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

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for <strong>Medicaid</strong> capitation rates and coordination of services. These implications are
discussed later in this chapter.
How Will Quality Be Ensured?
Given the warnings of early research, how can states ensure high quality in their
managed care programs for special populations? Boothl' has suggested that the
design features of most state managed care programs for TANF (formerly AFDC)
beneficiaries do not fully address the needs of special populations, but provide a
solid foundation for state efforts in this area. States will most likely find that the
same techniques used in their quality management systems for TANF beneficiaries
(e.g. use of practice guidelines, credentialing, licensing and certification) can also be
used to ensure quality of care for the elderly and persons with disabilities, but that
the system will need to address new issues that are of particular importance to these
new enrollees.
One challenge is the broader range of providers often used by special populations.
Commercial managed care organizations are not generally accustomed to having
Independent Living Centers, home and community based service providers, or
adult foster homes in their networks. Even if these services are not the direct
responsibility of the capitated contractor, states should consider monitoring the
degree to which all of these distinct provider systems come together to provide
seamless care to the beneficiary. Health plans have their own quality initiatives
(e.g., NCQA accreditation). Also, many types of providers are already steeped in
their own quality initiatives (e.g., the Minimum Data Set (MDS) for nursing
facilities and the Outcome and Assessment Information Set (OASIS) for home
health) while others have virtually no focused quality improvement programs.
As a starting point, states should consider implementing dynamic processes that can
provide early warnings of problems and give voice to beneficiaries. State experience
has shown that complaint and grievance systems are most effective when they offer
multiple avenues for registering problems, include staff who can communicate
effectively with special populations, and are easy to use. Ombudsman or other
special positions might be created to address individual and systemic problems that
arise around the needs of special populations. (Volume R contains more
information on complaints and grievances.)
In the longer term, states will need to define desirable outcomes that are specific to
the groups their programs serve, and develop performance indicators to measure
success. This is a more difficult undertaking that will evolve as programs gain
11 Maureen Booth, Look Before You Leap: Assuring the Ouality of <strong>Care</strong> of
<strong>Managed</strong> <strong>Care</strong> Programs Serving Older Persons and Persons with Disabilities, (Portland, ME: National
Academy for State Heahh Policy, 1996).
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