Data dilemmas
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home / healthcare / in the media

Modern Healthcare
Jun 11, 2001

by Ron Shinkman

Data dilemmas

Standardization urged for Calif.'s Medi-Cal providers
Data exchange for California's Medicaid managed-care programs is so complex that it may be difficult to effectively gauge the quality of care provided, according to recently published reports.

The reports were issued by Oakland, Calif.-based Medi-Cal Policy Institute, a not-for-profit organization that monitors Medi-Cal, the state's Medicaid program. They concluded that data exchange among physicians, health plans and the state Department of Health Services, which oversees Medi-Cal, is hampered by several problems, including:

  • Some health plans and providers have a ''limited understanding of the systems they operate and use,'' and the systems themselves are not extensively integrated. Many employees working for health plan information systems have a limited understanding of healthcare data and the requirements for submitting Medi-Cal data to state agencies.

  • There were extensive errors regarding patient demographic data, meaning many patients were inadvertently disqualified for eligibility from Medi-Cal coverage or denied care, and payments to providers were delayed.

  • Only 58% of the physicians surveyed have electronic billing capability, greatly complicating the gathering of patient encounter data. Many providers are unsure where claims and encounters should be submitted.

''Some health plans are handling their data better than others, and some states are doing it better than California,'' said Christopher Perrone, deputy director of the Medi-Cal Policy Institute. Perrone said without accurate data regarding patient encounters with physicians, it is difficult to gauge the care provided to the approximately 5 million Californians enrolled in Medi-Cal managed-care programs. His organization urged the standardization of data gathering among health plans, providers and the DHS.

The problems with data collection compound other gripes about Medi-Cal managed care: low reimbursement to providers and layers of administrative costs that can strip as much as 20% of money provided for coverage before it reaches patients.

''It's very hard to provide proper care for Medicaid managed-care recipients as it is,'' said Jamie Court, director of advocacy at the Foundation of Taxpayer and Consumer Rights in Santa Monica, Calif., and a longtime critic of managed-care practices.

Officials with some managed-care plans said they are aware of the problems, but two of the largest Medi-Cal managed-care health plans in California-Thousand Oaks-based Blue Cross of California and Woodland Hills-based Health Net-either declined comment or did not respond to questions seeking comment.

L.A. Care, a Medi-Cal managed-care plan with 670,000 enrollees in Los Angeles County, said it spends $3.5 million per year to improve data collection. In 1998, it also sponsored legislation that would have provided funds for physicians to buy computer systems to improve claims and encounter submissions. The legislation was never signed into law, according to L.A. Care spokesman Keith Malone.

''We clearly recognized that the (payments from the Medi-Cal program) did not take into account the experience of many of the smaller private doctors, the nonprofit safety net, traditional providers and the start-up costs for them to compete in managed care,'' Malone said.

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