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

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At the forefront of Wisconsin's managed care infrastructure is a broad public/private
partnership. We all must work together to implement our multi-prolonged quality
improvement (QI) process. The goals of our Ql process are simple, but broader than many
commercial managed care programs.
First, we strive to ensure that <strong>Medicaid</strong> managed care enrollees achieve the highest possible
health outcomes, whether the enrollee is a 2-year-old needing to be ftolly immunized, or an 80year-old
needing assistance with appropriate medication administration. We defin desired
health care outcomes differently, for differet populations- We strive to define outcomes that
are both objectively and clinically acceptable and subjectively important to consumers. We are
learning that there is a lot of work to be done to define outcomes that are acceptable to the
elderly and disabled. Traditional quality measures, such as those defined in HEDIS, for -
example, are just a starting point.
Secondly, we strive to make sure our managed care erollees access th care mmty need,
whether that means assuring transportation to clinic appointments or locating translators-for
non-English speaking enrollees. Again, we define opportunities for improved access
differently for targeted populations. For example, we are learning that-elderly persons are
more likely to access health care if they feel they have a comfortable personal relationship with
their health care provider. This is not a common goal in commercial managed care.
Finally, we are committed to ensuring enrollees maximum choice of managed care plans and
health care providers within thoe plans. Whenever we canot guarantee reasonable choice -
we do not enroll.
We implement these QI goals through a variety of strategies. Most importantly, we have
established basic contract requirements, some of which apply to all <strong>Medicaid</strong> managed care
enrollees and others which are unique to each population. The contract requirements are
routinely and rigorously monitored for all programs.
Examples of these contract requirements are: asstring round-the-clock easy access to
appropriate care; assuring the location of health care providers within 20 miles of consumers'
residences; requiring that managed care organizations offer a comprehensive range of services
equivalent to <strong>Medicaid</strong> fee-for-service; assuring calturally responsive health care providers,
education and communication; requiring formal and informal comqplaint and grievance
processes; and requiring managed care organizations to maitain comprehensive internal QI
system. Almost all state <strong>Medicaid</strong> managed care programs include such requiremnts.
Examples of contract requirements that are munique to Wisconsia's statewide managed care
program for low-income women and children that could be adapted for mandatory programs
for the elderly and disabled include the following featues:
1) We use an independent enrollment contractor to assure that <strong>Medicaid</strong> recipients enrolling
in HMOs are fully informed about how to chose an HMO that best meets the health care
needs of their family. The enrollment contractor helps Wisconsin avoid excessive and
inappropriate marketing to consumers by HMOs.
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