Serving the Disabled Population in Managed
Care
(National Trends and Issues)
by Arthur L. Pelberg, MD, MPA - April 17,
2002
Presentation Outline
- Defining the population
- Demographics/statistics
- Issues for special needs populations
- Moving from FFS to MCOs
- Challenges for state Medicaid agencies
- Challenges for MCOs
- Challenges for providers
- Measuring performance
- Vignettes
Congress’ Definition of Children with Special
Needs
Medicaid beneficiaries under age 19 who:
- Receive SSI
- Are eligible under 1902(e)(3) (children who need institution level of care
in the community)
- Are in foster care
- Are receiving foster care or adoption assistance (Title IV-E)
- Are receiving Title V-funded coordination services
Who is Typically Included
State disabled Medicaid populations can include some/all of the following:
- Children with special health care needs
- Persons with physical disabilities
- Persons with chronic illness
- Persons who have developmental disabilities
- Persons with mental illness
- Frail/elderly
- Persons who are deaf or blind
Identification Mechanisms
- Screening tool by enrollment broker
- Screening tool by MCO
- New member outreach
- Client Surveys
- MCO claims data
- Medicaid claims data
- Eligibility category
- Referrals
Once Enrolled, Always Enrolled
- Disenrollment for cause 2%-8%
- Disenrollment without cause 1%
Distribution of Reasons for Disability (D-link)
Distribution of Disabled Members by the Number of
Chronic Diagnoses (D-Link)
Expenditures and Membership (D-Link)
Medicaid Expenditures and Membership (D-Link)
| Membership |
$ Spent |
% |
Enrollees |
% |
$ Spent per Enrollee (Avg) |
| Elderly |
$45,948,429,579 |
29.77% |
4,089,805 |
10.13 |
$11,235 |
| Blind & Disabled |
$66,747,165,968 |
43.24% |
6,983,562 |
17.29% |
$9,558 |
| Children |
$25,308,460,014 |
16.40% |
20,664,617 |
51.17% |
$1,225 |
| Adults |
$16,349,616,638 |
10.59% |
8,642,895 |
21.40% |
$1,892 |
Source: Kaiser Family Foundation 1998 Data
DSH Not Reported Separately
Expenditures for the Disabled by Service
Type (D-Link)
% of Disabled Members Enrolled in Managed
Care - by State (D-Link)
| Amount of States |
% of Disabled Population Enrolled into Managed Care |
| 15 States |
0% enrolled |
| 23 States and the District of Columbia |
1-50% enrolled |
| 12 States |
51-100% enrolled |
Source: Economic and Social Research Institute - 1998
Disabled Populations and Managed Care
Enrollment (D-Link)
| Type of Managed Care |
Voluntary Enrollment |
Mandatory Enrollment |
| PCCM |
3% |
97% |
| Capitated MCO |
13% |
87% |
Total "Managed Care" enrollment = 1,594,260
Source: Economic and Social Research Institute - 1998
Sources of Insurance for Children
with Disabilities (D-Link)
Challenges for State Medicaid Agencies
- Difficulty identifying child prior to enrollment
- Insufficient information about status, current provider and contact information
- Access/network/availability of specialists
- Eligibility
- Quality of care
- Utilization/EPSDT
- Preventive services
- Cost
- Legislation issues
- Advocates
- Continuity/coordination of care
Challenges Moving from FFS Care to MCO Care
- Acute vs. chronic care
- Variances from FFS
- Approval for name brands
- Educationally vs. medically necessary services
- Court-ordered treatment
- Delays in authorization
Challenges for Managed Care Organizations
- State has not identified special needs member prior to enrollment
- Insufficient information about status, current provider and contact information
- Network development/geography
- PCP/specialty hospitals
- Specialists, behavioral health providers, ancillary providers
- Eligibility
- Quality
- Preventive care
- Cost
- Transportation
Challenges for Providers
- Lack of knowledge of a child's individual disability or health issue
- Reluctance to develop expertise because of lack of support to provide more
extensive care
- Population being served
- Appropriate levels of care and type of care
- Inadequate reimbursement
- Inability to schedule adequate appointment time
- Staff commitment
- Companions who usually do not know how to navigate the system - simply drop
off member
- Office re-design
General Issues, Challenges Magnified for Special
Needs Populations
- Dental care
- MCO formularies
- Transportation
- Durable medical equipment
- Home health services
Challenge: Measuring Performance
Obstacles which impede efforts to collect performance measures include:
- Lack of useful measures developed specifically for special needs populations
- Lack of data to calculate measures
- Heterogeneous populations and the lack of appropriate standards of care
make outcome measures difficult to develop and interpret
- Small numbers reduce reliability of results
Key to Success
"All individuals need to have an understanding of what it means to have
special needs; from personal care assistants to child welfare agency staff to
DME suppliers, to x-ray technicians, and the MCO staff themselves"
Vignettes
- Total Population needs Case Management - Perception
- Take their patients away or "I drop the contract"
- Getting pharmacies to stock special medications
- Creative reimbursement methodology (capp/ffs/Angel Provider)
- Special hospital contracts
- Enhanced preventive care
- Dental
- Women's health
- Delivery of DME
- Contracting with non-network providers (advocate/traditional provider)
- "You never told me about these members"
Go to: Final Summary | Disability
Conference | Provider Reimbursement | HRSA
| HHS