive lower-quality care than that received by commercial managed care enrollees. There were no differences in quality of care for the Medicaid population between Medicaid-only plans and commercial plans that also served the Medicaid population.      

Expanding Medicare and employer plans to achieve universal health insurance

This article presents a proposal for expanding Medicare and employer-based health insurance plans to achieve universal health insurance. Under this proposed health care financing system, employees would provide basic health insurance coverage to workers and dependents, or pay a payroll tax contribution toward the cost of their coverage under Medicare. States would have the option of buying all Medicaid beneficiaries and other poor individuals into Medicare by paying the Medicare premiums and cost sharing. Other uninsured individuals would be automatically covered by Medicare. Employer plans would incorporate Medicare's provider payment methods. This proposal would result in incremental federal governmental outlays on the order of $25 billion annually. These new federal budgetary costs would be met through a combination of premiums, employer payroll tax, income tax, and general tax revenues. The principal advantage of this plan is that it draws on the strengths of the current system while simplifying the benefit and provider payment structure and instituting innovations to promote efficiency.     

Relationship between quality of care and racial disparities in Medicare health plans

Context  Overall quality of care and racial disparities in quality are important and related problems in health care, but their relationship has not been well studied. In the Medicare managed care program, broad improvements in quality have been accompanied by reduced racial gaps in processes of care, but substantial disparities in outcomes have persisted. Objectives  To assess variations among Medicare health plans in overall quality and racial disparity in 4 Health Plan Employer and Data Information Set (HEDIS) outcome measures, to determine whether high-performing plans exhibit smaller racial disparities, and to identify plans with high quality and low disparity. Design, Setting, and Patients  We assessed the relationship between quality and racial disparity using multilevel multivariable regression models. The study sample included 431 573 individual-level observations in 151 Medicare health plans from 2002 to 2004. Main Outcome Measures  Hemoglobin A_1c of less than 9.5% or less than 9.0% for enrollees with diabetes; low-density lipoprotein cholesterol level of less than 130 mg/dL for enrollees with diabetes or after a coronary event; and blood pressure of less than 140/90 mm Hg for enrollees with hypertension. Results  Clinical performance on HEDIS outcome measures was 6.8% to 14.4% lower for black enrollees than for white enrollees (P<.001 for all). For each measure, more than 70% of this disparity was due to different outcomes for black and white individuals enrolled in the same health plan rather than selection of black enrollees into lower-performing plans. Health plans varied substantially in both overall quality and racial disparity on each of the 4 outcome measures. Adjusted correlations between overall quality and racial disparity were small and not statistically significant, ranging from 0.01 (blood pressure control) to –0.21 (cholesterol control in diabetes). Only 1 health plan achieved both high quality and low disparity on more than 1 measure. Conclusions  In Medicare health plans, disparities vary widely and are only weakly correlated with the overall quality of care. Therefore, plan-specific performance reports of racial disparities on outcome measures would provide useful information not currently conveyed by standard HEDIS reports.      

Effect of prepaid health plans on a family practice residency

The rapid growth of prepaid health care plans imposes clinical, financial, and educational changes on residency programs. In the study reported here, the authors examined some perceived and actual effects of such plans on a family medicine center associated with a family medicine residency training program. In the study, 37 residents and 19 faculty members completed a 5-point, 16-item survey covering the effect of the prepaid plans used at the center on the program's practice profile, cost-containment efforts, and education activities over a three-year period. Overall, the respondents agreed with the need for cost containment that accompanied participation in the prepaid plan and agreed that prepaid plans increased the number of patient visits and visits by family members. The residents and faculty members agreed that prepaid patients were more demanding and were seen more often for minor or inappropriate problems. Regarding the educational impact of the prepaid plans, the respondents agreed that they improved their clinical decision-making, and no significant concern regarding limitation of laboratory or consultations was noted. Some of the respondents' perceptions were corroborated by findings in the clinic data base that showed increased numbers of patient visits, more visits by members of the same family, and no significant change in outpatient consultation rates.     

Use of outpatient somatic health services by patients who use or need mental health services in three provider plans

A major topic in mental health (MH) research addresses the problem that patients who use mental health services have inappropriately high levels of somatic use, and examines whether provision of mental health services can decrease the inappropriate use (the so-called offset effect). However, the research showing higher somatic use by mental health patients has usually been unable to control for the patients' health status, or for their mental health status. In this paper we examine use of somatic health services by enrollees in three provider plans as a function of both mental health use and mental health need. In two of the provider plans (an HMO and a prepaid independent practice association), MH users used significantly more outpatient somatic services than non-MH patients, after control for age and sex, and after control for the number of chronic conditions they had. People with MH need, however, did not use significantly more MH services than those without MH need. In the third plan, a Blue Cross/Blue Shield type of plan, results were different; MH users did not have significantly higher somatic utilization after control for chronic conditions, and those with MH need did have significantly higher somatic utilization after control for age and sex, but not after control for the number of chronic conditions. These results suggest that the form of inappropriate use of outpatient somatic services, and the nature of an offset effect, may be specific to the type of insurance provided.     

美国乡村医学教育计划对我国农村地区卫生人才培养的几点启示

针对我国目前基层卫生人才紧缺、队伍较弱等客观现实,以美国乡村医学教育计划的成功模式为基础,在分析其特点和成功因素的基础上,提出了改善的措施。