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

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These principles apply to managed care for all enrolled populations,
including children and adults with special health care
needs. We define persons with special health care needs to include
frail elderly and disabled children and adults. We define disabled
children and adults to include persons with developmental delays
or disabilities, alcohol or other drug abuse problems, physical disabilities,
or mental illness. Persons in all of these groups are enrolled
in managed care in Wisconsin. Many of the children in our
largest HMO program for low-income families have special health
care needs.
Wisconsin's managed care principles allow and in fact require
our targeted programs to be flexible and responsive to different recipient
groups. However, the fundamental strategies needed to support
these principles are the same regardless of the population
served.
It is important to note that the States need flexibility to implement
these principles. I will describe for you what has worked in
Wisconsin, but must emphasize that States are different, and one
size does not fit all.
We believe that the great secret of <strong>Medicaid</strong> managed care is
that State <strong>Medicaid</strong> programs with their attention to populations
most at risk are improving managed care for everyone. In order to
meet our unique requirements and standards, we have found that
our commercial HMOs have to change the way they do business,
and when they change, they do it for everyone, not just for <strong>Medicaid</strong>
recipients.
At the forefront of Wisconsin's managed care infrastructure is
this broad public-private partnership I referred to. We must work
together to implement our multi-pronged quality improvement
process. The goals of our QI process are simple but broader than
many commercial managed care plans.
First, we strive to ensure that <strong>Medicaid</strong> managed care enrollees
achieve the highest possible outcomes, whether the enrollee is a 2year-old
needing to be fully immunized or an 80-year-old needing
assistance with appropriate medication administration. We define
desired health outcomes differently for different populations. We
strive to define outcomes that are both objectively and clinically acceptable
and subjectivel important to the consumers. We are
learning that there is a tot of work to be done to define outcomes
that are acceptable to the elderly and disabled. Traditional quality
measures such as those defined in HEDIS are just a starting point.
Second, we strive to make sure our managed care enrollees' access
the care they need, whether that means assuring transportation
to clinic appointments or locating translators. Again, we define
opportunities for improved access differently for targeted populations.
We are learning, for example, that elderly persons are
much more likely to access health care if they feel they have a comfortable
personal relationship with their health care provider. This
is not a common goal in commercial managed care plans.
Finally, we are committed to ensuring enrollees' maximum choice
of managed care plans and health care providers within those
plans. When we cannot guarantee reasonable choice, we do not enroll.