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In Brief
CU Review
Determining Utilization & Quality of Care in Managed Care Plans
Findings:
Recommendations
Common Acronyms
Footnotes
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Recommendations
In order to address existing problems, and ensure the quality of health care provided by the Medicaid program, Consumers Union recommends:
- Before contracting in any new expansion areas, a statewide, legislative reassessment of the Medicaid managed care program to determine whether access has improved, whether the new system is cost effective, whether expansion should continue, and what should be done to ensure the state's capacity to monitor and operate the program. It is possible that an HMO-based private health insurance system cannot provide the wide array of services needed by the Medicaid population in a cost effective manner. While evaluations of individual HMOs, using patient and doctor surveys, can provide some information about the effectiveness of care as experienced by those individuals, it cannot provide a systemic overview of whether the program as a whole is working-from DHS enrollment to the doctor's office.
- Legislation to implement an expedited process for determining eligibility and enrolling pregnant women and newborns to ensure immediate access to prenatal services.
- Assessment of savings that could be achieved with 12 month continuous eligibility, to include an analysis of the costs of reenrollment to plans and physicians, and the effect on quality of care and access for patients.
- Immediate public dissemination, including posting on the Internet, of all evaluation reports of the Medicaid managed care program, plans and other entities.
- Substantial improvements in data collection and data quality-enforced under the contracts-including verifiable encounter data for each doctor visit and service provided by an HMO. Contracts need to specify that full encounter data must be provided by physicians when HMOs delegate responsibilities to independent physician networks, or if the Medicaid program contracts directly with independant physician networks. De-identified encounter information should be publicly available for independent analysis. Contract renewal should hinge on the results of the audit verifying encounter data completeness and accuracy.
- A review of existing data and reports collected from HMOs and Maximus to identify data that reveals quality of care and access and ensure that these reports are accurate, while eliminating information that is not useful (this process is already underway in the TDH Bureau of Managed Care).
- Increased staffing at TDH for contract supervision and compliance to ensure that HMOs and other state contractors address problems as they arise.
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