April, 1999
This article was written by the Consumers Union Southwest Regional Office.
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Determining Utilization & Quality of Care in Managed Care Plans Findings:
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Determining Utilization and Quality of Care in Managed Care PlansIn the absence of good encounter data about the services members get under a manged care plan, HMOs collect utilization management (UM) data and conduct focused population studies to assess the services provided. Utilization management data is collected by sampling administrative records to determine what services are used by members, and then the sample is extrapolated to a rate of use per 1000 members. TDH used this UM information in its Summary Report to show key information: emergency room and hospital visits are reduced under managed care, people have fewer complex newborns and average hospital stays are shorter (Summary Report, pp 23-26). THQA attempted to audit the utilization management information by asking companies to provide the underlying source data, from which THQA reproduced the tables of ratios. They were unable to reproduce any table exactly, (Retrospective Review, Phase I, State Report, Americaid, p. 4, Community First, p. 4, FirstCare, p. 4, etc) and could not verify select reported information from many health plans.
Overall, THQA found that "reporting criteria for formulas stated in the TDH instructions are subject to varying interpretation." As a result, plans incorrectly annualized procedures and applied the formulas inconsistently. In the behavioral health area, many plans submitted incomplete UM reports. In order to audit the UM reports, auditors required certain underlying data from plans, and many were unable to provide the required data elements. Finally, the auditors were unable to reproduce the tables exactly from the underlying data provided. According to the auditors, UM administrative records are created from MCO encounter data. Therefore, the underlying problems with the encounter data cited elsewhere in this report will significantly effect the UM reports. Wherever TDH evaluates changes in the use of services due to managed care and bases its information on UM reports, this data cannot be verified and probably does not present an accurate picture of actual services delivered. TDH requires HMOs to conduct focused studies of pregnancy, well child, asthma, behavioral health, and substance abuse treatment during pregnancy. These "studies" are similar to the UM data, but they generally target a narrower population and look for rates of specific treatments and followup. "By isolating care delivered to a small group of clients over time, TDH and MCOs can identify benchmarks for care, measure performance goals, and identify quality of care issues of concern," according to TQHA. If the audit confirmed that MCO's complied with state reporting requirements and their results could be validated, the focus study results could be used to compare plans on vital quality of care issues. But, the auditors determined that "enough questions were raised ...concerning valid study methodology and the effect on findings" that the results of studies conducted by different plans could not be compared with one another. For example, plans reported a range of pregnancies with complications that varied from 11% to 85%, indicating that they did not conduct the study in the same way. Some studies were compromised by small sample size. Others were based on incomplete information. Seven plans identified information relating to outcomes of pregnancy and enrollment data (data that would identify the length of time between a woman's enrollment and her first prenatal visit) as difficult information to collect.
Conclusion Focus studies and utilization management reports have been used as a surrogate for good data about the services provided under the Medicaid managed care program. But even this information does not pass an audit and should not be relied on to present an accurate picture of the services provided by health plans. |
