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Health Care Reform:

Health Insurance & Affordable Care Act

Advocates Urge More Government Oversight Of Medicaid Managed Care


States are supposed to set rates, monitor contracts and enrollment practices, make sure that plans have sufficient networks of doctors, oversee quality and performance and ensure consumer protections for members. But how they each go about doing it is up to them.

For example, federal rules don’t say how many doctors a plan must contract with or how often state officials need to review the adequacy of the plan’s network of doctors.

Seventeen states require Medicaid health plans to be accredited by a national organization, which sets specific quality standards. Other states use some of those standards, but don’t require accreditation. Each state chooses its own approach.

States also must arrange for an external group to independently monitor the plans’ quality of care every year. But the federal requirement doesn’t specify how that monitoring should be done either.

“If you want to collect data about screening people for obesity, Minnesota may collect it, but Louisiana may not,” said Sarah Somers, a managing attorney for the National Health Law Program, a nonprofit legal services group for low-income people. “If you want to do a systematic comparison across the states, it’s not really doable.”

A July 2012 Urban Institute study of Medicaid managed care in 20 states found “tremendous variation” in the kind of quality monitoring conducted by states and health plans and in how they ensure the plans’ networks of doctors are adequate. The maximum number of patients per doctor, for example, varied from 750 in Michigan to 2,500 in Tennessee. In rural areas, primary care doctors had to be located within 10 miles of patients in California, but within 45 miles in Ohio.

Embry Howell, a senior fellow who co-authored the study, said that while states don’t necessarily need to use all of the same quality measurements, there should be a way to compare them state-to-state and plan-to-plan. “Otherwise the data is going to be apples and oranges,” Howell said. “This is important. It’s the accountability side of it.”

Even the health plans themselves are frustrated with the hodgepodge of state quality measures. “It adds an additional level of complexity for plans that operate in a dozen or more states,” said Joe Moser, executive director of Medicaid Health Plans of America, an industry trade group. “We do support more federal standardization.”

Wed, Jul 03 2013

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