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

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Ms. RILEY. I think that what you are looking for is recommendations
either to the reconciliation process that is going on right now
or to HCFA, some of the recommendations that we have talked
about here, around enrolling these populations into managed care.
I just want to start out by saying that I hope I don't leave people
with the impression of pessimism, because I believe that this is absolutely
where we are going to end up.
What I would like to urge is caution and carefulness and
thoughtfulness and engaging the population that we are talking
about bringing into managed care, because they have strong opinions
about how it should look. So that is kind of how I want to
leave it with this group in terms of caution rather than pessimism.
Ms. SMITH. I think I would echo that. I think that as we have
indicated, potentially, down the road, managed care offers a tremendous
opportunity to this population for continuity of care and
coordination of care.
I think the concern is that the political imperatives to change the
system quickly may not accurately reflect what is happening in the
marketplace right now in terms of the infrastructure that is being
developed, the ability of plans to deal with providers that they are
not accustomed to dealing with and create different types of networks.
Again, I use my analogy of Venus springing full-grown from
Zeus' head. There are some political imperatives to have that happen,
and it does not work that well on the ground in the delivery
system. I think that if you are looking for protections, again, the
protections would need to revolve around issues of access to care,
quality measurement, network composition, accountability in terms
of adequate protections around prior authorization and grievances,
so that if people are being denied care, they have expedited channels
to have those denials reviewed.
Mr. SCANLON. I would agree with Barbara. I think one of our
problems, though, is that we are not ready-we have not achieved
any consensus in terms of how to go about defining an adequate
network, setting up what is considered an adequate grievance process.
I think that in light of that, then, this may be appropriate for
HCFA to think about, the issue of guidelines for the States so that
we recognize that this is going to be an evolutionary process in
which some of the State experimentation with variants of different
approaches will actually be valuable in guiding us to better solutions.
One of the keys, though, that I think we need to focus on is that
it is critical to have information about the services that are being
delivered as well as, to the extent we can, the outcomes of services.
Today, we are very often focused on outcomes as what should be
the gold standard for deciding whether or not a plan is adequate.
Yet, we are not at the point at which we know the range of outcomes
that we should be measuring or even how to go about measuring
some of the things that we know that we should be measurine
We do need to be concerned about just the services that are being
provided, and I think that one of the areas that we have an opportunity
now to focus on is the question of encounter data. Information
systems are being developed. They are expensive to develop.