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

Observations
Agency Comments
and Our Evaluation
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In view of the billions of dollars that are being paid prospectively to
managed care plans and the questions about the degree to which managed
care is meeting the health care needs of <strong>Medicaid</strong> beneficiaries, there is a
new demand for public accountability. The continuing trend toward
expansion of mandatory, capitated <strong>Medicaid</strong> managed care programs
requires that states have the ability to adequately oversee their contracts
with health plans and ensure that states get what they are paying for.
However, developing systems to hold plans accountable for ensuring that
<strong>Medicaid</strong> beneficiaries receive the care that they need has been a
challenge for states-especially since there are few benchmarks and
standards against which states can measure beneficiary access to network
providers and the appropriateness of the care provided.
The four states that we visited have made progress toward developing
accountability measures to ensure that beneficiaries have access to quality
care. As they expand or refine their <strong>Medicaid</strong> managed care programs,
these states continue to scale the steep leaming curve to becoming an
effective purchaser of managed care. Yet, to instill greater public
confidence that managed care can effectively and efficiently meet the
health care needs of <strong>Medicaid</strong> beneficiaries, more effort is needed. For
example, to varying extents, these states could improve their
methodologies for collecting and analyzing data-especially encounter
data-on beneficiary care. They could better target their clinical studies,
medical record audits, beneficiary satisfaction surveys, and reviews of
grievance data on specific services and beneficiary groups-particularly
those with special needs or conditions whose numbers may be too small
to show up in broad-scale surveys or studies. The need for these
improvements takes on even greater importance for those states planning
to expand their managed care programs to other geographic areas or
populations, such as people with disabilities or other special needs.
We provided a draft of this report to the Administrator. HCFA. We also
provided a draft to <strong>Medicaid</strong> officials in each of the four states we visited
and to independent experts and researchers from the Center for Health
<strong>Care</strong> Strategies. Medical College of Virginia, and National Academy for
State Health Policy. Each provided technical or clarifying comments,
which we incorporated as appropriate.
In addition to technical comments. each state informed us of recent or
planned initiatives for ensuring plan and provider accountability in their
programs. For example. in February 1997. Pennsylvania Implemented
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