identified earlier in this section: assembling a set of highly trained, experienced HIV/AIDS providers; coordinating their activities in order to achieve the highest possible levels of adherence to HAART; and providing necessary medical and nonmedical services to complement and support HAART. The Committee assumes that a wide range of providers, including community-based providers who have experience and expertise in working with the new populations affected, will be considered when organizing Centers of Excellence.

Mechanisms of Accountability

Any of the potential structural models for an HIV/AIDS Center of Excellence can support mechanisms of accountability to the public funders of HIV/AIDS care. That is, there can be mechanisms to collect, analyze, and report data related to standards for access, cost, quality, and patient satisfaction.

Each CoE would be organized as an accountable health enterprise. Individual providers within each designated CoE would be reimbursed at a level to attract and retain the complete range of excellent providers required to meet the comprehensive service needs of the eligible HIV/AIDS population. Each designated CoE would be responsible for assuring that individual providers meet ongoing quality and service standards to maintain their individual eligibility to participate in the CoE. The designated CoE organization, itself, would receive compensation from the state Medicaid agency to support network management, quality management, and network care coordination expenses required to assure long-term efficacy and cost effectiveness of care services.

Each designated CoE would be accountable for assuring appropriateness of fund expenditures and for the cost and quality of services rendered. Expenditures, service levels, and quality levels would be reported to the state Medicaid agency by each designated CoE on an annual basis. The national Medicaid program would assume responsibility for compiling and reporting program access, cost, and quality results to all participants, to the Centers for Disease Control and Prevention, and to Congress on a regular basis. Where deficiencies are deemed to exist, the national Medicaid program would ensure that plans are placed in effect to correct the deficiencies at the state level. A general overall program accountability concept is summarized in Figure 5-2.

For true accountability to exist in the system, though, there must be consequences for good or poor performance that have the net effect of improving quality and efficiency. Most systems of accountability in health care involve consequences in either “market share” or funding. The former involves incentives that move members/patients to better performing orga-



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