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

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numbers of patients. Information from patients, while more accessible
than medical records, can be problematic as well. Patients typically are
not in a position to know what specific care or services they need for a
given condition and often cannot assess the appropriateness of the care
they receive-or do not receive. In addition, patients new to managed care
may confuse differences in the way the system is meant to operate with
deficiencies In the care provided. Problems associated with obtaining
meaningful patient survey information may be even more pronounced for
those in the surveyed population with unique language or cultural needs or
who are unaccustomed to receiving routine health care in a structured
system. Educating and Informing prospective and newly enrolled
beneficiaries about managed care and helping them learn how to use the
system-as some states have done in their <strong>Medicaid</strong> managed care
programs-can mitigate these problems. 8
Most states are grappling with these and other issues associated with
adapting and developing systems and processes for managed care-a
relatively new health care environment. According to some experts, many
states are struggling to maintain the staff needed to establish and oversee
their programs, since frequent turnover of staff with managed care
expertise is common. It is not surprising, then, that states are at various
stages in their program development and monitoring efforts. The four
states that we visited have taken a number of steps to overcome these
various challenges and improve the odds that their money is well spent in
their managed care programs. These states have established contract
requirements that aim to ensure that participating managed care plans
have the capacity to provide adequate care to enrolled <strong>Medicaid</strong>
beneficiaries. Prominent among these requirements are standards for
plans' provider networks. In monitoring participating plans, these states
obtain information to assess actual services delivered from various
sources, including plan-collected and -submitted data, state reviews of
patient medical records, and beneficiares reports on their experiences.
Measures to Assess Before a contract is awarded, managed care plans must demonstrate that
Measures to Assess their provider networks are sufficient to meet the anticipated needs of
Beneficiaries' Access enrolled <strong>Medicaid</strong> beneficiaries. In an attempt to measure provider
to <strong>Care</strong> Are Still network sufficiency, the states we visited-Arizona. Pennsylvania.
Tennessee. and Wisconsin-have focused on quantitative or other
Evolving measures related to primary care physicians and specialist care. But just
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