Kaiser Family Foundation Survey on State Medicaid Managed Care ...

Measuring, monitoring, and improving quality in Medicaid managed careKey Section Findings:All states with MCOs and most states with PCCM programs require HEDIS© or other measuresof performance and CAHPS© or other surveys of patient experience. Required measures focusheavily on Medicaid priority areas such as prenatal and post-partum care, child health,preventive care, management of asthma, diabetes, and other chronic conditions, and access.Of the 48 states with MCOs and/or PCCM programs, over a quarter also measure and monitorquality in their fee-for-service delivery systems.Of the 36 states with MCOs, 16 require health plans to be accredited by a recognized nationalaccrediting organization, such as NCQA, to participate in Medicaid.Over three-fourths of states with MCOs publicly report on the quality of their MCOs, and half ofPCCM states publish quality reports on their PCCM programs. A smaller number of states alsopublicly report on PHP performance. Sixteen states with MCOs reported that they prepare aquality report card, using HEDIS©, CAHPS©, and state-specific measures, that Medicaidbeneficiaries can use to compare and choose health plans.Quality improvement projects in the states with MCOs reveal the breadth of state priorities,including, among others, improved birth outcomes, increased access to pediatric subspecialists,identification of high-risk individuals for case management, and coordination betweenbehavioral health and medical providers.Managed care provides a platform for states to ensure the quality of care for Medicaid beneficiaries.Federal regulations define requirements that both states and health plans must meet to measure,monitor, ensure, and improve the quality of care provided to Medicaid beneficiaries enrolled in riskbasedmanaged care, including both MCOs and non-comprehensive PHPs. Each state contracting withplans must have a written quality strategy that includes specified elements, including nationalperformance measures, and must, through its contracts, ensure plan compliance with standards set bythe state. Contracts with plans must require ongoing quality assessment and performance improvementprojects (PIP), and submission of performance data to the state; states must also arrange for annualexternal reviews of the quality, appropriateness, and timeliness of services furnished to Medicaidenrollees. Similar requirements do not exist for fee-for-service.With electronic data increasingly available on many aspects of utilization, clinical outcomes, and patientexperience, states have growing opportunities to examine health plan and health system performanceacross a broad spectrum of quality-related measures. Managed care offers a structure in whichperformance can be measured and enforced. Through managed care contracts, states can specifybenchmarks for acceptable performance and hold health plans accountable for their achievement, andstructure payment to reward (or penalize) good (or poor) performance. The survey asked states anumber of questions concerning the nature and breadth of current and planned activity aimed atmeasuring and improving quality in Medicaid.Appendix 12 provides a summary of states’ use of selected quality tools.Of the 36 states with MCOs, 16 require that risk-based plans be accredited to participate in Medicaid.One means by which states can assure quality in risk-based plans is to require that, as a condition ofparticipating in Medicaid, they obtain accreditation from a national accrediting body, such as the33