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Advocates Urge More Government Oversight Of Medicaid Managed Care

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Ingram said Medicaid directors who are getting pressured by governors and legislatures to expand managed care often end up focusing on “bright and shiny” new initiatives. “Oversight of our managed care plans is less bright and shiny,” she said. “The day-to-day monitoring of managed care plans goes kind of on the back burner. That’s where you put your newer staff, your green staff.”

Florida’s experience with managed care underscores the importance of close monitoring. After the state launched a pilot program in 2006, doctors were unhappy about delayed payments and administrative obstacles, patients complained about being denied access to services and data on the quality of care was lacking. Several insurers dropped out because they couldn’t make enough money.

State officials say those problems have been fixed. In 2011, the federal government approved an extension of the pilot and in June agreed to allow Florida to expand it statewide.

But Georgetown University’s Health Policy Institute has been critical of Florida’s pilot program.  “Little data is available to assess whether access to care has improved or worsened,” it reported in 2011, noting there is no “clear evidence” the program is saving money and if it is, “whether the savings came at the expense of needed care.”

Advocates say access problems remain and Florida’s oversight is inadequate. “The state is supposed to be overseeing all of this. They haven’t done a good job of that,” said Laura Goodhue, executive director of Florida CHAIN, a statewide health care advocacy group.

Experts caution that even in states that devote lots of resources to oversight, many of the quality standards they use are aimed at figuring out whether services were provided, not the effect on patients’ health – what they call “outcome.”

“Even if there’s an intent to aggressively monitor, you have to figure out whether and how they’re doing it. And measuring quality is really, really tough,” said Michael Sparer, a Columbia University professor of health policy. “We can say immunization rates have gone up or waiting times are down…But measuring whether outcomes have changed substantively is very elusive and difficult to get at.”

In a few states, legislators have tried to beef up oversight.

In Kansas, which in January moved nearly all of its 380,000 Medicaid members into plans run by three commercial plans, the legislature decided to do its own oversight. It unanimously passed a bill in March that would establish a joint legislative committee to monitor the state’s Medicaid managed care program. The governor signed it in April.

“We need to make sure they’re adhering to contractual arrangements, that they’re providing the services they committed to provide, that our Medicaid clients have access to services and are actually getting them,” said Kansas State Sen. Laura Kelly, a Topeka Democrat.

Wed, Jul 03 2013

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