Medicaid and CHIP Risk-Based Managed Care in 20 States. Experiences Over the Past Decade and Lessons for the Future.. Impressions of Quality Monitoring under Risk-Based Managed Care


States, providers, and plans give somewhat contrasting impressions of the effectiveness of the quality monitoring initiatives that have been adopted in their states for Medicaid/CHIP risk-based managed care enrollees. State representatives generally expressed positive opinions about their programs, but providers were more negative in their assessments as shown by these opinions.

I don’t see managed care for Medicaid as being the driver of quality improvement just because they are tracking the data. (Provider Representative)

I think Medicaid managed care has helped some, but has it sufficiently addressed the opportunity to improve health? I don’t think so. (Provider Representative)

Plan representatives gave a more mixed assessment, reflecting an impression that the "cup is half empty and half full." On the positive side:

We have been proud of the fact that our principal focus is on the quality side and "patients first" side, and the finance piece follows second. (Plan Representative)

We take pride in the fact that we provide high-quality care even within the constraints of limited Medicaid funding. (Plan Representative)

[Speaking of quality improvement] We work hard to improve our results. Are there problems? Sure. But I think overall we get good quality. (Plan Representative)

However, one plan representative thought that the heavy emphasis on HEDIS as a quality improvement tool is misplaced.

I don’t think HEDIS drives quality; [it uses] very old, superficial metrics.
(Plan Representative)

And another plan representative admitted that quality of care may suffer when rates are cut.

We don’t want to admit that it [reimbursement cuts] affects quality, but we are certainly stretched. (Plan Representative)

View full report


"rpt.pdf" (pdf, 1.42Mb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®