Medicaid Managed Care - U.S. Senate Special Committee on Aging

123
thing, because you will have variables that are excellent in predicting
someone's health service needs, but it can be very impractical
to try to collect those same variables for the entire population.
QUESTION. [Inaudible.]
Mr. RILEY. Medica is the only non-gatekeeper model doing <strong>Medicaid</strong>
in Minnesota. All the other HMOs that do this are-some of
them are closed panels, almost staff models-but all of them are
gatekeeper models with the exception of ourselves.
We do not look at capitating or paying in any kind of way that
would look like a risk-sharing arrangement with specialists for this
population. Keep in mind that we are not doing the disabled right
now; what we are doing is enrolling the AFDC population and the
elderly.
On the elderly side-and back to the earlier question about
PACE and SHMO-our State is now engaging in a demonstration
around-we have never seen a demonstration that we don't like in
Minnesota, by the way, so we will demonstrate anything-and now
we are demonstrating sort of in between a SHMO and a PACE
demonstration for our existing dual-eligible populations in Minnesota,
and we have 5,000 of those. Half of Hennepin County's population
residing in nursing homes are my members, so we have a
big stake in whether or not the question relating to does the risk
adjustment or the rate methodology that they have put together for
this population-we are going to be paid under the PACE payment
methodology, so invite me back next year, and I will tell you if it
works-we have not started yet.
Ms. SMITH. There are a few contracts that specifically provide
that people with certain types of conditions be allowed to use specialists
as primary care providers. In general, I have to say that I
cannot be called upon to say what does Utah do about this and
what does Kansas do about that, but I do know that Massachusetts
in particular has a very elaborate contract specification on network
requirements for disabled populations, and the access that those
disabled populations have to have to specialists, and they specifically
delineate using specialists as primary care providers as one
of the requirements, and that a plan has got to be able to demonstrate
that they are doing that; and there are all kinds of performance
measures along that as part of this quality evaluation in
order to get renewal.
Ms. CHRISTENSEN. Go ahead.
QUESTION. [Inaudible] for 58,000 SSI, disabled and elderly recipients,
integrating acute and long-term care. In addition, [inaudible],
reconciliation bill, the States under flexibility will be allowed to do
mandatory enrollment for all <strong>Medicaid</strong> recipients except SSI children,
who are accepted, as long as [inaudible]. Given that States
see lots of money being spent disproportionately on these populations
compared with the AFDC populations, what recommendations
would all of you have for those of us who are working on reconciliation
to get some safeguards into the language or to advise
HCFA on what ought to be looked at as States are doing this [inaudible]?
Ms. CHRISTENSEN. Could somebody summarize the question, too,
for the mike?
44-098 97 -5