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

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Appendix I
Scope and Methodology
To ensure quality in their <strong>Medicaid</strong> managed care programs, states use a
number of quality assurance and oversight mechanisms. For example,
some states require accreditation of plans by independent entities, such as
the National <strong>Committee</strong> on Quality Assurance. Most states build into their
contracts with managed care plans a variety of accountability measures
and processes. Once states have contracted with plans, they monitor the
plans to ensure that they comply with these requirements.
Based on our review of federal requirements and guidelines and state
contracts and supporting documents, we identified a number of
accountability measures and processes that states commonly include in
their contracts with managed care plans. States can rely on various
controls to assess compliance with some of these measures-including
plan licensing, physician credentialing. and fiscal solvency requirements.
Some accountability measures are more difficult to develop controls for
and, therefore, are more difficult to monitor.
To assess state efforts to hold managed care plans accountable for
meeting <strong>Medicaid</strong> program goals and providing beneficiaries enrolled in
capitated managed care plans the care they need, we narrowed the focus
of our study to three areas: ensuring an adequate provider network,
tracking the medical care provided to beneficiaries. and assessing
beneficiary satisfaction. From among numerous quality assurance
measures and processes, we identified 10 that states commonly use to
monitor plan compliance In these accountability areas. Health <strong>Care</strong>
Financing Administration (HCFA) officials and experts we contacted agreed
that these measures and processes are essential to ensuring that plans
meet the terms of their contracts. (See table 1. 1.)
Table 1.1: Selected Accountability
Measures and P e Accountability area Measure or process
Adequacy of provider network -Patient-to-primary-care-physician raos
-Access to specialists
-Travel distances and waiting fimes
Adequacy of medical care
Beneficiary sassfacton
-Utilization statstics
-Encounter data
-Cirnical studies
_Medical record audits
-Satrsfaction surveys
-Grievance procedares
-Disenroliment data
PaP 30
GCAO/HSH97.86 M&did Ma-d Ce Aountsbdlty