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

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conditions, people who may have a physical condition or diagnosis
such as cerebral palsy, multiple sclerosis, spinal cord or traumatic
brain injury, hemophilia, or AIDS; also, people with mental retardation,
people with severe and persistent mental illness; and finally.
Even though their conditions are covered by the above categories,
the elderly stand out as a separate group, both because of
the prevalence of these types of conditions among elderly individuals
as well as the different financing arrangements available for
elderly individuals.
The panel described very well the need for services, services involving
the treatment of the conditions that these individuals had
that included medical and nursing services, therapies, drugs, prostheses,
durable medical equipment. They also talked about the
services that related to the consequences of these conditions, consequences
in particular with respect to the loss of functioning and
that require an individual to need assistance with services like personal
care, the maintenance of a household, or respite for family
caregivers.
I wanted to make that distinction because it is a distinction that
is not often made. There tends to be some confusion about the
range of services and who is responsible for what.
We hear many times that the system of health care in this country
is not well-suited for people with chronic illness, and that may
be very well true in terms of both types of services. However, it is
very frustrating to be engaged in a discussion or a debate when one
party is talking about the services related to the treatment of a
condition, and another party is talking about the services that are
supposed to compensate for the loss of functioning that results from
having a condition.
It is also an important distinction, I think, when we talk about
the issue of managed care for persons with special needs, because
we are often not asking, or generally not asking, the managed care
organizations to assume responsibility for the services related to
the loss of functioning; what we are asking them to do is assume
responsibility for the services related to the treatment of the conditions
that the individuals have.
One of the other strong themes coming out of that panel was the
real complexity of needs on the part of medical and professional
services that any one individual is going to need, let alone the
whole population. An example was given of a boy with cerebral
palsy who needed the services of a pediatrician, and preferably or
most importantly, a pediatrician familiar with cerebral palsy, as
well as a neurologist, a urologist, an orthopedic surgeon, physical
therapist, occupational therapist, and speech therapist. A similar
case was described of an individual having spina bifida who needed
a neurologist, a hematologist, a gastroenterologist, a urologist and
an internist to help manage all of those specialties that were providing
services.
It was clear that access to specialists is important, but even more
important, or a further distinction, access to subspecialists, specialists
who are not just a neurologist, but a neurologist who specializes
in the condition that an individual may have, and that there
is research that indicates that it matters whether or not an individ-