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Designing Healthcare Systems That Work for People With Chronic Illnesses & Disabilities
Managed Care Capabilities & Data Collection
Marjorie Hatzmann, M.B.A., Audit Services Director, The MedStat Group, Inc., Washington, DC.
Data may not be readily available from Managed Care Organizations (MCOs) although it is necessary to track and measure performance, monitor utilization and spending, and determine future payment rates. This lack of availability may be due to MCO mergers/takeovers, capitated provider contracts, services provided by subcontractors, vendor processing (some vendor processing systems cannot be modified quickly or without assistance), and data edits removing items not considered applicable to internal uses.
Policymakers need to be clear about data requirements during the initial discussions with MCOs. Ms. Hatzmann suggested creating a grid of required data elements. She stressed that while time-consuming, determining data requirements before implementing the program is much easier than changing the requirements in an existing program. The more specific the contract language with regard to these requirements, the better.
Program designers must bear in mind two questions:
- What is it I'm trying to measure/monitor?
- What data do I need to have to measure/monitor it?
Program designers should get input from stakeholders who will be evaluating the program (e.g., the State legislature). Talking to MCOs will help determine whether obtaining certain data elements is possible.
Formulating a data collection strategy includes:
- Developing the internal organization to deal with the data submitted, including data
submission requirements in the Request for Proposals (RFPs) and MCO contract language.
- Developing an MCO submission process (in terms of data elements required, layout, and
- Developing processes to handle problems.
Ms. Hatzmann stressed the importance of States working with MCOs to understand what data are available and to develop data collection processes that serve both parties. It is critical to understand an MCO's ability to meet these requirements before awarding a contract.
Site visits can be effective in assessing an MCO's information systems capabilities; regular meetings can flesh out a work plan to address missing systems elements.
States can provide technical assistance in areas new to MCOs, e.g., tracking services for people dually eligible for Medicare and Medicaid ("dual eligibles").
The Medstat Group, Inc. A guide for States to assist in the collection of analysis of Medicaid managed care data. Baltimore (MD): Health Care Financing Administration; 1999 Jun. Contract No.: 500-92-0035.