Problems with quality monitoring for medicaid managed care: Perceptions ofinstitutional and private providers in New York City

The study objective was to examine quality oversight efforts by Medicaid ma naged care organizations (MCOs) for children in a sample of ambulatory care institutions and private practices in New York City. This was a cross-sect ional study of quality assurance priorities and strategies of MCOs and thei r impact date in institutions in New York City. Data were from structured i nterviews administered in 1997 to medical directors in the eight largest MC Os; and medical directors, heads of ambulatory pediatrics, and institutiona l pediatricians in a random sample of 15 institutions and 20 private office -based providers. Medical directors in MCOs reported that their main priori ty areas were the preventive care measures (e.g., immunization and lead scr eening) that they must report to the state. Knowledge of these MCO priority areas and monitoring activities was high for medical directors in the rand om sample, but decreased from these medical directors to heads of ambulator y pediatrics to institutional pediatricians, with the differences between t he medical directors and institutional pediatricians significant (P < .05). However, 96% of the institutional pediatricians reported knowing their own institution's priorities and monitoring activities. In contrast, most priv ate pediatricians reported they knew MCO priorities and monitoring activiti es (80%). Less than 33% of any group reported activities as "very effective " or felt any incentive to improve performance. There was a high level of o verlap in provider networks, with institutions and private providers having children in many MCOs, and MCOs having children in many sites. Conclusions. The current model of quality oversight is producing reports fo r the state, but is not translating into effective strategies at the provid er level. The need to work through the leadership in institutions to influe nce quality is highlighted. The level of overlap in provider networks sugge sts the need for collaboration among MCOs in duality monitoring.