Guide to Monitoring Medicaid Managed Care Chapter 2

A Guide to Monitoring Medicaid Managed Care
Chapter 2:
How the State and Federal
Governments Monitor Medicaid Managed Care

Advocates are often challenged to prove that the managed care problems they know about anecdotally are widespread enough to warrant action. Data that are collected by managed care plans themselves, by states, or by independent reviewers can help to make the case. Sometimes, these data show clearly that managed care plans are not following the laws or contractual requirements that are meant to protect beneficiaries. Other times the data highlight weaknesses in managed care oversight. Understanding how the government monitors Medicaid managed care will help advocates determine both where data are available and how their states could better ensure the quality and accessibility of care. Basically, there are three sources of Medicaid managed care monitoring information:
1) Medicaid managed care plans are required by law and by their contracts to monitor their own service delivery and to improve the quality of their services.
2) State Medicaid agencies monitor managed care. They require contracting managed care plans to submit data; review managed care plans' compliance with laws, regulations, and contracts; and obtain an independent external review of the quality of each Medicaid managed care plan. States may also collect data about all managed care plans-including those that serve Medicaid beneficiaries and those that serve only the privately insured-under state licensure laws, auditing the financial solvency of these plans and perhaps also collecting information about service utilization and enrollees' complaints.
3) The federal Health Care Financing Administration (HCFA) monitors states' strategies for assuring the quality of contracting managed care plans.
This chapter describes each monitoring activity, the data produced, and how it may be useful to advocates.
Managed Care Plans' Internal Quality Assurance Procedures
Medicaid managed care plans must take some steps to monitor the quality of their own services and correct problems.1 Some of these steps are addressed by plans' operating procedures and administrative structures. For instance, plans credential their providers. Advocates may want to find out what is involved in this process: Does each plan require board certification? If historical providers are "grandfathered" into the plans without being required to meet certification standards, when must they bring their credentials up-to-date? Does the plan screen out doctors who have a history of malpractice? Once in the network, must doctors obtain continuing education on topics relevant to Medicaid patients?
Plans also have grievance procedures, and they should have some process for reporting back to plan administrators and providers about the issues raised in enrollee complaints. Plans survey members and disenrollees and should similarly use the information they gather to improve quality. Consumers and their advocates may be able to get seats on plan "member advisory committees," or even on quality assurance committees to find out whether plans respond adequately to consumer problems and strive to improve the quality and accessibility of their care.
Plans also undertake internal "performance improvement projects." Federal guidelines for these are available in a document called "Quality Improvement System for Managed Care" (QISMC). The standards set forth in QISMC are mandatory for Medicare managed care plans, but states can choose to use QISMC standards for plans serving Medicaid beneficiaries. If states do not use QISMC, they must create their own monitoring strategy. Because the federal government tells states that using QISMC will ensure that they are complying with federal law, many states refer to QISMC in their Medicaid managed care contracts.

CASE STUDY:
CALIFORNIA Why Plans' Internal Quality Assurance Procedures Matter

Dr. Bradley Gilbert, Medical Director of Inland Empire Health Plan (IEHP) in California, gives three examples of ways his plan's procedures have improved the quality of care for Medi-Cal beneficiaries (California's name for Medicaid):

A physician applied to join IEHP's provider panel. Investigating his credentials, IEHP learned that over 20 malpractice cases had been filed against this physician, many of them involving multiple procedures on the same patient. IEHP rejected his application. In contrast, under fee-for-service Medi-Cal, California has no process for investigating physicians' credentials and this same physician was able to obtain a fee-for-service Medi-Cal provider agreement.
During a physician site audit, the nurse reviewer noted that a primary care physician was not performing PAP smears on applicable female members. The physician was referred to Dr. Gilbert, who did another on-site medical record review that revealed the same finding. In discussion, the primary care physician stated that he did not believe in PAP smears as a cost-effective preventive test! Due to this non-compliance, IEHP terminated the physician. He continues to provide care to fee-for-service Medi-Cal and commercial patients.
By comparing physicians' treatment of asthma to national standards, IEHP was able to educate physicians about the most current asthma treatment standards and thus changed for the better the way they practiced.

Source: Information from Dr. Bradley Gilbert, Medical Director, Inland Empire Health Plan, San Bernardino, CA, April 2000.

Under QISMC, plans (in conjunction with states) choose two clinical focus areas from the following list to study each year:
Prevention of acute conditions, · Prevention of chronic conditions,
Care of acute conditions,
Care of chronic conditions,
High-volume services,
High-risk services, and
Continuity and coordination of care.
Plans (in conjunction with states) also choose one of three nonclinical performance areas to study annually:
Availability, accessibility, and cultural competency of services,
Interpersonal aspects of care (e.g., is the provider spending sufficient time with patients?), and
Appeals, grievances, and complaints (e.g., does the plan have good procedures to review grievances? how can services that have given rise to a high number of grievances be improved?).
Study topics rotate each year so that eventually, plans will have examined each area on the list.
The plans first measure their performance in a study area to establish a "baseline." They may take up to two years to establish this baseline. Plans then decide what interventions they will use to improve care or health delivery and implement these interventions. They measure their performance again against the baseline. Improvement is achieved if the intervention either brings the plans' performance up to "benchmark" levels established by the state or reduces the number of cases that failed to meet the benchmark by at least 10 percent. For example, a state goal might be to get 100 percent of 2-year-olds appropriately immunized. If the plan has immunized 80 percent of 2-year-olds when it takes its baseline measure, 20 percent of cases have failed to reach the goal. To reduce the failures by 10 percent, the plan will need to score 82 percent on immunizations when it measures its performance again.
How can the public learn the results of plans' quality assurance activities?
Currently, federal regulations do not explain whether the results of plans' internal studies of quality are public or proprietary. Policymakers often take the view that in order to get providers to examine problems seriously and to improve their own quality, problems must be kept confidential. Without this guarantee, policymakers argue, plans and providers are likely to choose quality improvement projects that make them look good and to underreport problems. Under proposed federal rules issued in December 1999, external reviewers would validate plans' performance improvement projects and the external quality review report would be available to the public. Federal rules should be finalized later in 2000.
Advocates can check with their state Medicaid agencies and the plans themselves to see what information is available in their states from plans' quality studies. By joining the Medicaid agency's state Medical Advisory Committees, which must include consumer representatives, or by joining managed care plan advisory committees, advocates and consumers may obtain more information and may also play a role in shaping plan quality studies and quality improvement efforts.
To learn about the strengths and weaknesses of plans' administrative structures related to quality (grievance systems, consumer surveys, provider credentialing, provider availability, etc.), advocates can turn to audits conducted by the state, external reviews, and results of private accreditation reviews. Advocates may also be able to obtain some information directly by reviewing documents such as member handbooks and provider directories. Audits and external reviews are described below.
State Monitoring Activities
Multiple state agencies may have responsibility for monitoring the performance of Medicaid managed care plans. Medicaid managed care plans may be subject to general HMO state licensure regulations. Depending on state law, the state insurance commissioner (or whatever department or agency oversees health insurance plans) may be required to review the financial solvency and/or the quality of all HMOs. Advocates should consult their state insurance agency regarding any state audits of HMOs and obtain both the audit protocols and the results, possibly after having to file a Freedom of Information Act request for them.
State Medicaid agencies are responsible for making sure that plans comply with federal Medicaid law and regulations and with Medicaid managed care contracts. In order to do this, states require plans to submit data regularly, and states may also perform on-site audits or contract compliance reviews.
a. Data collected by Medicaid agencies
You can compare your state's Medicaid managed care data submission requirements with those of other states by using Chapter 5.2 of Negotiating the New Health System: A Nationwide Study of Medicaid Managed Care Contracts. Through their managed care contracts, states usually require plans to submit information on provider availability, consumer complaints and grievances, enrollment and disenrollment, utilization, encounters, outcomes on clinical indicators, member satisfaction, and finances. Within these broad categories, states' requirements vary greatly. Some states obtain data on treatment of prevalent health conditions. Some states require data on access for members of various linguistic groups. As states draft requests for proposals and managed care contracts, advocates should comment on data that would help them track health care and access problems in their communities. Many state Medicaid agencies require plans to submit audited performance data. These are standardized measures of service use, access, finances, and the quality of care. The data examine, for example, the proportion of people with given health conditions who receive a particular service - e.g., the proportion of female enrollees who received a mammogram. Because the measures are standardized, states can use them to compare performance across plans.

CASE STUDY:
CALIFORNIA Community group uses state data to produce a "Consumer Report Card"

In 1999, Community Health Councils, Inc. (CHC), a community organization in Los Angeles, California, produced its first consumer report card on Medi-Cal managed care plans. CHC convened consumer focus groups in several different languages to find out what issues were most important to consumers when choosing a health plan. They turned these issues into ten "indicators." Then, CHC used data collected by the state on each indicator to grade the plans.

The top three issues important to consumers were: "I can choose the doctor I want," "The doctor speaks my language," and "Quick appointment." These three issues, along with seven additional issues, formed the ten indicators by which each health plan was graded. In order to assign a grade to each health plan, CHC collected data from the California Department of Health Services, the State Department of Corporations, and the individual health plans. Out of the ten participating health plans, two plans received above-average overall grades, and one health plan was below average in comparison to the other health plans.

CHC's report also called attention to weaknesses in California's monitoring system for Medicaid managed care. The state collected very little data on health outcomes. Data that did exist about access and quality of care did not readily support plan comparisons because reporting formats and review dates varied. Even when the state noted problems with plans, the deficiencies lingered for long periods of time. Finally, data were not readily available to the public-CHC had to make repeated requests over an eight-month period to obtain the data used in the report card.

Source: Community Health Councils, Inc. Los Angeles Medi-Cal Managed Care 1999 Consumer Report Card (Los Angeles, CA: Community Health Councils, 1999)

What is HEDIS®?
The Health Plan Employer Data and Information Set (HEDIS®)* is one set of standardized performance measures for managed care plans, which a private, nonprofit organization, the National Committee for Quality Assurance (NCQA), developed. 3 HEDIS® was originally created in 1991 to help employers evaluate private health plans. NCQA, HCFA, and the American Public Welfare Association (renamed the American Public Human Services Association) later worked to develop a version of HEDIS® specifically tailored for the Medicaid program, Medicaid HEDIS®. The latest editions of HEDIS® integrate measures for both Medicaid and private insurance. In 1999, more than 18 states required Medicaid managed care plans to report HEDIS® measures. HCFA is now requiring HEDIS® reporting for Medicare managed care plans, and it is likely that more states will require Medicaid plans to report HEDIS® in the future.
HEDIS® measures are grouped into "domains": effectiveness of care, access/availability of care, satisfaction, cost, stability of the health plan, informed health care choices, use of services, and health plan descriptive information. HEDIS® explains how each measure is calculated. A "childhood immunization status" measure calculates the percentage of children who turned two years old during the reporting year and were continuously enrolled in the plan for 12 months who received specified immunizations. "Availability of primary care providers" (in the access/availability of care domain) calculates the percentage of plan providers who serve the Medicaid population and the percentages of Medicaid primary care providers opened, partially opened, or closed to new members by office site. (For a list of HEDIS® measures, see Chapter 2 Appendix.)
Unfortunately, HEDIS® has several limitations for examining care to the Medicaid population. Few of its measures examine care to persons with disabilities. Most measures examine the process of health care (did a person with a certain condition receive a certain service) rather than health outcomes. Many HEDIS® measures collect data about people who have remained enrolled in the same plan for at least 12 months, whereas enrollment fluctuates for many Medicaid enrollees. Some states, therefore, supplement HEDIS® with other performance measures to examine aspects of health care not covered by HEDIS® or to examine care to shorter-term enrollees.
What is CAHPS®?
To learn Medicaid beneficiaries' views of their managed care plans, states often require surveys of member satisfaction. When plans design and administer their own surveys, the results may be biased, and it is impossible to compare satisfaction across plans. The federal government sponsored development of a national survey instrument, the Consumer Assessment of Health Plans (CAHPS®), which makes comparisons across states possible. Medicare and Medicaid versions of the questionnaire are available through the Agency for Healthcare Research and Quality, For more formation on CAHPS®, see Chapter 5.
b. Compliance reviews and audits
Typically, Medicaid agencies include contract compliance officers who periodically conduct a review of managed care plans' operations. On an ongoing basis, they work with plans to remedy complaints about contract violations. In some states, Medicaid agency personnel themselves conduct on-site reviews of plans' physical facilities and administrative structures. In other states, such on-site reviews are part of the external quality review organization's scope of work.
Review of a plan's administrative structure and operation answers questions such as: Does a quality assurance committee meet regularly, and what does it do to improve the quality of service delivery? Are enrollee rights spelled out in member handbooks? Are grievance decisions communicated to providers? Does the plan have appropriate procedures for authorizing and denying services?
Under current federal regulations, state Medicaid agencies must arrange for medical audits of HMOs and prepaid health plans. Auditors examine service utilization and reasons for member disenrollment and termination. Medicaid agencies also ensure that plans properly implement grievance procedures. HCFA is considering eliminating the annual audit requirements and subsuming audit responsibilities under external review.
What data are public?
Advocates should be able to obtain most data that plans submit to states either through an informal request or under the Freedom of Information Act or Public Records Act. Advocates can also ask their Medicaid agencies for compliance review survey instruments and results.

CASE STUDY:
TENNESSEE External Reviews Confirm Problems Noted By Advocates

External reviews of TennCare Partners, a managed care program for mentally ill Medicaid beneficiaries, showed that, in 1997, the program offered no preventive care and, in many cases, no follow-up care for the mentally ill who were released from hospitals. External reviews showed that the two companies contracting to provide mental health services:

notified case managers only sporadically when acutely ill patients were released from inpatient mental health treatment,
had no process in place for determining needs for case management and assigning case managers, and
did not notify patients of reasons for denying care or of patient appeal rights.

One of the two contractors was "grossly out of compliance" with requirements to adopt clinical standards to guide decisions on patient care. Clinical records showed that "a large percentage of eligible consumers discharged from (inpatient) facilities" had not received case management services from the contractor. Mental health advocates in Tennessee had complained about poor care for months before the external review findings were public, but state officials dismissed their reports as anecdotal. After newspapers reported the findings of the external review, the Governor assigned staff to address problems with TennCare Partners, hired an actuarial firm to determine whether mental health care was adequately funded, asked mental health professionals to assist the state in planning, and allocated direct funding to community mental health centers.

Source: Paula Wade, "TennCare Failing Mentally Ill," The Commercial Appeal, Memphis, TN, January 25, 1998; Tennessee Governor Don Sundquist, "Mental Health Program Announcement," March 12, 1998.

c. External reviews of Medicaid managed care organizations
Advocates have successfully used external reviews to show that problems reported by consumers are not merely random anecdotes but are confirmed in official documents. Advocates have also used external reviews to track whether a managed care plan improves its performance over time and whether the state and plan have taken appropriate action to correct quality problems.
External quality reviews may be the best available source for comparing the overall quality of care of Medicaid managed care plans within a state. These reviews of managed care plans are performed annually by an independent organization that is separate from the state Medicaid agency, state agencies that provide health care to Medicaid beneficiaries, and contracting managed care organizations.* As of spring 2000, the scope of review varies from state to state. Within broad federal guidelines, states determine what factors reviewers will examine and how reviewers will report their findings. The federal government is developing regulations and protocols to standardize external reviews, as required by the Balanced Budget Act of 1997.
In past years, external reviewers generally examined a broad sample of medical records to assess whether providers recorded disease histories, preventive screens, and appropriate diagnoses and follow-up. They also performed "focused studies," which assessed the quality of care provided to enrollees with specific health conditions. For focused studies, reviewers pulled medical records relevant to a study area and compared documented care to medical practice guidelines and quality indicators. External reviews also assessed plans' internal quality assurance systems, grievance processes, and enrollment and disenrollment procedures.
Recently, as states have required plans to conduct internal quality improvement studies and report their performance on standardized measures such as HEDIS®, external review activities have changed. In some states, external reviewers now validate plans' quality improvement projects and performance measures as well as reviewing plans' compliance with standards for access, enrollee rights, grievance systems, enrollment, utilization review, and other quality assurance procedures. Under proposed federal regulations, all Medicaid external review organizations would undertake these activities; at state option, external review organizations could also conduct focused reviews and validate other quality data submitted by plans.
Some plans are exempt from external review
The Balanced Budget Act of 1997 made a change in external review requirements that could have serious implications for oversight of Medicaid managed care. In the future, not all Medicaid managed care plans will be subject to external review. When Medicaid managed care plans are accredited by private independent entities, the Balanced Budget Act provides that external review activities "shall not be duplicative of review activities conducted as part of the accreditation process." 5 Further, states may exempt plans from annual external reviews entirely if the plans contract with both Medicare and Medicaid and have contracted with Medicaid for at least two years. These provisions are of concern to advocates because plans' compliance with Medicare quality standards and private accreditation may not indicate that plans are providing quality care to Medicaid beneficiaries. Plans may, for example, have good geriatric care networks but poor pediatric networks; and they may have separate networks of physicians that serve Medicaid patients. Federal regulations are expected in 2000 that will further explain when plans can be exempted from all or part of the external review process and what accreditation reports or other documents states must review for these exempt managed care plans.
What data are available to the public?
The Balanced Budget Act of 1997 clearly states that external review reports must be available to participating health care providers, enrollees, and potential enrollees of a managed care organization, except that the results may not be available in a manner that discloses the identity of an individual patient. Federal regulations implementing the Balanced Budget Act, expected in 2000, should specify what data must be made available about plans that are exempt from all or part of the external review process. For example, these managed care organizations may need to make data available from their Medicare reviews or private accreditation reports.
How can you analyze results of external quality reviews?
Step One: Find Out What Organization Your State Has Contracted With To Perform External Quality Reviews
Ask either the state or the review organization for a copy of its "scope of work." The scope of work will tell you what the reviewers are supposed to examine and what standards of care they are using to evaluate health plan performance. The scope of work might be part of the request for proposals or the contract with the external quality review organization.
Step Two: Get the Review Results
You may want to ask for reviews for all contracting HMOs in an area, and you may want to look at reviews for several successive years. Portions of the review that address plans' policies and procedures for quality assurance should be readily available to the public after HMOs have had an opportunity to comment on the findings. Portions of the review that address medical issues may be harder to get because they might identify particular providers or patients. Ask your state to delete the confidential data and send you the remainder of these sections. Look back at the scope of work to make sure you have information from all sections of the report.
Step Three: Decide How You Will Compare and Display Findings
In some states, external reviews numerically score plans' performance on various standards. For example, in Maryland, HMOs are scored up to a maximum of 100 percent on meeting performance standards for quality improvement, peer review, marketing, enrollee rights, etc. They are similarly given percentage scores in the medical records review for ambulatory care, continuity of care, hypertension, immunizations, etc. Maryland HMOs can be sanctioned if they do not achieve scores of at least 70 percent in each area. In other states, reviews simply show whether a plan meets or does not meet a particular standard. You may want to prepare a chart showing various plans' scores on standards.
Consumer groups may care more about some standards than others. It is important to find out, for example, what constitutes a 70 percent score in a particular area and explain whether the low score indicates poor patient care or poor data collection that may or may not be indicative of actual care. You can highlight problems that are of particular concern through an accompanying narrative.
Step Four: Find Out What Action Health Plans and Your State Have Taken To Correct Problems
The review report will probably explain the HMO's corrective action plan on any negative findings and will state whether the plan was sufficient in the eyes of the reviewer. If it was not sufficient, follow up with your state to see what is being done. Find out whether the corrective action plan was actually implemented and whether the HMO improved its performance over several years.

CASE STUDY:
CALIFORNIA Medical Audits Show Problems

In California, the Center for Health Care Rights examined medical audits from California's Medi-Cal Prepaid Health Plans in 1992, 1993, and 1994. The audits evaluated whether plans had no deficiency, a minor deficiency, a significant deficiency, a major deficiency, or a severe deficiency in various categories. Audits indicated that:

All seven of California's Medi-Cal prepaid health plans had "significant" or "major" problems with preventive services; six of the seven had "significant" or "major" problems with continuity of care; and four of the seven had "significant" or "major" problems with quality.
Reports of serious continuity or quality of care problems discovered in 1991 and 1992 medical audits did not generally result in improved plan performance the following year. One health plan's 1992 medical audit showed the plan to be "significantly deficient" in the provision of preventive services. In one case, a patient with a corneal transplant was referred to optometry, which found that stitches in one eye were still in place but provided no referral or follow-up care. In 1993, the health plan's preventive services worsened to a major deficiency: children's histories, assessments, and lead levels were not documented in medical records; adult care, including history, Pap smears, breast exams, and EKG, was not "provided, documented or repeated when necessary."

Source: Geraldine Dallek, State Oversight of Medi-Cal Managed Care Plans: How Well Does California Protect Poor Families? (Los Angeles, CA: Center for Health Care Rights, 1994).

Step Five: Find Out How Your State Plans to Disseminate Information About Quality Reviews to Consumers. You might want to convene a meeting of consumers to discuss what you found from the external quality reviews and what information would be most useful to Medicaid managed care enrollees or potential enrollees. You can then make recommendations to the state about how to publish comparative information.

CASE STUDY:
CALIFORNIA Make Sure Your State Uses External Quality Reviews To Improve Care, Not Just To Improve Data Collection

In 1998, California's external quality review organization reported on the quality of plans' care to pregnant women and well-children. Reviewers asked plans to submit medical records from their contracting providers. Using the medical records, reviewers calculated performance measures for each plan-for example, the proportion of three-to-six-year olds enrolled for a year who received well-child visits and the proportion of pregnant women who received care during their first trimester. In many cases, plans and/or providers failed to submit medical records for review. To hold plans accountable when medical records are missing, reviewers count the patient as one who did not receive appropriate care.

Many plans scored very poorly on the external review studies. However, some plans disputed whether the scores reflected poor care or flaws in the methodology for obtaining and reviewing medical records. Advocates sought to answer this question by performing another analysis of the data. Advocates excluded all cases with missing records and then calculated the proportion of records examined that showed appropriate care. This analysis showed that there were indeed problems with care delivery. For instance, of the children whose records were actually examined, fewer than 40 percent received well-child visits in two plans.

Source: Medi-Cal Community Assistance Project, Is Quality Really Being Measured in Medi-Cal Managed Care?, July 1999 (Available from Health Access, San Francisco, CA, 415-395-7955; http://www.familiesusa.org/pubs/caqual.htm).

Federal Government Monitoring Policies and Procedures
HCFA must approve any state proposal to require Medicaid beneficiaries to enroll in managed care, whether states amend their state Medicaid plans or request a waiver of certain federal Medicaid rules under Section 1915(b) or Section 1115 of the Social Security Act. HCFA also approves states' contracts with managed care organizations, and these contracts set forth quality assurance and data collection requirements for managed care organizations. 6 On an ongoing basis, HCFA is responsible for assuring that state Medicaid programs comply with federal laws. Advocates can report problems with managed care to HCFA's regional offices.
The Department of Health and Human Services' Office for Civil Rights can also act to stop practices that discriminate against Medicaid beneficiaries based on race, ethnicity, gender, age, or disability status. For example, the Office for Civil Rights found that Illinois's managed care program did not provide hearing-impaired persons and individuals with limited English proficiency with equal access to services. Subsequently, Illinois agreed to policies to ensure interpreters and to require HMO marketing information in the primary language spoken by the beneficiary.
When states mandate managed care under waivers, HCFA takes an active role in monitoring compliance, requiring states to submit data to the federal government. For example, HCFA has conducted "readiness reviews" to determine whether states' administrative systems were adequate for managed care. In California, HCFA delayed mandatory managed care enrollment in certain counties until California improved its enrollment systems. Through terms and conditions on waivers, HCFA has required states to regularly report data on access to care, grievances, enrollment and quality. Prior to renewal of a 1915(b) waiver, states must submit an independent evaluation of their managed care programs to HCFA. The evaluations must show that quality of care under the waiver is equal or better than quality of care without the waiver. HCFA itself obtains an evaluation of quality and access to care under 1115 waivers.
Endnotes
1 Under federal law, states must require Medicaid managed care contractors to provide quality assurance data, and states must develop and implement quality assessment and improvement strategies (Social Security Act § 1932 (c)). Current federal regulations requiring Medicaid managed care plans to have internal quality assurance systems, 42 CFR § 434.34, are expected to be updated in 2000.
2 Sara Rosenbaum, et al., Negotiating The New Health System: A Nationwide Study of Medicaid Managed Care Contracts, Third Edition [Washington, D.C.: George Washington University Center for Health Services Research and Policy, 1999.
3 Other organizations have also developed performance measurement sets. The Foundation for Accountability, FACCT, has developed and endorsed measures to determine whether treatment has made a difference for people with specific medical conditions or common health care needs. Various groups are developing performance indicators for mental health care (e.g., American College of Mental Health Administration, National Association of State Mental Health Program Directors, and the National Association of State Alcohol and Drug Abuse Directors). The Joint Commission on Healthcare Accreditation has developed measures for hospital care.
4   Private accreditation reviews address similar questions. However, while private accreditation examines the overall structure of a managed care plan, Medicaid reviews focus on the structures pertaining to Medicaid beneficiaries. This is important because Medicaid beneficiaries often use distinct provider networks.
5    Social Security Act § 1932(c)(2).
6   Letter from Sally Richardson, Center for Medicaid and State Operations, HCFA, Baltimore, MD, December 17, 1997 to state Medicaid directors.
7 Office for Civil Rights, OCR Update (U.S Department of Health and Human Services, Washington, DC, Fall 1999).