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

Targeted Quality-of-<strong>Care</strong>
Studies
Quality Improvement Goals
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Consumer surveys could include questions about eligibility status, and
samples could be designed to ensure that sufficient numbers of disabled
beneficiaries were included States could also request disenrDliment or
utilization data reported by eligibility category to allow comparisons with
other eligibility groups or across health plans. States might, as one
reported, interview individuals requesting disenrollment to gather more
in-depth information about the care received. In 1996, Virginia win
conduct a survey of all disabled beneficiaries who disenrolled during the
year.
States have great flexibility in deciding how to structure required external
reviews, which represent an opportunity for closer scrutiny of issues
facing disabled individuals. Oregon, the District of Columbia, and Virginia
are seeking proposals from external professional review contractors for
studies specifically designed to measure the quality of care for disabled
enrollees.
The steps taken to monitor plans once they are up and running need not
be limited to modiying existing <strong>Medicaid</strong> oversight requirements.
Targeted quality-of-care studies and quality improvement goals have been
instituted by one or more of the eight states.
Arizona, the District of Columbia, Ohio, and Virginia will begin in 1996 to
conduct additional quality-of-care studies focused specifically on care for
disabled enroliees. Arizona's studies will include outcome measures, such
as the frequency and reasons for hospitalizations and emergency room
visits, rates and changes in pressure ulcers, and changes in functional
abilities. Since 1990, Arizona staff have also visited a random sample of
developmentally disabled beneficiaries in their homes to determine
satisfaction with services and progress in fulfilling individualized plans of
care developed by their health plans The District of Columbia, Ohio, and
Virginia are collecting encounter data from health plans and will evaluate
care beginning in 1996 or 1997. A fourth state-Wisconsin-is scheduled
to release by December 1996 an evaluation of its program conducted by
independent researchers.
Massachusetts uses quality improvement goals and contractor selection
specifications to build health plan capacity to meet the needs of <strong>Medicaid</strong>
beneficiaries Each year, the state identifies quality improvement goals for
all health plans and requires each plan to select additional goals. Twice
annually, <strong>Medicaid</strong> staff meet with health plans to review progress in
meeting stated goals. For each contracting cycle, the state identifies
capabilities it expects successful contractors to possess. These goals and
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