The Quality of Medicaid compared with Private Coverage

Is Medicaid worse than no insurance at all? Of course not. But it is not as good as private coverage for quality.

"Nursing" (by Carl Glover via Flickr, Creative Commons License)Medicaid, the much-maligned , seeks to emulate the effectiveness of private insurance coverage. A recent study explores hospital-based quality metrics in Medicaid relative to private coverage. It sheds light on whether or not Medicaid is achieving one of its important goals.

Researchers, looking at data regarding quality process measures for acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia (PNA), compared composite quality scores for each condition between the different payers and the fifty states. Composite scores were “all-or-none” in that eligible patients had to receive all recommended process measures in order to score positively. If any one measure was not successfully achieved for a particular patient, the composite score would be zero for that patient.

The data encompass 5.2 million patients ages 18-64 discharged from 4,622 acute care hospitals in 2007-2008 and diagnosed of either AMI, CHF, or PNA.

Nationally, 88% of Medicaid beneficiaries received all 8 core measures for AMI. For CHF (4 measures) and PNA (6 measures), the percentages were 73% and 77%, respectively. Privately insured patients were statistically more likely to receive all quality measures compared to Medicaid patients (p<0.05) for each of the 3 diagnoses: AMI (91%), CHF (76%), and PNA (78%). The authors note that while significant, the magnitude of the differences were small.

When comparing between the states, there were wide ranges of quality scores for both Medicaid and private insurance. However, quality scores were highly correlated between Medicaid and private coverage state-to-state indicating that within states such differences in quality varied little based on insurance coverage.

The authors note that their findings contrast with prior studies of ambulatory quality metrics. Hospital care may be less subject to disparities in quality for Medicaid.

Commentary

The quality of health care delivered to patients is of paramount importance to policy makers and payers. When it comes to Medicaid, , quality has the potential to be sacrificed.

This study suggests that Medicaid patients may suffer small disparities in the quality of care for common conditions – heart attacks, congestive heart failure, and pneumonia –  that result in a large number of hospital admissions.

While the authors attempt to minimize the disparities as small in magnitude, they clearly exist for these three common conditions whose care is largely driven by evidence-based medicine. How much further then should we expect that Medicaid patients suffer adverse consequences for  conditions that are less common or less scientifically standardized?

These data should serve as a baseline from which quality should be monitored in the coming years as millions more Americans transition from the ranks of the uninsured and into the nation’s Medicaid programs.

If these 18 core measures do not show improvements, and especially if disparities worsen, stakeholders must seek to understand Medicaid’s quirks.

Weissman, JS, et al. Med Care. 2013; online in advance of print

by

Cedric Dark, MD, MPH