Date February 8, 2022
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In Medicaid managed care plans, minority group members report lesser care than white enrollees

A study led by Brown University researchers found significant racial and ethnic disparities in patient care experience among enrollees of Medicaid managed care plans.

PROVIDENCE, R.I. [Brown University] — To ensure equity in Medicaid managed care health coverage, there is a need for accurate, recent data on how plans perform for members of different racial and ethnic groups. When Brown University researchers analyzed data on care experiences stratified by racial and ethnic identity, they found that members of minority groups reported significantly worse care experiences compared with white enrollees.

The disparities were largest when the groups were enrolled in the same Medicaid managed care plan.

"Medicaid managed care plans have a responsibility to detect and reduce disparities in health care among their enrollees,” said senior author Dr. Amal Trivedi, a professor of medicine and of health services, policy and practice at Brown. “Our findings indicate that Medicaid plans should collect systematic data on racial and ethnic disparities in patient experiences, and then implement interventions and track progress in eliminating these disparities."

Measuring care experiences is a way to assess how the plans are working for individual enrollees and include their perspectives, the researchers said.

“What’s exciting about this study is that it incorporates the patient’s voice, through care experience measurements, to help researchers understand the barriers to access,” said lead study author Kevin Nguyen, an investigator in the Department of Health Services, Policy and Practice at the Brown School of Public Health. “It also assesses racial and ethnic disparities between different plans as well as within the same plan. This distinction has important implications for how such disparities are addressed.”

The study was published in the February issue of Health Affairs.

Managed care has become the dominant care delivery model for Medicaid enrollees, with nearly 70% of all beneficiaries enrolled in a comprehensive managed care plan in 2018. Most states collect experience-of-care metrics, Nguyen said, but the reports using this data tend to be at the plan or state level. The authors say their study is the first to assess within- and between-plan disparities in a multi-state sample of Medicaid managed care enrollees since the implementation of the Affordable Care Act in 2010.

To conduct the analysis, the researchers pooled five years of data from the Consumer Assessment of Healthcare Providers and Systems Health Plan Survey, which assesses patient experience of care and is submitted annually by state Medicaid agencies and individual Medicaid managed care plans. They merged this information with Medicaid managed care enrollment reports. Their sample consisted of 2014 to 2018 data on 242,274 nonelderly Medicaid managed care enrollees in 37 states. They measured experience of care on a 0-100 point scale in four areas: access to needed care, access to a personal doctor, timely access to checkup or routine care, and timely access to specialty care.

The researchers found that compared with white enrollees, Black enrollees in the same plan consistently reported worse experiences of care, ranging from 1.2 percentage points less for access to needed care and 4.5 percentage points less for access to a personal doctor.

There were significant within-plan disparities between white and Hispanic or Latino enrollees for all outcomes except access to needed care.

Compared with white enrollees, Asian American, Native Hawaiian or other Pacific Islander enrollees within the same plan reported significantly worse experiences of care on all metrics, ranging between 8.6 percentage points less for access to a personal doctor and 16.8 percentage points less for timely access to specialty care.

“The magnitude of disparity between white enrollees and Asian American, Native Hawaiian or Pacific Islander enrollees was quite striking,” Nguyen said.

However, those results align with other surveys of Medicaid and Medicare beneficiaries, he said. Previous studies have suggested that different experiences of care may be driven by discrimination, availability of culturally inclusive providers or linguistic barriers to accessing care; some studies have also suggested that there might be differential expectations of care among this group of in a way that informs their ratings and responses.

“All of these factors are working together concurrently, and it’s important to assess why they’re happening,” he said.

“ Our findings indicate that Medicaid plans should collect systematic data on racial and ethnic disparities in patient experiences, and then implement interventions and track progress in eliminating these disparities. ”

Dr. Amal Trivedi Brown University Professor of Medicine; Professor of Health Services, Policy and Practice

The researchers hope that this data, and future studies like this, can be used to inform interventions to reduce disparities and improve care equity among enrollees. For example, Nguyen said, between-plan disparities suggest that racial and ethnic minorities are being disproportionately enrolled in lower-quality plans, and efforts should be made to ensure they have access to better plans.

Because the study showed the greatest disparities within the same plans, that suggests that there is differential treatment of racial and ethnic minorities within those plans.

“To address within-plan disparities, for example, a plan might want to directly target services to people from a racial or ethnic minority group,” Nguyen said.

Notably, Nguyen said, in plans with higher concentrations of Asian American, Native Hawaiian or Pacific Islander enrollees, or of Hispanic or Latino enrollees, the magnitude of disparities was smaller for those groups of enrollees. While this study didn’t specifically examine the mechanisms driving that result, the researchers suggested some plausible explanations could be that these plans are able to provide more targeted engagement or outreach to minority groups, or may develop provider networks that perform better for these enrollees.

“These results warrant further exploration about what state- and plan-level strategies may lead to more equitable patient experience of care,” Nguyen said.

Brown University researcher Ira B. Wilson and Anya Wallack of the University of Vermont also contributed to this study.