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

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* The type(s) of data necessary to show that this standard/outcome has
been met
* The method for gaining this data
* The definition of non-compliance to the standard/outcome and the
sanction(s) for that non-compliance.
Determining performance standards and targets is difficult without having prior
data to show what is reasonable. Trying to compare services delivered through riskbased
managed care and fee-for-service systems does not work well, for several
reasons. Different organizational structures make comparison difficult. <strong>Managed</strong>
care may provide more flexible benefits than fee-for-service. Fee-for-service
beneficiaries may experience access barriers which would affect their use of services.
<strong>Managed</strong> care is often provided in more urban areas, complicating comparisons
with fee-for-service, which may have a more rural focus. In many areas, data is
incomplete or not comparable between fee-for-service and managed care.
Focusing on what is realistic-as opposed to what is merely possible-makes for a
stronger contracting and monitoring process. The staff time needed to monitor
quality -in most cases already more complicated and time-consuming than
overseeing the fee-for-service system-increases with every additional measure to
be evaluated. (Tennessee noted that the 110 performance measures in its initial
contract were too many for appropriate measurement and reporting. Those
measures have been reduced to 33.) Also, there may not be enough people receiving
a certain type of care for its meaningful evaluation. Finally, the contractor being
evaluated must be able to affect the issue being measured.
Monitoring takes place at multiple levels-the managed care organizations, the
behavioral health organizations, providers, etc. States must also monitor the
system as a whole, as changes made in one area may affect other areas in unforseen
ways.
Monitoring also involves other state agencies. In its children's program, Delaware's
<strong>Medicaid</strong> agency holds the Division of Child Mental Health Services accountable by
withholding the reimbursement if problems with services arise. Agencies can also
work together to monitor managed care organizations and providers. Data collected
by one agency may be valuable as performance measures to another agency's
monitoring efforts. For example, in Washington, payroll data submitted to the
Department of Employment Security is being used to measure employment
outcomes for people served in the mental health, developmental disability,
substance abuse and vocational rehabilitation-systems. While for Wisconsin's
Children Come First program, the <strong>Medicaid</strong> and mental health agencies share data
The National Academy for State Health Policy e © 8/97
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