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

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179 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:]
180 State of Maryland Department of Health and Mental Hygiene ^ Parris N. Glendening. Governor -Martin P Wasserman. M.D., J.D., Secretary -, Presentation of Barbara Shipnuck Deputy Secretary for Health <strong>Care</strong> Policy, Finance and Regulation State of Maryland Before The U.S. <strong>Senate</strong> <strong>Special</strong> <strong>Committee</strong> on Aging Forurn on <strong>Medicaid</strong> and <strong>Managed</strong> <strong>Care</strong> July 22, 1997 For More Information Contact: Stephanie Kennan, Office of Governmental Affairs (410) 767-6459 207 vreft Preston Street -Balimore, Maryland 21201 TDO for Disabled -Maryland Relay Service (800) 735- 2258 Healthy People in Healthy Communities
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S. HRG. 105-262 MEDICAID MANAGED CA
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CONTENTS PEOPLE WITH SPECIAL NEEDS,
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V Bazelon Center for Mental Health
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2 also apparent that structuring a
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4 through the doors when somebody o
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6 delay the onset of secondary disa
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8 BRIEFING FOR CONGRESSIONAL STAFF
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10 obstetric and gynecological serv
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JlSAes CRi. E CalD5Vilb J~iiiLi uls
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14 people with disabilities and spe
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16 and prospective enrollees the pl
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18 by the disorder. In fact, schizo
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20 r_ 06/23/1997 16: 03 7836845968
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22 Kathy. STATEMENT OF KATHLEEN H.
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24 even lead to an improvement-but
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26 MANAGED CARE AND LONG TERM T h e
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Consortium for C. 20249&Oid Citizen
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30 11 Managed care
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Strong Oualitv Assurance Measures 3
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NATIONAL ASSOCIATION 34 DEVELOPMENT
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36 Mrs. M.'s care plan is quite com
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38 nurses and social workers be ava
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40 EXPENDITURES FOR NURSING HOMES S
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REQUIRES THE SKILL OF A HIGHLY TRAI
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44 ALZHEIMER'S DISEASE AND RELATED
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46 WITHOUT ADEQUATE RESPITE CARE, I
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48 PROBLEM FOR PEOPLE SUFFERING FRO
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50 Ms. CHRISTENSEN. Thank you. Don.
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52 it will eradicate the virus. Man
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I 54 Today I participate in a state
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56 Ms. CHRISTENSEN. Thank you. [Ina
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58 rather than to community-based s
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60 now has to start looking at thin
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62 plan for that matter, can measur
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64 ual is getting state-of-the-art
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66 a larger population of people wi
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68 of recovery or rehabilitation th
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70 are entitled to renew their pres
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72 point and say that Patsy comes f
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74 .The WASHNTND MEDICAL CENTER CEN
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76 exceptions - have largely based
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78 Plans have not shown a willingne
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eligible people and for the program
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Table l.b Selected Provisions Relat
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VariiaIioils in rownlr-c1t language
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Variations in cbonIlrlcl Is1sgu;age
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Executive Summary 1. Setting the Co
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age, which pays for those M
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This consensus building exercise is
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95 Ms. CHRISTENSEN. I'm going to in
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97 abled population will all need s
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5601 Smetua- Drive PO. r,. 9310 Mmn
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101 Our experience with the AFDC po
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103 I have tried to list both the o
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105 BACKGROUND INFORMATION PATRICIA
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164 Communicating the Quality Messa
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119 Dr. SCANLON. In this series of
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121 lation in managed care in Minne
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123 thing, because you will have va
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125 If we develop them now around e
Page 132 and 133: 127 I think those are the things yo
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Page 136 and 137: 176 Communicating the Quality Messa
Page 138 and 139: 134 unlikely though that these futu
Page 140 and 141: 136 While we are in the midst of th
Page 142 and 143: 138 Center for Health Program Devel
Page 144 and 145: 140 ('enter for Hearlth Proeram Dev
Page 150 and 151: 146 If More is Better, Cost Contain
Page 152 and 153: 148 ANALYSIS OF OUTCOMES SF-36 phys
Page 154 and 155: 150 4-Year Physical Health Outcomes
Page 156 and 157: 152 MAJOR FINDINGS -1 PHYSICAL DECL
Page 158 and 159: 154 INTERPRETATION OF RESULTS * Equ
Page 160 and 161: 156 Additional Information is on th
Page 162 and 163: order) were followed. Samplingpatie
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Page 166 and 167: 162 Tlbb. 5-Plso91 A& MerohJ H89t0
Page 168 and 169: and chest pain sufficient to requir
Page 170 and 171: 166 Quality Special</strong
Page 172 and 173: THE STATE OF THE STATES TUESDAY, JU
Page 174 and 175: 171 a little bit about some of the
Page 176 and 177: 173 gatekeeper, and we also wondere
Page 178 and 179: 175 Maryland ought to submit that w
Page 180 and 181: 177 fined by us in our regulations,
Page 184 and 185: 181 Outline of Presentation for Dep
Page 186 and 187: 183 B. Approaches to Ensure Quality
Page 188 and 189: 185 * Holds MCOs accountable for qu
Page 190 and 191: 187 HealthChoice and People with <s
Page 192 and 193: 189 HealthChoice and People with <s
Page 194 and 195: 191 Take these three steps to choos
Page 196 and 197: 193 Call 1-800-888-1965 if you are
Page 198 and 199: IF YOU HAVE HIV/AIDS 195 MCO staff
Page 200 and 201: 197 * Refer you to a medical specia
Page 202 and 203: *pV 199 SERVICES FOR CHILDREN IN ST
Page 204 and 205: 201 Ms. CHRISTENSEN. Thank you. Go
Page 206 and 207: 203 We implement these QI goals thr
Page 208 and 209: 205 Medicaid recip
Page 210 and 211: 207 My name is Peggy Bartels. I am
Page 212 and 213: 209 At the forefront of Wisconsin's
Page 214 and 215: 211 Finally, we believe that high q
Page 216 and 217: 213 WISCONSIN DEPARTMENT OF HEALTH
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Page 220 and 221: Mental Health 217 * HMOs reported f
Page 222 and 223: 'Nisconsin Medicaid</strong
Page 224 and 225: Program for Program Chareolorletice
Page 226 and 227: Primary Program AFDC/H8 Provlqar Ch
Page 228 and 229: 225 Children Come First of Dane Cou
Page 230 and 231: 227 Wraparound Milwaukee saving dol
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229 Another positive outcome of the
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231 AltDoughl Nkvie' iniCil costs i
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233 CCE's staff consist of a variet
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235 Al the cturent time, there is n
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237 PACE/Partnership programs guide
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239 necessarily relevant to the AFD
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241 about including these specialty
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EXECUTIVE COMMITTEE Ct-u B.1r- M.mb
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Considerations: 245 Enrolling <stro
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247 Medicaid <stro
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a. some counties 249 b. mandatory e
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251 counties as well-of managed car
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253 In other States devolution is m
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255 /-LCenter for Health Ca
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257 Forums on Managed</stro
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259 Medicaid Carve
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261 So I view Medicaid</str
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264 Medicaid: Spen
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266 a 50 percent match. 2 Since 198
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268 If enrollment of eligible indiv
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270 drugs, ICF services, and optome
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272 Table 20-1. Medicaid</s
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274 The slowdown in spending after
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276 Section 1115 Demonstration Waiv
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278 primary care case management ar
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280 Table 20-2. Enrollment in <stro
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282 / Figure 20-6. Enrollment Growt
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284 Marnaged-care growth at the sta
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286 Figure 20-9. Enrollment in Risk
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288 The extent of problems in repor
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290 plans (PPRC 1996). In other are
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292 There appears to be a clear tre
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Enrollment and Disenrollment Polici
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296 individually with plans over ra
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298 Health Care Fi
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Medicaid M
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Support & Services Office 120 W. Tw
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INTRODUCTION 304 Presently, nearly
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306 more mandatory services. Full-r
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308 the ability of beneficiaries to
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310 managed care also requires the
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312 condition period. Such requirem
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314 If a state contracts with or in
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Appendix A State Activity* 316 Many
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GA { I ~United States (3 Mu General
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Results in Brief E.. - 320
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Significant Efforts Needed to Ensur
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Recommendations Agency Comments E-d
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cow 326 Chapter 4 Traditional Rate-
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Chapter I Background 328 Me
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ovapt I 330 the option of extending
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Federal Requirements Govern State U
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Table 1.2: Comparison of Ma
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Objectives, Scope, and Methodology
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338 Chapter 2 States Are Moving Tow
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Table 21 nEnollmen of Disabled Bene
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342 chona Se. As To~ed Id C"fn, Dai
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Table a& Eabent to Which 17 State I
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346 So A- hbydf TSo -d Cam fo DIbbi
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Table 2.5: Extent to Which 17 State
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350 8t" Age Bowi T-Mar 11 Cue fRa D
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352 C".Pt a Q...itA- Efl~t. . - C f
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Addressing Concerns Through Enrollm
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Assignment Active Management of a D
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358 fo.V D Axd B ref .Ak,.d - CC-e
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Targeted Quality-of-Care</s
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Encounter Data Analysis Shows Poten
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364 Chapter 4 Risk-Adjusted Rates a
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366 Cu.pd 4 Rk-A4tAjLd Row Ad RIASW
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States Could Experience Adverse Sel
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370 Ckspt. 4 JUek-Mtod Rate Wd HIa
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372 Ch.piWr 4 JU-i.k.d Row md RJAk-
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374 Coob,, 4 RkikAdjned Rtr -d Rub-
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376 rued R.I. . 2".shBd c- provider
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378 c-5 Obh- .. I, Co.eWda, ad CHe
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380 Ob-e-eU-o, Co-ded, end C-ost pr
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382 United States General Accountin
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Results in Brief B-Z70335 384 manag
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B-2Kn0 386 assess service utilizati
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Table 1: Characteristics of <strong
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B-27035 390 numbers of patients. In
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B-270335 392 number of primary care
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B-Z7Oa33 394 developed on the premi
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States Challenged to Develop Effect
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B-270335 398 that beneficiary use o
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B.270335 400 of the care provided a
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States Could Learn More From Improv
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Targeted Analyses of Grievance Data
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Observations Agency Comments and Ou
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B-270335 408 Finally, the experts w
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410 Appendix I Scope and Methodolog
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- I 412 App-edU I Sw Wd Methodology
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414 AppeAdt U Fedo.I aod Stt. Ove0s
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416 Appendix III Major Contributors
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GAO July 1996 GAO/HEHS-96-120 418 U
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B-26632 420 family home, rather tha
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Background 1-206320 422 traditional
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States Use Waivers to Expand and Ch
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84=20 426 Figure 1: Staftes Use of
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B-266320 428 began the 1990s with s
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B26320 430 variety of other service
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Enrollment Caps and Management Prac
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Change in Federal Rule Could Result
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States Are Introducing Innovations
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B-nato 438 offered and the means fo
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440 We are sending copies of this r
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C-m 442 Table 2: Changes in Number
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444 App-ar I So-p and Mraodsogo ent
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446 Appendix H Medicaid</st
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448 App-di. f M~I Wd., _. So 4 Of0
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450 App-.i. il _-.1 - Desd s UCFVA'
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452 Apeadls mn Stadad Seee - Defind
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454 Appedi. M St.d.ed Se&ee s Dneoe
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Chore 456 Am..& IV LAO n.Gd .Mt. ,
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Occupational Therapy and Assessment
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Psychological Services Provider Typ
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462 AWppdi IV U-e, Cotfi-, E d Othe
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Licensure/Registration Other Standa
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466 United States General Accountin
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Results in Brief B-276078 468 care
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B-270078 470 Medi-Cal was implement
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_.27_7 Tab 1: Mad-C Eiglbli and Enr
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~~- - o~~BZ760?S 474 I J I the enro
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B.276078 476 delaying the contracti
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State's Education Process Has Not R
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B.276078 480 and thereby supplement
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Weaknesses in State Management of t
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B-276078 484 standards can provide
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Insufficient Communication and Invo
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Some Safety-Net Providers Are Encou
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Conclusions B-276D78 490 Safety-net
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B-270078 492 current enrollment bro
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Contents Letter 494 Appendix 30 Sco
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(1115) oPP. -.M.taoy 496 oversight
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498 ACKNOWLEDGEMENTS This Volume of
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500 Is Lock-in to a Managed
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502 Plan and Provider Issues ......
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504 Chapter 1 Program Design Issues
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506 Other studies attest to improve
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508 Will the Program Be Voluntary o
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510 additional option for people wi
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512 contractor collect spenddown pa
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514 Option A is still quite rare. P
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516 experience with special populat
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518 particularly on a full risk bas
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520 Dual eligibility raises a disti
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522 special populations, and states
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524 Chapter 2 Care
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526 settings. Finally, plans that s
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5281 needs. For example, women who
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530 Oregon's rules require that pla
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532 beneficiaries on July 1, 1997.
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534 facility's delivery, dosage, an
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536 * Strategies for measuring netw
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538. arrangements with traditional
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540 community based or well elders.
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542 Finally, coordination for vulne
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544 Care Coordinat
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546 home health agency developed a
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548 develop a case management syste
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550 Coordinating services is compli
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Highlights 552 Effective care coord
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554 beneficiaries that belong to th
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556 services when needed. This is t
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558 federal government and not at s
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560 cannot enroll a person in a Med
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562 Medicare members are not typica
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564 Regence HMO Oregon staff noted
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566 community based organizations t
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568 Although technical advice for c
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570 Risk pools are usually used to
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572 Internal Quality Program Standa
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574 enrollee utilization patterns,
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576 that the overall prevalence of
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578 HMOs with risk contracts must h
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580 Summary As Medicaid</st
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582 Chapter 3 Medicaid</str
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584 carve-out approach: - improves
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586 Coordinating Medical and Non-Me
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588 Oregon,8 program planners origi
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590 Medicaid syste
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592 Oversight/Monitoring Quality De
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594 with family and friends, contac
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596 * The type(s) of data necessary
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598 * Specificity of desired result
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600 Initiatives under way may prove
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602 a estring the services authoriz
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604 Development of appropriate plan
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606 OFFICE OF INSPECTOR GENERAL The
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Establishing core developmental tea
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610 taken into account considerable
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PURPOSE 612 INTRODUCTION Our purpos
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614 MANAGED CARE PENETRATION The de
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616 CHALLENGES AND RESPONSES Our re
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618 > In building up and maintainin
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620 * For the most part, the agenci
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622 beginning to look for associate
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624 challenge will be to ensure tha
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626 RETOOLING AS AN ISSUE Retooling
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628 finding effective ways of deali
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630 COMMENTS ON THE DRAFT REPORT We
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Defining Managed <
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DATE: JU 27 1997 TO: June Gibbs Bro
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636 protocols will be enhanced thro
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638 Broad and explicit state health
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640 APPENDIX C ENDNOTES 1. See, for
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642 The First Biannual Report of th
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644 30. In Massachusetts, for examp
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646 CHILDREN WITH SPECIAL HEALTH CA
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Prface 648 The U.S. Maternal and Ch
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650 L DEFINING AND IDENTIFYING CHIL
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2. Child Health Questionnaire (CHQ)
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654 Limits * This approach identifi
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656 To what extent does the definit
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658 II. FAMILY PARTICIPATION IN MAN
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660 Description This is an integrat
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12. American Academy of Pediatries
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664 knowledge of a child's conditio
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666 though only the NACHRI approach
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668 Sources Ash A, Porell F, Gruenb
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C. Recommended Adivities 670 With t
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672 B. Examples of Current Research
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674 The Practice Parameters Project
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076 -Administrative Survey: Enrollm
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678 Description This guide provides
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680 APPENDIX 1: PARTICIPANT LIST MA
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682 MANAGED CARE EXPERT WORK GROUP
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684 APPENDIX H: BIBLIOGRAPHY MANAGE
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686 MANAGED CARE EXPERT WORK GROUP
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688 MAKING MEDICAID MANAGED CARE PR
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690 On Saturday, July 13, 1996 and
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INTRODUCTION Medicaid</stro
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694 INTRODUCTION People living with
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696 |CONSENSUS FOR ATO of many of o
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- 698 There is a huge need to educa
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700 People fiving with HIV, and the
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702 The HIV epidemic disproportiona
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NATIONAL ASSOCIATION OF PEOPLE WITH
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706 People living with HIV must be
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708 CONSENSUS FOR ACTION service Fo
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710 E . | CONSENSUS FORACTION Peopl
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712 CONSENSUS FOR ACTION _ Under Cr
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714 PNDX Aj MedIcaId -A health care
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Resources 716 NAPWAserves as the vo
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Medicaid Working G
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Background 720 FAMILY"7OICES A nati
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722 was included. A telephone numbe
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724 provider to ask questions. fami
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726 * Families were twice as likely
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728 carefully to explain why they a
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Table I Family Voices Survey on <st
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Table 2 (continued) Family Voices S
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Table 4 Family Voices Survey on <st
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736 Table 7 Family Voices Survey on
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738 Table 8 Family Voices Survey on
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740 Table 10 Family Voices Survey o
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al 742 Table II Family Voices Surve
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744 Tn Uvman 1usoUU - Ya..e. PeMh i
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746 Tihe b d. - Yc'.n-e-aPcopb bith
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748 UT1, W L= 1. - Y g o. ith ,Pb M
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750 o As with the rest of the <stro
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752 Mlbe 1 Mediaid Benefici7 ibtas
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754 9: Office of the Assistant Secr
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The research for this paper Was sup
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Definitions of "Medically Necessary
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Who Should Define What Is Necessary
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762 contract. In that situation, th
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764 sannes and for certain conditio
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Defining Elements of a Definition o
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768 (6J identify and evaluate a men
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770 This paper highlights children'
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772 din resulut in inadequate or in
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774 dividual under public-sector ma
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BAZELON CENTER RESOURCES ON MANAGED
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ivn58ffR1eL_ 778 THF VARIAI LITY OF
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_4 What are the essential benefits
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WHAT PUBLIC PURCHASERS CAN DO - Oen
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ASSESSMENT OF STANDARDS - Quality M
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Accessibility, Availability, Referr
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- Credentialing and Recredtentialin
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Standards for Members' Rights and R
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Preventive Behavioral Health Servic
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9b4 etfJovrk9imut July 16, 1997 794
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hel,4Neipaork SEmi July 16, 1997 79
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798 Principles for Accountable <str
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800 The Coalition for Accountable <
Page 804 and 805:
802 Principles for Accountable <str
Page 806 and 807:
Im. Community 804 Health plans shou
Page 808 and 809:
806 4. participating in community p
Page 810 and 811:
808 5. give patients opportunities
Page 812 and 813:
810 aRve New Children With Disabili
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Table of Contents 812 Executive Sum
Page 816 and 817:
814 combination of HealthPartners d
Page 818 and 819:
Introduction 816 F amilies whose ch
Page 820 and 821:
818 Of the 24 families asked, 13 pa
Page 822 and 823:
820 Shriner's Hospital, or claims s
Page 824 and 825:
822 Major Child and Family Concerns
Page 826 and 827:
Services and Funding Sources 824 Nu
Page 828 and 829:
Physician Survey 826 M ost physicia
Page 830 and 831:
828 Discussion and Recommendations
Page 832 and 833:
830 * Claims and billing informatio
Page 834 and 835:
832 El Advocate for a safety net of
Page 836 and 837:
834 :i:PTNG F'AITH SYMThMr -"r W, M
Page 838 and 839:
836 We recognize that managed care
Page 840 and 841:
due to a host of complex demographi
Page 842 and 843:
affect many different facets of an
Page 844 and 845:
state agencies, must be held accoun
Page 846 and 847:
In selecting managed care entities
Page 848 and 849:
Z, W 0 V==4 . k PQ- 0 V-- 9 Q) bo =
Page 850 and 851:
plans were virtually identical in b
Page 852 and 853:
to chronically i persons has been t
Page 854 and 855:
Managed Risk Medic
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the lead. Large purchasers might wo
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ISBN 0-16-055952-9 9 [ 10111111 155
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Medicaid Managed Care - U.S. Senate Special Committee on Aging

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