Improving Care Through Better Communication

Barry E. Handon, MD, MPH; Medical Consultant

Medi-Cal Managed Care Division

California Department of Health Services

California's Medi-Cal Managed Care Program: The Basics

Some Facts

• In 1993, the California Department of Health Services made the decision to significantly expand the Medi-Cal (M/C) managed care program. As a result, the number of M/C beneficiaries in managed care plans increased from 600,000 in 1993 to nearly 3 million in 2002, out of a total of 5.6 million beneficiaries currently enrolled in M/C.
• Due to this rapid expansion, DHS currently has over 30 contracts with 25+ managed care plans (MCPs) to provide health care services to approximately 3 million beneficiaries in CA’s 22 most populous counties.
• The following slide shows the geographic distribution of M/C managed care plans in CA.

• M/C beneficiaries with Temporary Assistance to Needy Families (TANF) aid codes were required to enroll in the M/C MCPs developed as part of the expansion. These aid codes cover women of child-bearing age and most beneficiaries under 21 years of age.
• TANF aid codes include approximately 2/3 of the total M/C population.
• Therefore, the switch from a predominantly fee-for-service to a managed care system involved mainly the development of MCPs designed primarily to serve M/C beneficiaries with TANF aid codes, i.e. women and children.

Enrollments 2002

Two-Plan Model = 2,188,263
GMC = 324,811
COHS = 438,822
FFS Managed Care = 26,647

Total = 2,978,543
Total Medi-Cal = 5,620,847

Current Demographic Make-Up of the M/C managed care program (by age, sex, and ethnicity) (D-link)

Further Important Program Considerations

In addition to the basic program background described above, there are several further program considerations of importance to the delivery of services to persons with disabilities in M/C managed care.

"Carve-Outs"

• Most M/C MCP contracts include many “carve-outs”. These are services for which the MCPs are not capitated and which are delivered to MCP members by out-of-plan provider systems. “Carve-outs” include:
  • most mental health services
  • alcohol and substance abuse services
• Services provided by:
  • the California Children Services (CCS) program
  • Regional Centers for the Developmentally Disabled
  • Head Start or Early Intervention Service Programs for toddlers and children at risk for developmental disabilities
  • Local education Agencies (LEAs) and/or Special Education Local Project Areas

No Prior Authorization

• Some services may be provided to plan members without prior authorization and may be delivered by out-of-plan providers.
• These services include: immunizations; HIV testing and counseling; family planning and sexually transmitted diagnosis and treatment.

Disenrolls

A MCP member may have to disenroll from the MCP to fee-for-service in order to receive some services. This applies to certain in-home and community-based waiver services administered by M/C; to long-term care services provided for longer than 60 days and for approved major organ transplant services.

Final Program Comments

• MCPs deliver health care services only to members residing in the county served, although some MCPs provide services in more than one county.
• MCPs are reimbursed on a capitated basis, using a per member per month calculation. Contracts are full-risk, essentially without risk adjustment arrangements.

Consequences of the M/C Managed Care Program Design for Serving Persons with Disabilities

The manner in which M/C chose to expand its managed care program meant that:

• Most of its traditionally-defined disabled population were not to be formally included in the expansion;
• No risk-adjusted rates were developed;
• Delivery of services remained fragmented, especially for high-risk populations;
• Planning for the needs of the disabled who might be included in M/C MCPs was not initially a high priority;
• Data systems that can adequately identify and track services to persons with disabilities, especially across provider systems, have yet to be adequately developed.

Very Important Facts

• All MCPs must accept any beneficiary who wishes to enroll, regardless of aid code or preexisting condition(s).
• In 8 counties (currently), all M/C beneficiaries are served by only one MCP, called a county-organized health system, regardless of aid code.
• Therefore, from the inception of expansion, it was recognized that many persons with disabilities or special health care needs were, in fact, enrolled or could subsequently enroll in M/C MCPs.
• The next slide gives an estimate of the special health care needs population currently enrolled in M/C managed care.

Special Health Care Need Population (D-link)

Impproving Care Through Better Communication: Policy Letters

The first efforts to improve care for the disabled through better communication required DHS to clarify for MCPs their responsibilities in terms of providing services to persons with disabilities. This was done through the development of policy letters which:

• Define in detail how MCPs should interface with certain out-of-plan providers of service to members with disabilities.
• Made clear that the M/C managed care program considers the contracted MCP as the “medical home” of the beneficiary.
• Were developed to guide plan responsibilities for children With CCS-eligible conditions or who were receiving services from regional centers, early intervention or Head Start programs; and/or LEAs and SELPAs.

Compliance with policy letters is contractually mandated.

Improving Care through Better Communication: Memoranda of Understanding (MOUs)

• All MCP contracts now require that MOUs be developed between the MCP and selected local health department and mental health programs, which continued to provide services to MCP members by law or by contract, often without prior authorization from the MCP.
• MOUs are designed to address interface issues between the MCP and the out-of-plan program serving the MCP member and to explicitly delineate the respective responsibilities of each party in the provision of services to the MCP members.
• Development of MOUs occurs at the local (county) level and involves detailed communication between the MCP and the local provider program(s).
• The Medi-Cal Managed Care Division (MMCD) has facilitated and guided this process and MOUs must be approved by MMCD, in consultation with relevant State public health programs.

Improving Care through Better Communication: Workgroups and Task Forces:

California Children Services (CCS)/ MMCD Workgroup

The CCS Program:

• is designed to identify children with certain physically handicapping conditions which are amenable to amelioration, control or cure and, through medical case management activities, to deliver appropriate multispecialty, multidisciplinary care for children with eligible conditions using CCS-paneled providers and institutions.
• Services for CCS conditions are “carved out” of most MCPs.
• Local CCS programs exist in all MCP counties to determine CCS eligibility and to medically case manage eligible children and to authorize payment for services.
• Payment authorized for approved services by CCS is made through the Medi-Cal fee-for-service (FFS) program.
• Reimbursement to providers for services authorized for payment by the CCS program are only made to CCS paneled providers retroactive to the date of referral, after the CCS program has approved eligibility.
• The importance of the relationship between MCPs and local CCS programs, which both provide health care services to an estimated 100,000 CCS-eligibles enrolled in MCPs, was recognized early.
• Both the local CCS program staff and staff of MCPs needed to understand the workings of each other’s program and the rules governing referral, reimbursement, coordination of care, etc

CCS/MMCD Workgroup:

• A workgroup was established in late 1998 to identify interface issues and resolve problems.
• The workgroup consists of equal numbers of State CCS and MMCD staff and representatives from local CCS programs and MCPs.
• Workgroup is still functioning.
• Workgroup has been singularly successful in promoting better understanding between the two programs and is an excellent example of how to improve service through improved communication
• Many operational and policy issues have been and continue to be addressed by this forum, and some have been resolved.

Improving Care through Better Communication: Workgroups and Task Forces:

M/C Managed Care Task Force on Children with Special Health Care Needs

• In February 2002, the first meeting of the MCMC Task Force on Children with Special Health Care Needs was held.
• This long-planned-for Task Force brings together representatives of a variety of State, academic, professional society, advocacy and other groups who serve children with special health care needs.
• The Task Force will meet frequently over the next year to develop recommendations for MMCD as to how to:
  • Identify children with special health care needs;
    Coordinate care between major providers;
  • Measure the quality of care delivered.
• The Task Force is facilitated by staff from the Foundation for Accountability (FACCT), who have worked extensively in this field;
• The effort has received a small grant from the California Health Care Foundation.
  The work of the Task Force is expected to result in:
  • Adoption and operationalization of a definition of children with special health care needs, which can be used for adults, with minimal modification;
  • Development of a policy letter and a performance measure for services provided to this population. The performance measure will become part of M/C managed care’s quality improvement program, for measurement by all MCPs.

Other Activities to Improve Communication or Services: Developmental Disabilities

• MMC staff have recently begun a more intensive effort to facilitate meetings between MCPs and staff of the many Regional Centers serving some of the California’s most disabled populations.
• MMCD is contemplating requiring that MOUs be developed between MCPs and Regional Centers.

Other Activities to Improve Communication or Services: HIV/AIDS

The disenroll required for MCP members with HIV/AIDS to receive AIDS waiver services has been cancelled. Members with AIDS, or persons with AIDS who wish to become MCP members, can now be enrolled and receive AIDS waiver services. In addition, there are extra dollars in the capitation rate to allow MCPs to care for persons with AIDS.

Including a Best Practices Approach

• All of the above efforts are being scrutinized to enable a “best practices” approach to be developed regarding populations with disabilities/special health care needs.
• Some MCPs are participating in the Center for Health Care Strategies’ Best Clinical and Administrative Practices in the Children with Special Health Care Needs area.

A Best Practices Approach

Some of the best work is going on at the local MCP level and this wealth of experience needs to be analyzed and utilized by our system as a whole - another challenge to improving services through improved communication.

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