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

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<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
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