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

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BAZELON CENTER RESOURCES ON MANAGED BEHAVIORAL HEALTH CARE Defining Medically POLICY ANALYSIS BY 776 The following materials are available from the Bazelon Center, as indicated below (prepaid by check, Visa or MasterCard, unless otherwise indicated, add $4 for postage and handling for orders under $15 and $1 more for each $10 above that): * Managing<strong>Managed</strong>CreforPublicly Financed Mental Health Services (November 1995), $9.40 * Managing Behavioral Health <strong>Care</strong>for Children & Youth: A Family Advoraters Guide (August 1996), $9.95 in English or Spanish (single copy includes 16-page booklet for parents, Your Family and <strong>Managed</strong> <strong>Care</strong>, in the same language; booklet separately, $3.50) * Protecting Consumers in <strong>Managed</strong> Gre: Resourmcsfor LegalAdvotates June 1996), $5 * Buying in the Public Interest. A Primerfor Purchasers of <strong>Managed</strong> Behavioral Health <strong>Care</strong> in the Public Sector (November 1996), $20 * Can <strong>Managed</strong> <strong>Care</strong>Meet the Mental Health Needs of Very Young Children? October 1996 issue paper), $3 * Assessing Approahes to <strong>Medicaid</strong> <strong>Managed</strong> Behavioral Health <strong>Care</strong>, on the use of carve-outs for managed mental health care, prepared for the Kaiser Commission on the Future of <strong>Medicaid</strong> (February 1997), $7 includes postage and handling * MentalHealth<strong>Managed</strong><strong>Care</strong>SurveyoftheStates 1996-97(March 1997), $10 includes postage/handling * LIue Paper #1:Defining 'Medicay Necessary'Services to ProtectPlan Members (March 1997), $5 includes postage/handling * Issue Paper #2: NCQA Accreditation Standards: Insufficient Quality Check Unless Supplementedfor Public.Sector Systems (April 1997), $5 * Issue Paper #3: An Evaluation of State EPSDTScraening Tools (une 1997), $5 * Issue Paper #4: Assat-ng Report Crds June 1997), $5 * Successful Coalition AdvocacyforState-Based<strong>Managed</strong> <strong>Care</strong>:A Ca Exanmple (in preparation) * Consumer Rights in <strong>Managed</strong> Car (in preparation) Excerpts from some of these publications and announcements of new materials as they are developed can be found on the managed caue page of the Bamz Center's Internet site: http://www.bazelon.org. To order publications, send check or Visa/MasterCrd authorization to Publications Desk, Bazelon Center for Mental Health Law, 1101 15th Street NW, Suite 1212, Washington DC 20005; fax: 202-223-409. Necessary' Services to Protect Plan Member, r)1, THE BAZELON CENTER FOR MENTAL HEALTH LAW 242
777 MANAGED CARF & V , AMER VUI.FRAR F!AFRICNIS _ _ _ __*a a July 1997 KIDS WITH SPECIAL NEEDS Providing to inr 'are than 10 million children with special health needs poses tome of the most difficult, complex, fumstning and costly challenges Ino their families, their fstimates of the numhber of children with spe- schoolt, social service programs - and the cbl health nerds nosy depending on medical health system These children meqire care conditions and other facros included in the over a Iong proud of time that can be as im- defhnition Some sudies that include n broad pleas speech and physical therapy or as coi- ange of conditio, such as recuovot ear KEY DATA ples as home management fora child needing infctions and headaches, have found that one a 10.5 respirator m llon us 12,6 to benathe of every theen children, or 23 million, have ro on childee specal special Realth needs. care needs The (13% to most widely 18961 accepted The goal study in providing appropoate tranens in 1994-95 - for these children is not simply ro stabiliar or for this roeprss purpose pots the numhbe at -shore p the effecs of ther immediate medical 15% to 18%, or 0o5 million to 12.6 million.' 955,n00 childre ith dcagbhlti satn conditions wit to ue pediaric heatkh sevices in Macy health Supplenentat conditions Security Inc-me require (SS children quafied alm fan <strong>Medicaid</strong> In 19996 a combinatin of setting to help them develop and their families to seek medial and other (as mry at 30,000 could Ise Me. dhad ro their fllest potential i a cost-effective man- suppers s-ecices over a Iong coae of tim c srage don us melfare reforms) one Costs can nosy considerably, with a handful Most are are, bwt collectively significant The 7,128 verge pen capit Medicai lid of children -eipinog the vast majoriy of s.ences most prevalent chronic conditions affecting speeding Ion kids on 551 i 1995 each year. For oample, the aveage cost to children include asthma, and atenton deficit 0920 anerage <strong>Medicaid</strong> pee aptia of canvg Mediaid for a child with diabetes is and disroptive behavior disorder Other les spending far all kids 5 1996 $2,300 n year - bt roceeds $370,000 f.u . few prevalnt conditions include diabetes, sickle As with mutt Amecca-s, children with spe cell anemia, cystic fibhosis, spina bifida, ne- 1.4 million childrn with specl hee th cial needt am today facing a netooled health -bh1 palty-o-ensal impoimnest, Thsy can be needs am uninsured care marketplace govered by the principles of children with unstahbl or derenoraing condi- 36%s with specol health needs dis h-nged magd care Whether covered by pevate tions, roc as muscular dystrophy or HIV hamn cnildrin s husptith as ssied bq inurance plans or public health progrms- infection Some have congenital anomalies, <strong>Medicaid</strong> m 1996 and many attittance -eceice fom wth - roch as ceh palate, or are her with problems 40% with spedal health needs dischanged maged care in the furore may well dictate making it difficult to digest or retaboliae flod 2mm childrn's hospitals anisted by the location quantity and quality of services Ofth a child has morn than one condition private ki-urseca in 1 996 for these children But befone managed care i Some o hnse infants, children and adoles- 30 sttes m-anang mranged are rmbracrd as the coverage of choice for chilcents may have muhblr panicipating in whoal or aangeren he at u one chidusts die- with special nerds, stae and federl poli- ply Others need a range of therapies and spe- wth se needs cy makers, as well as employers, must address cial ovaream ss, while still nthers am dependent a number of key issues. Ultimately, they most on life nsaining medications on diets, o use of decide whether care can be managed to such devices s wheel chair, prostheses or hear -- improve quality and coordination fur children tog aids Most need ongoing medications, self with special health nerds-and achieve and family case management and insreirtens savings mental heath are and family rappers Alliance for Health Reforen, 1900 L Street NW., Suite 512, Washington., DC. 20036 ALLIANCE Phone 202/466-5626, Fan 202/466-6525 - F O R - Suppoted by a gr-nt from the Rober Wood lohoron Foundation HEALTH REFORM
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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
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668 Sources Ash A, Porell F, Gruenb
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C. Recommended Adivities 670 With t
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672 B. Examples of Current Research
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674 The Practice Parameters Project
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076 -Administrative Survey: Enrollm
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678 Description This guide provides
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680 APPENDIX 1: PARTICIPANT LIST MA
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682 MANAGED CARE EXPERT WORK GROUP
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684 APPENDIX H: BIBLIOGRAPHY MANAGE
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686 MANAGED CARE EXPERT WORK GROUP
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688 MAKING MEDICAID MANAGED CARE PR
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690 On Saturday, July 13, 1996 and
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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 720 and 721:
Medicaid Working G
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
Page 770 and 771: 768 (6J identify and evaluate a men
Page 772 and 773: 770 This paper highlights children'
Page 774 and 775: 772 din resulut in inadequate or in
Page 776 and 777: 774 dividual under public-sector ma
Page 780 and 781: ivn58ffR1eL_ 778 THF VARIAI LITY OF
Page 782 and 783: _4 What are the essential benefits
Page 784 and 785: WHAT PUBLIC PURCHASERS CAN DO - Oen
Page 786 and 787: ASSESSMENT OF STANDARDS - Quality M
Page 788 and 789: Accessibility, Availability, Referr
Page 790 and 791: - Credentialing and Recredtentialin
Page 792 and 793: Standards for Members' Rights and R
Page 794 and 795: Preventive Behavioral Health Servic
Page 796 and 797: 9b4 etfJovrk9imut July 16, 1997 794
Page 798 and 799: hel,4Neipaork SEmi July 16, 1997 79
Page 800 and 801: 798 Principles for Accountable <str
Page 802 and 803: 800 The Coalition for Accountable <
Page 804 and 805: 802 Principles for Accountable <str
Page 806 and 807: Im. Community 804 Health plans shou
Page 808 and 809: 806 4. participating in community p
Page 810 and 811: 808 5. give patients opportunities
Page 812 and 813: 810 aRve New Children With Disabili
Page 814 and 815: Table of Contents 812 Executive Sum
Page 816 and 817: 814 combination of HealthPartners d
Page 818 and 819: Introduction 816 F amilies whose ch
Page 820 and 821: 818 Of the 24 families asked, 13 pa
Page 822 and 823: 820 Shriner's Hospital, or claims s
Page 824 and 825: 822 Major Child and Family Concerns
Page 826 and 827: Services and Funding Sources 824 Nu
Page 828 and 829:
Physician Survey 826 M ost physicia
Page 830 and 831:
828 Discussion and Recommendations
Page 832 and 833:
830 * Claims and billing informatio
Page 834 and 835:
832 El Advocate for a safety net of
Page 836 and 837:
834 :i:PTNG F'AITH SYMThMr -"r W, M
Page 838 and 839:
836 We recognize that managed care
Page 840 and 841:
due to a host of complex demographi
Page 842 and 843:
affect many different facets of an
Page 844 and 845:
state agencies, must be held accoun
Page 846 and 847:
In selecting managed care entities
Page 848 and 849:
Z, W 0 V==4 . k PQ- 0 V-- 9 Q) bo =
Page 850 and 851:
plans were virtually identical in b
Page 852 and 853:
to chronically i persons has been t
Page 854 and 855:
Managed Risk Medic
Page 856 and 857:
the lead. Large purchasers might wo
Page 858:
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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