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

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I will also just mention that in your packet, there is a page about
our Web site. Several panelists have mentioned the contracting
study that was done by Sara Rosenbaum at George Washington
University. Those of you who have seen this document know that
it is 2,300-pages long. We are offering you the opportunity to give
up carrying it around, because you can get it on the Web site in
searchable fashion much more quickly.
In sum, we are working in about 20 States at this point under
MMCP. In terms of what are we finding out there, I would like to
make just a few summary observations. The purchaser's capacity
is extraordinarily uneven. You have before you today two States-
Maryland and Wisconsin-that really have a great handle on purchasing
issues. There are States that come to mind where they
have just two or three professional staff working on <strong>Medicaid</strong> managed
care. This is too complicated an undertaking for such sparse
staffing, even in a sparsely populated State.
We are working with relatively rural counties in Minnesota that
probably have ten times more staff working on <strong>Medicaid</strong> managed
care. So the range is really enormous in terms of capacity, and part
of what we are trying to do in MMCP is to try to build the purchasing
capacity of States.
It has also struck me as I have been doing this work that there
are a number of Federal agencies with "offices of managed care,"
like HRSA and CDC and SAMSHA and CSAT-you name it, they
have an office of managed care-to help their constituencies cope
with the coming of <strong>Medicaid</strong> managed care.
HCFA, on the other hand, provides remarkably little direct technical
assistance to State <strong>Medicaid</strong> agencies. I am sure there are
historical reasons for that gap, but it seems out of kilter. There are
probably people in this hearing room who could do something about
this imbalance.
The other issue that I want to raise is the fact that there are
very few models for special needs populations. I am actually quite
taken aback that no one has mentioned the Community Medical
Alliance (CMA) in Boston as a premier model of managed care for
special needs populations. It serves people with end-stage AIDS
and severe physical disability. Several attempts were made to replicate
the model under the <strong>Medicaid</strong> Working Group initiative
funded by RWJF and the few charitable trusts, but they have been
very slow to take hold. Even in Boston, CMA is only serving 190
people or so, and we are talking about thousands and thousands,
if not millions, of people who will need to be cared for in such
model special needs plans.
In sum, there are few models; that is why we are in this business.
One of the emerging issues that may complicate the development
of managed care for special needs populations is that counties
are going to play a much more significant role than most of us anticipated.
This is all part of the devolution trend," particularly in
States where counties are enormously important politically. Minnesota
is just one example. Minnesota could end up with 87 different
enrollment brokers because 87 different counties may insist
on having the enrollment broker responsibility. That is not necessarily
the most efficient way to do business but that may be how
it will get done in Minnesota.