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

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are entitled to renew their prescriptions as they come into this
managed care plan, and the contracts have simply not set up the
infrastructure, generally, to deal with that.
Now, some contracts have, and when they do, they will, for example,
require that the plan pay for the person to continue with
their previous provider until such time as the plan can arrange an
appointment and evaluation by a plan provider; that they have got
to continue with the same prescription drugs until such time as
their drug therapy regimen can be reviewed by a plan provider and
either changed or reinstigated by a plan provider. But at least
there is a hook-up.
Now, that does not guarantee that the person continues to get
the same level of care once they get into the plan, that they are
going to continue to have access to the same types of specialists,
but it at least assures a nexus between the two systems. The issue
of continuing the treatment and how you assure continuity of treatment
becomes much more complicated, and those few States that
have dealt with the issue have basically done so through requiring,
again, specifications of certain types of specialists in the systemthat
they have to have pediatric neurologists, pediatric hematologists,
geriatric providers of all different types and subspecialties.
Some require that they have, for example-this is not a chronic
illness-but specialists with an expertise, for example, in dealing
with tuberculosis. Most do not. I would say you almost never see
contracts specifying network composition made up of providers who
meet condition-specific or disease-specific expertise.
To back track a little bit, the interesting thing is that the disabled
population, as Bill mentioned, is really in theory ideally suited
for managed care, unlike the AFDC population, which is the
population that we are most rapidly bringing into managed care,
because the disabled population are "lifers" on the system, and
managed care tends to operate best in an environment where they
have continued enrollment so that they may have the incentives to
provide the preventive care, the maintenance care to maintain
function. These people do tend to be very long-term enrollees if you
get them in, so that if everything worked according to theory, they
would be ideally suited for managed care. But this is an evolutionary
process, and what has happened is that the industry in the
commercial sector and the private sector has not developed this
kind of capability, and therefore, the public sector basically mirrors
that.
It is a process that will occur gradually over time, incrementally,
but the notion that you can somehow, as if Venus springs from
Zeus' head full-grown, in one fell swoop, transfer large segments of
people with complicated health care needs into the managed care
system before it is largely ready, I think is going to be a misplaced
notion; it is not going to work, and I don't think the plans are going
to be ready to take them, and there is going to be a lot of resistance
in the marketplace to integrating them before the capability is
there.
In terms of payment issues, we have talked a lot about the need
to risk-adjust payment to adequately pay for people who have more
complicated health care needs. I think that at this point, it is useful
to bring out the fact that we really have not come very far in