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

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296 individually with plans over rates (within constraints) (Gold et al. 1996). In several states. notablv Tennessee, the level of the capitation rates has been a central issue in debates over the program's future. Several managed-care plans withdrew from state programs in 1996, blaming state cuts in payments among other factors (Page 1997). An additional issue is whether states are making progress in developing and implementing innovative approaches to risk adjustment. The NASHP survey found that a majority of states make risk adjustments for age, sex, geography, and eligibility category. Most states also used some type of risk sharing or reinsurance. Only four reported adjusting rates for health status in 1996 (Horvath and Kaye 1997). Further Research States' experiences in implementing their managed-care programs may be instructive both to other states' <strong>Medicaid</strong> programs and to the Medicare program. With the variety ofrapproaches in use, several natural experiments are under way. Although the studies identified here offer some suggestions about what approaches have been more successful than others, more systematic research on these issues is needed. Some studies are in progress, including ongoing survey work by the National Academy for State Health Policy and projects funded by HCFA and by the Robert Wood Johnson Foundation. The first stage in a study to examine these issues further would be a survey of states with significant managed-care activity. The survey should cover some of the topics identified in this section. For example, it might ask about restrictions states place on plan marketing, use of enrollment brokers, how information is communicated to beneficiaries, use of competitive bidding to select plans, setting of capitation payments, and risk adjustment. A second stage could explore the success and failure of these different approaches and some of the factors that help determine which succeed and which fail. REFERENCES Center for Budget and Policy Priorities, "An Analysis of the AFDC-Related <strong>Medicaid</strong> Provisions in the New Welfare Law," unpublished memorandum, September 19, 1996. Congressional Budget Office, The Economic and Budget Outlook Fiscal Years 1998-2007 (Washington, DC: January 1997). Congressional Research Service, <strong>Medicaid</strong> Source Book- Background Data and Analysis (A 1993 Update), <strong>Committee</strong> Print 103-A (Washington, DC: <strong>Committee</strong> on Energy and Commerce, U.S. House of Representatives, January 1993). Congressional Research Service, <strong>Medicaid</strong> Spending and Enrollment: A State Chart Book, No. 96-839 EPW (Washington, DC: October 10, 1996). 445 Physician Payment Review Commission
297 General Accounting Office, Arizona <strong>Medicaid</strong>: Competition Among <strong>Managed</strong> <strong>Care</strong> Plans Lowers Program Costs, GAO/HEHS-96-2 (Washington, DC: October 1995a). General Accounting Office, <strong>Medicaid</strong> <strong>Managed</strong> <strong>Care</strong>: More Competition and Oversigh; Would Improve California's Expansion Plan, GAO/HEHS-95-87 (Washington, DC: April 1995b) General Accounting Office, Health Insurance for Children: Private Insurance Coverage Continues to Deteriorate, GAO/HEHS96-129 (Washington, DC: June 1996a). General Accounting Office, <strong>Medicaid</strong>: States' Efforts to Educate and Enroll Beneficiaries in <strong>Managed</strong> <strong>Care</strong>, GAO/HEHS-96-184 (Washington, DC: September 1996b). Gold, Marsha, Karyen Chu, and Barbara Lyons, <strong>Managed</strong> <strong>Care</strong> and Low-Income Populations: A Case Study of <strong>Managed</strong> <strong>Care</strong> in Oregon (Menlo Park, CA: Henry J. Kaiser Family Foundation, July 1995a). Gold, Marsha, Hilary Frazer, and Cathy Schoen, <strong>Managed</strong> <strong>Care</strong> and Low-Income Populations: A Case Study of <strong>Managed</strong> <strong>Care</strong> in Tennessee (Menlo Park, CA: Henry J. Kaiser Family Foundation, July 1995b). Gold, Marsha, Michael Sparer, and Karyen Chu, "<strong>Medicaid</strong> <strong>Managed</strong> <strong>Care</strong>: Lessons from Five States," Health Affairs 15(3):153-166, Fall 1996. Health <strong>Care</strong> Financing Administration, Department of Health and Human Services, <strong>Medicaid</strong> <strong>Managed</strong> <strong>Care</strong> Enrollment Report: Summary Statistics as of June 30 1994 (Baltimore: 1995). Health <strong>Care</strong> Financing Administration, Department of Health and Human Services, <strong>Medicaid</strong> <strong>Managed</strong> <strong>Care</strong> Enrollment Report: Summary Statistics as of June 30, 1995 (Baltimore: 1996a). Health <strong>Care</strong> Financing Administration, Department of Health and Human Services, "Link between <strong>Medicaid</strong> and SSI Coverage of Children under Welfare Reform," Fact Sheet #2, 1996b. Health <strong>Care</strong> Financing Administration, Department of Health and Human Services, "Link between <strong>Medicaid</strong> and Temporary Assistance for Needy Families," Fact Sheet #1, 1996c. Health <strong>Care</strong> Financing Administration, Department of Health and Human Services, "Link between <strong>Medicaid</strong> and the Immigration Provisions of the Personal Responsibility and Work Opportunity Act of 1996," Fact Sheet #3, 1996d. Health <strong>Care</strong> Financing Administration, Department of Health and Human Services, Section 1915(b) Freedom of Choice Waivers (Baltimore: 1996e). 1997 Annual Report to Congress/Chapter 20 446
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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
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Program for Program Chareolorletice
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Primary Program AFDC/H8 Provlqar Ch
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225 Children Come First of Dane Cou
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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
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
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Page 256 and 257: 253 In other States devolution is m
Page 258 and 259: 255 /-LCenter for Health Ca
Page 260 and 261: 257 Forums on Managed</stro
Page 262 and 263: 259 Medicaid Carve
Page 264 and 265: 261 So I view Medicaid</str
Page 266 and 267: 264 Medicaid: Spen
Page 268 and 269: 266 a 50 percent match. 2 Since 198
Page 270 and 271: 268 If enrollment of eligible indiv
Page 272 and 273: 270 drugs, ICF services, and optome
Page 274 and 275: 272 Table 20-1. Medicaid</s
Page 276 and 277: 274 The slowdown in spending after
Page 278 and 279: 276 Section 1115 Demonstration Waiv
Page 280 and 281: 278 primary care case management ar
Page 282 and 283: 280 Table 20-2. Enrollment in <stro
Page 284 and 285: 282 / Figure 20-6. Enrollment Growt
Page 286 and 287: 284 Marnaged-care growth at the sta
Page 288 and 289: 286 Figure 20-9. Enrollment in Risk
Page 290 and 291: 288 The extent of problems in repor
Page 292 and 293: 290 plans (PPRC 1996). In other are
Page 294 and 295: 292 There appears to be a clear tre
Page 296 and 297: Enrollment and Disenrollment Polici
Page 300 and 301: 298 Health Care Fi
Page 302 and 303: Medicaid M
Page 304 and 305: Support & Services Office 120 W. Tw
Page 306 and 307: INTRODUCTION 304 Presently, nearly
Page 308 and 309: 306 more mandatory services. Full-r
Page 310 and 311: 308 the ability of beneficiaries to
Page 312 and 313: 310 managed care also requires the
Page 314 and 315: 312 condition period. Such requirem
Page 316 and 317: 314 If a state contracts with or in
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
Page 324 and 325: Significant Efforts Needed to Ensur
Page 326 and 327: Recommendations Agency Comments E-d
Page 328 and 329: cow 326 Chapter 4 Traditional Rate-
Page 330 and 331: Chapter I Background 328 Me
Page 332 and 333: ovapt I 330 the option of extending
Page 334 and 335: Federal Requirements Govern State U
Page 336 and 337: Table 1.2: Comparison of Ma
Page 338 and 339: Objectives, Scope, and Methodology
Page 340 and 341: 338 Chapter 2 States Are Moving Tow
Page 342 and 343: Table 21 nEnollmen of Disabled Bene
Page 344 and 345: 342 chona Se. As To~ed Id C"fn, Dai
Page 346 and 347: 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
Page 698 and 699:
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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