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

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context of enrolling people who represent a highly vulnerable populations and making sure, that to
the extent that these measures are not adequate, we take other steps to ensure that persons with
special needs are adequately cared for by the managed care organizations with whom we contract.
It is important to recognize that we have only a handful of measures, and that we need to be
concerned about the incentives that using these measures may create to "teach to the test". In other
words, given that there are only a handful, fewer than 50, different aspects of care that are going to
be monitored, it would be expected that a savvy organization would insure that it scored well on
those dimensions. What was happening with other aspects of care would be unknown. Potentially,
some other dimensions of care not being monitored, are not receiving adequate attention.
In terms of the future and the evolution of these approaches, adding more and more comprehensive
measures is not an easy task. It is very difficult to decide what the norm for the receipt of care or
an outcome should be. Furthermore, even when we decide that receipt of a particular treatment is
the norm for a particular condition, we need to understand what the prevalence of need for that
particular treatment is. In other words, we need to understand what the denominator is, or how many
persons should receive that service -- in order to be able to identify whether or not enough of that
service has been provided. In terms of establishing the norms for an outcome, there needs to be
considerable attention devoted to the linkage between services and outcome. There are many
extraneous factors that may influence outcomes associated with the service. There also is the need
to consider the timing of an outcome. The outcomes for many services may be long delayed and
may involve the receipt of additional services in the interim.
Some of these problems are very similar to issues raised in the discussion of risk adjustment. We
need to develop measures that are going to be fair to the health plan, in that, as we hold them
accountable for delivering services, we should be holding them accountable for services that do have
a positive impact and for outcomes that are actually attainable.
Comments of Dr. Scanlon Summarizing Discussion in Forum Three: Quality and Outcome
Measures, July 15, 1997 4