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

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To get to that kind of situation, a managed care organization
must deliver the care. They can appeal whether that decision was
appropriate, but only after the care was delivered, at which point
then the question becomes who pays for it-was the department in
error, so we pay for it because we exceeded the bounds of our authority,
or do they pay for it. But the care gets delivered first, and
then the question involves, really, a grievance about payment.
We have a enrollee action hotline for complaints, we have provider
hotlines, and we have a number of different ways to measure
whether the program is working successfully, including satisfaction
surveys.
We have one small carve-out that I want to bring to your attention
and then close my comments. Given the special needs populations
that we serve in Maryland, we defined several diagnoses
that have very small numbers of cases statewide and cost a great
deal of money. We call these rare and expensive cases, so we have
a rare and expensive case management program. Those folks are
not enrolled in managed care organizations.
There is a separate and specific case management arrangement
for dealing with their care. Their care is paid for fee-for-service,
and we will monitor over time whether we need to expand the
number of diagnoses in that category. That covers between 2,000
and 3,000 people statewide in Maryland of the 330,000 individuals
eligible for health choice. Most of the diagnoses are pediatric spina
bifida, pediatric AIDS, but we have a few that go across age lines,
and that is one of the areas where I know a lot of States are looking
to see how we fare in terms of our proposal.
If I could leave you with anything this morning, I think there
were two very clear lessons learned from the way Maryland developed
our managed care proposal for <strong>Medicaid</strong> and we move through
the implementation.
First and foremost, having a very extensive and open public process
along the way at the very beginning to let you know what your
pitfalls are up front, let you know what areas of the program to
eliminate to start with, let you bring people on line to be your advocates
and your supporters as you then go through a legislative
process, and it fosters acceptance. So for those States or those advocacy
groups that are working with various States, I would say
that having a public process to start with is just an absolute essential
for making sure that you come out with a successful program
at the end.
Second, making your provision of care to the <strong>Medicaid</strong> population
with your public health key indicators really can become a measure
of success because managed care should not be managed care just
for the sake of going on the bandwagon for the buzzword of how
we pay for things in the 1990's, but managed care really ought to
lead to better care for an underserved population that provides for
better health throughout the community.
To me, those would be the measures of success for any demonstration
project.
Thank you very much.
[The prepared statement of Ms. Shipnuck follows:]