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

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272 Table 20-1. <strong>Medicaid</strong> Expenditures by State, 1994 (dollars) Expenditures per Total Poor <strong>Medicaid</strong> (millions) Capita Person Beneficiary United States $137,112 $523 $2,041 $4,011 Alabama 1,769 420 1.300 3,287 Alaska 288 500 2.083 4,181 Arizona 1,571 379 1,382 3,088 Arkansas 1,074 437 1,226 3,185 California 14,065 437 1,476 2,809 Colorado 1,119 306 1,602 3,904 Connecticut 2,424 744 4,874 7,042 Delaware 281 389 1,850 3,773 District of Columbia 790 1,350 3.530 6,214 Florida 5,347 372 1,225 3,096 Georgia 3,274 468 1,787 3,058 Hawaii 458 398 1,789 3,841 Idaho 312 264 1,069 2.833 Illinois 5,286 447 1.942 3.668 Indiana 2,811 483 2,085 4,676 Iowa 1,089 386 1,857 3,609 Kansas 981 390 1,798 3,897 Kentucky 1,867 493 1,579 3,007 Louisiana 4,065 949 2,593 5,368 Maine 932 729 2,689 5,288 Maryland 2,246 451 2,228 5,414 Massachusetts 4,696 779 4,254 6,672 Michigan 4,930 513 2,243 4,154 Minnesota 2,470 562 2,818 5,978 Mississippi 1,330 511 1,324 2,529 Missouri 2,533 483 1,685 3,788 Montana 344 398 1,513 3,627 Nebraska 615 372 1,984 3,867 Nevada 418 274 1.317 4,374 New Hampshire 830 726 4,472 10,036 New Jersey 4,793 598 3,256 6,152 New Mexico 665 400 1,249 2,581 New York 21,223 1,164 4,442 7,311 North Carolina 3,175 463 1,769 3,230 North Dakota 279 443 2,019 4,469 Ohio 5,499 486 2,174 3,676 Oklahoma 1.041 310 969 2,680 Oregon 1,105 354 1,531 2.686 Pennsylvania 6,432 531 2,496 5.123 Rhode Island 787 816 4,066 6,224 South Carolina 1,900 521 1,612 3,932 South Dakota 291 406 1,490 4,063 Tennessee 2,694 519 1,753 2,261 Texas 8,137 437 1,466 3,237 Utah 513 262 1,295 3,268 Vermont 284 479 2.442 3,088 Virginia 1,871 285 1.535 2,917 Washington 2,543 478 2,589 3,805 West Virginia 1,254 692 2.015 3,426 Wisconsin 2,256 445 2,133 4,797 Wyoming 158 323 1,355 3,186 SOURCE: Uska et al. 1996. NOTES: Expenditures Include disproportionate share hospital payments. Beneficiaries are defined as individuals enrolled In the <strong>Medicaid</strong> program who actually receive medical services. Poor defined as the number of individuals under 150 percent of the federal poverty threshold, which was $12,320 for a family of three in 1994. 421 Physician Payment Review Commission
Trends in Program Spending 273 In 1966, spending for <strong>Medicaid</strong> and its predecessor program accounted for $1.5 billion or 3.7 percent of the nation's personal health care expenditures. By 1994, <strong>Medicaid</strong>'s spending (excluding administration) had increased to $122.9 billion and its share had climbed to 14.8 percent of personal health care expenditures (Lazenby et al. 1986; Levit et al. 1996). During this same period, the number of <strong>Medicaid</strong> beneficiaries grew from 12 million to 35 million (Kaiser Commission 1996b). <strong>Medicaid</strong> spending growth has been quite volatile over the last decade. Spending went through a period of extremely rapid growth from 1988 to 1992 (Figure 20-4). The average annual growth rate over those years was 22.4 percent. From 1992 to 1995, spending growth declined to 9.5 percent (Holahan and Ligka t996). The current estimate of spending growth for 1996 is 3.3 percent (CBO !997). Figure 20-4. Average Annual <strong>Medicaid</strong> Expenditure Growth Rate, 1988-2002 (percentage) 22.4% 9.5% 3.% 7.7% 1988-1992 1992-1995 1995-1996' 1997*2002 (projected) SOURCE: Holahan and Liska 1996; CBO 1997. * Based on CBO estimate of spending. The rapid growth from 1988 to 1992 was driven by three principal factors (Holahan et al. 1993; Holahan and Liska 1996). One was general health care inflation. A second was a significant expansion in enrollment due to both legislative changes and overall economic recession. During the 1980s, the Congress enacted a number of expansions in program eligibility-some mandatory and some optional. States responded by adding almost 8 million people to the <strong>Medicaid</strong> rolls, a one-third increase, from 1988 to 1992. A third factor was the use by many states of new financing practices, including provider taxes and donations and disproportionate share hospital (DSH) payments. 7 7 Disproportionate share hospital expenditures go to hospitals that serve a disproportionate number of low-income patients. States typically encouraged provider contributions or imposed taxes on providers. The state <strong>Medicaid</strong> program-with matching federat funds-would then increase payment to the hospital enough to retuan much or all of the donation or tax payment. In some cases, new funds were used to support care for the poor, more often, federal funds were substituted for state funds. DSH payments grew from $400 million in 1988 to more than $17 billion in 1992 (Holahan and Liska 1996). 1997 Annual Report to Congress/Chapter 20 422
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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
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127 I think those are the things yo
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130 to use, and they will be collec
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134 unlikely though that these futu
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136 While we are in the midst of th
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138 Center for Health Program Devel
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140 ('enter for Hearlth Proeram Dev
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146 If More is Better, Cost Contain
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148 ANALYSIS OF OUTCOMES SF-36 phys
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150 4-Year Physical Health Outcomes
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152 MAJOR FINDINGS -1 PHYSICAL DECL
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154 INTERPRETATION OF RESULTS * Equ
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156 Additional Information is on th
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order) were followed. Samplingpatie
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AP Ag. 0065(0 og. qP e8 y. d-ftd 04
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162 Tlbb. 5-Plso91 A& MerohJ H89t0
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and chest pain sufficient to requir
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166 Quality Special</strong
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THE STATE OF THE STATES TUESDAY, JU
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171 a little bit about some of the
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173 gatekeeper, and we also wondere
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175 Maryland ought to submit that w
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177 fined by us in our regulations,
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179 To get to that kind of situatio
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181 Outline of Presentation for Dep
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183 B. Approaches to Ensure Quality
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185 * Holds MCOs accountable for qu
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187 HealthChoice and People with <s
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189 HealthChoice and People with <s
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191 Take these three steps to choos
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193 Call 1-800-888-1965 if you are
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IF YOU HAVE HIV/AIDS 195 MCO staff
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197 * Refer you to a medical specia
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*pV 199 SERVICES FOR CHILDREN IN ST
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201 Ms. CHRISTENSEN. Thank you. Go
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203 We implement these QI goals thr
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205 Medicaid recip
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207 My name is Peggy Bartels. I am
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209 At the forefront of Wisconsin's
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211 Finally, we believe that high q
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213 WISCONSIN DEPARTMENT OF HEALTH
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2 SELECTED INDICATORS Access to <st
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Mental Health 217 * HMOs reported f
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'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
Page 232 and 233: 229 Another positive outcome of the
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Page 236 and 237: 233 CCE's staff consist of a variet
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Page 240 and 241: 237 PACE/Partnership programs guide
Page 242 and 243: 239 necessarily relevant to the AFD
Page 244 and 245: 241 about including these specialty
Page 246 and 247: EXECUTIVE COMMITTEE Ct-u B.1r- M.mb
Page 248 and 249: Considerations: 245 Enrolling <stro
Page 250 and 251: 247 Medicaid <stro
Page 252 and 253: a. some counties 249 b. mandatory e
Page 254 and 255: 251 counties as well-of managed car
Page 256 and 257: 253 In other States devolution is m
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Page 260 and 261: 257 Forums on Managed</stro
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Page 268 and 269: 266 a 50 percent match. 2 Since 198
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Page 278 and 279: 276 Section 1115 Demonstration Waiv
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Page 282 and 283: 280 Table 20-2. Enrollment in <stro
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Page 288 and 289: 286 Figure 20-9. Enrollment in Risk
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Page 296 and 297: Enrollment and Disenrollment Polici
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Page 306 and 307: INTRODUCTION 304 Presently, nearly
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Page 310 and 311: 308 the ability of beneficiaries to
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Page 318 and 319: Appendix A State Activity* 316 Many
Page 320 and 321: GA { I ~United States (3 Mu General
Page 322 and 323: 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 <
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802 Principles for Accountable <str
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Im. Community 804 Health plans shou
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806 4. participating in community p
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808 5. give patients opportunities
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810 aRve New Children With Disabili
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Table of Contents 812 Executive Sum
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814 combination of HealthPartners d
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Introduction 816 F amilies whose ch
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818 Of the 24 families asked, 13 pa
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820 Shriner's Hospital, or claims s
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822 Major Child and Family Concerns
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Services and Funding Sources 824 Nu
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Physician Survey 826 M ost physicia
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828 Discussion and Recommendations
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830 * Claims and billing informatio
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832 El Advocate for a safety net of
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834 :i:PTNG F'AITH SYMThMr -"r W, M
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836 We recognize that managed care
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due to a host of complex demographi
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affect many different facets of an
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state agencies, must be held accoun
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In selecting managed care entities
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Z, W 0 V==4 . k PQ- 0 V-- 9 Q) bo =
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plans were virtually identical in b
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to chronically i persons has been t
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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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