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

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specifications have included developing capacity to serve disabled
individuals. For example, one health plan elected to develop and
implement a program for enrollees with human immunodeficiency virus
(Hmy) or Awos to provide case management and access to specialists trained
in infectious diseases. Selection criteria for 1995 required prepaid plans to
demonstrate how they provided reasonable access to services for
enrollees with physical and coutiudcatinal disabilities as measured, in
part, by enrollee satisfaction.
Programs Can Be Under a fee-for-service approach to <strong>Medicaid</strong>, states have ready access to
data on services performed because they reimburse providers for those
Strengthened by services. These data-called claims data in fee-for-service systems and
Analysis of Encounter encounter data in prepaid managed care-consist of such information as
the patient's identity, type of service, date of delivery, diagnosis, and
Data provider. In a prepaid care setting, states do not need such data for
reimbursement purposes. Many plans have-and use-this information,
but unless states specifically request it, the information can largely
disappear from view.
This information can play an important role in quality assurance,
estimations of future service use, research, and program planning. It can
also play an important role in rate-setting, the subject of the next chapter.
However, state experience to date shows that a substantial investment of
time and effort is needed to assemble a workable encounter database,
although the potential applications appear to make the effort worthwhile.
Encounter Data Have Had When Arizona, Oregon, and Tennessee received approval to implement
Limited Use to Date statewide <strong>Medicaid</strong> mandatory managed care programs, HcFA required
them to collect and validate encounter data, mainly for use in independent
evaluations of the programs. These states, which have had significant
experience in collecting such data, all had difficulty obtaining information
of sufficient quality and comprehensiveness to use in quality assurance
reviews. The problems were numerous: The data were not readily
available, health plans used a variety of data systems, and definitions
varied from plan to plan.
Arizona has had by far the most experience in collecting and using this
information for quality assurance purposes. However, the state spent over
10 years and $30 million getting to the point that the <strong>Medicaid</strong> department
could use encounter data for quality analysis.
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