System change: quality assessment and improvement for Medicaid managed care

Abstract

Rising Medicaid health expenditures have hastened the development of State managed care programs. Methods to monitor and improve health care under Medicaid are changing. Under fee-for-service (FFS), the primary concern was to avoid overutilization. Under managed care, it is to avoid underutilization. Quality enhancement thus moves from addressing inefficiency to addressing insufficiency of care. This article presents a case study of Virginia's redesign of Quality Assessment and Improvement (QA/I) for Medicaid, adapting the guidelines of the Quality Assurance Reform Initiative (QARI) of the Health Care Financing Administration (HCFA). The article concludes that redesigns should emphasize Continuous Quality Improvement (CQI) by all providers and of multi-faceted, population-based data.

Figure 1. Comparison of Methods of Monitoring Quality and Service Use Under Medicaid Fee-for-Service, Primary-Care Case Management, and Capitated Care

Figure 2. Quality of Care Framework for Medicaid Managed Care

Figure 3. Immunization Report Form

Figure 4. Quality Assessment and Improvement Project: Sampling Schemes for Detailed Chart Review of Primary-Care Physician (MEDALLION) and Health Maintenance Organizations (OPTIONS)

Figure 5. Capitation and Quality Oversight Relationships in Medicaid Managed Care