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

Finally, relationships with public health agencies, in particular,
are needed to ensure that key public health functions
can be properly carsed out.
Findings on the Relationship Between <strong>Managed</strong>
<strong>Care</strong> Plans and the Large Health <strong>Care</strong> System
Our study indicates that:
es States are just beginning to grapple with an exceedingly
complex issue which was never satislactonly
addressed in the fee-for-service system: the coordination
of care between different entities and different
type of providers.
+ States are not currently in a position to purchase
continuous enrollment in managed care for <strong>Medicaid</strong>
beneficianes, creating gaps in coverage.
4 Few contracts contain specifications for referrals
to non-network agencies or providers or for coordination
of treatment plans ordered by courts, school
systems, and other parts of the social service or
justice system.
4 States generally focus on encounter, grievance, and
financial data to measure plan performance, and
only a few focus on issues related to plan integration
with larger system, the process of care, and
population health outcomes.
*> Coordination between managed care and public
health agencies is largely unspecified, and contracts
do not cover traditional public health functions.
Send to:
Name:
Title:
Organization:
Address:
Phone:
92
4. Constructing Business Terms and Relationships
Finally, <strong>Medicaid</strong> managed care contracts define the
nature of the business relationship between the buyers (the
state <strong>Medicaid</strong> agencies), the sellers (the managed care
organizations), the providers, and the enrollees. The terms
of the contract can reflect both the practical and financial
aspects of the business arrangement that guarantee the stability
of performance, as well as the purchasers judgment
about how the contract duties should be performed.
Because the purchase of an integrated health delivery
system is a business transaction, the state has a strong interest
in assuring that its contractors remain a financially viable
businesses capable of deliverng the contracted services.
Perhaps of greatest importance, states must be able to address
effectively contractor non-compliance with its contracted
duties.
* Findings on Constructing Business Relationships
This study shows that:
4 Reflecting the recognition that purchase of a health
care system for the poor is a business transaction,
all states have included some provisions defining
the terms and relationships necessary to establish
the business framework for <strong>Medicaid</strong> managed care
contracts.
4 States vary in the degree to which they rely on state
insurance regulation rather than the contracts to
regulate the financial stability of plans.
> States differ in the degree to which they give plans
the discretion to design enrollee and provider grevance
procedures and in the degree of specificity
they use in defining minimum procedures.
v While all states establish sanctions for non-perdormance,
states vary in the range of sanctions applied
and in the degree to which specific sanctions are
tied to specific performance measures.
*> Even in states with detailed purchasing and perdormance
specifications, there may be no clear link
between particular specifications and particular
sanctions.
Ill. Summary of Recommendations
1. Defining the <strong>Medicaid</strong> <strong>Managed</strong> <strong>Care</strong> Delivery System
We recommend that a joint, multi-disciplinary <strong>Medicaid</strong>
managed care purchaser's Initiative be undertaken
to develop a consensus on model practice-style specificatlons
in contractors' service delivery systems.