Managed Care - April 2008 - (Page 49) ical services. Transportation, outreach, and case management are essential.” Kelly says his company is focusing on the medical home concept and trying to more closely integrate its disease management programs with its provider network. Health Net serves over 400,000 Medicaid members in Los Angeles county. “Our operating environment is extremely complex. Everything we do must take into consideration that our members, collectively, speak 12 languages and generally function at a fourth grade reading level,” says David Friedman, government programs officer. “On top of that, the monthly turnover is 20,000 to 25,000.” Somers says that today’s Medicaid-focused plans are using “state-of-the-art techniques, including care management and predictive modeling, as a means to better control and predict costs.” aid program, disputes the findings. “The study methodology did not compare apples to apples; the commercial and Medicaid populations are very different, with Medicaid members being a high-risk population with behavioral disorders, the elderly, and people with disabilities.” Yet Rodgers is not daunted by the study. “It’s reasonable to be held to the same standards as the commercial plans.” Cracks in the facade In spite of the progress that both the states and plans are making, problems with the quality of care have come up, and cracks in the relationships between the states and the plans have appeared. An October 2007 study in the Journal of the American Medical Association concluded that Medicaid managed care enrollees receive lower quality care than that received by commercial managed care enrollees. “The study looked at 11 HEDIS quality indicators such as immunization rates, prenatal care, and hemoglobin testing in diabetes, across three different plan types — commercial plans, Medicaid-only plans, and commercial/ Medicaid plans,” says Bruce Landon, MD, lead author and associate professor of health care policy at Harvard Medical School. “For 10 of the measures, the quality was substantially lower for the Medicaid population, regardless of the plan type. The study commented that “these findings suggest that the type of health plan enrolling the population (commercial, Medicaid commercial, or Medicaid only) is less important than differences in the characteristics of the population being served, the local provider networks in which they receive care, access to care, patterns of care seeking, and adherence to treatment recommendations.” Landon said it is extremely difficult to study these elements because they cannot be controlled sufficiently to produce a valid study. Anthony Rodgers, director of the Arizona Health Care Cost Containment System, the state’s Medic- Monitoring The quality issues highlight the question of the states’ monitoring of the plans. “Although progress has been made, some states have not taken full advantage of their opportunities to set specific performance requirements,” says Hurley. In the early days under capitation, plans did not get claims or encounter data from many providers and it was difficult for them to report detailed information to the states. In recent times, encounter and claims data have become commonplace and are used by both the states and the plans in financial and operational management. In the area of quality management, 21 states now require their plans to submit HEDIS information to NCQA, says Kristine Thurston Toppe, director of public policy for NCQA. However, many plans do not publicly report that information, or report only a subset of the HEDIS measures. Somers points out that as the plans move into the ABD population, HEDIS measures do not reflect the needs of patients with comorbidities. Arizona is implementing its own quality measures, such as the incidence of bed sores for longterm-care patients, and it is building a health information interchange to coordinate care among providers. Although full risk capitation steams ahead, some states are looking at changing course. “There is some bubbling going on, not yet a trend, where the states are thinking about ways in which they can take back some of the managed care activities, based on the expertise they have developed,” says Somers. “For example, rather than having multiple disease management programs through the private plans, they are looking at establishing their own program that will standardize activities across the state.” MC Tom Reinke is a freelance writer who specializes in health and business topics. APRIL 2008 / MANAGED CARE 49
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