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

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Clinical guidelines are specific recommendations that a plan makes to a provider regarding what consti-
tutes high quality HrV care They indude recommendations for assessing when it is necessary to refer an
individual to a specialist when a provider should recommend prophylaxis for opportunistic insfections,
when to offer antiretroviral therapy, when to switch regimens, and when to provide diagsostic services
such as viral load testing.
In order to know what is actually happening within a managed care organization, sophisticated manage.
mert Infurmzation systras are necessary. Management information systems involve setting up record
keeping systems that enable a managed care organization to track the composition of iu beneiciaries,
the seavices they are receiving. which services are costing the most money, and assess the ultimate impact
on the health of the beneficiaries of various treatment options.
Once a monitoring system has been developed, and expectations have been established for what a
managed care organization should be doing. proceas and outcome measures help to track what is
happening. Process measures look at issues such as how often a beneficiary is offered a specific
A MODEL MANAGED CARE PROGRAM
The Comumsanty MedicalA~ilance, Butn,M4A
Since 1989. the Cormmunity Medical Alliance (CMA4 rian
operated a rmnaged care program for people w+ht secuen
phsiai) disabllties. in iS9, this program was esipanded
to cover people with A WhereaS most masaged Wre;
program seek to avotd peaple Ifving with Wd's nd other
high cosc benelicaHnies, CMA has actively recruitd people
withAlDS- -
CMAs nmod Of care In based on using tams fnoe
practitioners and physicians to coordimvts and provide prilmarrand
acute care services.CKA receives dsree (p0leted
rates from Iassachusetr Medicid.Oe re tomes people
In theatvnced-atage AIDS program and in the ^ighest
PVysset.The nextirace covers peopii In cthesevere plsystcal
disabilty program, which primarily covers People with
qradripiegia. he third payment re is for- any Medialdt
reclpleac with a disabilIty weho does isot qualify for One of
the oisr two rate, ncluding sme people lvn wIth Hk
MAKING MEDICAID MANAGED CARE WORK | An Aatiae Plan In P-epo - trq wIth HIV