Presented by: The Connecticut Health Policy Project And The Agency for Healthcare Research and Quality, User Liaison Program
Robert Hurley, PhD Associate Professor, Virginia Commonwealth University The Changing Face of State Medicaid Programs: A Context and Framework for Addressing the Issues of Medicaid Managed Care
States originally turned to managed care for Medicaid in the early 1980s to meet several challenges, including low provider participation, diminishing access to care for beneficiaries, virtually no data for quality of care, and rigid program design and regulation. Initially managed care was not expected to save states money. States expected managed care to provide a medical home for every beneficiary, provide care coordination, and promote primary and preventive care. For the most part, managed care was successful at those goals. In the 1990's more states turned to managed care, and cost pressures accelerated. Evidence grew that access to care improved and modest savings were possible under managed care. Lessons learned included the need for carefully crafted contracts, the need to consider larger market conditions, create long term relationships with insurers, realistic payment rates and the importance of measurement. In the future, state variation in managed care models will continue to grow - some states will continue with HMO-based systems, others will invest in PCCM programs and others will build their own network-based arrangements. States must invest in program management and infrastructure. Quality improvement must be a measurable goal. Overall, states' Medicaid programs are resilient and are adapting to new challenges.
In response to questions, access to dental services is a challenge in virtually every state and there are no easy or universal solutions. The dental service problem is probably independent of managed care. Recognizing their critical role in serving Medicaid populations, several states have made special arrangements to ensure the integrity of safety net providers. Carving out various service areas has a mixed record across states.
Vernon Smith, PhD Health Management Associates, former Michigan Medicaid Director Primary Care Case Management Across States
Twenty-eight states now use Primary Care Case Management (PCCM) to operate their Medicaid programs, either alone or parallel to an HMO-based system. In PCCM, beneficiaries are enrolled with a Primary Care Provider (PCP), serving as their medical home -- providing all primary care and responsible for coordinating their care. Consumers are guaranteed access. Providers are generally paid on a fee-for-service basis, in addition to a per member, per month case management fee. States that excel at provider relations and recruitment involve the provider community as partners in program design and operation, survey providers to define key issues, and develop special approaches for areas of provider shortage. Utilization management and quality improvement work best with significant input from providers, credible easy-to-read PCP report cards, HEDIS measures, and formal disease management programs. States that excel at member services and education use professional quality booklets, videos and newsletters to clearly explain program rules, participate in community activities, use call centers, measure member satisfaction and involve advocacy groups. States must make thoughtful decisions about enrollment of children with special needs, children in foster care, SSI-related elderly and disabled and dual eligibles. To best serve special populations, states must seek input from advocates and enrollees, allow specialists as PCPs, use provider education, special care managers and disease management, and focus on coordination with behavioral health services. PCCM programs are improving across the country and are providing better access to care, better provider participation, better quality and measurement of quality, better care for all Medicaid populations and cost savings similar to HMOs.
In response to questions, states are saving between 3% and 13% compared to fee-for-service program spending, in the same range that other states report saving under HMOs. Some states help PCPs in recruiting specialists that will accept Medicaid referrals. The importance of formal systems for feedback from consumers, providers and advocates during both program design and implementation was stressed. The importance of coordination between PCPs and any services provided in a carve out program is critical. PCCM implementation costs vary depending on whether functions are contracted out or conducted in-house by the state.
Francis Finnegan HealthWatch Technologies, former Maine Medicaid Director Charles Kight Charles Kight Associates, former Florida PCCM Director Beth Tortolani, RN, MS Public Sector Partners, former Massachusetts PCCM Director Peter D. Rappo, MD Beansprout Network, practicing pediatrician in Massachusetts Panel: Promising Strategies and Innovative State Initiatives
Maine's PCCM program, Maine PrimeCare, has seen an increase in primary care use, reduced ER visits and a reduction in costs compared to non-enrolled beneficiaries. HMO contracting has ended in Maine; the state intends to expand its PCCM program. Two unique features of Maine's PCCM program are the Primary Care Physician Incentive Program (PCPIP) and the Physician Directed Drug Initiative (PDDI). Both programs were designed in collaboration with providers. These programs are pools of funding distributed to individual providers based on quality measures. For PCPIP, indicators include Medicaid caseload, ER utilization, and prevention measures. Incentive payments reach as high as $4,150 per patient per quarter for providers with the highest performance. PDDI is a similar funding pool based on appropriate prescribing practices. The need for state-of-the-art information systems, involvement of provider groups, looking beyond cost containment, and the need for agreement on measurement of savings and performance were stressed.
MediPass, Florida's PCCM program, grew in stages geographically. Program savings average 13.7% including administrative costs and has improved access to care. MediPass operates parallel to Medicaid HMOs and includes TANF-related and SSI populations. Florida has highly developed disease management programs covering asthma, AIDS, diabetes, hemophilia, end stage renal disease, congestive heart failure, hypertension, cancer and sickle cell anemia. Lessons learned include the importance of good data systems, managed care elements such as NCQA accreditation and HEDIS outcome measures, and testing new approaches.
Massachusetts' PCCM Program, the Primary Care Clinician Plan (PCP), is run in-house by the state like a very good HMO. It was originally envisioned as a temporary step toward fully-capitated managed care, but has proved so successful, the state is now fully committed to the program. The PCP Plan operates parallel to HMOs. The state uses HEDIS to measure outcomes and compares as well or better than both the HMO-based Medicaid programs and commercial populations. The state conducts member satisfaction surveys, pre-tests member materials, site visits to providers, clinical profiles, and special studies. Providers, consumers and advocates provide on-going, significant input into the program design and implementation through formal advisory councils. The state takes pains to make the plan "something special" for both providers and consumers. 82% of beneficiaries choose the PCC Plan over HMOs. The PCC Plan has excellent provider participation and only 3.5% of program funding goes to administration. The state is saving between 9 and 14% compared to fee-for-service. The program has included TANF-related and disabled populations from the beginning.
The clinician perspective of the PCC Plan is positive. The assignment of a PCP medical home for each beneficiary ensures enhanced efficiency for children and families, efficient use of limited resources, expanded expertise and competence for professionals, a forum for problem-solving, increased patient and family satisfaction, and increased professional satisfaction. Barriers to the medical home include ineffective communication, lack of knowledge of service system resources, varying eligibility requirements, gaps and duplication in services, inadequate parent-professional partnerships, and geographic distance. The importance of adequate reimbursement, hospital incentives to steer patients away from ER visits, quality improvement projects targeted at the local level and communication and collaboration with providers were stressed. Carving out behavioral health services has improved access to care but has allowed poor communication with primary care providers. The challenges of serving Children with Special Health Care Needs were highlighted including the difficulty of measuring infrequent events, defining effective actions based on measurements, adequate reimbursement for care management, adverse selection and the appropriate use of carve outs. The challenges of risk management were discussed - "how do you differentiate between doctors with expensive patients and doctors who are just expensive." Minimizing the hassle factor for providers and the effectiveness of a Pediatric Advisory Council were stressed.
In response to questions, it was felt that HMOs are pulling out of Medicaid not because of unfair competition from PCCM programs but for reasons related to overall markets and national factors. Massachusetts made no provisions to ensure that HMOs did not "cherry-pick" healthier consumers, but it does not appear to be a problem. The need for on-going, significant communication with providers and a collaborative attitude were stressed. Partnership was valued more than funding by providers. The importance of a comprehensive focus to disease management was noted.
Michael Starkowski Deputy Commissioner, Connecticut Department of Social Services David Parrella Dir. Medical Administration, Connecticut Department of Social Services Senator Toni Harp Chair, Public Health Committee, Medicaid Managed Care Council Ron Preston Associate Regional Administrator, Health Care Financing Administration Robert Zavoski, MD Pediatrician, Hartford Connecticut Michael Lindberg, MD Physician, Hartford Connecticut Panel: The State of Affairs in Connecticut
DSS has commissioned a study of alternatives to evaluate PCCM as an option for Connecticut's Medicaid program and identify the populations most appropriate for that model. The parameters of the study are improving provider coordination, quality of care, access to care, providing options for consumers, information systems, organizational structure, accountability, infrastructure needs and cost savings.
The panel discussion focused on the need for strong information technology systems, collaboration with stakeholders, inclusion of safety net providers, the wisdom of pilots, and adequate reimbursement. Recognition of the special needs of the Medicaid population was clear. There was a general enthusiasm for thoughtful progress in the program and involvement of all parties in that planning.