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Original Contribution |

Quality Management by State Medicaid Agencies Converting to Managed Care:  Plans and Current Practice FREE

Bruce E. Landon, MD, MBA; Carol Tobias, MMHS; Arnold M. Epstein, MD, MA
[+] Author Affiliations

From the Department of Health Policy and Management, Harvard School of Public Health (Dr Epstein), Section of Health Services and Policy Research, the Division of General Medicine, Brigham and Women's Hospital (Drs Landon and Epstein), Department of Health Care Policy, Harvard Medical School (Drs Landon and Epstein), and the Medicaid Working Group, Boston University School of Public Health (Ms Tobias), Boston, Mass. Dr Landon is now with the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center and the Department of Health Care Policy at Harvard Medical School, both in Boston.


JAMA. 1998;279(3):211-216. doi:10.1001/jama.279.3.211.
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Context.— Enrollment in Medicaid managed care plans has increased more than 5-fold in this decade, but how states monitor and encourage quality of care in these programs is not known.

Objective.— To characterize the quality monitoring and assurance activities of state Medicaid agencies for Medicaid beneficiaries enrolled in comprehensive prepaid managed care programs.

Design.— Structured telephone survey conducted between October 1996 and January 1997.

Setting.— State Medicaid agencies.

Participants.— Representatives from all state Medicaid agencies, including the District of Columbia, with beneficiaries enrolled in comprehensive prepaid managed care plans as of July 1, 1996.

Main Outcome Measures.— Proportion of states with specific quality monitoring and assurance activities for Medicaid managed care.

Results.— We surveyed all 34 states enrolling beneficiaries in comprehensive managed care programs. In 1996, all 34 states enrolled the population receiving assistance from the Aid to Families With Dependent Children (AFDC) program, while only 21 (62%) and 15 (44%) enrolled the disabled and elderly populations, respectively. In the period 1995 to 1996, 19 states (63%) collected data on satisfaction with care, and 25 states (83%) collected data on childhood immunizations. No more than half of the states collected data on other selected measures of access and quality, but a substantial number planned to collect such data in 1997. While at most 37% of states were providing comparative data to health plans, up to 80% were planning to provide such information in 1997. Similarly, while at most 10% of states provided beneficiaries with such information, up to 38% planned to do so in 1997. The breadth of contracting requirements designed to assure quality varied substantially across states.

Conclusions.— State Medicaid agencies have already begun adapting to their new roles as purchasers of health care. Continued monitoring is essential to ensure that state agencies implement planned programs and that quality of care for Medicaid enrollees is preserved or improved.

ENROLLMENT OF Medicaid beneficiaries in managed care health plans has grown remarkably in recent years. Between 1990 and 1996, enrollment increased more than 5-fold from 2.3 million to more than 13.3 million people.1,2 Approximately 40% of all Medicaid beneficiaries now belong to managed care organizations. The most rapidly growing format of managed care contracting is capitation, and capitated health plans now account for 70% of the Medicaid managed care market.3

Although the shift to managed care has been prompted largely by efforts to control costs, analysts are concerned that health care quality will prove to be an Achilles' heel, partly because capitation provides incentives to economize on care. Furthermore, the Medicaid population is inherently vulnerable and often presents challenges, including illiteracy, inadequate social supports, poor nutrition, and problems with transportation and communication that many health plans are unprepared to meet. Medicaid beneficiaries are also generally unfamiliar with managed care settings and may have difficulty negotiating complex bureaucratic impediments. All these difficulties will only become magnified when state Medicaid programs begin concentration on higher-risk populations such as the elderly and the disabled.4

The Medicaid program is jointly administered by the federal and state governments. At the federal level, regulations governing managed care quality are limited in scope and are sometimes nonspecific.5 For example, these regulations specify that plans must conduct an annual external review of quality and have a program in place for quality assurance, but the details of these activities are not defined. The Quality Assurance Reform Initiative (QARI), developed by the Health Care Financing Administration (HCFA), the National Academy of State Health Policy, and others, provides guidelines for a program of quality assurance at the state level.6 Its components include structural and process standards for quality assurance programs based at health plans and focused studies of specific clinical areas or service issues (eg, pregnancy, access to care).7

Although the need for quality management and oversight in Medicaid is clear, many states still have little experience in providing it in the context of managed care.8 The shift to managed care has been a dramatic change for state Medicaid agencies. States previously negotiated or set payment rates for health care providers, paid claims, and, in some instances, managed utilization.9 Now states must become sophisticated and prudent purchasers of care, competent to specify contracting language, design benefits, and establish health plan performance requirements. Most importantly, states must monitor the quality of care and access to care for Medicaid beneficiaries, assure minimal standards, and foster improvement in medical practice.

To date, there is little information about how well state Medicaid agencies have adapted to this new role.10,11 Do state agencies collect and monitor standardized data on satisfaction, quality, and access? Do they provide these data to beneficiaries making enrollment choices or to health plans to guide quality improvement? Is there a cooperative process between Medicaid agencies and health plans to improve care? Is there any evidence that such a process has worked? In this study, we surveyed state Medicaid agencies in all the states that provide care to Medicaid enrollees under comprehensive prepaid contracts. The survey was designed to assess existing quality management as well as perceived needs for technical assistance to improve quality assurance efforts.

Survey Sample and Procedures

Through published reports and information released from HCFA, we identified all states, including the District of Columbia, that enrolled Medicaid beneficiaries in comprehensive prepaid managed care arrangements as of July 1, 1996. We excluded states that only had contracts in place for mental health and substance abuse services, dental care, or special conditions such as high-risk pregnancy or the acquired immunodeficiency syndrome. We also excluded small state programs (<500 enrollees) or those that only contracted for a limited amount of outpatient services on a prepaid basis. For any states in question, we telephoned the appropriate state Medicaid agency to verify the format of managed care arrangements before administering the survey.

We asked an appropriate individual in each state (either the head of the state's Medicaid agency, the director of quality assurance, or the managed care director) to respond to a survey questionnaire, designed for telephone administration, that solicited information about quality management and needs for technical assistance. We then sent a copy of the questionnaire to these individuals and scheduled a 40-minute telephone interview at a later time that allowed the respondent to review the instrument and seek out answers needed from other agency personnel. Structured interviews were conducted between October 1996 and January 1997. With a single exception, one of the authors (C.T.) administered all the interviews. Respondents were directed to refer only to prepaid (capitated) managed care programs and to exclude primary care case management programs. This information was repeated and verified over the telephone. Follow-up calls were made to query missing items and clarify responses.

Survey Questionnaire

The survey instrument, designed for closed-ended responses, first requested basic descriptive information about state Medicaid managed care activities, including number of years the managed care program had been in place, the number of contracting plans, the populations (eg, Aid to Families With Dependent Children [AFDC]), and the proportion of these populations enrolled in managed care. We did not differentiate between voluntary and mandatory enrollment. We then asked about existing data collection and feedback to health plans or enrollees in the areas of patient satisfaction, access to care, and quality of care. Where appropriate, we asked about existing programs and planned activities for next year, as well as efforts to collect data on comparable fee-for-service Medicaid or commercial managed care populations. For each area, we then asked if any health plans in the state serving Medicaid beneficiaries developed "specific plans and parameters for improvement as a quality improvement goal" and if any health plans, or the majority, had demonstrated improvement. In the areas of access and quality, we chose 5 and 6 tracer measures, respectively, that we thought applicable to the Medicaid population. We mostly asked about specific Health Plan Employer Data and Information Set (HEDIS) measures because we thought that states would preferentially target these measures for quality improvement initiatives. We asked a parallel though smaller series of questions in the area of mental health.

The second part of the survey asked about specific regulatory requirements for Medicaid managed care plans, including requirements for National Committee for Quality Assurance accreditation, case management services, analysis of disenrollment, health needs assessment, provision of encounter data, mental health and substance abuse prevention and education programs, mental health and substance abuse self-referral, member services, and financial disclosure. We also asked responders to rate the importance of 9 potential areas for technical assistance.

Analysis

The analyses in this study were descriptive. We analyzed all responses, with the exception of those concerning activities related to the previous year. For these questions, we only analyzed responses from agencies enrolling patients in prepaid managed care as of July 1, 1995.

We were successful in surveying representatives from all 34 states that were enrolling Medicaid beneficiaries in prepaid managed care as of July 1, 1996. As of that date, all these states had enrolled their AFDC and pregnant population in managed care (Table 1). Only 21 states (62%) had enrolled any of their disabled population, and 15 (44%) had enrolled a portion of the elderly population. Although 1 state had enrolled Medicaid recipients in managed care as early as 1972, 15 (44%) started enrolling them after 1992. The number of states enrolling disabled persons in managed care plans increased substantially (15 to 21) between 1995 and 1996.

Table Graphic Jump LocationTable 1.—Changes in Enrollment in Medicaid Managed Care (MMC) in 1995 and 1996*

By July 1996, 2 of the states had enrolled their entire Medicaid population in managed care programs, while an additional 2 states had enrolled their entire AFDC population. Overall, the proportion of the population enrolled in managed care varied greatly across the states. On average, states enrolled a mean (SD) of 49% (31%) of the AFDC population, 28% (35%) of the disabled population, and 35% (41%) of the elderly population in managed care programs (Table 1). The median proportions of enrollments for the AFDC, disabled, and elderly populations were substantially lower at 45%, 9%, and 10%, respectively.

Collection of Performance Data

Table 2 summarizes the extent to which state agencies collected data on the Medicaid population enrolled in managed care plans. In the period 1995 to 1996, 19 states (63%) collected uniform performance data on satisfaction with care, and, with the exception of child immunizations, 50% or less of states collected data on every indicator of access or quality we inquired about. We examined whether programs established prior to 1993 were more likely to collect performance data. We found that with the exception of prenatal care (58% vs 36%), Papanicolaou tests (63% vs 18%), and diabetic glycohemoglobin (32% vs 9%), they were not.

Table Graphic Jump LocationTable 2.—Collection of Performance Data by State Medicaid Agencies in 1995 Through 1997*

Many more states reported that plans were going to collect comprehensive performance data in 1997. For example, in the period 1995 to 1996, only 15 states (50%) collected data on prenatal care in the first trimester; whereas, 31 states (91%) planned to collect these data in 1997. Similarly, 25 (83%) collected data on immunizations in the past year; whereas, all states planned to collect them in 1997.

A potentially revealing aspect of quality monitoring is the extent to which the experiences of Medicaid enrollees in managed care might differ from those of other populations. For instance, Medicaid beneficiaries might have more difficulty with access to care than commercial populations. For comparison, we asked states whether they collected similar data for enrollees in traditional fee-for-service Medicaid or for commercially insured populations enrolled in the same managed care plans serving the Medicaid population. Few states collected data on satisfaction with care, access to care, or quality of care on the Medicaid fee-for-service population; even fewer collected such data on commercial populations (Table 2).

Provision of Performance Data to Health Plans and Consumers

Table 3 demonstrates the extent to which state agencies provide comparative data to health plans and Medicaid beneficiaries in the process of choosing a health plan. Although few states have provided comparative data to health plans to date, many were planning to do so in 1997. For instance, 9 states (30%) provided feedback data on childhood immunizations in the period 1995 to 1996, while 27 states (79%) have plans to do so. In the period 1995 to 1996, virtually no state provided comparative data on health plans to enrollees at the time of enrollment, but a number of states were planning to provide some kind of comparative information in 1997. In many cases, states expressed interest in this area but lacked methods for providing the information in a useful format.

Table Graphic Jump LocationTable 3.—Provision of Comparative Data to Enrollees and Health Plans by State Medicaid Agencies*
Targeted Areas for Quality Improvement and Improving Care

State Medicaid agencies can also play an important role in fostering quality improvement initiatives within health plans. States can potentially mandate quality improvement initiatives in specific areas or work cooperatively with health plans to develop initiatives in the areas of the plans' own choosing. Table 4 shows a substantial number of quality improvement initiatives under way in different states in selected areas. Thirteen states (43%) reported that at least some health plans were targeting improvement in patient satisfaction, and 20 states (67%) reported that health plans were targeting improvement in rates of childhood immunizations. On the other hand, only 4 states (13%) knew of targeted programs to improve access to specialty care, and only 3 (9%) of 21 states enrolling the disabled knew of any health plans with specific programs that targeted quality improvement in any indicator of disability care. Programs established prior to 1993 were not more likely to report knowledge of health plans targeting improvement.

Table Graphic Jump LocationTable 4.—Quality Improvement in Medicaid Managed Care in 1995-1996

To date, few states have documented improvement by health plans in measures of satisfaction, access, or quality (Table 4). This may be because few if any plans demonstrated improvement in any of these targeted areas. Since many state programs are new, longitudinal data might not yet even be available. Alternatively, states may simply not yet be capable of monitoring health plans that closely. This second interpretation is supported by the large number of states that responded "don't know" (n=18-20, depending on the measure) when asked if plans had demonstrated improvement.

Requirements for Health Plans

In addition to monitoring health plan performance by collecting data, state agencies were also setting requirements for health plans. Table 5, which summarizes such provisions, shows that requirements varied substantially among states. For example, in the area of member services, 30 states (88%) required specific member service representatives for Medicaid enrollees, while only 10 (29%) required that plans provide orientation either in person or over the telephone rather than by mail. Fifteen states (44%) required descriptions of the health plans' risk arrangements with providers, while only 8 (23%) put some kind of limit on such arrangements. Also, 22 states (73%) reported collecting encounter-level data from health plans in the past year, and 33 (97%) planned on collecting such data in 1997. However, because states have only recently begun collecting such data, many respondents commented that they lacked the ability to analyze meaningfully encounter data from multiple health plans.

Table Graphic Jump LocationTable 5.—State Medicaid Agencies' Quality Improvement Requirements for Health Plans in Medicaid Managed Care in 1996-1997*
Needs for Technical Assistance

Finally, the state Medicaid agencies in our survey expressed a need for technical assistance in multiple areas (Table 6). A total of 71% of states surveyed rated assistance in identifying and developing performance measures to assess special populations and the disabled as extremely important. A similar proportion felt that assistance with developing national benchmarks of performance would be extremely valuable.

Table Graphic Jump LocationTable 6.—Types of Technical Assistance Rated as ‘Extremely Important' or ‘Moderately Important' by State Medicaid Agencies

With recent dramatic growth in Medicaid managed care, state Medicaid agencies have seen a cardinal shift in their role from that of claims payer to that of purchaser of care. This change requires that states develop a new set of skills and orchestrate an entirely new set of activities.9 Our study suggests that state Medicaid agencies have just begun adapting to this new role and are designing and implementing programs to ensure the delivery of appropriate care to Medicaid beneficiaries. They have incorporated plans for a wide range of activities based on the collection and use of performance data to monitor quality of care, aid beneficiaries' choices, and stimulate programs in health plans to achieve quality improvement.

It should not be surprising that many of the activities for quality monitoring in Medicaid are still in the planning stages. The time frame to identify problems, plan and execute interventions, and measure results is probably 2 to 3 years for simple problems and longer for more complex problems.

Furthermore, HEDIS, developed by the National Committee for Quality Assurance, Washington, DC, has been available with full specifications for only 4 years.12 Fledgling efforts to release these data to the public are beginning, although no clear consensus exists on the best format for releasing such information.13 The early versions of HEDIS contained few quality indicators relevant to the Medicaid population. In 1995, a Medicaid version of HEDIS was introduced that includes additional quality indicators targeted at the Medicaid population,14,15 such as well-child visits and substance abuse counseling for adolescents.16 These measures were subsequently incorporated into the most recent HEDIS 3.0 (National Committee for Quality Assurance, Washington, DC).17 Although these quality indicators will continue to be included in future versions of HEDIS, not enough time has passed for many health plans to incorporate them into routine data collection.

When assessing the performance of state Medicaid agencies as purchasers of care, we should recognize that progress in the commercial sector has been slow. Only in the last 5 years have large-scale purchasers become a dominant force in the health care market. To date, most private purchasers have used their market power to drive down premiums rather than assure quality. The challenge for Medicaid agencies will be to demand accountability and add quality to the purchasing criteria.

Compared with the commercial market, the Medicaid managed care market offers both greater challenges and increased opportunities. Many Medicaid enrollees cycle in and out of the program, with 45% of new enrollees leaving within a year.18 Health plans often have insufficient time to establish a relationship with patients and perform routine screening and other testing as implicitly mandated by HEDIS. Furthermore, because many health plans enroll only small numbers of Medicaid beneficiaries, calculating quality indicators for these plans can be difficult. Low-income patients, typical of those found in Medicaid, are often difficult to survey. Response rates to mailed questionnaires are typically low, and telephone numbers are often unavailable.19 These problems are further compounded by illiteracy and primary languages other than English.

Medicaid, however, also has some distinct advantages when it comes to quality management. States have the ability to compel change through regulation. They can also require collection of performance data and have strong levers to promote "cooperative" efforts in quality improvement. Data on performance provided to Medicaid beneficiaries may substantially influence enrollment decisions, since beneficiaries selecting health plans face no cost constraints in their decisions. Increasing regulation, however, has limits. If states require too much of plans participating in the Medicaid program, then plans could stop participating in it.

Our survey highlights the rapid evolution of the Medicaid managed care market. Since 1994, 10 states have implemented new managed care programs, and the number of states enrolling the disabled and elderly in managed care programs has increased substantially. The disabled and elderly represent the most expensive and vulnerable patients within the Medicaid system. As the shift to managed care continues to accelerate, these populations will likely represent the areas of largest managed care enrollment growth. Unfortunately, managed care organizations have the least experience caring for these populations, and, at present, relatively few tools are available to assess plan performance for these sorts of patients. So, it will be particularly important to monitor quality management and quality of care as conversion of Medicaid to managed care continues and tools for measuring and improving performance expand.

Our survey also highlights the increasing importance of surveying the consumer in Medicaid managed care. A total of 63% of states collected enrollee satisfaction data in the year 1995 to 1996, while more than 80% of states planned to do so in 1997 . States can do even more to harness the value of this information. Less than 25% of states collected any comparative information on either Medicaid fee-for-service or commercial populations in the year 1995 to 1996, and few fed such information back to health plans. Almost 80% of states, however, planned to do in 1997, and some states will even release such data to the public. To use these data more effectively, states might also improve the quality of data collection. Most respondents could not tell us response rates, and, when they could, rates were uniformly low. Improved methods for collecting and comparing data from consumers will therefore be of increasing importance.20

Our study has several limitations. There is no guarantee that our survey respondents had accurate knowledge about all the issues contained in the survey. We did, however, target the senior Medicaid official with responsibility for quality management and encouraged respondents to consult with others in instances where their own knowledge was lacking. We doubt that other state agencies had programs targeted to Medicaid that were unknown to our respondents. We relied on personnel of the various state agencies to report on their own specific programs and activities. Finally, because of respondent burden, we were unable to ask comprehensively about all programs and policies at the state level. We focused on issues related to quality management but did not address other important topics such as marketing, enrollment, and financial viability. Even in quality management, we were unable to include questions that could provide detailed information on such issues as the algorithm used to calculate quality indicators and the survey questions used to gauge satisfaction.

In summary, the transition from traditional fee-for-service Medicaid to managed care requires that state Medicaid agencies undergo a major change in role. Our survey suggests that states have already begun to make this transition and are designing and implementing programs to ensure the delivery of appropriate medical care for Medicaid beneficiaries. However, programs in planning or the early stages of implementation differ from programs that are in progress or have demonstrated results. This is clearly a challenging time. Thus, it will be important to revisit this issue periodically and closely observe the progress of state Medicaid agencies in monitoring the quality of care.

Health Care Financing Administration.  Medicaid Managed Care Enrollment Report: medical statistics and data. Health Care Financing Administration Web site. Available at: http://www.hcfa.gov/medicaid/omc1996.htm. Accessed November 30, 1997.
Hegner RE. Medicaid Managed Care: How Effective a Cost-Containment Tool?  Washington, DC: National Health Policy Forum; 1995. Issue Brief 675.
Rowland D, Hanson K. Medicaid: moving to managed care: a quick summary of Medicaid managed care trends: the numbers, the models, the waivers.  Health Aff (Millwood).1996;15:150-152.
Hurley RE, Freund D, Paul JE. Managed Care in Medicaid: Lessons From Policy and Program Design.  Ann Arbor, Mich: Health Administration Press; 1993.
Felt-Lisk S, St Peter R. Quality assurance for Medicaid managed care: lessons from a quality improvement demonstration in three states.  Health Aff (Millwood).1997;16:248-252.
Gold M, Felt-Lisk S. Reconciling practice and theory: challenges in monitoring Medicaid managed-care quality.  Health Care Financ Rev.1995;16(4):85-105.
Felt-Lisk S, St Peter R. The Quality Assurance Reform Initiative (QARI) Demonstration for Medicaid Managed Care Final Evaluation Report, Vol 1.  Washington, DC: The Henry J Kaiser Family Foundation; 1996.
Iglehart JE. Health policy report: Medicaid and managed care.  N Engl J Med.1995;332:1727-1731.
Riley T. State health reform and the role of 1115 waivers.  Health Care Financ Rev.1995;16(3):139-149.
Schulte F, Bergal J. Profits from pain.  Fort Lauderdale Sun-Sentinel.December 11-15, 1994.
Gold M, Sparer M, Chu D. Medicaid managed care: lessons from five states.  Health Aff (Millwood).1996;15:153-166.
National Committee for Quality Assurance.  Health Plan Employee Data Information Set and User's Manual, Version 2.0.  Washington, DC: National Committee for Quality Assurance; 1993.
Edgman-Levitan S, Cleary PD. What information do consumers want and need?  Health Aff (Millwood).1996;15:42-57.
 Mathematica Policy Research: Experience in Collecting Selected HEDIS 2.0 Measures for the Medicaid Population.  Washington, DC: The Henry J Kaiser Family Foundation; 1996.
National Committee for Quality Assurance.  HEDIS 2.5.  Washington, DC: National Committee for Quality Assurance; 1995.
National Committee for Quality Assurance.  Medicaid HEDIS.  Washington, DC: National Committee for Quality Assurance; 1995.
National Committee for Quality Assurance.  HEDIS 3.0, Vol 1.  Washington, DC: National Committee for Quality Assurance; 1997.
Short PF, Cantor J, Monheit A. The dynamics of Medicaid enrollment.  Inquiry.1988;25:504-516.
Sisk JE, Gorman SA, Reisinger AL, Glied SA, DuMouchel WH, Hynes MM. Evaluation of Medicaid managed care: satisfaction, access, and use.  JAMA.1996;276:50-55.
Cleary PD, Edgman-Levitan S. Health care quality: incorporated consumer perspectives.  JAMA.1997;278:1608-1612.

Figures

Tables

Table Graphic Jump LocationTable 1.—Changes in Enrollment in Medicaid Managed Care (MMC) in 1995 and 1996*
Table Graphic Jump LocationTable 2.—Collection of Performance Data by State Medicaid Agencies in 1995 Through 1997*
Table Graphic Jump LocationTable 3.—Provision of Comparative Data to Enrollees and Health Plans by State Medicaid Agencies*
Table Graphic Jump LocationTable 4.—Quality Improvement in Medicaid Managed Care in 1995-1996
Table Graphic Jump LocationTable 5.—State Medicaid Agencies' Quality Improvement Requirements for Health Plans in Medicaid Managed Care in 1996-1997*
Table Graphic Jump LocationTable 6.—Types of Technical Assistance Rated as ‘Extremely Important' or ‘Moderately Important' by State Medicaid Agencies

References

Health Care Financing Administration.  Medicaid Managed Care Enrollment Report: medical statistics and data. Health Care Financing Administration Web site. Available at: http://www.hcfa.gov/medicaid/omc1996.htm. Accessed November 30, 1997.
Hegner RE. Medicaid Managed Care: How Effective a Cost-Containment Tool?  Washington, DC: National Health Policy Forum; 1995. Issue Brief 675.
Rowland D, Hanson K. Medicaid: moving to managed care: a quick summary of Medicaid managed care trends: the numbers, the models, the waivers.  Health Aff (Millwood).1996;15:150-152.
Hurley RE, Freund D, Paul JE. Managed Care in Medicaid: Lessons From Policy and Program Design.  Ann Arbor, Mich: Health Administration Press; 1993.
Felt-Lisk S, St Peter R. Quality assurance for Medicaid managed care: lessons from a quality improvement demonstration in three states.  Health Aff (Millwood).1997;16:248-252.
Gold M, Felt-Lisk S. Reconciling practice and theory: challenges in monitoring Medicaid managed-care quality.  Health Care Financ Rev.1995;16(4):85-105.
Felt-Lisk S, St Peter R. The Quality Assurance Reform Initiative (QARI) Demonstration for Medicaid Managed Care Final Evaluation Report, Vol 1.  Washington, DC: The Henry J Kaiser Family Foundation; 1996.
Iglehart JE. Health policy report: Medicaid and managed care.  N Engl J Med.1995;332:1727-1731.
Riley T. State health reform and the role of 1115 waivers.  Health Care Financ Rev.1995;16(3):139-149.
Schulte F, Bergal J. Profits from pain.  Fort Lauderdale Sun-Sentinel.December 11-15, 1994.
Gold M, Sparer M, Chu D. Medicaid managed care: lessons from five states.  Health Aff (Millwood).1996;15:153-166.
National Committee for Quality Assurance.  Health Plan Employee Data Information Set and User's Manual, Version 2.0.  Washington, DC: National Committee for Quality Assurance; 1993.
Edgman-Levitan S, Cleary PD. What information do consumers want and need?  Health Aff (Millwood).1996;15:42-57.
 Mathematica Policy Research: Experience in Collecting Selected HEDIS 2.0 Measures for the Medicaid Population.  Washington, DC: The Henry J Kaiser Family Foundation; 1996.
National Committee for Quality Assurance.  HEDIS 2.5.  Washington, DC: National Committee for Quality Assurance; 1995.
National Committee for Quality Assurance.  Medicaid HEDIS.  Washington, DC: National Committee for Quality Assurance; 1995.
National Committee for Quality Assurance.  HEDIS 3.0, Vol 1.  Washington, DC: National Committee for Quality Assurance; 1997.
Short PF, Cantor J, Monheit A. The dynamics of Medicaid enrollment.  Inquiry.1988;25:504-516.
Sisk JE, Gorman SA, Reisinger AL, Glied SA, DuMouchel WH, Hynes MM. Evaluation of Medicaid managed care: satisfaction, access, and use.  JAMA.1996;276:50-55.
Cleary PD, Edgman-Levitan S. Health care quality: incorporated consumer perspectives.  JAMA.1997;278:1608-1612.

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