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

Results in Brief
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managed care programs and on state efforts to (I) ensure <strong>Medicaid</strong>
beneficiaries have access to appropriate providers, (2) assess the
adequacy of medical care provided through contracted plans, and
(3) determine beneficiary satisfaction with plan performance.
To understand the types of Issues states face In ensuring accountability
and quality In their capitated <strong>Medicaid</strong> managed care programs and the
steps taken to address these issues, we visited four states-Arizona,
Pennsylvania, Tennessee, and Wisconsin. At the time of our review, these
four states collectively had almost 1.9 mIllion <strong>Medicaid</strong> beneficiaries
enrolled in their managed care programs. To analyze and illustrate state
actions, we focused the scope of our work on 10 core accountability
measures or processes deemed essential by HCFA and experts we
contacted. 2 We reviewed these states' contracts with managed care plans
and other plan requirements, as well as their efforts to monitor plan
performance. Appendix I provides more detailed information on our scope
and methodology.
Ensuring that managed care plans provide enrollees the care that they
need is a formidable task for private and public purchasers alike. In
establishing their managed care programs, purchasers can require
contracted plans to meet certain conditions-such as maintaining
adequate provider networks and complying with data collection
requirements-that help to hold them accountable for providing enrollees
with appropriate care. However, establishing criteria for these conditions
and monitoring plan compliance are often difficult because of a lack of
population-based standards or benchmarks for what constitutes
appropriate care or expected outcomes. in addition, Individual-level data
on patient care, such as those that are generated in a claims-based
fee-for-service system, are not readily available. For states, establishing
standards of care and tapping into alternative information sources on
service utilization to assess the care that <strong>Medicaid</strong> beneficiaries receive
can be a challenge. The four states that we visited-Arizona. Pennsylvania.
Tennessee, and Wisconsin-have built access and data collection
requirements into their contracts with managed care plans. We found.
however, that plan compliance with the requirements we reviewed does
not necessarily ensure that beneficiaries are receiving the care that they
need.
rD. work did not konlude a complntr m ot en. sut q.Wlty - -ru
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rGAOEHE1-917 M.Ued Mo.d <strong>Care</strong> A-Mifty