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

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<strong>Medicaid</strong> Working Group/ Boston University School of Public Health 441 Stuart Street, Sixth Floor Boston, MA 02116 PHONE- (617)437-1550 FAX: (617)437-0031 E-MAIL tcarol@bu.edu Thc <strong>Medicaid</strong> Working Croup provides training education and technical assistance to states, providers and consumers on managed care for people with disabilities. Technical assistance indudes <strong>Medicaid</strong> contracting rate-setting benefits, provider networks, and quality standards. National Academy for State Health Policy 50 Monument Square, Suite 502 Portland, ME 04101 PHONE: (207)874-6524 FAX. (207)874-6527 NASHP serves as a technical resource center for states. It acts as a dearing. house for best practices, as well as providing direct technical assistance to state policymakeas. National Health law Program .2369 South. a Cienega Boulevard Los Angeles, CA 90034 PHoNE, (310)204--6010 FAXt (210)204-0891 E-mAIL nhelp@healthlaw.org NHeLP is a national public interest law firm with extensive Expertise related to <strong>Medicaid</strong> and managed care. NHeU has produced managed care consumer education materials and has anaylzed state <strong>Medicaid</strong> waivers, 718 National Minority AIDS Counnul 1931 13th Street, NW Washington, DC 20009 PHONE- (202)483-6622 FAX. (202)483-1135 E-MAIL NMACI@aol.com NMAC provides policy analysis and advocacy on <strong>Medicaid</strong> and managed care and its impact on people with HiV. ,Northwest AIDS Foundation 127 Broadway East, Suite 200 Seattle, WA 98102-5786 PHONE, (206)329-6923 FAX: (206)325-6923 E-MAIL STEVEJ@sisna.com NWAF provides state and.federal advocacy efforts on <strong>Medicaid</strong> and managed care, as well as other health care concerns of individuals living with HIV/AIDS. Project Inform 1945 Market Street, Suite 220 San Francisco, CA 94103-1012 PHONE- (415)558-8669 FAXt (415)558-0684 E.wttA Pinformthooked.net 1Project Inform provides information to consumers and advocates for people living with HIV. Project Inform also advocates on issues related to <strong>Medicaid</strong> and managed care. * NATIONAL ASSOCIATION OF P[OPLE WITH AIDS I APPE NDIEXB San Francdoco AIDS Foundaton P. O. Box 426182 San Francisco, CA 94142-6182 PHONE- (415)487-3000 FAX. (415)487-3089 SFAF engages in San Francisco Countylevel advocacy on <strong>Medicaid</strong> and privatesector managed care, as well as advocating on the state and federal levels Texas AIDS Network P.O. Box 2395 Austin, TX 78768 PHoNEt (512)447-8887 FAX: (512)447-IllS E-MAL. tan@global.org Texas AIDS Network advocates on behalf of people living with HiV in Texas. This indudes working at the state and federal level on issues related to <strong>Medicaid</strong> and managed care
G rn-ge BOARD OF DIRE( CTRS| 719 Chair Jim Graham Whitman-Walker ainic Washington, DC Vice Chair Roger Gooden Misroudi Prevention/<strong>Care</strong> Collaboration Task Force Kansas Cit Missouri Reasurer Thomas S. Berg United Way of Cascade County Great Falls, Montana Secrtarry Beiynda A. Dunn AIDS Action <strong>Committee</strong> of Massachustets Boston, Massachusetts Val Bias National Hemophilia Foundation Washington, DC Bartholomew T. Casimir American College of Chinese Medicine San Francisco, California Pat Christen San Francisco AIDS Foundation San Francisco, Califomia William J. Gunn Hill & Knowlton Atlanta, Georgia David S. Landay, I.D. National Viator Representatives New York New York ReX). Sandborg Cook County HIV Primary <strong>Care</strong> Center Chicago, Illinois Valerie P. Selow, Ph.D. Institute of Medicine/National Academy of Sciences Washington, DC Paul Wisotrzky Harder + Company Community Research (former) San Francisco, California A. Comelius Baker Executive Director leffrey S. Crowley, M.P.H., Project Director
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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
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Conclusions B-276D78 490 Safety-net
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B-270078 492 current enrollment bro
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Contents Letter 494 Appendix 30 Sco
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(1115) oPP. -.M.taoy 496 oversight
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498 ACKNOWLEDGEMENTS This Volume of
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500 Is Lock-in to a Managed
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502 Plan and Provider Issues ......
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504 Chapter 1 Program Design Issues
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506 Other studies attest to improve
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508 Will the Program Be Voluntary o
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510 additional option for people wi
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512 contractor collect spenddown pa
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514 Option A is still quite rare. P
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516 experience with special populat
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518 particularly on a full risk bas
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520 Dual eligibility raises a disti
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522 special populations, and states
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524 Chapter 2 Care
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526 settings. Finally, plans that s
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5281 needs. For example, women who
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530 Oregon's rules require that pla
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532 beneficiaries on July 1, 1997.
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534 facility's delivery, dosage, an
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536 * Strategies for measuring netw
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538. arrangements with traditional
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540 community based or well elders.
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542 Finally, coordination for vulne
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544 Care Coordinat
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546 home health agency developed a
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548 develop a case management syste
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550 Coordinating services is compli
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Highlights 552 Effective care coord
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554 beneficiaries that belong to th
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556 services when needed. This is t
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558 federal government and not at s
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560 cannot enroll a person in a Med
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562 Medicare members are not typica
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564 Regence HMO Oregon staff noted
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566 community based organizations t
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568 Although technical advice for c
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570 Risk pools are usually used to
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572 Internal Quality Program Standa
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574 enrollee utilization patterns,
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576 that the overall prevalence of
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578 HMOs with risk contracts must h
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580 Summary As Medicaid</st
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582 Chapter 3 Medicaid</str
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584 carve-out approach: - improves
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586 Coordinating Medical and Non-Me
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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
Page 670 and 671: 668 Sources Ash A, Porell F, Gruenb
Page 672 and 673: C. Recommended Adivities 670 With t
Page 674 and 675: 672 B. Examples of Current Research
Page 676 and 677: 674 The Practice Parameters Project
Page 678 and 679: 076 -Administrative Survey: Enrollm
Page 680 and 681: 678 Description This guide provides
Page 682 and 683: 680 APPENDIX 1: PARTICIPANT LIST MA
Page 684 and 685: 682 MANAGED CARE EXPERT WORK GROUP
Page 686 and 687: 684 APPENDIX H: BIBLIOGRAPHY MANAGE
Page 688 and 689: 686 MANAGED CARE EXPERT WORK GROUP
Page 690 and 691: 688 MAKING MEDICAID MANAGED CARE PR
Page 692 and 693: 690 On Saturday, July 13, 1996 and
Page 694 and 695: INTRODUCTION Medicaid</stro
Page 696 and 697: 694 INTRODUCTION People living with
Page 698 and 699: 696 |CONSENSUS FOR ATO of many of o
Page 700 and 701: - 698 There is a huge need to educa
Page 702 and 703: 700 People fiving with HIV, and the
Page 704 and 705: 702 The HIV epidemic disproportiona
Page 706 and 707: NATIONAL ASSOCIATION OF PEOPLE WITH
Page 708 and 709: 706 People living with HIV must be
Page 710 and 711: 708 CONSENSUS FOR ACTION service Fo
Page 712 and 713: 710 E . | CONSENSUS FORACTION Peopl
Page 714 and 715: 712 CONSENSUS FOR ACTION _ Under Cr
Page 716 and 717: 714 PNDX Aj MedIcaId -A health care
Page 718 and 719: Resources 716 NAPWAserves as the vo
Page 722 and 723: Background 720 FAMILY"7OICES A nati
Page 724 and 725: 722 was included. A telephone numbe
Page 726 and 727: 724 provider to ask questions. fami
Page 728 and 729: 726 * Families were twice as likely
Page 730 and 731: 728 carefully to explain why they a
Page 732 and 733: Table I Family Voices Survey on <st
Page 734 and 735: Table 2 (continued) Family Voices S
Page 736 and 737: Table 4 Family Voices Survey on <st
Page 738 and 739: 736 Table 7 Family Voices Survey on
Page 740 and 741: 738 Table 8 Family Voices Survey on
Page 742 and 743: 740 Table 10 Family Voices Survey o
Page 744 and 745: al 742 Table II Family Voices Surve
Page 746 and 747: 744 Tn Uvman 1usoUU - Ya..e. PeMh i
Page 748 and 749: 746 Tihe b d. - Yc'.n-e-aPcopb bith
Page 750 and 751: 748 UT1, W L= 1. - Y g o. ith ,Pb M
Page 752 and 753: 750 o As with the rest of the <stro
Page 754 and 755: 752 Mlbe 1 Mediaid Benefici7 ibtas
Page 756 and 757: 754 9: Office of the Assistant Secr
Page 758 and 759: The research for this paper Was sup
Page 760 and 761: Definitions of "Medically Necessary
Page 762 and 763: Who Should Define What Is Necessary
Page 764 and 765: 762 contract. In that situation, th
Page 766 and 767: 764 sannes and for certain conditio
Page 768 and 769: 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
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_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
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Accessibility, Availability, Referr
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- Credentialing and Recredtentialin
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Standards for Members' Rights and R
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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
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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
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822 Major Child and Family Concerns
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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
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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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