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

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grams than others, and in fact the contract probably could not tell
you that because it does not tell you how the States enforce their
contracts.
What we found with respect to disabled populations was particularly
interesting. Obviously, there is tremendous variation among
the States. The States are operating in radically different managed
care markets. Some States have had sophisticated managed care
markets for years, and the States can easily move into those markets.
The plans have been operating in markets that have taken
in different types of populations. Other States have just started to
develop managed care. Large portions of their populations have
never heard of HMOs. So you are talking about dramatically different
capability levels within the markets.
Having said that, I think that what we should say in general
terms is that the <strong>Medicaid</strong> managed care contracts tend to parallel
the commercial managed care experience, and by that, I mean that
it is a managed care system designed to meet the needs of populations
that need mainly primary care and that are basically
healthy working populations. That is the market that the managed
care industry has served over the years.
What is emphasized in these contracts is basically health care
systems that are designed to meet the needs of the AFDC population,
women and children. When they talk about network specification,
to the extent that they mention specialists, and many contracts
do not even mention specialists, as part of the network composition,
they will mention general pediatricians, they will mention
obstetricians. They do not, or example, typically mention pediatric
neurologists or geriatric neurologists. They do not talk about multiple
specialists being necessary.
Interestingly enough, many of the contracts when they list the
services included in the benefit package do not specifically include
case management services, which is one of the things that you traditionally
associate with managed care. This would indicate that
they are not envisioning caring for a population that requires extensive
complicated interactive health care services.
There are a few contracts that mention the ability to choose a
specialist as a primary care provider in certain circumstances, most
typically for prenatal care. Those contracts that do, again, are still,
as Bill mentioned, operating on a primary care model as opposed
to envisioning a patient care sy stem where somebody may need
multiple specialists to be actively engaged on an ongoing basis in
caring for the person, and what you are looking for at that point
is case management services.
The other thing that the contracts often do not address is the
issue of people in ongoing treatment and how you transition them
into managed care. If you can, envision somebody coming into this
system. The State sets up the <strong>Medicaid</strong> managed care program,
somebody is enrolled in this managed care plan who has had an
ongoing relationship with a specialty outpatient clinic at the city's
public hospital for years, and they have a detailed plan of treatment
and management and a series of prescription drugs as long
as your arm. Now they are enrolled in this managed care plan, and
all of a sudden, they are no longer dealing with those providers
that they have been dealing with. It is not even clear whether they