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

578
HMOs with risk contracts must have an agreement with a Peer Review
Organization. Beginning in 1997 HCFA required that Medicare HMOs begin
submitting HEDIS 3.0 data which is also required by some state <strong>Medicaid</strong> programs.
Finally, the external quality review conducted for Medicare by Peer Review
Organizations, follows a prescribed scope of work which is revised periodically. The
current scope of work includes focused pattern of care studies in the areas of
improving the care of beneficiaries with acute myocardial infarctions or diabetes and
4 3
preventive health care, including mammography services and flu vaccines.
Potential for Coordination Between <strong>Medicaid</strong> and Medicare
Since the goal of both programs is to provide access to quality care for their
beneficiaries and many of the requirements are very similar there is potential for
coordination between the two agencies. For example, Oregon is holding discussions
with the HCFA regional office about combining the PRO and EQRO functions.
Though each program has its own philosophy, practices and goals, there is an
interest in collaborating where possible. State officials supported a previous
recommendation by the Institute of Medicine which proposed developing regional
quality improvement organizations to develop Medicare, <strong>Medicaid</strong> and private
sector collaboration. Also, one of the current priorities for Medicare is diabetes
management. Arizona has also made diabetes management a priority for clinical
studies, yet it will focus on children and adults as well as the elderly in its study.
Finally, an emerging project may help states address overlapping responsibilities for
dual eligibles in managed care. HCFA has contracted with the National Academy
for State Health Policy to revise the QARI guidelines and, to the extent feasible
within current regulatory authority, develop a common set of quality management
standards for <strong>Medicaid</strong> and Medicare. This initiative, known as the Quality
Improvement System for <strong>Managed</strong> <strong>Care</strong> or QISMC, will result in the development
of a common approach to quality management and improvement, standards, and
reviewer guidelines to evaluate compliance with the standards. Public review
documents will be available in the Fall of 1997 with final approval expected in June
1998.
The QISMC initiative blends the strengths of each program. Through use of the
QARI guidelines, <strong>Medicaid</strong> agencies have historically been quite definitive about
their expectations on how plans should conduct their internal quality management
programs. While the standards themselves have been explicit, few states have had
43 The Balanced Budget Act of 1997 promotes coordination between the external quality
review s conducted under the <strong>Medicaid</strong> and Medicare programs. States are encouraged not to duplicate
review activities conducted as part of the Medicare external review and, at the option of the state, to
exempt certain Medicare risk contractors who would otherwise be subject to an external quality review
under <strong>Medicaid</strong>.
The National Academy for State Health Policy * 0 8/97
IV-75