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

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Those states that use managed care to serve persons with disabilities and the elderly
believe that, with proper oversight, managed care can also produce improvements
in the care delivered to these special populations. Of course, since almost all of
these programs are new, they have not yet proven their ability to improve the
health status of these groups of <strong>Medicaid</strong> beneficiaries.35
As described in Volume II of this Guide, state oversight activities include
developing standards for health plan performance, measuring plan performance,
and working with plans to improve performance. States use this same approach to
overseeing contractors that serve <strong>Medicaid</strong> beneficiaries who are elderly or have a
disability. However, state staff report that they modify this generic system to better
accommodate the needs of persons with disabilities and the elderly by developing
measures for aspects of health plan performance that are more pertinent to special
populations. For example, in a program serving AFDC (TANF) beneficiaries
measuring plan performance in providing childhood immunizations is extremely
important. But, for persons with AIDS developing standards and measures for the
use of protease inhibitors (as Massachusetts has done) is a more pertinent measure.
Earlier sections of this chapter discussed standards and structures in areas of
particular concern to programs serving elderly beneficiaries or those who have a
disability (e.g., access and care coordination) and the means for measuring plan
performance is unchanged from those described in Volume II. Therefore, the bulk
of this chapter will focus on those aspects of plan performance that are formally
identified as part of a quality improvement system-the standards states require a
plan's internal quality program to meet and the external reviews states conduct.
(This discussion assumes the readers familiarity with HCFA's Quality Assurance
Reform Initiative (QARI) guidelines, which contain guidelines for both of the
aspects of quality assurance/improvement discussed here.) Finally, since many
members of special populations are dually eligible, 3 6 this section will discuss the
impact that Medicare has on <strong>Medicaid</strong> quality assurance activities and some efforts
underway to bring the two systems closer together.
35 For more information on quality assurance for special populations please refer to:
Maureen Booth, Look Before You Leap: Assunng the Quality 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 Health Policy,
1996).
programs.
36 Dual Eligibles are beneficiaries who are served by both the <strong>Medicaid</strong> and the Medicare
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