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

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enrollee utilization patterns, and conducts surveys. This team selects areas for
EQRO review based on information gathered from the other activities it manages
and from data collected by the State Ombudsman Office.40 The EQRO function in
Oregon has four main components: quality studies including focused studies on
diabetes and adult depression, encounter data analysis, delivery of selected
preventive services (mammograms, pap smears, immunizations, diabetes) and
statewide focus studies of identified issues such as emergency room use. The
encounter data review looks at 39 performance measures. For the elderly and
persons with disabilities, the reviews examine access to specialists and durable
medical equipment.
Arizona made diabetes management a priority for clinical studies. This State will
focus on children and adults as well as the elderly in its study. The state's EQRO
study will develop baseline information that can be used to measure improvements
over time.
Reviews Performed by State Staff
These reviews are not required by federal regulations, but many states perform these
studies at their own initiative.4 1 These are usually performed to examine an area of
particular concern with program performance. As discussed in Volume II states use
a number of sources of information to identify potential topics for these studies,
such as, utilization reports from plans, complaint and grievance information,
information from advocates and providers, and health outcomes (after the program
has operated long enough for it to produce any such outcomes). These studies may
focus on one or two plans that have been identified as experiencing a particular
problem, but most often these reviews examine the provision of care by all plans
participating in the managed care program.
Oregon
Oregon staff has performed or is performing three reviews.
* An evaluation of the Exceptional Needs <strong>Care</strong> Coordination (ENCC) program
was completed in the fall of 1996. This review assessed whether the program
was meeting the needs of the population eligible for ENCC services (elderly,
persons with disability and children in foster care) as intended by the
legislature, to gather information about innovative use of the position and to
40 For more information on Ombudsman programs please refer to: Jane Horvath and Neva
Kaye, Snapshot of <strong>Medicaid</strong> <strong>Managed</strong> <strong>Care</strong> Ombudsman and Grievance Procedures, (Portland, ME: The
National Academy for State Health Policy, 1997).
41 The Balanced Budget Act of 1997 requires states to develop a quality assessment and
improvement strategy and to conduct periodic regular examinations of the scope and content of the
strategy. This would include monitoring and evaluating the quality and appropriateness of care.
The National Academy for State Health Policy * 0 8/97 IV-71