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

133
care organizations, we need to know enough about services provided so that we can understand and
evaluate plan performance. Information can play an essential part to counter the incentives for
under-service that exist in the financial arrangements that define managed care, namely capitation,
as well as to create real competition among plans on the basis of quality of service. That competition
will ensure that individuals receive services that they need--and the best services possible--given the
revenues available.
In today's marketplace, we are witnessing many larger purchasers seeking more information about
services that managed care plans provide. In general, they are seeking information about population-
based measures of the services provided to the individuals that they have enrolled in managed care
organizations. To a more limited extent, they also are seeking information about the outcomes
associated with those services. Certainly one of the most prominent examples of the movement to
information collection for quality assurance is the Health Plan Employer Data Information Set, or
HEDIS, which has been created by the National <strong>Committee</strong> for Quality Assurance, an organization
of both purchasers and managed care plans. HEDIS is a series of measures that combines some
structural characteristics--such as the turnover in a plan's network, the composition of a plan's
beneficiary population, the plan's financial status--with process measures that identify the receipt
of different services by individuals within the plan. HEDIS, while an extremely valuable step in the
direction of collecting information about services received by individuals within a health care plan,
focuses to a large extent on the general population, and not persons with special needs. The kinds
of measures that are collected include items such as: immunizations, receipt of well childcare, and
receipt of care for diabetes. It does not include the infrequently occurring types of conditions that
we have been talking about in this series of seminars.
HEDIS is, however, a system, or a system that is continually in a state of evolution. <strong>Managed</strong> care
organizations are now using HEDIS version 3.0 and efforts are underway to create the next version
of HEDIS. I would anticipate that future versions will include a broader arrays of measures that will
capture the services received by more narrowly defined segments of the population. It seems
Comments of Dr. Scanlon Summarizing Discussion in Forum Three: Quality and Outcome
Measures, July 15, 1997 2