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Advocates Urge More Government Oversight Of Medicaid Managed Care


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.”

Matt Salo, executive director of the National Association of Medicaid Directors, said states may oversee quality and access differently, but that he’s “not aware of anyone doing it badly.”

Salo pointed out that in traditional Medicaid, with states focused on paying doctors and hospitals for each service they provide, there is little monitoring and oversight, other than for financial fraud and abuse.

“The irony about quality is that consumer advocates say we’re not sure there’s a proper focus on quality. But where are the quality measures for fee-for-service Medicaid?” he said.

Some state Medicaid offices have taken a hit in recent years because of budget cuts – Washington state’s program lost more than 200 positions since 2009. And oversight isn’t always a priority, says Carolyn Ingram, a former New Mexico Medicaid director who is senior vice president of the Center for Health Care Strategies, a nonprofit health policy center.

Wed, Jul 03 2013

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