Medicaid HMOs can deliver good health care—but some fall short

For people with Medicaid, finding doctors who accept their health plan can be a challenge. Enrolling in a Medicaid HMO (health maintenance organization), in which the insurance provider has lined up a roster of participating physicians, can simplify finding care.

Many states now contract with private insurers to enroll Medicaid recipients in managed care plans to help reduce expenses and improve coordination of care. Many Medicaid enrollees receive some or all of their health services through managed care.

How well does Medicaid managed care provide care? As part of the Robert Wood Johnson Foundation's "Care About Your Care" campaign, Consumer Reports is publishing National Committee for Quality Assurance (NCQA) rankings of Medicaid HMO plans (see PDF on this page).

The Medicaid rankings include results from 99 Medicaid HMO plans in 30 states and the District of Columbia.

The rankings are based on 2010 performance data that focus on:

• member satisfaction as expressed in well-established scientific surveys
• prevention services that health plan enrollees receive
• the delivery of treatment services for many common conditions
• NCQA accreditation, which focuses on key consumer protections and quality-related administrative processes, such as how doctor qualifications are checked

The good, the bad, and the silent

This year's rankings reveal that some Medicaid HMOs are outperforming others. While some Medicaid HMOs are satisfying their enrollees, others seem to be struggling. And still others do not publicly report their performance data, so it's hard to know how they're doing. The 99 Medicaid plans that NCQA ranked represent less than half of Medicaid HMOs. All 99 are probably better than many of the plans that don't publicly report results and whose quality is therefore unknown.

The overall scores for plans that are ranked by NCQA show considerable variation. In Massachusetts, for example, all four reporting plans are in the top 10 ranked plans, while the seven ranked plans from California were in the bottom half.

Plans at the top of the rankings tend to be in Northeastern and Midwestern states, which have made a long-term commitment to Medicaid. They also tend to be plans that work with other Medicaid providers in organizations focused on improving plan performance. Often their states are making "pay for performance" rewards for higher quality.

Community plans lead the rankings

Some Medicaid plans are sold by health-insurance companies and others are "community" plans. Community plans are usually nonprofit, while health insurers can be either for profit or nonprofit. The top 10 ranked Medicaid plans are all community nonprofit plans, but some of the lowest ranked are, too.

Many community plans belong to one of two national associations that assert that their Medicaid HMO members are focused on quality improvement and innovation. The results suggest they might be right.

Six of the top 10 ranked Medicaid HMOs are members of the Alliance of Community Health Plans (ACHP), which says that "Drawing on years of experience, our members collaborate, share strategies, and work toward solutions to some of health care's biggest challenges." The top-ranked ACHP plans are: Fallon Community Health Plan (Mass.), Kaiser Foundation Health Plan of Hawaii (Hawaii), Capital District Physicians' Health Plan (N.Y.), Security Health Plan of Wisconsin (Wis.) Priority Health (Mich.), and UPMC For You (Pa.). ACHP also has the 62nd and 82nd ranked plans, but overall it seems to us that ACHP is on to some successful strategies and other Medicaid HMOs should take note.

Likewise, another organization, the Association for Community Affiliated Plans (ACAP), has more than 50 member plans and focuses on advocating for community plans and the populations they serve. Seventeen of their members are ranked by NCQA and five of them are in the top 10 Medicaid HMOs—Boston Medical Center HealthNet Plan (Mass.), Neighborhood Health Plan (Mass.), Network Health (Mass.), Neighborhood Health Plan of Rhode Island (R.I.), and UPMC For You (Pa.). But CareSource in Ohio and CareSource Michigan (Mich.) are two of the lowest ranked Medicaid HMOs.

Four health insurers with recognizable brand names—Amerigroup, Blue Cross/Blue Shield, Molina, and United Health—reported results to NCQA for at least four of their plans. None of these brand-name plans ranked in the top 10 nationally, but BlueCaid of Michigan ranked 12th. When we analyzed our rankings, we found that many plans from United Health scored in the top half. The other brands had about as many plans in the top half as they did in the bottom half of the rankings.

(We identified plans owned by brands through their names, such as United Healthcare of Tennessee, and from a database maintained by Atlantic Information Services Inc., which identifies corporate ownership of some health-insurance plans. Plans owned by these brands that aren't identifiable by those two means might have been inadvertently left out of our analysis.)

Some states lack Medicaid HMOs

For a consumer choosing health insurance, the most important ranking is for plans that serve your community. Go to the full list of ranked plans to get a sense of how well your community is served. In some cases you will find several choices and differences in performance.

There are, alas, many communities that have no ranked plans. It appears that some states have no Medicaid HMOs, though other less comprehensive primary-care oriented options might be offered in most of those states. But the lack of an HMO choice leaves lower-income people without an important option. In some states none of the Medicaid HMOs report performance information to NCQA. Medicaid HMOs in 32 states report performance data in some fashion and some might be accredited by organizations other than NCQA.

Some Medicaid HMOs provide solid health coverage. And motivated Medicaid plans can improve care. But the reality is that a majority of Medicaid HMOs do not report comprehensive performance results that can be compared across the country, leaving their communities and taxpayers with a lack of objective information. More plans need to report—and report more thoroughly—to serve consumers and taxpayers better.

It is possible that some Medicaid plans will be attracted to the opportunities that health reform brings as they have been to Medicare Advantage (the Medicare managed care program). We hope that the best-performing Medicaid HMOs will consider entering the commercial market via the health exchanges on the horizon and bring along the approaches they have successfully developed to improve care.

Consumer Reports and NCQA will be releasing scores for private and Medicare HMO and PPO plans in early October on ConsumerReports.org/health and in the November edition of Consumer Reports magazine. The Medicaid rankings released here will be available at that time.