States? use of managed care has expanded steadily over the last 30 years. The Kaiser Commission on Medicaid and the Uninsured recently surveyed Medicaid managed care in the 50 states and found that, overall, 30 of the 48 states with comprehensive managed care programs are contracting with risk-based managed care organizations (MCOs). See Kaiser Comm?n on Medicaid and the Uninsured, A Profile of Medicaid Managed Care Programs in 2010: Findings from a 50-state Survey 2 (Sept. 2011) (also reporting 31 states operated primary care case management systems).
When MCOs aggressively entered the Medicaid market 30 years ago, they promised budget predictability to states and a medical home to Medicaid beneficiaries. And while the former has been achieved to some extent, the latter has not. More than two-thirds of responding states with MCOs report that enrolled Medicaid beneficiaries experience access problems. Id. at 3.
The Role of HEDIS
The Health Effectiveness Data and Information Set (HEDIS) is a group of performance measures owned by the National Committee for Quality Assurance (NCQA). Some state Medicaid programs use HEDIS to measure MCO performance.
More than 100,000 District of Columbia Medicaid beneficiaries are enrolled in, and thus depend on, one of four MCOs for their health care services. In 2009, the following four MCOs were contractors: Chartered Health Plan (CHP), Health Right, Inc. (HRI), Health Services for Children with Special Needs (HSCSN), and Unison Health Plan.
The most recent 2009 external quality review report of MCOs? performance on HEDIS measures shows wide variation among MCOs and some alarmingly low performance.
(Reminder: The MCOs are paid ahead of time to provide the services to their patients/enrollees.)
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