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

IV. QUALITY OF CARE
A. Problem Statement
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The state-of-the-art in assessing quality of care both at the managed care plan level and
state and community system level for children with or at risk of chronic conditions is very
limited. At the plan level, performance measures specifically targeted for this population have
been difficult to develop for several reasons. The time and cost associated with developing
practice guidelines is enormous. Relatively few pediatric practice guidelines exist, restricting
plans' ability to adequately judge outcomes of care. Also, given the nature of childhood
chronic conditions - few prevalent and many rare conditions with large differences in
functional impacts and frequent co-morbidities -- it is unlikely that major quality gains will
come by proceeding condition by condition, except for the most prevalent conditions. Further
complicating progress in developing quality measures at the plan level is the absence of a
uniform definition, the concern of many managed care plans regarding adverse selection if
they do a good job in this area, and the competing demands on plans to collect an
unprecedented amount of quality data to meet new accreditation standards and contractual
requirements.
At the systems level, performance measures have lagged behind the development of
individual or plan measures. A core set of well-tested indicators, comparable to HEDIS, do
not exist for monitoring the quality of state and community-based systems for children with
special health needs. The organization, financing, and delivery health services for this
population varies tremendously across and within states and communities making
comparability almost impossible. Also, unlike encounter data and medical records, data
sources for monitoring state and community systems performance are very limited. Finally,
still unresolved is the question of authority and responsibility for conducting system-wide
performance reviews for children. Is this the function of the Title V program, the <strong>Medicaid</strong>
agency, or the state health department?