Brown University, Providence, RI, USA.
Providence Veterans Affairs Medical Center, Providence, RI, USA.
Med Care Res Rev. 2021 Feb;78(1):36-47. doi: 10.1177/1077558719841157. Epub 2019 Apr 4.
Medicaid managed care allows Medicaid beneficiaries to receive services through contractual relationships between managed care organizations and state Medicaid offices. Medicaid offices monitor quality of care, and many states encourage or require plans to adopt quality management practices. This research examines quality management in Medicaid managed care from the perspectives of Medicaid officials, managed care plan representatives, and providers through 25 qualitative interviews in one Northeastern state. Plan representatives described quality management efforts as robust and discussed strategies targeting providers and beneficiaries. Medicaid officials indicated motivations for plans to be responsible for quality management. Providers were unaware of plan efforts or reported them to be counterproductive since performance data were thought to be inaccurate or limited, and modest incentive programs presented excessive administrative burden. Providers' general skepticism about managed care plans' quality improvement efforts may hinder their effectiveness, cause frustration, and lead to administrative burden that may harm care quality.
医疗补助管理式医疗允许医疗补助受助人通过管理式医疗组织与州医疗补助办公室之间的合同关系获得服务。医疗补助办公室监督医疗质量，许多州鼓励或要求计划采用质量管理实践。这项研究通过在东北部一个州的 25 次定性访谈，从医疗补助官员、管理式医疗计划代表和提供者的角度考察了医疗补助管理式医疗中的质量管理。计划代表描述了强有力的质量管理工作，并讨论了针对提供者和受益人的策略。医疗补助官员表示，计划有责任进行质量管理的动机。提供者不知道计划的努力，或者报告说这些努力适得其反，因为他们认为绩效数据不准确或有限，而且适度的激励计划带来了过度的行政负担。提供者对管理式医疗计划质量改进努力的普遍怀疑可能会阻碍其有效性，导致沮丧，并导致可能损害护理质量的行政负担。
