External Quality Review and Related Issues for Medicaid Plans: Policy Recommendations for an Enhanced Public/Private Partnership

摘要

The National Association of Urban-Based HMOs, Inc. (NAUMO) is a non-profit 501 (c)(3) organization, established in 1993, comprised of health plans with a mission of service to vulnerable populations. Historically, many of these populations faced numerous inadequacies in the quality of care they received and sufficient access to providers, resulting in increased health risks and costs. Consequently, NAUHMO is committed to ensuring the highest level of care and service to these populations. The current trend of inconsistent, and often conflicting, state and federal practices in quality monitoring and oversight of health plans, however, compromises plans ability to meet this quality commitment. NAUHMO, on behalf of its members, is requesting that HCFA undertake a more proactive role in the oversight of states quality monitoring process to ensure that the states process, goals and objectives comport with the intent of the federal government in its establishment of quality monitoring goals and objectives. This paper presents an overview of issues and recommendations related to the Medicaid plan external quality review and monitoring. The member plans of NAUHMO have observed and are experiencing several problems in monitoring and managing the various quality performance guidelines, mandates, and policies that affect their business. Currently, there is lack of consistency and/or synergy of the various quality performance standards and measurements of federal and state contractual requirements and guidelines for Medicaid Managed Care Organizations (MCOs). More specifically, with regard to consistency, is that NAUHMO believes that HCFAs intended result of Medicaid managed care is that of demonstrable improved value to the government, as purchaser, as exhibited by quality measures. However, NAUHMO plans experience with states has indicated that generally states interests are limited to cost savings. While cost-effectiveness is essential, the experiential reality that improved value and quality outcomes result in expenses to plans is not usually reflected in Medicaid rates paid to plans.