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

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540 community based or well elders. The capitation payment for each group includes Medicare acute care, <strong>Medicaid</strong> acute care, and <strong>Medicaid</strong> long term care costs. Participants who reside in the community and meet the nursing home level of care criteria earn a <strong>Medicaid</strong> payment for long term care services that equals the average spending for participants in the state's <strong>Medicaid</strong> home and community based services waiver. Participants who have lived in a nursing home for more than six months and who are relocated to the community earn the plan a rate that is twice the average HCBS rate. In addition the plan receives the PACEI2 adjuster-2.39 the AAPCC-for Medicare services for nursing home eligible participants who live in the community or who have moved to the community. Other incentives are being developed in Texas which will pay lower rates for a period of time when a beneficiary is placed in a nursing home from the community or when a beneficiary who is "well" and not receiving HCBS services becomes frail and requires in-home care. This mechanism creates an incentive for the plan to conduct risk assessments and deliver adequate preventive care. Highlights * Opportunities for savings and care coordination are maximized and opportunity for cost shifting is minimized if the scope of benefits provided by the plan reflects the full range of needs of the population to be served. * States need to consider how implementing a managed care program will impact long term care service providers and how to maximize enrollee choice of in-home, community, residential and institutional services as the individual's needs dictate. * The structure of the capitation payment can create incentives to authorize in-home and residential services rather than institutional care. * Safeguards are needed to ensure that beneficiaries are receiving an appropriate level of care in the community and to monitor incentives to underserve beneficiaries. 12 The Program of Al Inclusive <strong>Care</strong> for the Elderly (PACE) is a program designed to serve frail elderly beneficiaries of <strong>Medicaid</strong> and Medicare. PACE sites receive an adjusted AAPCC rate from Medicare. The National Academy for State Health Policy * a 8/97 IV-37
541 <strong>Care</strong> Coordination and Case Managementl 3 An analysis of <strong>Medicaid</strong> spending shows that vulnerable populations use a mix of health, supportive and social services. Persons with complex health care needs and needs which cross the health care and other service systems benefit from a process to coordinate services. Elderly persons often use both acute and long term care services. People with disabilities use acute care, long term care, attendant care, educational, vocational and housing services. The use of multiple provider systems adds to the complexity of serving vulnerable populations. Referrals require follow up. Treatment interventions need to be scheduled and coordinated. Office appointments should not conflict with delivery of in-home services. Physicians must be informed of any changes in health conditions observed by social workers and other professional and paraprofessional providers. Depending upon the degree of integration between <strong>Medicaid</strong> and Medicare, 14 and acute and long term care services, the nature of the care coordination may vary. Plans that provide a full range of services members of these special populations may need potentially have greater control and ability to coordinate decision making since the majority of providers work for the same organization. As the authority for authorizing services is spread across multiple organizations, coordination becomes more difficult when each organization is accountable to a separate funding source. For example, an HMO nurse may refer a person for services from a community based organization. The community organization may have to complete its own assessment and apply different eligibility rules to determine whether services can be authorized. Funding may not be available and the person could be placed on a waiting list. The lack of access may affect the service planning of the referring organization or the involvement of separate organizations may delay the date for initiating services. If the HMO had authority over the funding, services could be initiated more directly and systems would be in place to coordinate the activity. 13 The terms case management and care coordination are often used interchangeably. Case management means assessment, care planning, service authorization and monitoring of services over which the organization has direct control. In the case of managed care entities that usually limits these activities to coordinating medical care. <strong>Care</strong> coordination refers to activity related to accessing, delivering and monitoring services that are the responsibility of, or are controlled by, another organization. 14 For those states that enroll dual eligibles into managed care coordinating Medicare services can be critical to coordinating over-all care to beneficiaries since Medicare is the primary payor of many acute medical services. In other words, the physician (who is usually paid by Medicare) drives the health care system through referrals. It the physician is not part of the plan's network it is likely that the physician will order <strong>Medicaid</strong> covered services that the plan might not cover either because the plan disagrees with the need or the physician fails to follow plan protocols for obtaining care. The National Academy for State Health Policy * 0 8/97 IV-38
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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
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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
Page 492 and 493: Conclusions B-276D78 490 Safety-net
Page 494 and 495: B-270078 492 current enrollment bro
Page 496 and 497: Contents Letter 494 Appendix 30 Sco
Page 498 and 499: (1115) oPP. -.M.taoy 496 oversight
Page 500 and 501: 498 ACKNOWLEDGEMENTS This Volume of
Page 502 and 503: 500 Is Lock-in to a Managed
Page 504 and 505: 502 Plan and Provider Issues ......
Page 506 and 507: 504 Chapter 1 Program Design Issues
Page 508 and 509: 506 Other studies attest to improve
Page 510 and 511: 508 Will the Program Be Voluntary o
Page 512 and 513: 510 additional option for people wi
Page 514 and 515: 512 contractor collect spenddown pa
Page 516 and 517: 514 Option A is still quite rare. P
Page 518 and 519: 516 experience with special populat
Page 520 and 521: 518 particularly on a full risk bas
Page 522 and 523: 520 Dual eligibility raises a disti
Page 524 and 525: 522 special populations, and states
Page 526 and 527: 524 Chapter 2 Care
Page 528 and 529: 526 settings. Finally, plans that s
Page 530 and 531: 5281 needs. For example, women who
Page 532 and 533: 530 Oregon's rules require that pla
Page 534 and 535: 532 beneficiaries on July 1, 1997.
Page 536 and 537: 534 facility's delivery, dosage, an
Page 538 and 539: 536 * Strategies for measuring netw
Page 540 and 541: 538. arrangements with traditional
Page 544 and 545: 542 Finally, coordination for vulne
Page 546 and 547: 544 Care Coordinat
Page 548 and 549: 546 home health agency developed a
Page 550 and 551: 548 develop a case management syste
Page 552 and 553: 550 Coordinating services is compli
Page 554 and 555: Highlights 552 Effective care coord
Page 556 and 557: 554 beneficiaries that belong to th
Page 558 and 559: 556 services when needed. This is t
Page 560 and 561: 558 federal government and not at s
Page 562 and 563: 560 cannot enroll a person in a Med
Page 564 and 565: 562 Medicare members are not typica
Page 566 and 567: 564 Regence HMO Oregon staff noted
Page 568 and 569: 566 community based organizations t
Page 570 and 571: 568 Although technical advice for c
Page 572 and 573: 570 Risk pools are usually used to
Page 574 and 575: 572 Internal Quality Program Standa
Page 576 and 577: 574 enrollee utilization patterns,
Page 578 and 579: 576 that the overall prevalence of
Page 580 and 581: 578 HMOs with risk contracts must h
Page 582 and 583: 580 Summary As Medicaid</st
Page 584 and 585: 582 Chapter 3 Medicaid</str
Page 586 and 587: 584 carve-out approach: - improves
Page 588 and 589: 586 Coordinating Medical and Non-Me
Page 590 and 591: 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
Page 782 and 783:
_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
Page 788 and 789:
Accessibility, Availability, Referr
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- Credentialing and Recredtentialin
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Standards for Members' Rights and R
Page 794 and 795:
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
Page 818 and 819:
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
Page 824 and 825:
822 Major Child and Family Concerns
Page 826 and 827:
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
Page 838 and 839:
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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