Medicaid Managed Care - U.S. Senate Special Committee on Aging

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Dr. SCANLON. In this series of seminars, we have been looking at the issue of the readiness of
managed care organizations and purchasers to use managed care as a means of providing health care
for persons with special needs. In last week's seminar, I indicated that I thought there were four key
components that were important in trying to assure that persons with special needs are adequately
served by managed care organizations. I discussed three of those components then.
First was the issue of assuring that the managed care organizations have adequate networks of
providers exists. In this instance, an adequate network of providers would include specialists and
subspecialists that would be able to provide for the unique needs of the individuals in this
population.
Second was the issue of rate setting. Rates need to be set in a way that does not compromise the
ability of managed care plans to provide the services necessary for persons with special needs or
discourages plans from enrolling. Third was appropriately defining the scope of coverage--
recognizing that the needs of persons in this population can extend beyond the normal concept of
medical necessity. Medical necessity in this context can include the need for services, not just for
rehabilitation or to cure an illness, but to maintain one's existing level of functioning and health or
to cope with the pain and discomfort associated with one's condition.
I would like to talk today about the fourth component -- accountability. The other three components
dealt with issues that one might address before actually contracting with a managed care
organization and enrolling individuals with special needs. Establishing accountability or quality
assurance is a process that must be continuous and sufficient once plan contracts are signed and
individuals enroll. Perhaps the key to quality assurance or accountability is information. It is not
just critical for success with managed care for persons with special needs, but for other consumers
as well. <strong>Managed</strong> care is a very large and undefined product. If we expect that individuals or group
purchasers are going to be able to assess the quality of services that are being offered by managed
Comments of Dr. Scanlon Summarizing Discussion in Forum Three: Quality and Outcome
Measures, July 15, 1997 1