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

363
Ch.ov a
Q-ft Apg effft F-d
f- DI.nd B..d .A
- C.-
lCa.. ttd
W H.I H o rso..
comparing utilization to adopted practice guidelines to asaess the extent to
which they had been implemented; identifbing providers serving special
needs populations; identifying and tracking high-cost enrollees; identifying
areas of underservice for selected services; identifying gaps in follow-up
care or preventive care for selected enrollees; and analyzing enrollment to
detect adverse selection by selected diagnoses.
We also identified other innovative uses of data systems for more limited
quality or access reviews:
Arizona monitors case management for certain disabled <strong>Medicaid</strong>
beneficiaries through on-line systems. The state provides case managers
with the terminals and software with which they record the individuals'
plan of care and progress in meeting stated goals. This information is then
transmitted to the <strong>Medicaid</strong> department for immediatiate review.
The contracting health plan in the District of Columbia also plans to use an
on-line system for its own and the District's monitoring of care for
enrollees. For case managers providing 24-hour medical access to
beneficiaries and their families, the system gives access to care plans,
service authorizations, and even scanned-in photographs of the children.
In Massachusetts, the <strong>Medicaid</strong> department compared managed care
aggregated utilization data with fee-for-service claims data to determine
whether mental health services were underutilized. The state took
immediate action to work with prepaid plans that needed to correct
utilization problems.
Pwe 47
PoseHEEGSa 1SGi MAdld I. Sd c-o fo the Dru ed