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

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home health agency developed a list of supplies that would be needed for the
month. The daughter trusts that the ENCC will obtain services and supplies when
needed.
Plans report that providers often call ENCCs with referrals to solve problems, often
for people who are abusive in the office or emergency room. The ENCC tries to
learn more about the cause of the behavior. Sometimes a change to a primary care
physician who is more sensitive and effective in communicating is proposed. Other
interventions require that staff from a facility or a case manager from a program that
is serving the member escort the member to an appointment. In other cases the
ENCC may write a letter to the member outlining guidelines to be followed. ENCCs
have developed restrictions for members making repeated emergency room visits
for chronic neck and headache pain in order to obtain drugs. The restrictions
generally limit the member to one emergency room, one pharmacy and doctor
accompanied by a referral to a mental health chemical dependency provider.
ENCCs have also arranged wood delivery and installation of phone systems. The
role has created a shift to a psycho-social focus compared to the traditional medical
focus of commercial plans. Citing the broader scope of services and role
accompanying the Oregon Health Plan compared to its commercial business, one
HMO official said, "NCQA made us a better company but OHP has given us heart.
Education empowers people. ENCCs have people sign contracts after reaching
agreement with a beneficiary to follow a treatment plan. That never happened
under the old system." The fee-for-service system was described as too complicated
to develop one point of access to a range of services.
Plans reported that the role of the ENCC was important because of the needs of the
populations served and the confusing nature of managed care for some members.
One plan suggested that the function was included in state law because advocates
were concerned that fragile members would be lost in health systems designed for
healthier commercial members. The plan noted that managed care has dealt with
fragile members for many years although the position has helped create a central
focal point for contact within plans.
The ratio of ENCCs to members in Regence HMO Oregon is 1 to 4,000 but each
carries an active caseload of around 100. ENCCs in the plans have developed good
relationships with the state ombudsman and frequently communicate with State
Ombudsman office staff on specific cases.
Regence HMO Oregon invited staff from programs serving people who are seriously
and persistently mentally ill, developmentally disabled, people with disabilities and
older people to learn about the needs of different populations and to train ENCCs.
Registered nurses with special skills were hired. The role has a greater social
orientation and a consumer view of access to health care services than traditional
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