NEWS RELEASE
May 4, 2000

External Quality Review for Medicaid Managed-Care Released

 

Michigan Department of Community Health Director James K. Haveman, Jr., today released the 1998 External Quality Review Summary Report of Medicaid Qualified Health Plans. This review included 23 health plans who had a contract in place with Medicaid effective on or before July 1, 1998. The report focused on Prenatal Care, Early and Periodic Screening, Diagnosis and Treatment (EPSDT), Immunizations, Diabetes, Pediatric Asthma and HIV/AIDS.

"Before moving to managed-care, it was not possible to measure for these crucial health indicators. Under fee-for-service we wouldn't have this important data to learn from and use as a tool to improve the health of Medicaid beneficiaries," said Haveman. "One of the important goals behind the move to a managed care system for Medicaid beneficiaries was to make sure that people are receiving preventive care so they can avoid serious medical emergencies. This External Quality Review assists us in these efforts."

The prenatal care review found that 91% of women received prenatal care during their pregnancy, with 50% of the women receiving care in the first trimester. 29% of the women receiving care had their initial prenatal visit in the second trimester and 12% in the third. In 1998, postpartum visits within two months of delivery was 45% in Michigan. The national Medicaid benchmark is 44%.

Screenings for Maternal Support Services (MSS) and Infant Support Services (ISS) include an assessment of psychosocial factors, substance abuse and nutrition and may result in referral for infant care instruction or nutritional assistance programs. In 64% of the records reviewed, components of MSS/ISS screenings were documented, an increase of one-third from 48% in 1997. Of these screenings, 32% were referred for MSS/ISS services.

EPSDT components emphasize disease prevention and developmental assessment for children and should be provided at recommended intervals for children from birth through adolescence. 99% of children under the age of two received at least one EPSDT component during 1998 and 93% of children had at least one physical exam which includes inspection of the eyes, ears, nose, throat, chest, abdomen and extremities.

87% of children had a least one head circumference measurement and 93% had at least one height and weight measurement. 63% of children had their hearing screened, 67% had their vision screened and 47% had a dental inspection. At least one nutritional assessment was done in 81% of children. 75% of two year olds were fully immunized in the Medicaid population--the national Medicaid benchmark is 56%.

Diabetes has numerous complications including low resistance to infections, blindness and cardiovascular disease. The Department of Community Health and the Michigan Association of Health Plans have partnered in the "Taking on Diabetes in Michigan" program that will encompass core measures and a comprehensive diabetes education plan to prevent and minimize complications of diabetes. To create a baseline study on plans performance on diabetes this 1998 review included a broader diabetic population than the 1997 review. This 1998 review will now be used for all future comparisons.

Diabetes can affect circulation and over time may lead to foot ulcers and amputations. Regular foot examinations allow for early detection of complications when treatment is likely to be most effective. At least one foot examination was documented in 51% of records reviewed. Regular dilated eye examinations are important to prevent vision loss, and evidence of dilated eye examinations was documented in 24% of the records. Glycosylated hemoglobin testing provides an accurate long-term measure of blood glucose levels over a period of months. Medical records documented glycosylated hemoglobin testing at least once during 1998 in 60% of the medical records reviewed.

Asthma is the leading serious chronic disease in children and the leading cause for school absenteeism related to chronic conditions. A majority of records did not classify the severity of the enrollee's illness. The lack of this information limits the ability to assess asthma care, as appropriate management is dependent upon the severity of the disease. An interval history enables review of the enrollee's symptoms and interventions and provides the health care provider with on-going information regarding the individuals response to therapy. In 84% of the records reviewed, an interval history was documented for at least one asthma-related office visit.

Despite assurances of confidentiality, some qualified health plans and their providers chose not to release records for the HIV/AIDS study due to confidentiality concerns. The absence of this information has a significant impact on the results of the study as the enrollee may have received care, but the specialist records were not always present at the time of review.

Routine CD4 counts measure the number of cells that are routinely available to fight the HIV infection in the body and viral load testing indicates the level of the HIV virus in the body system. Appropriate CD4 and viral load testing was documented in 50% and 48% of the records reviewed respectively. Enrollee refusal of CD4 and viral load testing was documented in 11% of the records reviewed. Pneumoncystis carinii pneumonia (PCP) is the most common serious illness in people living with AIDS. When CD4 counts become low, prophylactic medications are indicated because without treatment, over 80% of people with HIV would eventually develop PCP. Of the cases reviewed, PCP prophylactic was documented in 69% and antiviral therapy was documented in 84%.

The External Quality Review of health plans contracted with Medicaid was conducted by the Michigan Peer Review Organization (MPRO). MPRO evaluated the care provided using generally accepted medical guidelines and evaluated each medical record for quality of care issues. The results of the studies have been shared with the health plans and they are in the process of preparing Quality Improvement Plans to further improve care to the Medicaid population.