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Use of Medicaid reviews unclear

CHARLESTON, W.Va. - Several dozen states pay for annual reviews of their Medicaid program and a 2008 review found most of the states used the audit findings to make changes, but it's not clear what West Virginia officials use the audits for.

A 2008 federal inspector general's report found 33 of 37 states surveyed used such reviews to make changes to their Medicaid programs. While the inspector general's report didn't name states that used the quality control reports, state Department of Health and Human Resources officials told state lawmakers last month that they did not use the reviews to make changes.

"The testimony we had during our committee was that they had not done any sanctions and had not utilized that report, at least functionally, in any way," House Health Chairman Don Perdue, D-Wayne, said.

Perdue said that's particularly alarming because the quality control report is the product of a $600,000 contract.

"I hate to beat up the department, but - dammit - $600,000 a year," Perdue said in a telephone interview. "Good God."

The state Medicaid program, managed by the DHHR, has subsequently declined to comment on how it used the reports, if at all.

But there is at least some indication the insurance companies themselves - if not also the department, albeit without saying so - use the reviews to make changes.

Maryland-based Delmarva Foundation has conducted the quality reviews of the state's private Medicaid insurers since 2008.

The three private companies - Carelink, The Health Plan and Unicare - insure about 160,000 Medicaid recipients. The companies, like private sector HMOs, attempt to coordinate health care while controlling costs.

The Medicaid program overall insures more than 400,000 low-income West Virginians.

The federal inspector general's report found 33 states "required their managed care plans to make changes" based on the quality control reports.

Jane Cline, a former state insurance commissioner, now works for the HMO Association, which represents the managed care companies.

She said the three companies do use the Delmarva reviews to make changes. She said the state also uses them, even if DHHR officials didn't make that clear to the Legislature several weeks ago.

"The report is the actual tool that is used by (Medicaid) to monitor and improve MCO performance," Cline and fellow lobbyist Mary Jane Pickens said in a statement on behalf of the association.

The performance of the companies is under particular scrutiny now because the state is preparing to turn over the care of 57,000 elderly or disabled Medicaid patients to them, giving each company a larger portfolio than they have now.

The plan, which was delayed from late this year until next summer, is expected to help the state save money. Critics of managed care have questioned whether DHHR has carefully thought out the plan.

In its latest report, Delmarva gave the companies mixed reviews.

An analysis of the Delmarva report by West Virginians for Affordable Health Care found the companies were getting results below the national average in nine categories but were getting above-average results in a dozen categories.

Cline and Pickens said a careful review of the report shows the companies have been successful in encouraging preventative measures.

"They encourage visits and screenings, but patient compliance with the physician's treatment recommendations including lifestyle changes is more difficult," the pair said.

Contact writer Ry Rivard at or 304-348-1796. Follow him at



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