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National Medicaid HEDIS Database/Benchmark Project

With the rapid growth of Medicaid managed care over the past several years, states are beginning to place greater emphasis on measuring and evaluating the quality and delivery of services in health plans serving the Medicaid population. Until recently, however, states lacked comprehensive, national data on plan performance as well as national Medicaid benchmarks against which to gauge performance.

In National Medicaid HEDIS Database/ Benchmark Project: Pilot-Year Experience and Benchmark Results, Lee Partridge of the American Public Human Services Association (APHSA) and Carrie Ingalls Szlyk, formerly of the National Committee for Quality Assurance, provide a preliminary look at the quality of care provided to Medicaid beneficiaries. With support from The Commonwealth Fund, Partridge and Szlyk examined patient data from 112 plans in 21 states and Puerto Rico and found substantial differences in plan scores on standardized quality indicators developed by the Health Plan Employer Data and Information Set (HEDIS).

On one measure-the percentage of two-year-olds who received all 12 recommended immunizations-the median score reported by plans was 58 percent. The range on this measure, however, varied from 10 percent to 86 percent. Similarly, 39 percent of diabetic Medicaid enrollees age 31 or older had received a retinal eye exam in the reporting year, yet scores for individual plans ranged from 10 percent to 99 percent.

Partridge and Szlyk also found that when the quality of care provided to beneficiaries was compared with that provided to commercially insured patients, Medicaid plans scored lower on seven of nine benchmark measures. For the most part, however, the disparity was small. Differences between the two types of plans may be partially attributed to Medicaid beneficiaries' generally poorer health relative to privately insured patients.

Medicaid plans actually bested commercial plans on two measures: well-child visits and eye exams for diabetics. A second year of data collection now under way by APHSA will provide more information on the comparative quality of Medicaid versus commercial managed care plans.

Facts and Figures

  • From 1991 to mid-1998, the proportion of Medicaid beneficiaries enrolled in a managed care plan had grown from 9.5 percent to 53.6 percent, or to more than 16.5 million people.

  • Both Medicaid and commercial plans performed well in ensuring children's access to primary care, especially for those age 2 and younger: 82 percent of children enrolled in Medicaid plans, and 89 percent in commercial plans, saw a physician during the year.

  • Neither commercial nor Medicaid plans did well in ensuring that adults with diabetes age 31 and older receive a retinal eye exam. Only 39 percent of diabetic patients in commercial plans, and 41 percent in Medicaid plans, received an eye exam in the reporting year.

Publication Details



National Medicaid HEDIS Database/Benchmark Project, Lee Partridge and Carrie Ingalls Szlyk, American Public Human Services Association., The Commonwealth Fund, February 2000