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

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and therefore have greater ability to control the full scope of services. Coordination
is easier since the plan can develop multi-disciplinary teams or other mechanisms
for making referrals, authorizing services, monitoring delivery and outcomes and
adjusting service plans based on reported changes in the beneficiary's condition.
Medicare HMOs are required to coordinate services for beneficiaries. The Medicare
manual requires that plans promote continuity of care which is described as "the
degree to which the care needed by a patient is coordinated effectively among
practitioners across provider organizations over time. This concept emphasizes:
* coordination of health care services among primary and specialty care
physicians;
* coordination among specialists;
* appropriate combinations of prescribed medications;
* coordinated use of ancillary services, including social services and
other community resources;
* appropriate discharge planning; and
* timely placement at different levels of care, including hospital, SNF
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[skilled nursing facility], and home health care."
Services provided to members should be structured in a manner which assures
continuity. Medicare rules indicate that continuity can be achieved "by having a
primary physician responsible for coordinating a member's overall health care and
by maintaining record keeping systems through which pertinent information
relating to the health care of the member is accumulated and readily available and
shared among appropriate professionals and available for external peer review.
Make arrangements for the physician or other health professional coordinating the
members overall health care to be kept informed about referral services provided to
members." 2 1
The manual requires that HMOs "employ systems to promote continuity of care and
case management. This could include development of a plan for the overall
treatment of each patient. This plan could cover the full course of illness and
related medical conditions. It should also address issues related to treatment at the
proper level of care and ensure adequate follow-up."
20 Medicare manual, § 2304.
21 Medicare manual, §2304.
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