Reconciling practice and theory: challenges in monitoring Medicaid managed-care quality.
Date of Pub
The massive shift to managed care in many State Medicaid programs heightens the importance of identifying effective approaches
to promote and oversee quality in plans serving Medicaid enrollees. This article reviews operational issues and lessons from
the ongoing evaluation of a three-State demonstration of the Health Care Financing Administration's (HCFA) Quality Assurance
Reform Initiative (QARI) for Medicaid managed care. The QARI experience to date shows the potential utility of the system
while drawing attention to the challenges involved in translating theory to practice. These challenges include data limitations
and staffing constraints, diverse levels of sophistication among States and health plans, and the practical limitations of
using quality indicators for a population that is often enrolled only on a discontinuous basis. To overcome these challenges,
we suggest using realistically long timeframes for system implementation, with intermediate short-term strategies that could
treat States and managed-care plans differently depending on their stage of development.
Guidelines : Health Services Research/methods : Managed Care Programs/statistics & numerical data/standards : Medicaid/statistics
& numerical data/standards : Pilot Projects : Program Evaluation : Quality Assurance, Health Care/organization & administration
: State Health Plans/organization & administration/standards : Support, Non-U.S. Gov't : United States : United States Health
Care Financing Administration