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

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B. Examples of Current Research and Innovative Approaches
Quality indicators are needed for a number of purposes -- accreditation by outside
organizations, external monitoring for the purpose of population-based planning and
regulation, marketing to provide information to purchasers and consumers, and internal
management of the plan. There are numerous efforts underway to measure these different
aspects of quality. Some are focused on developing improved measures for structure, process,
or outcome and others are aimed at developing conceptual frameworks. Several of these new
initiatives are summarized below.
I1. <strong>Medicaid</strong> Health Plan Employer Data and Infonnation Set (HEDIS)
Purpose
Relevant Quality
Indicators
Source
Provide state <strong>Medicaid</strong> agencies with information on the
performance of their managed care contractors, assist managed
care plans in their quality improvement efforts, support emerging
efforts to inform <strong>Medicaid</strong> beneficiaries about plan performance,
and promote standardization of managed care plan reporting
across the public and private sectors.
* Utilization measures -- ambulatory care, newborn care,
mental health, and chemical dependency
* Access measures -- availability of mental health providers
and low birthweight deliveries at facilities for high-risk
deliveries and neonates
* Quality measures -- substance abuse counseling for
adolescents; low birthweight rate; ambulatory follow-up
after admission for specified mental disorders; and asthma
inpatient admission rate
* General plan managements measures -- quality and service
improvement studies, case management; utilization
management; arrangements with public health, education,
and social service entities: new member orientation and
education; and pediatric mental health services
National <strong>Committee</strong> for Quality Assurance: HEDIS 3.0 Draft:
Health Plan Employer Data and Infonnation Set. Washington,
DC: NCQA, 1996. (Request from NCQA, 2000 L Street, NW,
Suite 500. Washington, DC 20036; Phone 202-955-3500.)
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