Case Studies in Reducing Regulatory Duplication in Managed Care was prepared for the California HealthCare Foundations Quality Initiative. It was written by Allan Baumgarten, email@example.com. To help inform discussion on this topic, this report contains case studies of how managed care organizations and providers are regulated and evaluated in five states: Florida, Maryland, Minnesota, New Jersey, and Texas. Three of the states Florida, New Jersey and Maryland have each created a requirement that commercial HMOs undergo an external review and, in the case of Florida, secure accreditation by a national body. These reviews of the accreditation can then, at least in theory, take the place of other state-required reviews. In this report, the term deeming is used for instances where the state will accept outside reviews or accreditation of health plans and forego other audits by state agency reviewers. Copies of the report may be ordered by calling the Foundation's publication line, 510-587-3199. The report also may be downloaded in PDF format at http://quality.chcf.org
California HealthCare Foundation The Quality Initiative 476 Ninth Street Oakland, CA 94607 Tel: (510) 238-1040 Fax: (510) 238-1044 e-mail: firstname.lastname@example.org http://quality.chcf.org
Here is an excerpt from the report.
Lessons Learned in Other States
1. Collaboration is hard work Most states still maintain the divided model of regulatory responsibility. By definition, this leads to overlapping and redundant efforts. A few states have consolidated regulation of commercial HMOs into a single agency, but even there oversight of Medicaid managed care programs is still assigned to a second agency.
2. Politics is important
These three illustrations demonstrate the difficulties involved in regulatory streamlining efforts. First, the increased attention mostly negative paid to HMOs in recent years has resulted in states trying to be much more active and more visible in their oversight. Regulators are concerned about taking any action that might be seen as being too easy on the HMOs.
Second, the right people in key positions can make a big difference. The wrong people or frequent turnover of leadership will hurt efforts to streamline regulation.
Third, some of the states studied in this report agreed that there were obvious ways to streamline HMO regulation but raised vague objections about outside evaluation being inadequate. In some sense, they are reflecting a reluctance to accept something if it "wasnt invented here." 3. Is any of this useful? Many states have made a significant investment in trying to gather comparative information about health plans and to make that information widely available, at least to anyone with Internet access.
The efforts represent an important step in making comparative information available to consumers and testing their appetite for that information. Yet that overlooks the fundamental question of whether any of this information is actually helpful to consumers.