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Serving Persons with Disabilities in Medicaid Managed
Care: TECHNICAL ASSISTANCE CONFERENCE
Los Ángeles, California
HRSA and CMS
Dear Colleague: The Health Resources and Services Administration (HRSA) and the Center for Medicare and Medicaid Services (CMS) are pleased to share with you the enclosed publication entitled, “Serving Persons with Disabilities in Medicaid Managed Care: Assuring Continuity, Quality and Cost Effectiveness.” The proceedings highlight the events of a national conference that was conducted in Los Angeles, California on April 17, 2002 and was developed by the Health Resources and Services Administration’s Managed Care and Health Services Financing Technical Assistance Center (MCTAC). This conference offered the core information that will enable participants to provide quality, comprehensive services to persons with disabilities in a Medicaid managed care environment. Within this document, you will find:
Please note that the proceedings contain much data demonstrating the cost effectiveness of various managed care and other delivery systems and risk adjustments in addition to statistics concerning persons with disabilities. Hopefully, this publication will serve as a valuable resource for your organization. Copies of this publication may be downloaded from HRSA’s Center for Health Services Financing and Managed Care’s website at www.hrsa.gov/financeMC or from the MCTAC website at www.jsi.com/hrsamctac. For more information, please call HRSA’s Center for Health Services Financing and Managed Care at 301-443-0940. Table of Contents Introduction and Executive Summary Focusing on the Disabled Population in a Managed Care: National Trends and Issues Panel Discussion I: Creating Healthcare Teams for the Disabled
Panel Discussion II: Rate Setting and Data Collection
Family Voices: The Role of Families of Disabled Persons in Medicaid Managed Care Special Focus: Improving Care through Better Communication
Panel Discussion III: Developing a Network of Providers with Relevant Experience
Introduction and Executive Summary This document serves as a summary of the conference “Serving Persons with Disabilities in Medicaid Managed Care: Assuring Continuity, Quality, and Cost Effectiveness” co-sponsored by the Health Resources and Services Administration (HRSA) and the Centers for Medicare and Medicaid Services (CMS), operating divisions of the U.S Department of Health and Human Servicesn ed by the ding patients withdicaid managed care enviroments,te mental health agencies and others . On April 17, 2002, representatives from State Medicaid agencies, managed care organizations (MCOs), State and local health departments, Ryan White CARE Act providers, community health centers, special need children's organizations, public hospitals, family support groups, State mental health agencies and others convened in Los Angeles, California to address the unique issues related to providing healthcare for patients with disabilities in Medicaid managed care environments. The intensive, one-day conference drew nearly 100 participants from across the Nation. The conference began with opening remarks from Rhoda Abrams, MBA, Director of HRSA’s Center for Health Services Financing and Managed Care (CHSFMC), which is based in Rockville, Maryland. Joining Ms. Abrams in welcoming the group was Peggy Clark, MSW, MPA, Technical Director for the Disabled and Elderly Health Programs Group at CMS. After general introductions and administrative announcements, the objectives for the meeting were set forth.
After objectives were established, a plenary presentation, “Focusing on the Disabled Population in a Managed Care Setting,” commenced. Art Pelberg, MD, MPA, President and Chief Medical Officer of Schaller-Anderson, Inc. in Phoenix, Arizona provided a national perspective on trends and issues surrounding the management of care for persons with disabilities. He focused on expenditures as well as challenges facing the individuals and agencies responsible for providing care for persons with disabilities: providers, Medicaid agencies, MCOs, and social service agencies. Following Dr. Pelberg’s presentation, the program continued with a panel discussion of several successful examples of how healthcare teams can facilitate effective care for persons with disabilities. The three panel members were Ana Clark, Public Health Programs Administrator for Health Net of California, Owen B. Ellington, MD, Vice President and Medical Director for AMERIGROUP Corporation in Houston, Texas, and Calvin Sia, MD, FAAP, Chair of the American Academy of Pediatrics Professional Advisory Committee of the National Medical Home Initiative for Children with Special Needs, who is located in Honolulu, Hawaii. This expert panel discussed the development of standards of care and effective systems for caring for the persons with disabilities. Specific concepts such as the value of the “medical home” and “empowered managed care staff” were highlighted. The second panel discussion concentrated on strategies related to payment options and levels of financial risk involved in caring for persons with disabilities, including “high-utilizers” such as the HIV/AIDS populationf financial risk involved in . Bob Lederer moderated this panel comprised of 3 speakers. Christine M. Bowser of the Pennsylvania Department of Public Welfare presented Pennsylvania’s new Medicaid managed care network, HealthChoices, Robert J. Master, MD, Chief Medical Officer for Neighborhood Health Plan discussed community alliances, and David H. Shippee, Executive Director of Chase Braxton Health Services, Inc. focused on the HIV/AIDS population in Medicaid managed care. The discussants identified vital areas such as critical mass, size of population, reimbursement systems, risk adjustments, provider contracts, and carve-out agreements. Actual data was presented to demonstrate the cost-effectiveness of various programs and systems of care for patients with disabilities. A lunch-time talk was led by Cassie Johnston, the Region 10 Coordinator for Family Voices, who spoke to the group about the Data to Action Project, an initiative which gathered feedback from MCOs to improve the understanding of issues and barriers to family-centered care. Ms. Johnston also highlighted another Family Voices initiative, the Your Voice Counts Project, which collected data from families about their views and suggestions for improving systems of care for special needs youths. The presentation wrap-up included a video prepared by Family Voices, in which patients and their families shared their unique and personal perspectives about the kind of care they receive from Medicaid managed care plans. Carolyn Gleason moderated the first afternoon session, which featured Barry Handon, MD of Medi-Cal and Larry Fricks of the Georgia Division of Mental Health. The speakers highlighted the importance of communication when providing care for a person with disabilities. Discussions centered on the myriad entities involved in the care process and how each may have unique and competing interests. In caring for a person with disabilities, it is essential to find solutions to disparate agendas through clear communication. Dr. Handon and Mr. Fricks suggested several strategies from both the State and the MCO perspective. The third and final panel discussion explored how plans develop a network of providers with relevant clinical and health-related experience to accommodate the special needs of persons with disabilities. Rebecca Pasternik-Ikard, JD, MS, RN (replacing Mike Fogarty, MD) moderated the session which highlighted creating access to primary and specialty care and coordinating services with public agencies. State Medicaid agencies and health plans were represented by three speakers: Sue Bulger, BSN, MA of AXIS Health Care, Bruce Chernof, MD of HealthNet of Southern California, and Sally Venator of Heartland Health Plan of Oklahoma. The full day concluded with an audience input session facilitated by Peggy Clark, MSW, MPA. This portion of the program allowed participants an opportunity to directly engage speakers in a dialogue of questions and comments, sharing their own experiences with managing the care for persons with disabilities. Note to Readers: Remainder of Document The remainder of this document includes a more detailed account of the meeting “Serving Persons with Disabilities in Medicaid Managed Care: Assuring Continuity, Quality and Cost Effectiveness.” Appendices I and II include many slides shared by the meeting faculty. For easier reading, specific references are made to these appendices in the text of the document; Appendix I may be indicated by “AI”, while Appendix II may be indicated by “AII”. Focusing on the Disabled Population in Managed
Care: National Trends and Issues Dr. Pelberg examined the issue of healthcare for persons with disabilities from a national perspective, identifying the major issues and creating a backdrop for the rest of the day’s presentations. He began by defining the population at-hand. Individuals who typically qualify as disabled under State Medicaid programs include children with special healthcare needs, people with physical or developmental disabilities, people with chronic illness, people with mental illness, people who are frail or elderly, and people who are deaf or blind. Classifying patients with special needs can be a challenging task, but Dr. Pelberg listed several strategies MCOs can use to identify these patients so that they can be offered supplementary services. Screening tools, new member outreach, and Medicaid or MCO claims data are a few such options. Once persons with disabilities are enrolled in Medicaid, they tend to stay enrolled, unlike the general Medicaid population. Persons with disabilities have Medicaid disenrollment rates as low as 1-8 percent (Appendix I, slide 6). As increasing numbers of persons with disabilities enroll in mandatory or voluntary Medicaid managed care programs throughout the U.S., a greater focus on how to provide cost-effective, quality healthcare in this setting has emerged. Expenditures for persons with disabilities comprise the greatest portion of total Medicaid expenditures despite the fact that this population represents only ~17 percent of total members (See figure: Appendix I, slide 9). Of the $67 billion spent annually for the care of Medicaid members with disabilities, costs can be identified by services type, with the largest percentages going to inpatient hospital costs (17 percent), intermediate care facilities (14 percent), ambulatory care (13 percent), and home healthcare (13 percent). Notably, the areas of care and distribution of expenditures differ from those of the general population because the disabled tend to utilize a greater number of intermediate care steps (Appendix I, slide 11). As of 1998, the percentage of Medicaid members with disabilities enrolled in managed care plans varied nationwide: 15 States had no members with disabilities in managed care, 23 States and the District of Columbia had 1-50 percent of members with disabilities in MCOs, and 12 States enrolled 50-100 percent of members with disabilities (Appendix I, slide 12). Many States that have adopted managed care programs have made MCO membership mandatory for persons with disabilities. Dr. Pelberg explained that mandatory enrollment protects MCOs from assuming risk for patients who move in and out of care. Also, many Medicaid-enrolled patients with disabilities-for example, 30-40 percent of enrollees under 18-also have some type of private insurance (Appendix I, slide 14); this provides an opportunity for coordination of benefits, according to Dr. Pelberg. Managed care may emerge over the long-term as an effective solution for Medicaid patients with disabilities. However, in these early years, challenges-some real and some perceived-may arise as State Medicaid agencies begin covering the population with disabilities within the managed care setting. Dr. Pelberg spent time discussing some anticipated and actual issues from the vantage points of all stakeholders: MCOs, State Medicaid agencies, providers and, of course, patients themselves. The switch from Medicaid fee-for-service (FFS) coverage to MCO care will include an inevitable transition period in which all parties will need to adjust to new systems (e.g., acute versus chronic care, prior authorization rules). States entering into partnerships with MCOs may experience an adjustment period as they learn how to meet enrollees’ needs in complex systems. States will need to address regulatory oversight and advocacy issues, which may be unfamiliar to MCOs, with their new partners. Some other potential challenges for States include identifying the special needs of members prior to enrollment or a lack of sufficient information about member’s eligibility status and current contact information. Caring for members with disabilities gives rise to additional considerations for MCOs. Primary issues include quality of care, costs, legislative issues, advocacy, and continuity of care. The services for persons with disabilities differ from those of the general population of MCO members. For example, many more intermediate care services (e.g., home healthcare) are utilized by these individuals. Likewise, many persons with disabilities (63 percent) have one or more chronic conditions for which they need regular medical care (Appendix I, slide 8). Patients with chronic diseases require long-term solutions via special systems of care, such as case management and disease management programs, which can be costly but necessary to meet patients’ healthcare needs. MCOs will need to find quality, cost-effective ways to manage these issues. Providers working with Medicaid MCOs to care for patients with disabilities must also be prepared for unique challenges. For example, patients with disabilities may present special health issues that require providers to acquire additional training, but providers may be reluctant to develop expertise in the area because of a real or perceived lack of support for more extensive services. Likewise, providers may be concerned about reimbursement issues, the additional time required to serve patients with special needs, garnering support from their office staff, and even the possible need to physically renovate office space to accommodate new patients. MCOs that anticipate and address these concerns before enrolling Medicaid members with disabilities will be more likely to receive positive responses from providers. Patients may experience a parallel period during which they learn to navigate the new MCO healthcare environment. Similar attention should be paid to preparing persons with disabilities and their families for the switch to managed care. Measuring success in overcoming these challenges will be an important part of the process of not only establishing but also maintaining quality care for patients. Because caring for persons with disabilities in Medicaid managed care is a relatively new phenomenon, there is a dearth of useful data and performance measures for special needs populations. Systems for gathering data as well as benchmarks and performance indicators for measuring data will need to be established. Moreover, when data are available for measurement, the small size of this group (in numbers of patients) should be considered as it may impact the reliability of any results. Despite these challenges, efforts are continuing to enhance the quality of care and to manage the costs associated with special needs patients in Medicaid MCOs. The key to success, as articulated by Neva Kay and Deborah Curtis of NASHP, may be ensuring that every individual involved and invested in the care process has “an understanding of what it means to have special needs-from personal care assistants to child welfare agency staff to durable medical equipment (DME) suppliers, to x-ray technicians, and the MCO staff themselves.” 1 1 N. Kay and D. Curtis. “Certain Children with Special Health Care Needs: An Assessment of State Activities and Their Relationship to CMS’s Interim Criteria.” June 2000. Available on-line at: http://www.nashp.org/Files/Certain_Children_w_Special_HC_needs.pdf (PDF file - 1,124 KB) Panel Discussion I: Creating Healthcare Teams for the Disabled Following Dr. Pelberg’s presentation, the program continued with a panel discussion of several successful examples of how healthcare teams can facilitate effective care for persons with disabilities. The session, moderated by Peggy Clark, MSW, MPA, included 3 presenters: Ana Clark, Public Health Programs Administrator for Health Net of California, Owen B. Ellington, MD, Vice President and Medical Director for AMERIGROUP Corporation in Houston, Texas, and Calvin Sia, MD, FAAP, Chair of the American Academy of Pediatrics Professional Advisory Committee of the National Medical Home Initiative for Children with Special Needs in Honolulu, Hawaii. Serving Persons with Disabilities: The Health Net Experience Ana S. Clark, RN, BSN, PHN described Health Net of California’s experience with providing care for persons with disabilities in a managed care environment. Health Net, a network-model MCO, delivers care to 2.6 million members Statewide, many of whom are Medicaid members requiring special services. Health Net focuses on coordinating care for children with special healthcare needs (CSHCN) by “thinking out of the box” to reach children with disabilities. Key objectives for this population include the following:
Health Net partners with four major, State-sponsored programs to achieve these aims: California Children Services (CCS), Department of Developmental Services (DDS), Local Education Authority (LEA), and Children’s Mental Health Services. CCS is a Title V program that arranges, directs, and pays for the medical care of youths with disabilities in California. It is the most complicated of all four carve-out programs, yet partnership with this organization may offer maximum opportunities for coordination of care. Health Net and CCS collaborate by sharing resources, creating a “medical home” for patients, and establishing systems for tracking patients and collecting data. Health Net and LEA work together to develop school-based health centers, which have been shown to be an effective method of improving access to care for children and adolescents nationwide. With DDS, Health Net shares responsibility of providing care for eligible children and adults in regional centers throughout the State. The DDS/Health Net Regional Services Centers offer Early Start programs, respite care, counseling, case management, and Individual Family Service Plans. Mental health services for Medi-Cal/Health Net members are provided at a local level, with over 20 public health programs available. This fragmentation sometimes makes it challenging to identify the program responsible for treating individual patients and specific conditions; overcoming delivery system separations is a major goal for the future. By building collaborative systems of care with these four agencies, Health Net is better able to reach California’s children and adults with disabilities. Adult Medicaid Members and Their Special Needs Owen B. Ellington, MD, Vice President and Medical Director of AMERIGROUP Corporation’s Houston Market, discussed his organization’s focus on caring for low income and uninsured families and persons with disabilities living in urban communities. AMERIGROUP provides healthcare for nearly 375,000 persons in seven cities throughout the U.S. Most of AMERIGROUP’s members are covered by Medicaid, CHIP, FamilyCare, and/or SSI, with funding from both Federal and State agencies. AMERIGROUP’s four areas of management ensure that its primarily adult members receive the care they need within the financial parameters required to maintain corporate solvency. These areas are care coordination, quality management, behavioral health, and long-term care plus community-based alternatives. To provide cost-effective care coordination, AMERIGROUP practices concurrent review of services, case management, and disease management. Quality management is supported by an external quality review organization, while behavioral health follows the standard carve-out model. Dr. Ellington notes that there are specific challenges associated with the AMERIGROUP Medicaid members, particularly patients with disabilities, which requires the company to give special attention to these individuals. For example, because Medicaid members are permitted to switch MCOs every 30 days, enrollment varies significantly from month to month. Also, when a new Medicaid member joins AMERIGROUP, it is sometimes difficult to get past medical records for the individual from the State, requiring a complete health assessment for new patients. Dr. Ellington commented that within the population with disabilities, there tends to be a select proportion-usually about 20 percent-who account for a major percentage (~80 percent) of costs. It is important to identify these high-utilizers early so they can receive intensive case management. Compliance with a physician-prescribed treatment plan and co-morbidity are also a concern with this group. Despite the challenges, AMERIGROUP has launched innovative strategies to improve outreach and care for their adult members with disabilities. Disease management programs which focus on caring for a population of patients with a particular medical condition (e.g., diabetes) facilitate cost-effective team care. The AMERIGROUP Health Promotion and Member Education Team documents improved 20 percent-who account for a major percentage (~80 percent) of costs medical management of patients. Similarly, provider education has shown improvement over the past 10 years, although Dr. Ellington acknowledged that some providers would always be difficult to reach. A Field Nurse Care Intervention program has been implemented so that nurses can interface with high-use members in multiple clinical and community settings. Finally, the Team Care approach allows AMERIGROUP to use all specialists to improve the health of patients with disabilities. AMRIGROUP has identified several objectives for the future: 1) to increase reimbursement s for providers who care for persons with disabilities, 2) to enhance the management of persons with disabilities, 3) to increase the number of high risk clinics, and 4) to assume only out-patient risk for members with dual eligibility. It is anticipated that these next steps will reduce recidivism of patients with frequent hospital stays and improve quality and costs overall. The Role of the Medical Home for Children with Special Healthcare
Needs The final presentation within the “Healthcare Teams for the Disabled” panel was led by Calvin C. J. Sia, MD, FAAP, Chair of the American Academy of Pediatrics Professional Advisory Committee of the National Medical Home Initiative for Children with Special Needs. Dr. Sia explained that the ideal care environment for a child with disabilities is one that offers an integrated system of services focused on the child within the context of the family. The concept of family-centered care reflects the idea that families should be at the center of service delivery systems (see figure). Furthermore, every child is entitled to a “medical home”, defined in 1992 by the American Academy of Pediatrics as a clinical setting that provides primary health care services which are comprehensive in addressing the needs of the whole child (Appendix II, slide 32).
The first step in making the medical home a reality is implementing physician education and training programs to enhance skills and awareness about treating children with special healthcare needs. Several grant programs have been developed to meet this objective, such as the AAP Medical Home Initiatives and the Annie E. Dyson Pediatric Residency Training in Community Pediatrics. Next, integration of public and private care and coverage is needed to optimize outcomes and avoid duplication of services. This can be achieved through a systems approach to care delivery that includes both medically necessary and educationally necessary services, as identified under the Individuals with Disabilities Education Act, IDEA 1997. This integrated approach is challenging because many disparate sources outline and fund healthcare and education services-and because appropriate services and required reimbursement varies from State to State. Nevertheless, a systems approach which pulls together a community-based team for the care of special needs children is the ultimate framework for supporting the Medical Home concept. Panel Discussion II: Rate Setting and Data Collection The second panel discussion concentrated on strategies related to payment options and levels of financial risk involved in caring for persons with disabilities, including high-utilizers such as the HIV/AIDS populationf financial risk involved in . Bob Lederer, MD, a consultant to HRSA’s Center for Health Services Financing and Managed Care (CHSFMC) with many years of experience in the managed care arena, moderated this panel comprised of three speakers. Christine M. Bowser of the Pennsylvania Department of Public Welfare presented Pennsylvania’s new Medicaid managed care network, HealthChoices, Robert J. Master, MD, Chief Medical Officer for Neighborhood Health Plan discussed community alliances, and David H. Shippee, Executive Director of Chase Braxton Health Services, Inc. focused on the HIV/AIDS population in Medicaid managed care. Data Collection and Rate Setting in Pennsylvania’s Medicaid Managed
Care Plan Christine M. Bowser of the Pennsylvania Department of Public Welfare led the first of three presentations given by the panel on data collection and rate setting, using Pennsylvania’s experience as an example. Of the State’s $45.5 billion budget of State and Federal funds, nearly one-quarter is spent on medical assistance (Appendix I, slide 27). Pennsylvania is currently moving towards a mandatory Medicaid managed care model, which will be fully implemented by 2005. The HealthChoices Medicaid Managed Care Network currently has seven MCOs serving nearly one million medical assistance recipients through the State (Appendix I, slide 29). This comprehensive plan covers almost all health services (ie, no carve-out programs) and serves many eligibility groups, including adults and children with disabilities. HealthChoices’ structure consists of core teams throughout Pennsylvania that adhere to detailed regulatory guidelines for its Medicaid managed care members. Though the plan offers open enrollment, less than one percent of its members change plans in any given month. Importantly, HealthChoices operates State-mandated Special Needs Units (SNUs) for patients with disabilities (Appendix I, slide 36). The Special Needs Units are quite inclusive and provide essential services to patients: assistance with accessing and coordinating care, linkages to community resources, and navigation of managed care systems. Specifically, SNUs document activities such as TTY interventions, language line interventions, transportation, and case management as well as training, education and outreach. These activities allow members with disabilities to be included in mainstream medicine with better access to quality care. For its MCOs, HealthChoices provides incentives to serve persons with disabilities while managing costs. Another key aspect of HealthChoices is the emphasis on measuring its own performance. Currently, the Network collects data on HEDIS, EQR and CAHPS2 indicators to generate performance profiles and design quality improvement plans. To date, most data reflect process measures, but HealthChoices hopes to measure health outcomes in the future. In addition to providing information for internal use, performance profiles of each HealthChoices MCO are given to members at the time of enrollment and are also available via the HealthChoices Web site. These profiles compare MCOs to one another and to national benchmarks for success. Because of its intense focus on measurement, HealthChoices has made marked progress in its quality improvement efforts. As the Network expands Statewide, quality indicators may be more closely linked to reimbursement. Along with linking reimbursement to performance, HealthChoices plans to address rate setting with equal vigor. The group is preparing for risk-adjusted rates over the next two years, with implementation slated for January 2003 (Appendix I, slides 49 - 52). The goal of enhancing risk-adjustment is to more closely link capitation to health diagnoses of MCO’s members. During developmental meetings, HealthChoices identified one major problem impeding risk-adjusted rate setting; several MCO’s were not requiring or providing complete and accurate encounter data from their physicians. This information is essential for determining how diagnoses are grouped and building a MCO’s case mix (ie, a figure that indicates how sick a particular population is compared to others). The case mix is used re grouped and what a in determining how diagnoses are grouped and what a to adjust capitation rates: MCOs and individual practices with higher case mixes/sicker patients have higher capitation rates. 2 HEDIS-The Health Plan Employer Data and Information Set; EQR-External Quality Review; CAHPS-Consumer Assessment of Health Plans Community Medical Alliances: Clinical Programs at Neighborhood Health
Plan As a pioneer of the risk-adjusted system, CMA approaches primary care based on a team philosophy for treatment. Nurse practitioners are responsible for primary care, along with links to specialists on the care team. In addition, home visits for clinical care are commonly used (74 percent home vs. 26 percent office for primary care). This approach has resulted in an essentially stable per member/per month (PM/PM) cost over the past 10 years ($1749 in 1990 vs. $1735 in 1999). More striking is the reduction in acute hospitalization costs this system has incurred: $854 PM/PM in 1990 vs. $104 PM/PM in 1999 (see figure). This reflects not only cost-saving but also improved quality of life for patients who now require fewer inpatient stays, and presumably, have fewer acute medical events. Even in the HIV/AIDS group, a high-use population, CMA has netted significant cost savings over the old fee-for-service plan: $4884 vs. $2392 (see figure). This savings has coincided with improved life expectancy in patients with HIV/AIDS. Since 1994, the mortality rate for patients in the CMA program has dropped 545 percent, with 60 deaths per 100 patient years in 1994 versus only 11 per 100 patient years in 2000. To date, the progression systems implemented by CMA have proved to be both cost-effective and clinically efficacious. A Provider’s Perspective on the HIV/AIDS Population Dr. David H. Shippee presented his own experience as the Executive Director of Chase Brexton Health Services, Inc. (CBHS), a small practice which primarily serves ~1400 HIV positive patients, 250 who are in an HIV positive Medicaid managed care arrangement. The main challenge his Baltimore-based organization faces is assuming nearly 100 percent financial risk for a managed care population of high-use patients. The center is at full financial risk for the costs of all physician, in-patient and ancillary services. In 1998, CBHS established its initial risk contract, the terms of which included 86 percent reimbursement for all HIV/AIDS patients; however, high dollar medications (ie, protease inhibitors) were still paid for by the State. By 2001, risk-adjusted rates for HIV positive patients with and without AIDS had been established and CBHS assumed risk for all medications and services (Appendix I, slide 100). The new contract structure challenged the practice to ascertain new strategies for living within the premium dollar (Appendix I, slide 98). Dr. Shippee identified several key components for doing so. First, CBHS has many on-site services to meet patient needs: a multidisciplinary staff to assist in managing complicated cases, an on-site pharmacy with access to 340B pricing, and on-site addictions intervention services. In addition to a team of experienced HIV primary care providers, CBHS has a solid referral network in place for instances when outside services are required. Second, the practice has a good working relationship with the State Medicaid office, which allows them to manage patient care and reimbursement efficiently. For example, sicker patients are stabilized while still eligible for Ryan White CARE Act coverage before they transition to Medicaid eligibility. Also, the CBHS-Maryland Medicaid relationship has enabled the practice to align capitation rates with current treatment modalities. Nevertheless, Dr. Shippee admits that sometimes the key to money management extends beyond the clinic to how patients live at home. Life-sustaining needs must be met, and this requires that CBHC shift a portion of the premium to non-clinical needs that can impede the patient’s ability to stay in care. Over the past four years, CBHS has collected data based on actual experience to assess the effectiveness of these practices. The figures indicate that through 2000, costs remained fairly stable, but have been increasing since then. This mainly reflects considerable increases in pharmacy claims, 40 percent of which are for non-HIV medications used to treat the comorbidities their patients often suffer. Medical costs have remained fairly stable. (See Appendix for figures detailing these data.) Dr. Shippee notes that for the future, the group will need to focus on how to manage increasing pharmaceutical costs (Appendix I, slide 101). Overall, though, CBHS has achieved financial solvency (Appendix I, slide 100). He ended his presentation by emphasizing the major reason for the practice’s economic success has been its ability to keep at least 50% of the premium income in-house. Family Voices: The Role of Families of Persons
with Disabilities in Families play an enormous role in the healthcare of patients with disabilities, acting as advocates, supporters, and sometimes even care providers. Family Voices is a national grassroots network of more than 40,000 families and friends who have joined forces to formalize their roles in the care of their disabled loved ones. Family Voices offers information, education, support and advocacy for children of all ages with special needs. Cassie Johnston, the Region 10 Coordinator for Family Voices, spoke to the group about the Data to Action Project, an initiative that gathered feedback from MCOs to improve the understanding of issues and barriers to family-centered care. She also highlighted another Family Voices initiative, the Your Voice Counts Project, which collected data from families about their views and suggestions for improving systems of care for special needs youths. The Data to Action Project was based on interviews with a variety of managed care leaders, from medical directors to CEOs to health plan attorneys. Findings focused on several key areas:
Information from the Your Voice Counts initiative was provided to participating health plans to help them understand the parent/family perspective. Further, family leaders participated directly in dialogues with health plan leaders. This activity resulted two sets of suggestions about providing care for CSHCN: one set from families to MCOs and one set from MCOs about how to adapt plan procedures to better serve their patients. The overall outcomes from these sister projects included an enhanced rapport between families and plans, a recognition by plans that parents were proficient and well-informed about their children’s healthcare needs, and a joint agreement that that there is potential for further collaborative work between families and MCOs. Special Focus: Improving Care through Better Communication This special session, moderated by Carolyn Gleason and featuring Barry Handon, MD of Medi-Cal and Larry Fricks of the Georgia Division of Mental Health, highlighted the importance of communication when providing care for a person with disabilities. Myriad entities are involved, and each may have unique and competing interests. Finding solutions through clear communication is crucial in caring for a person with disabilities. Better Care through Communicating in California’s Medi-Cal Medicaid
Managed To give context to his discussion, Barry Handon, MD shared a brief background of California’s Medicaid managed care plan. Rapid expansion of California’s Medi-Cal (e.g., Medicaid) managed care program over the past nine years has resulted growth in membership from 600,000 in 1993 to nearly three million in 2002; over 25 MCOs Statewide are contracted to accommodate this growth. In addition, approximately two-thirds of these Medi-Cal MCO members are eligible under Temporary Assistance to Needy Family (TANF), suggesting that most beneficiaries are women and children. Members come from a variety of ethnic backgrounds, and for many, English is not their primary language. The rapid growth of membership and the membership’s inherent diversity have made effective communication between the State, contracting MCOs, carve-out agencies and patients essential to providing quality care to beneficiaries, particularly those with special healthcare needs. Although the initial expansion of Medi-Cal managed care did not formally identify persons with disabilities for enrollment, many persons with disabilities were in fact enrolled or were eligible for enrollment. However, early on systems were not in place to provide special services to these members outside the parameters of the regular system. To address this need, several activities were conducted. First, efforts to improve care through better communication required the California Department of Health Services to clarify the responsibilities MCOs have in terms of serving persons with disabilities. A series of policy letters were drafted and disseminated to MCOs. The letters identified and defined MCOs as the “medical home” for enrollees with disabilities, explained how MCOs should interface with carve-out providers who provided out-of-plan services for members with disabilities, and outlined special requirements to be met for children with special healthcare needs. Compliance with the letters was mandated by contract. Also, all Medi-Cal MCOs now require Memoranda of Understanding contracts with local health departments and mental health providers that explicitly delineate the responsibilities of each party. Workgroups and taskforces were also developed to ensure the continued advocacy for members with disabilities. One such group established a partnership between California Children’s Services and the Medi-Cal program to focus on the needs and services provided to children. An important long-term goal the Workgroup has identified is the development of performance measures for providers and MCOs who care for children with special healthcare needs. To date, there is a dearth of tools to measure success in this area, and the Workgroup has decided to create assessments that would fill this gap. They are currently working with the Foundation for Accountability (FACCT), an organization with extensive expertise in the field of measurement, to achieve this objective. Other initiatives focus on better care through communication for those with severely developmental disabilities and the HIV/AIDS populations. All of these activities are being scrutinized to assure best clinical and administrative practices are employed. Dr. Handon stressed that some of the best work is occurring at the local level, and that the practices of successful MCOs should be analyzed and brought to the Medi-Cal system as a whole. The Evolution of Peer Supports in Georgia Larry Fricks, Director for the Office of Consumer Relations at the Georgia Division of Mental Health, provided a different strategy for using communication to better serve the needs of patients with disabilities, specifically those with mental illness. Through a partnership with APS Healthcare, Georgia completely revamped its mental health day treatment program in July of 1999. Prior to that time, day treatment services for patients with mental health problems primarily relied on medication as the main treatment modality. Often, patients were overmedicated, and a sense of hopelessness and helplessness prevailed. When the decision to change the treatment paradigm was made, a radically different system was put in place. Adults still participated in day treatment, but the new methods pulled away from a heavy medical emphasis with a simultaneous push towards professional and peer supports to help patients manage their mental health issues. Nearly half of the patients who had been enrolled in traditional day services prior to July 1999 were able to transition to the progressive peer support program. The peer support program revolutionized the Georgia mental health system from a system focused on stabilizing symptoms and providing custodial care to one that is focused on self-help and recovery. The program trains mental health consumers well-grounded in recovery as certified peer specialists who support other patients in the system. This structure offers certified peer specialists a powerful sense of accomplishment while providing successful role models for the consumers who receive support. A highly detailed training plan with 31 measurable objectives must be completed before an individual can become a peer specialist. One aspect of the plan is based on the work of Mary Ellen Copeland who conceived the Wellness Action Recovery Plan (WRAP). Other objectives focus on learning to navigate the Georgia Health System, understanding why self-help works and negative self-talk doesn’t, and gaining the skills needed to help other patients find and procure satisfying employment. Future plans include opening one or more peer centers where members can seek companionship and support. A major concern about any new program is its financial feasibility. However, Georgia has been successful as the first State in the U.S. to bill and receive reimbursement from Medicaid for peer supports. In fact, this program is costing the State less money than the conventional model of day treatment; the drop in costs from ~$1300 to ~1000 per consumer patient translates to a ~25 percent savings. While the Peer Support program is not right for every mental health patient, it has been successful enough in Georgia that eight other States across the country have requested that Georgia assist them in bringing the program to their own States. Panel Discussion III: Developing a Network of Providers with Relevant Experience Rebecca Pasternik-Ikard, JD, MS, RN moderated this session which dealt with how to attract and create a network of providers who specialize in the health issues of persons with disabilities. Both the State Medicaid and managed care perspectives were explored. Ms. Pasternik-Ikard began with a brief overview of her own organization, SoonerCare, which is Oklahoma’s Medicaid managed care plan serving ~330,000 TANF and members with disabilities (Appendix II, slides 141 - 147). When Oklahoma transitioned its members with disabilities from fee-for-service (FFS) to managed care in 1999, it experienced several challenges: a lack of infrastructure to care for these patients in the FFS model causing a pent-up demand for services immediately after the switch, as well as a need to revise rate setting and financial parameters. Since this time, most of these issues have been resolved and the SoonerCare plan is now functioning well in its services to disabled members. One aspect of the plan that Ms. Pasternik-Ikard noted as a very good strategy is the use of Exceptional Needs Coordinators (ENC). ENCs are individuals with a nursing or social work background who have a minimum of five years of experience working with individuals with disabilities. The ENCs act as advocates and point-people to assist patients with getting their medical and social needs met through the SoonerCare system. After Ms. Pasternik-Ikard’s comments, she turned the discussion over to three panel members. Sue Bulger, RN, MA, the Director of Health Coordination for AXIS Healthcare in Minnesota, discussed the AXIS model for developing a network of providers to care for persons with disabilities. Next, Bruce Allen Chernof, MD, FACP described his experience as Regional Medical Director for Health Net, the largest network model HMO in California. Finally, Sally Venator, CEO of Heartland Health Plan of Oklahoma (HHPO), described a study that HHPO conducted to assess its member’s and provider’s satisfaction with the plan compared with the previous FFS model. Minnesota Disability Health Options: A Voluntary Managed Care Program
for Persons with Physical Disabilities AXIS was created by physical disability providers as a joint venture
of
To identify key providers with experience handling patients with disabilities,
AXIS conducted interviews with staff at provider organizations (e.g.,
hospitals, private practices, etc.), identified provider preferences,
gathered consumer experiences through focus groups, tracked utilization,
reviewed existing contracts, and gave priority to providers who expressed
interested and had creative solutions for service delivery.
As AXIS moves forward to improve their health network, they face challenges from four fronts: partnering with a health plans, enrollment issues, PCP commitment, and rate-setting challenges (see above). Despite the obstacles, AXIS will continue to strive to reach its ultimate goal: To create a health network that allows all people, regardless of ability, to receive healthcare service and support needed for lives they find meaningful and productive. Network Development: Assuring Continuity, Quality and Cost Effectiveness The hallmark of Health Net, one of the largest Managed Medicaid providers with 530,000 members in seven California counties, is its diverse network of providers available to serve an equally diverse population of patients. Health Net contracts with 10,000 PCPs, 25,000 specialists, and 117 school-based health programs. A wide range of provider types and payment options are offered, with the goal of building flexible structures which can serve all patients, including those with disabilities. As a Medicaid managed care plan, Health Net includes various models-COHS, GMC, 2-plan-as well as 24 linked, waived, or carved-out programs for critical needs such as California Children’s Services (CCS), dental care, and mental health care. Like Medi-Cal, Health Net uses the “Memoranda of Understanding” technique for managing its programs. Dr. Chernof described challenges and successes Health Net has experienced, which are outlined in the table below. Health Net Challenges
Health Net Successes
For the future, Health Net is looking towards several opportunities for growth and development. For example, the organization would like to realize greater coalescence between government-sponsored programs and network programs. Also, they aim to simplify care coordination, which is always difficult because of complicated funding streams. Finally, Health Net intends to update their information systems in order to share data internally and with allied groups. This last objective is an achievable short-term goal, despite confidentiality limits. Overall, the vision according to Dr. Chernof is for “a more seamless system-one application that answers all kinds of questions for public health insurance.” Serving the Aged, Blind and Disabled Populations through Managed Care
Programs: A Four-Part Study Ms. Venator described a study that HHPO, a university-based health center and Medicaid provider group, conducted to assess member and provider satisfaction compared with the previous FFS model. The four-part study consisted of a member survey, a provider survey, focus groups, and a cost-effectiveness component. The figure below describes the study timeline and corresponding plan activities. The study results indicated that overall, patients documented improved health after voluntary enrollment in the managed care plan. Responses were positive, with most services scoring above 80 percent member satisfaction for child and adult care. Nearly all members indicated that compared with the FFS model, the MCO plan was at least as good or better in areas such as access to and cost of prescriptions (90 percent), satisfaction with services received (92 percent), ease of seeing a doctor (82 percent), and rating of doctors visited (92 percent). Provider satisfaction was also high, with providers perceiving the MCO as at least as good as or better than with FFS in home health services (100 percent), case management services (100 percent), ability to obtain information (100 percent) and timeliness of reimbursement (100 percent). Surveyed advocates also commented on improvements in various areas. Accountability has increased and a wider range of services is now available, they say. The system is less complex, making navigation easier for patients and providers. The addition of Exceptional Needs Coordinators (ENCs) is a major success, according to the survey. Advocates also made suggestions for the future: 1) Continue to train and educate providers and staff, 2) Enhance home health access, and 3) Increase family resources such as access to respite care. On the whole, the study showed very affirmative outcomes. But what does it cost for HHPO to achieve this success? Actually, according to claims data, costs are down approximately 15 percent since transitioning from FFS to managed care. Furthermore, when the 10 costliest enrollees (five hemophiliacs and five complex cases) were excluded, cost-savings amounted to 17 percent. This suggests that future strategies may focus on managing costs of high-utilizers, to the extent that this is possible. Ms. Venator attributes HHPO’s success to quite a few variables. Clearly, outreach, training, education and strong provider partnerships have played a significant part. Also, allowing specialists to act as PCPs has proven efficient and effective. The addition of ENCs has had a considerable impact, which is only furthered by preauthorization and concurrent review strategies. All these factors have produced effective care with manageable costs for HHPO. The demanding day of dialogue closed with a segment allowing participants to share comments and pose questions to the speaker faculty. The following are composite questions and answers based on key issues that arose during the session. Q: We have concerns about the lack of information sharing and case
coordination among providers. What are some recommendations to address
this? Q: Regarding the Medical Home concept-how will HIPAA affect the exchange of information that a Medical Home requires? A: One option is to identify family members as the case managers. If family members retain the records, privacy issues can be limited. Q: To whom can we advocate to bypass confidentiality issues that impede care measurement and improvement? A: Communicate with PCP and representatives from MCOs. These are legal and regulatory issues and will also require lobbying to legislators, government officials and attorney generals. Ask for information and action. Q: How are ENCs different from case managers and what is the most effective way to utilize both? A: Understand that the ratio of ENCs to patients is much better than with case managers: about 1:35 with ENCs versus 1:100+ with case managers. However, this difference occurs because the patients ENCs assist are all relatively high utilizers with complex cases. With case managers, patients vary more widely. Make sure your ratio reflects the level of need for that particular group of patients. Remember, too, that under the old insurance models, the ratios for case managers in SSI and TANF populations were as high as 1:1500 and 1:11,000, respectively. We are getting away from figures like that. Q: How do you build a relationship between an MCO and local (county) public service organizations? A: This is an excellent opportunity to turn to the Memoranda of Understanding model. Policy letters, letters of agreement, and all-stakeholder task forces can be used as effective tools for building a partnership at the local level. Specifically, provide an overview of your plan and include an outline of the minimum requirements for participation. It seems to be best to give guidelines to local groups early, and then allow them to dialogue about their questions or concerns. In terms of enrolling patients in partnered programs, field nurses are a great resource. They can go out into the community and enroll individuals with acute and long-term care needs. Another option is to serve the public health needs within the MCO (e.g., plans are not required to support existing public health programs). This does result in duplication of services, but as in the case of Oklahoma, it may force the local public health providers to change to fit the new model. Q: Can we identify some of the “best practices” discussed throughout the day? A: Overall, strategies based upon collaboration appeared to generate the most positive reactions from participants. The following list highlights several activities that the group agreed were successful, innovative practices that could serve as models for other States and MCOs.
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