Arizona Health Care Cost Containment System - Quality of Care

Monitoring quality of care within a managed care system is important to ensure that members receive needed services.  We found AHCCCS could improve some of the methods it uses to monitor quality of care. First, AHCCCS should place more emphasis on performance outcomes during its annual onsite reviews of health plans.  AHCCCS assessment methods often focus on ensuring that a policy or process is in place and not on how effectively the health plan is providing services.  Additionally, AHCCCS needs to take additional steps to ensure that member complaints are appropriately resolved. AHCCCS receives several hundred potential quality-of-care complaints annually and refers most of these complaints to the appropriate health plan for investigation and resolution. However, AHCCCS’ approach does not ensure that these complaints are appropriately resolved.

AHCCCS also needs to continue to work with the Department of Economic Security’s Division of Developmental Disabilities (DDD) to address concerns with care for the developmentally disabled. AHCCCS has had two long-standing concerns with DDD’s provision of services; complaint handling and the provision of home modification services. AHCCCS needs to take additional steps to ensure DDD meets standards in these areas. Finally, the report presents information on AHCCCS’ clinical performance indicators.  These indicators are valuable in assessing the performance of health plans in critical healthcare areas and help determine how AHCCCS members are progressing in meeting national health goals.