Medicaid Managed Care Shows Marginal Increase in Preventative Care

MM Curator summary


A new study shows that managed care is better at hitting quality goals than fee for service, but still consistently underperforms CMS quality goals by about 20%.


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To reach the CMS goal preventative care rates among children enrolled in Medicaid Managed Care plans, stakeholders must promote care access.


Source: Getty Images


By Hannah Nelson

March 03, 2021 – Although children enrolled in Medicaid managed care plans increased over the past seventeen years, children’s preventative care rates still fall short of the Centers for Medicare and Medicaid Services’ (CMS) goal, according to a study from Ann & Robert H. Lurie Children’s Hospital of Chicago published in the journal Academic Pediatrics.

Researchers analyzed annual state-level CMS data to determine the relationship between Medicaid managed care, the predominant form of Medicaid coverage for children that focuses on preventative care, and receipt of preventive care services. Services included immunizations, lead level monitoring, growth and development evaluation, oral health surveillance, and screening for anxiety and depression.

The study found that Medicaid enrollees under the age of 21 enrolled in managed care plans increased from 65 percent in 2000 to 94 percent in 2017, a 29 percent jump. However, youth preventative care for Medicaid managed care enrollees increased just 10 percent nationally, from 49 percent in 2000 to 59 percent in 2017.

Preventative care rates among youth in Medicaid managed care increased significantly in 17 states, decreased significantly in six states, and stayed the same in 28 states. Tennessee had the largest increase in preventive care associated with Medicaid managed care and North Carolina experienced the largest decrease.

The study’s lead author, Jennifer Kusma, MD, noted that state-specific differences in the relationship between managed care Medicaid coverage and preventative care may be a result of variations in statewide primary care access, Medicaid reimbursement, availability of clinicians in managed care networks, and oversight of the quality of care of Medicaid managed care organizations.

“Managed care by itself is not enough to improve care for children who are covered by Medicaid,” Kusma, a physician at Lurie Children’s and Instructor of Pediatrics at Northwestern University Feinberg School of Medicine, said in a press release. “States must consider multiple factors that influence access to care and delivery of care at the community and clinic level within managed care systems.”

Annually, CMS aims to have an 80 percent participation rate for the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit is 80 percent, meaning that 80 percent of children enrolled in Medicaid should receive at least one preventative care visit or screening in a year. These preventive care expectations are based off recommendations from the American Academy of Pediatrics and US Preventive Services Task Force.

However, even with significant increases in managed care beneficiaries over the past 17 years, preventative care rates among this group have only increased slightly and still come in 21 percent below the CMS goal.

The researchers also found that older children had lower rates of preventative care receipt than younger children.

“This pattern has been reported in other research, and it reveals an opportunity for managed care plans to help improve quality of care by encouraging preventive care visits for adolescents as well as for younger children,” explained Kusma.

Routine screenings are important for detecting developmental delays, like autism spectrum disorder, when early intervention is known to be advantageous.

However, regular screenings are equally important for adolescent health, as this age group engages in higher risk behaviors. Additionally, up to 20 percent of adolescents have undiagnosed behavioral health disorders that can be flagged through routine primary care check-ups.

With a rise in youth uninsurance in recent years and decreased rates of vaccinations and well-child visits due to COVID-19, payers must focus on promoting preventative care access for managed care Medicaid beneficiaries through ensuring the quality and quantity of providers in managed care networks. Additionally, legislature should ensure reimbursement for managed care providers.

“In order to increase the overall EPSDT participation ratio, and thereby facilitate opportunities for preventive and therapeutic interventions, clinicians and caregivers must do more to promote well visits particularly among adolescents and young adults,” the study authors wrote.

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