Assessing the Quality of Medicaid Managed Health Care Plans

It was in 1965 when Medicaid was created. It is a government program funded by both the states and federal government. Medicaid was created to provide health care services to low-income families, elders, disabled and blind who require assistance beyond what Medicare can provide.

From the time Medicaid was established, health care costs grew exponentially. The health care system was mainly fee-for-service system wherein doctors, hospitals and other medical practitioners and institutions charge the patient for each service provided separately. Individuals and health insurance policies or plans paid for each service rendered as they were used. Medicaid operated on the same system as the private health insurance providers.

It soon became apparent that the fee-for-service system was responsible for health care costs skyrocketing. The fee-for-service system allowed patients and medical service providers to access expensive but not necessarily efficient services. Because of this, manage health care was created. Managed health care brought in new health care delivery and financing arrangement that eventually controlled the costs of health care.

For the past couple of decades, Medicaid also observed a notable increase in its yearly spending. This increase in spending was basically a by-product of the problems that are inherent to the Medicaid program. It was evident that Medicaid beneficiaries were having difficulty in finding health care providers because of Medicaid’s low reimbursement rates and the fact that the paperwork needed to claim reimbursement were considered burdensome. In order to get medical attention, Medicaid beneficiaries frequented emergency rooms. But trips to the emergency room were never a guarantee that the patient will be treated continuously.

Because of this alarming problem, different states adopted the new health care delivery program to the existing Medicaid program. The managed health care plans helped the federal and state government officials to see that with managed care, health care costs can be controlled. Managed health care also provided better care coordination as well as maintaining control over the network of health care providers available to Medicaid beneficiaries. With these changes, more and more people enrolled in Medicaid managed health care plans.

Over the years the government agencies used different methodologies in assessing the quality of Medicaid managed health care plans.  These methodologies will enable government officials to tell whether or not Medicaid is providing quality managed health care. The result of this assessment will be used as a basis for improvement in the Medicaid managed health care programs. Below are some descriptions that different states use in assessing the quality of Medicaid managed health care plans.

Ø  Requiring periodic plan reports: The state is required to collect accurate, reliable and valid data form the managed care plans. Accurate, reliable and valid data is important in measuring the quality of care for Medicaid managed care. The federal government requires that all states must submit periodic plan reports.

Ø  External quality reviews: This is a federal requirement that is done on a yearly basis. The state usually contracts the services of an external quality review organization to conduct such tasks. The organization may review medical records, data procedures and collection and conduct of quality care studies.

Ø  Focused quality care review: The State assesses the quality of care provided by Medicaid managed health care plans.

Ø  Provider feedback: Surveys and focus group discussion make it possible for the State to elicit feedback from providers.

These are just some of the ways that the federal government use to assess the quality of Medicaid managed health care plans for each State. Some of the descriptions are not applicable in some states or they may have different ways in conducting assessment programs.

Medicaid managed care still faces a lot of criticism. Since the main reason why managed care was established was to control costs, many argue that what Medicaid is providing is low quality of health care. Up to this time, government officials are continuously seeking new ways to assess and make sure that the quality of managed health care being provided to Medicaid beneficiaries are not low quality.


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