The 131st Annual Meeting (November 15-19, 2003) of APHA

Abstract #60152

Stephen Engle, MD, Dipl ABIM, Medical Review Branch, California Department of Health Services, 5701 South Eastern Avenue, Suite 601, Commerce, CA 90040, (323) 869-2535, Sengle@dhs.ca.gov

INTRODUCTION: In fee-for-service Medicaid programs, it is difficult to systematically monitor medical care quality as it pertains to specific patients. The purpose of this presentation is to describe a pilot project in California’s Medicaid program (“Medi-Cal”) which includes a novel form of proactive administrative medical oversight, management, and intervention on an individual beneficiary basis. PROJECT DESIGN AND METHODS: From 1,915 beneficiaries, 94 with the highest number of different providers claiming for healthcare services were selected for review. Of these 94, a physician identified 49 whose detailed claims information was highly suggestive of inadequate and/or substandard medical care. Next, registered nurses attempted to determine through beneficiary interview if any of the suspected deficiencies in medical care actually existed. RESULTS: 38 beneficiaries could not be located, and were required to prospectively obtain prior authorization of all future medical services. Two beneficiaries were enrolled in Medi-Cal managed care programs, while having some claims for inappropriate medications submitted to their Medi-Cal fee-for-service accounts. Nine beneficiaries were identified as receiving inadequate medical therapy, inadequate diagnostic evaluations, inadequate continuity of care, inadequate case management, and/or inadequate attention to profound psychosocial circumstances. All nine of these were placed under a case management program to coordinate and monitor these beneficiaries’ medical care services. CONCLUSIONS: The procedure described has the potential to identify significant numbers of Medicaid beneficiaries who are receiving inadequate and substandard fee-for-service medical care, and who could potentially benefit from structured case management and oversight of their medical care.

Learning Objectives:

At the conclusion of the session, the participant (learner) in this session will be able to:
• Describe the California Medicaid pilot system for monitoring and identifying fee-for-service beneficiaries who may be receiving inadequate and substandard medical care;
• Analyze medical claims data for patterns suspicious of inadequate and substandard medical care;
• Determine appropriate options for disposition of Medicaid beneficiaries who are identified as receiving inadequate and substandard medical care.

Keywords: Medicaid, Health Care Quality

Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: California Department of Health Services
I have a significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.
Relationship: Employee