Recorded presentation

Sara Rosenbaum, JD¹, Anne R Markus, JD, PhD¹, Colleen Sonosky, JD², Lee Repasch, MA¹, and Rick Mauery, MPH¹. (1) Department of Health Policy, The George Washington University Medical Center, 2021 K St, NW, Suite 800, Washington, DC 20006, 202-530-2339, armarkus@gwu.edu, (2) Children's Defense Fund, 25 E Street, NW, Washington, DC 20001

Objective: To examine state experiences with monitoring and enforcing managed care contractual standards of pediatric care.

Design: Semi-structured telephone interviews with Medicaid/SCHIP officials involved in contract oversight in 9 states. Questions focused on the logic behind selecting one high/one low prevalence condition (oral disease/lead poisoning) to emphasize in the contract, the development of expectations regarding MCO performance in these two areas of child health, and the monitoring of actual performance against those expectations.

Findings: Medicaid and SCHIP contractual provisions varied in specificity across/within states but generally addressed the oral health and lead screening service components and periodicity schedules. All agencies had a formal monitoring plan and collected data regularly to measure MCO compliance with quantifiable standards but few used quality benchmarks specific to oral health and lead screening. Many designed a graduated incentive and penalty system, believed to favor compliance; many also stressed the need for collaboration with MCOs due to underlying systemic issues.

Conclusions/Implications: States adapt their strategies to the conditions of local markets to achieve the best possible outcomes for children under the circumstances. They pay attention to the contract and generally perform some contract monitoring. However, they do not consider the contract as all encompassing on quality improvement. Implications are twofold. First, legislation on Medicaid/SCHIP quality improvement should remain broad so that states can tailor their approaches to local circumstances. Second, states should be encouraged to turn to additional, non-contractual strategies, such as community awareness, to address underlying systemic problems.

Learning Objectives: At the conclusion of the session, the participant (learner) in this session will be able to

• Describe the various elements of state approaches to ensuring pediatric quality;
• Recognize similarities and differences in these approaches by type of program, managed care market, and standard of care; and
• Articulate public health policy implications

Keywords: Child Health, Quality Assurance

Presenting author's disclosure statement:
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.

Recorded presentation