263063 How States Ensure Access and Quality of Care to Medicaid Managed Care Enrollees

Tuesday, October 30, 2012 : 10:50 AM - 11:10 AM

Ashley Palmer, MPP , Health Policy, Urban Institute, Washington, DC, DC
Embry M. Howell, MSPH, PhD , Health Policy Center, The Urban Institute, Washington, DC
Fiona Adams, BA , Health Policy Center, The Urban Institute, Washington, DC
Research Objective: To describe the methods that states use to ensure that Medicaid managed care enrollees have adequate access to a primary care provider, and to understand how they currently evaluate the quality of that care.

Study Design: We interviewed state Medicaid and CHIP officials, health plans, and provider groups in 20 states. We also reviewed managed care contracts and collected HEDIS and CAHPS data.

Principal Findings: All states have adopted specific standards regarding primary care provider availability. Most of the 20 states in our study held similar standards regarding appointment wait times, geographic proximity to enrollees, and PCP–to-enrollee ratios. It was common for states to allow health plans to monitor these provider networks and provide information on their compliance directly to the state (13 out of 14 states answering the question said that they obtained regular reports on network availability from their health plans). Only 3 states called provider offices directly to verify availability. States monitored quality of care through grievances, survey data (CAHPS), HEDIS, and encounter data. The extent to which this data was audited and verified varied.

Conclusions: In order for states to better understand the experiences of their Medicaid managed care enrollees, they must take a direct approach to provider network monitoring and create processes to ensure that quality data is robust.

Learning Areas:
Administration, management, leadership
Program planning
Provision of health care to the public
Public health or related laws, regulations, standards, or guidelines
Public health or related organizational policy, standards, or other guidelines
Public health or related public policy

Learning Objectives:
Describe how states currently monitor quality of care in Medicaid managed care programs Differentiate between state approaches Determine advantages and disadvantages of different types of approaches

Keywords: Access to Health Care, HEDIS

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I conducted many of the interviews for this research, the data analysis, and wrote up the findings
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

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