*This is an archive page. The links are no longer being updated. 

1993.
10.20 : Guide for States on Health Care Quality Improvement System for Medicaid Managed Care

Contact: Anne Verano (202) 690-6145
October 20, 1993

     The Health Care Financing Administration has released
guidelines for states to use in examining the care provided to
Medicaid recipients by prepaid managed-care health plans.
     The guidelines are contained in a 67-page publication titled
"A Health Care Quality Improvement System for Medicaid Managed Care
-- A Guide for States."
     In the document, managed care refers to Medicaid risk
contracts in which a health plan, such as a health maintenance
organization, accepts full financial responsibility for a Medicaid
enrollee's medical care.
     The topics addressed by the guide include:
     o  A framework for monitoring the quality of health care in a
state-federal managed care system.  Within this framework, the
responsibilities of the federal government and states are outlined.
     o  The standards for quality assurance activities to be
undertaken by managed-care programs.  Among the standards are
internal quality assurance, state monitoring of each managed care
organization to determine the quality of the health care it
delivers and continued federal monitoring of states to ensure they
comply with federal laws governing quality of care.
     o  The identification of 33 high-priority clinical conditions,
such as pregnancy, childhood immunization and lead toxicity,
recommended as important areas for quality-of-care monitoring by
states and the managed-care organizations.  Studies of health-care
services relating to these conditions may be conducted by various
methods including review of medical records, claims or other
administrative data, or special surveys.
     The total number of Medicaid recipients in all types of
managed care, including HMOs, has increased nearly 33 percent in
the past year -- from 3.62 million in 1992 to 4.81 million.
     "This guide has already received widespread praise and is
supported by the managed-care industry," said HCFA Administrator
Bruce C. Vladeck.  "The Physician Payment Review Commission has
called it a 'significant milestone' in the development of quality
assurance for Medicaid managed care.
     "The standards are being issued as suggestions or guidelines
for the states, which the states may use fully or in part," Vladeck
said.  "However, I am urging the states to adopt them, as much as
their resources will allow."
     The Henry J. Kaiser Family Foundation is funding a
demonstration of these guidelines in Minnesota, Ohio and Washington
state.  The National Academy for State Health Policy is
administering this demonstration.
     The document is available from HCFA's Medicaid Managed Care
Office in Baltimore.  Phone: (410) 966-9510.