Quality of care for children in commercial and Medicaid managed care

JAMA. 2003 Sep 17;290(11):1486-93. doi: 10.1001/jama.290.11.1486.


Context: Many states have turned to commercial health plans to serve Medicaid beneficiaries and to achieve cost-containment goals. Assumptions that the quality of care provided to Medicaid beneficiaries through these programs is acceptable have not been tested.

Objective: To compare the quality of care provided to children and adolescents in commercial and Medicaid managed care in the United States.

Design, setting, and population: Using 1999 data collected through the Health Plan Employer Data and Information Set, we examined reported quality-of-care indicators for children and adolescents. Results from 423 commercial and 169 Medicaid plans were compared. Matched pairs analyses were performed using data from each of the 81 companies serving both populations to control for corporate differences. Correlation coefficients and regression procedures were used to examine observed variations in health plan performance.

Main outcome measures: Quality indicators including prenatal care, childhood immunizations, well-child visits, adolescent immunizations, and myringotomy and tonsillectomy rates.

Results: Using standard indicators of clinical performance, children and adolescents enrolled in Medicaid received worse care compared with their commercial counterparts. For most of the 81 health plans serving both populations, Medicaid enrollees had statistically significantly (P<.001) lower rates than commercial plans for clinical quality indicators (eg, childhood immunization rates of 69% vs 54%); for clinical access indicators (eg, well-child visits in the first 15 months of life, 53% vs 31%); and for common procedures (eg, myringotomies for children aged 0-4 years, 35 vs 2 per 1000 members). Conversely, some plans demonstrated equal and high-quality care for both populations. Regression models failed to identify consistent plan characteristics that explained the observed differences in quality of care.

Conclusions: Most commercial health plans do not deliver high-quality care on a number of performance indicators for children enrolled in Medicaid. Policy makers and the public need plan-specific quality information to inform purchasing decisions.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Child
  • Child Health Services / standards*
  • Child, Preschool
  • Humans
  • Infant
  • Managed Care Programs / standards*
  • Managed Care Programs / statistics & numerical data
  • Matched-Pair Analysis
  • Medicaid / standards*
  • Medicaid / statistics & numerical data
  • Quality Indicators, Health Care
  • Quality of Health Care*
  • State Health Plans / standards
  • United States