Comments of the Connecticut Health Policy Project in response to the Department of Social Services' report: Assessment of Medicaid Health Care Delivery and Primary Care Case Management
We want to thank the Department of Social Services (DSS) for their hard work on this report. We would especially like to thank DSS for their openness to consumers, advocates, and providers throughout the Primary Care Case Management (PCCM) project. We are confident that this spirit of openness will lead to a successful program that meets the needs of all stakeholders.
There are many recommendations in the report with which we strongly agree.
The report makes very strong reference to the need to work with consumers and providers from the beginning of the process. The report recommends that the first step in developing a PCCM program be to create an advisory council with clients from each eligibility group, providers and other stakeholders. As described, the council would have a significant role in program design, implementation and evaluation. The council would drive policy decisions, not simply fill a token "window dressing" function. The input of such a council will provide DSS with important information they could not attain in any other way. It is critical that this council include generous supports to ensure that consumers can easily participate and feel comfortable doing so. It is importance to get honest, sincere input from all stakeholders and not to wait for complaints or worse, lawsuits, to act. This council, and the Department's sincere willingness to listen and act on what they hear, will be critical to the success of the program.
We particularly endorse the report's description of the goals of any PCCM program as, "not solely contingent on cost savings" but to include "increased access to care and improved quality as measured by its clients." This is a clear lesson from the experience of other states with successful PCCM programs.
We agree with the report's recommendations regarding clear and well-defined roles for all participants in the program, a timely, user-friendly and fair reimbursement system for providers and, most importantly, clear communications with consumers and effective client services. These last two recommendations have been significant challenges in Connecticut, and the department would be well-advised to look to test of all materials and processes with consumers before implementation.
We strongly agree with the report's recommendation to strengthen Medicaid data systems. This recommendation stands, regardless of whether Connecticut institutes a PCCM program or not. We are hopeful that PCCM will allow better tracking of program quality as providers will communicate directly with the state. The department can isolate differences at the provider level, rather than the aggregate HMO level where differences are less meaningful due to overlapping provider panels.
We also urge the department to follow the lead of most other states and allow consumers the option to choose a Primary Care Provider (PCP) not on the state's approved list, as appropriate. This is particularly important for children with special health care needs who may receive care regularly from a specialist. It is only appropriate that, in those cases, the specialist have the ability to coordinate care.
The recommendation to begin PCCM in Connecticut with a pilot program is very wise. A thoughtful, well-evaluated pilot could be the difference between success and chaos. However a note in the report states that the state has decided to begin PCCM with the State Administered General Assistance (SAGA) population. We are hopeful that DSS does not stop there.
While the implementation of PCCM for SAGA will have some lessons for other populations, many of the experiences learned with SAGA will not be appropriate to the current Medicaid Managed Care (MMC) population -- in fact it may be hazardous to make those assumptions. The current MMC population is now in mandatory HMO-style managed care; the SAGA population currently receives care in a fee-for-service system. The MMC population includes predominantly women and children; SAGA serves mainly adults without children. Pediatrics and obstetrical services dominate MMC medical care; SAGA provides very little of those services but includes very high prescription drug usage. Mental health services are included in MMC, but are carved out of SAGA. SAGA has far lower income eligibility levels than MMC. Homelessness is a significant problem in care delivery and case management in the SAGA program. The spectrum of providers and the needs for care management and disease management are very different between the two populations.
Many of the benefits of PCCM to the state will not be realized without a MMC pilot. For PCCM to act as a credible alternative to HMO-style managed care, the state must have the experience of a pilot. It is critical that as HMOs leave the program, a stable, functional alternative be available. Improving Medicaid consumer choices will ensure that consumers find a better fit for their families' needs. It is critical that the Department begins development of a PCCM pilot in the current MMC population, as well as SAGA.
We take issue with a few observations and recommendations in the report.
In their research on PCCM, the authors appear to have only solicited input from Medicaid agency staff in other states. They are not alone; it appears that many Connecticut stakeholders groups in researching PCCM have contacted only their counterparts in other states -- providers contacting providers, advocates contacting advocates, etc. While this is a natural tendency, we have found that this leads to very different perspectives on PCCM, and conflicting guidance for Connecticut. This is particularly true in discussions of maintaining a "level playing field" for HMOs in the program. It is critical as the program develops that we collect information and consider the perspectives of all stakeholders to ensure that the program is successful.
The report is troubling in its almost exclusive discussion of hiring an outside vendor(s) to administer the program. If the political reality is that the program will be outsourced, so be it. However it is not accurate that the experiences of other states support outsourcing. States' success with PCCM appears to be independent of the decision to administer in-house or privatize.
While it is absolutely true that DSS does not now have the resources to administer such a program, there is a strong case to be made that the state should develop that expertise. The state's record of holding vendors accountable is mixed. While it is true that in-house administration of a PCCM program would require a significant dedication of staff time, the current situation consumes a great deal of staff resources in negotiating contracts, responding to lawsuits and other complaints regarding vendors, and in some cases micromanaging program areas that could arguably be considered the responsibility of vendors. Another advantage to in-house expertise is that the state owns the information and lessons learned; nothing is lost because of corporate actions or contract changes. If the state does not develop such expertise, we will always be held hostage to the interests of private vendors.
While disease management programs were mentioned in the report, they were not highlighted as a recommendation. Very popular with consumers, these programs are our best hope of reducing disease and thereby reducing costs. The state must design disease management programs in collaboration with providers and consumers, ensure their integration with treatment plans and include strong evaluations. Currently each HMO runs its own disease management programs leading to fragmentation and competitive pressures inhibit sharing best practices to benefit the entire population.
The report gives weight to a partial capitation option under which PCPs would be at risk for some medical services. There is little experience in partial capitation from other states. It is unlikely to be successful in Connecticut, as providers do not favor it (as noted in the report) and it may serve as a disincentive to participation. Medicaid HMOs, with far more resources at their disposal, couldn't handle the risk in this population; it is unclear how individual providers might be expected to. While the idea may be comforting to budget analysts, it is unwise.
The report also did not reflect the strong objections of providers and consumers at the DSS hearing to engaging an HMO as the program administrator. The state would not benefit from competition between the HMOs and PCCM programs to improve care and reduce costs if both systems are controlled by HMOs. The state would not be able to use PCCM as a negotiating tool to reduce costs. PCCM's usefulness even as a benchmark for rate setting would be limited. HMOs do not have a record of success in Connecticut's Medicaid program by any measure (despite the report's dubious contention). As the CT State Medical Society has filed suit against Connecticut's HMOs, providers would not be attracted to a system that is run by those same HMOs.
Overall, the report provides a detailed, well-reasoned approach to design and implement a PCCM program for Connecticut. The best part is the intention to work with all stakeholders in a collaborative process from the beginning. An inclusive process will prevent problems to the benefit of consumers, taxpayers and providers.