As with strategies that target providers, provider perceptions of these beneficiary-based strategies were mixed. This research examines quality management in Medicaid managed care from the perspectives of Medicaid officials, managed care plan representatives, and providers through 25 qualitative interviews in one Northeastern state. The proportion of providers patient panels enrolled in Medicaid varied from 5% to 90%. Unmet social need is an additional theme that arose during these interviews. This is problematic given enormous changes to health care following implementation of the Affordable Care Act and intensive efforts by the Centers for Medicare & Medicaid Services to increase federal and state oversight of Medicaid managed care. The present research includes the units of providers, managed care plans, and the Medicaid office. This study suggests that in this state representatives from the Medicaid office were closely aware of plans quality management strategies and their descriptions closely aligned with those of plan representatives. Managed Care is a health care delivery system organized to manage cost, utilization, and quality. Managed care is specific to health care in the United States. HMOs, PPOs, and POS Plans Enrollment and spending on Medicaid managed care, Qualitative data analysis: A methods source-book. Managed care: Practice, pitfalls, and potential - PMC - Definition & Examples Quiz, What Is Case Management? All interviews were audio recorded (with participants consent) and transcribed for data analysis. Despite this impression of improved customer service, Medicaid officials did not find plan strategies targeting providers to be especially helpful: We pick a measure in which our plans perform below a certain percentile, usually the 75th percentile. I would say in general thats been a rather unsatisfying process. By the following January, $80,000had been expanded to cover services provided. - Definition & Process Quiz, What Is OASDI? This research is an important step in examining how managed care plans structure their efforts and how critical stakeholders view the efficacy of these efforts. Plan representatives described quality management efforts as robust and discussed strategies targeting providers and beneficiaries. One provider considered HEDIS measures a minimum of what should be required by a physician: They do have the HEDIS data. But if youre not doing these things, youre not really doing your job as a pediatrician. You can move this in the right direction so that we get up to 90th percentile or 80th percentile. And I think that all of these approaches work. In the Medicaid office, we recruited and interviewed experts about contracting with managed care plans, quality management initiatives, and outcome measures. The model posits that managed care plans affect the quality of care through four mechanisms: (1) defining the nature and capabilities of providers, (2) directly interacting with beneficiaries (e.g., through reminders or incentives for preventive care services), (3) implementing broad population health-focused efforts, and (4) influencing provider behavior (e.g., through financial incentives or management or administrative strategies like chart review and performance feedback). While acknowledging the feedback, provider participants described feedback as either not helpful or that the focus on HEDIS measures was not sufficient. Assist with social issues or needs that may arise that could be really the issue. I think more so now than ever, its really looking at the person holistically and having a person-centered approach. Managed Care: Types & Examples - Study.com So whatever strategies there are, if theyre out there, I really dont know about them. Such representatives commonly described both monetary and non-monetary incentives. In addition to simply providing physicians with their own data, plans may also compare their performance with their peers: Sometimes well contact them directly to say, Heres your data. Quality oversight for Medicaid managed care plans: Impact on providers, Journal of Public Health Management Practice, Mixed methods in health sciences research: A practical primer, How the Affordable Care Act will strengthen the nations primary care foundation. Under Medicaid managed care, private health insurance plans receive capitated payments from state Medicaid programs to finance health services for Medicaid beneficiaries. Interview participants discussed that Medicaid managed care plans made some efforts to coordinate care for their beneficiaries. I think if they were to work cooperatively, to meet with providers to set common goals, to open lines of communication, all of which are absent. Provider participants included 11 pediatricians (of which 2 were residents), 1 pediatrician/internal medicine physician, 1 family physician, and 2 obstetricians. This article is part of a larger project that leveraged a novel policy experiment, in which a Northeastern state, following the 2010 exit of one of the three managed care plans serving Medicaid beneficiaries, randomly assigned the exiting plans beneficiaries to the remaining two plans offered in the state. The interviews presented here were conducted between February and October of 2016. Thats an automatic call that goes to the parents or guardian of the child, and its really to remind them that theres a milestone thats coming up. You can assess your knowledge of this care and its history by completing the quiz and worksheet. However, the siloed administration and payment of health care complicates the provision of coordinated care and creates the potential for efforts to be duplicated (Rich, Lipson, Libersky, & Parchman, 2012). Thats one place where Medicaid has actually some dollars on the table for the providers to fill out the assessment forms on pregnancy, and be able to manage them accordingly. Any time we have a new pregnant woman, were supposed to do a risk assessment form that is sent to [the plan]. Although previous research has suggested that the provision of performance feedback to providers may be a key strategy to manage quality of care (Williams et al., 1999), this did not emerge as a best practice in the present study. Ch 3 Review and Test Yourself.docx - The intent of managed What do you think? So things like posters and letters, and primary care provider reminders, those are all helpful. One provider described some materials as helpful: We have promotional materials all the time for the health plan. We get materials about the program and how to tell people to enroll, and all of that stuff Patients tell us that they use [the programs], and that it can help em! Adding further complexity to these challenges, previous research has found that Medicaid managed care plans are hindered from attempting to directly address social determinants of health of their beneficiaries by regulatory requirements, and authors suggest, among other strategies, that plans be more engaged in regulatory decision making (Gottlieb, Quinones-Rivera, Manchanda, Wing, & Ackerman, 2017). Two providers reported practicing in patient-centered medical home settings. (2016). True. Performance data must be accurate, valid, and reflect measures that providers consider to be important in assessing quality of care. So we meet with members periodically and talk with them. Managed Care: MedlinePlus Because prior research examining quality management efforts by Medicaid managed care date from the late 1990s and early 2000s, recent evidence following the striking growth of managed care enrollment over the past decade is limited and needed. Providers were compensated with a $50 gift card for their time. When a managed care organization is known for being the best in a specific service field, the number of cases using that service increases. State Medicaid offices that contract with managed care plans are responsible for monitoring the quality of care and outcomes of Medicaid beneficiaries enrolled in these plans, and many states either encourage or require managed care organizations to participate and invest in quality improvement or management (Centers for Medicare & Medicaid Services, n.d.). However, the state Medicaid office did not prescribe specific quality management strategies to health plans, believing them to be the responsibility of the plan even when they believed the strategies to not be particularly robust. But [the plan] telling me that this kid is obese isnt helpful. If so, our finding about whether or not communication with beneficiaries is an effective strategy is especially relevant. The experiences of these 16 providers may not be representative of the experiences of providers in the state more broadly. Sometimes this feedback took the form of lists of noncompliant patients: They will, sometimes, come to us with lists of patients, like we think these patients are overdo for care (Provider 1). So thats been a great program. What is Managed Care? | Cigna See the Supplemental Material for the interview protocols. One representative described a financial program: We also have member incentive programs, so right now members who are eligible can receive 25 dollars for completing their mammogram. These included outreach and reminders, incentives, a combination of outreach plus incentives, and more active engagement through beneficiary advisory boards. One representative explained their plans program that focused on managing care for pregnant women: It is a web-enabled app that pregnant moms can get; we offer it broadly through the prenatal care providers, and then once the woman signs up, she gets messages that come through based on where she is in her pregnancy, like, Ooh you might be feeling nauseous today. Although providers described performance feedback as helpful, many said that it was not sufficient in the goal of improving/managing care quality. 4 (Summer 1996): 65-76; and Stephanie L. Shimada et al., "Market and Beneficiary Characteristics Associated with Enrollment in Medicare Managed Care Plans and Fee-for-Service," Medical Care 47, no. - Definition, Eligibility & Coverage, What Is Medicare? Start Preamble Start Printed Page 72754 AGENCY: Centers for Medicare & Medicaid Services (CMS), Health and Human Services (HHS). I can tell you, I never heard any of my patients come to me and say, I got a brochure from [plan B] or from [plan A], and they sent me, you know, why dont you do this, or do that, or whatever. But maybe they get them. The remaining $20,000 is: One provider described a desire to hear more about patient outreach and suggested that plans seek input from providers: I would also ask if there were times when they were doing mailings, if they are sending things directly to our patients, we would love a copy to come to us, like if they were going to do outreach we would love to know in advance so that we could anticipate questions or influx of patients with significant issues and be prepared for it. If [plans] have interest in incentive programs to kind of draw on a little bit or seek input about what might work from their practices, that would be pretty neat. 2021 Feb; 78(1): 3647. Before Schneider EC, Landon BE, Tobias C, & Epstein AM (2004). What are Medicare managed care plans doing to measure and improve quality of care? - Definition & Shortage Quiz, What Is a Standing Order? c. an inexpensive form of payment for healthcare services d. managing healthcare provider stress See answer Advertisement A managed care organization functions like a. a provider b. an insurer
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