Table Of Content

\n .AIM AchievingServiceIntegrationfor ChildrenwithSpecial HealthCareNeeds: AnAssessmentofAlternativeMedicaid ManagedCareModels Volume I: SynthesisofStudyResults Preparedby: • 's' IanHill,ReneeSchwalberg,BethZimmerman,andWiimaTilson HealthSystemsResearch,Inc. Washington,DC Preparedfor: TheDivisionofChildrenwithSpecialHealthCareNeeds MaternalandChildHealthBureau HealthResourcesandServicesAdministration Rockville,MD CooperativeAgreementNo.:93-nO-C U.S.DeportmentofHeolfti&HumanServices PublicHealthService MCHB HealthResources&ServicesAdministration Moternol8,ChildHealthBureau MateRtalandChildHeailhBunm July1999 RJ 138 A24 1999 v,1 51 TableofContents I. BackgroundandPurposeoftheStudy 1 A. DefiningServiceIntegration 3 B. StudyDesignandMethods 4 C. OrganizationofReport 6 II. MedicaidManagedCareModelsandtheStudyStates 6 III. ServiceIntegrationUnderAlternativeMedicaidManagedCareModels 12 A. Eligibility,Identification,andEnrolhnentofCSHCN 12 B. PrimaryCare 1 C. SpecialtyMedicalCare j7 D. LinkstoMentalHealth,EarlyIntervention,SpecialEducation, andOtherSupportServices 21 E. CaseManagement/CareCoordination 25 F. Financing 28 G. FamilyInvolvementinSystemPlanning,Implementation, andOversight 3 H. State-LevelCollaboration 33 IV. Conclusions 35 A. TheFalseSecurityOfferedbytheFee-for-Service"System" 35 B. TheLimitationsofMainstreamManagedCareand"CarveOuts" 36 C. ThePromiseofSpecialtyManagedCareSystemsforCSHCN 38 HealthSystemsResearch,Inc. TableofContents i BackgroundandPurposeoftheStudy I. Childrenwithspecialhealthcareneeds(CSHCN)aregenerallyconsideredashavingoneor morechronicphysical,developmental,behavioral,oremotionalconditionsthataffecttheir abilitytofunction(McPherson,etal.,1998;Steinetal,1993). Whileprecisedefinitionsofthe populationvary,policymakers,researchers,andadvocatesagreethatCSHCNoftenexhibit multipleandcomplexneedsforservicesbeyondthoserequiredbychildrengenerally,andoften mustrelyonalargenumberofsystemstoaddresstheseneeds,includingnotonlythemedical caresystem,butalsothoseprovidingearlyintervention,specialeducation,mentalhealth,anda hostofotherfamilysupportservices. Becauseofthesefactors,theneedforcoordinatedand integratedservicedeliveryisperhapsgreaterforCSHCNandthefamiliesthatcareforthem thanforthepopulationatlarge. Withoutstrongmechanismsandstructurestolinkthese varioussystemstogether,parentsareleftwdththeburdenofnavigatingdisparateand fragmentedsystemsontheirownandorchestratingthediversecareneededbytheirchildren. Recentyearshavewitnesseddramaticchangesinournation'shealthcarefinancinganddelivery systemsthatmayholdimplicationsforthegoalofbuildingmoreintegratedsystemsofcarefor CSHCN. Mirroringtrendsintheprivatesector,stateMedicaidprogramsacrossthecountryare increasinglyenrollingtheirbeneficiariesintomanagedcare. AccordingtothefederalHealth CareFinancingAdministration(HCFA),almosthalf(48percent)ofallMedicaid — — recipients 15.3millionindividuals receivedtheirhealthcareservicesthroughmanagedcare arrangementsin1997,representingagreaterthanfive-foldincreasesince1991(Regensteinand Schroer,1998). Ofparticularnote,moststatesarealsoincreasinglyenrollingtheirMedicaid beneficiarieswithdisabilitiesintomanagedcare,aswell. Onceapopulationthatcouldroutinely beexpectedtobe"carvedout"ofmanagedcare,personsreceivingMedicaidbyvirtueoftheir eligibilityforSupplementalSecurityIncome(SSI)arenow,moreoftenthannot,includedin states'managedcareinitiatives. In1998,36statesenrolledatleastsomeoftheirMedicaid/SSI beneficiariesintomanagedcare,accountingforroughly1.6millionindividuals,orone-fourthof Medicaid'snon-elderlydisabledenrollees(RegensteinandSchroer,1998). AstheSSIprogram HealthSystemsResearch,Inc. SynthesisofStudyResults Page1 employsrathernarroweligibilitycriteria,thesenumbersdonotrepresentthetotalnumberof beneficiarieswithdisabilitieswhoareenrolledinMedicaidmanagedcare. AschildrencomprisealargeproportionofthisSSI/disabledpopulation,thislattertrendhas raisedissuesamongthoseconcemedwithCSHCN. Whilemanagedcare,intheory,holds promiseforimprovedorganizationandaccountabilitythroughtheuseofintegratednetworksof providers,traditionalmanagedcaresystemshavebeendesignedtoprovideprimaryandacute medicalcaretoagenerallyhealthypopulationandhavetendednottobetargetedto disadvantagedgroupssuchasCSHCN. Manyquestionshavebeenraisedregardingthecapacity ofmanagedcareorganizations(MCOs)toprovideappropriateaccesstohigh-qualitycarefor thispopulation,withconcernsmostoftencenteringaroundthebreadthandadequacyofMCOs' networks,financialincentivesthatmaycauseMCOstolimitaccesstoneededbutexpensive services,MCOs'generallackofawarenessofthecomplexanddiverseneedsofthesechildren, andinadequatelinksbetweenMCOsandthemuhiplehealth-related,educational,and community-basedsupportsystemsthatfamilieswithCSHCNrelyonincaringfortheirchildren (CommitteeonChildrenwithDisabilities,1998;Zimmerman,etal.,1996;Cartlandand Yudkowsky,1992). ThefactthatchildrenonSSIrepresentjustaportionoftheoverall populationofchildrenwithchronicillnessesanddisabilities,andthatthepopulationofCSHCN hasbeenenrolledinMedicaidmanagedcareforyears,simplyexacerbatesconcernsover whetherornotpublicmanagedcaresystemsareuptothetaskofcaringforthesechildrenwith specialneeds. Addressingtheseconcernsiscomplicatedbythefactthatnosinglemodelof"Medicaid managedcare"exists. Rather,amultitudeofprogramdesignshaveemergedovertheyearsthat employnumerousvariationsonthetypicalfully-capitated,partially-capitated,andmanagedfee- for-service/primarycarecasemanagementapproachesusedbystates:somerelyoncommercial "mainstream"healthplans,whileothersutilizeMedicaid-onlyplansthatdrawextensivelyon safetynetprovidersmoreexperiencedwithservinglow-incomefamilies;someplace responsibilityforallserviceswiththeMCO,whileothers"carveout"clustersofservicestobe deliveredbyseparatesystems;andmostserveallMedicaidpopulations,whileafeware specificallydesignedtoservenarrowertargetpopulations. HealthSystemsResearch,Inc. SynthesisofStudyResults Paqe2 Togainamorecompleteunderstandingoftheeffectsofmanagedcareonservicedeliveryfor CSHCN,theNationalPolicyCenterforChildrenwithSpecialHealthCareNeedsstudiedeight stateswithdifferentMedicaidmanagedcaremodelsand,usingqualitativeevaluationmethods, examinedtheextenttowhichthealternativemodelssupportedeffective,cross-systemservice integrationforCSHCN. Thisreportcontainstheresultsofthisanalysis. A. DefiningServiceintegration Asafirststepinouranalysis,theCenterconductedareviewoftheliteratureonservice integrationand,fromit,developedadefinitionoftheconcept. Forthepurposesofthisstudy, wedefinedserviceintegrationas: anongoingprocessofcombiningresourcesacrossmedical, health,mentalhealth,social,andeducationsystemstosupportandassureahighquality programofcareforthechildandthefamily. Thekeycomponentsofthisdefinitionare discussedinmoredetailbelow. Thephrase"ongoingprocess"recognizesthattheneedsofchildrenandfamilies evolveovertime,resultinginacontinuingchallengetointegratenewservicesor discontinueunnecessaryones. Theterm"combining"referstopoliciesorstructuresthatfacilitate(orinhibit) theblendingofresources. "Resources"includefinances,specificinterventionsorprograms,personnel,and othergoodsandservices. Theterms"support"and"assure"conveyanactive,goal-directedprocessthat includesdevelopingsystemsformonitoringandevaluationbythecombined effortsofparents,providers,andstaffofanMCOorpublicagency. "Programofcare"referstoaplanthatincludesshort-andlong-termobjectives andspecifieshowdifferentservicescontributetotheachievementofthese objectives. Throughoutthedesignandconductofourstudy,weemployedthisdefinitionasaframework forconsideringwhetherornotmanagedsystemsofcarewerepromotingorunderminingthe goalsofserviceintegration. Aswillbediscussedinmoredetailbelow,thedefinitionwasalso HealthSystemsResearch,Inc. SynthesisofStudyResults Page3 usedtoguideourdevelopmentofinterviewprotocolsand,byextension,ourdiscussionswith stateandlocalofficials,providers,andfamilymembers. B. StudyDesignandMethods ThisstudyrepresentsaqualitativeevaluationoftheeffectsonserviceintegrationforCSHCNof alternativeMedicaidmanagedcaremodels. Itisbasedonanin-depthanalysisofprogramsin placeineightstates. Indevelopingourstudy,wefollowedanumberofstepsconsistentwith wellacceptedqualitativeresearchmethods,asdescribedbelow. Asampleofeightstateswasidentifiedandrecruitedbasedontheiralternative approachestoservingCSHCNunderMedicaidmanagedcare. Modelsof PinCteCreMstsiynsctleumdse,dafnuldlyt-racdaiptiitoantaeldfmeaei-nfosrt-rseearmviacendsysspteecmisa.l'tymanagedcaresystems, Aseriesofstructuredinterviewprotocolswasdevelopedtopermitinvestigators tocollectconsistentinformationacrosssites. Separateprotocolswere developedforthevariouskeyinformantsweplannedtointerview,including officialsandindividualsrepresentingMedicaidagencies;TitleV/Matemaland ChildHealthagencies;stateagenciesresponsibleformentalhealth,early intervention,andspecialeducation,andotherprogramsservingCSHCN; managedcareorganizations;localprovidersofcare,includingprimarycare physicians,pediatricspecialists,andvariouscommunity-basedproviderssuchas localhealthdepartmentstaff;andparentsofCSHCN. Ineachofthese protocols,weincludedaconsistentseriesofquestionsexploringsuchcritical issuesas: Eligibility,identification,andenrolhnentpoliciesandpractices; - Primaryandspecialtymedicalcareservicesystems; Linkswithothersystemsofcare,includingmentalhealth,early intervention,specialeducation,andcommunity-basedsupportservices; - Systemsforcasemanagementandcarecoordination; - Qualityassuranceandmonitoringstrategies; Theeightstatesstudied,andthemodelsofmanagedcaretheyuse,arediscussedindetailinthenext section. HealthSystemsResearch,Inc. SynthesisofStudyResults Page4 - Financingandpaymentpolicies; - Familyinvolvementwithprogramdesign,implementation,andoversight; and - State-levelandpublic/privatecollaboration. Medicaidmanagedcarecontractsandotherdescriptivematerialswereobtained foreachofthestudystatesandinformationwasextractedfromthemregarding theprincipaldesigncharacteristicsoftheirmanagedcaremodels. Twoin-depthtelephoneinterviewswereconductedforeachstudystate,one withtheMedicaiddirectorandonewiththeTitleVofficialresponsibleforthe CSHCNcomponentoftheblockgrant. Theseinterviewsservedtoestablishour baselineunderstandingofthemanagedcaremodelinplaceineachstate,and allowedustoobtaintwoperspectivesonthestrengthsandweaknessesofthose modelswithregardtoserviceintegration. Inaddition,duringtheseinterviews, weaskedstateofficialsforrecommendationsregardingspecifickeyinformants weshouldmeetwithduringoursitevisitstothestate. Finally,wealso requestedthatstateofficialsforwardtous,inadvanceofourvisits,anywritten backgroundinformation,documents,anddatathatwouldhelpusdevelopafuller understandingofthedesign,experiences,andimpactsoftheMedicaidmanaged caresystems. BasedontheinputreceivedfromstateMedicaidandMCHofficials,we contactedandscheduledappointmentswithabroadrangeofpublic-andprivate- sectorofficialsandproviders,aswellasthedirectorofthestatechapterof FamilyVoices,anationalgrass-rootsorganizationcomprisingparentsof CSHCNwhoworkatthefederal,state,andlocallevelstopromotethe developmentofhigh-qualitysystemsofcarefortheirchildren. Multi-daysitevisitswereconductedinsevenofoureightstudystates;forthe eighthstate,allinterviewswereconductedbytelephone. Usingourinterview protocols,weconductedindividualinterviewswitheachofthekeyinformants identifiedabove. Inaddition,wearrangedandconductedafocusgroupof parentsofCSHCNineachstate. Finally,asameansforcreatingaforumfor collaborativediscussionofserviceintegrationchallengesandstrategies,we attemptedtoconductaconcludingfocusgroupofallkeyinformantsattheend ofeachsitevisit,wherepossible. Followingoursitevisits,individualstatecasestudyreportsweredeveloped usingaconsistentoutlineandformat. Inaddition,thissynthesischapterwas developedtohighlightcross-cuttingissues,observations,andlessonsleamed fromtheanalysis. HealthSystemsResearch,Inc. SynthesisofStudyResults Page5 C. OrganizationofReport Theremainderofthischaptercontainsasummaryoftheresultsofourstudy. SectionII providesanoverviewofthetypesofmanagedcaremodelscommonlyusedbystateMedicaid programs,aswellasbriefsummariesofmodelsinplaceineachofthestudystates. SectionIII describeshowtheseprogramsstructureandintegratetheirservicedeliverytoCSHCN,with particularemphasisonpoliciesandpracticesrelatedtoeligibility,identification,andenrollment; primaryandspecialtymedicalcare;linkstoothersystems;systemsforcarecoordination; financingandpaymentpolicies;qualityassuranceandmonitoring;familyinvolvementwith systemplanning,implementation,andoversight;andstate-levelcollaborationandtheroleof TitleVprograms. Finally,SectionIVpresentsoverarchingconclusionsandlessonslearned regardingthestrengthsandweaknessesofalternativemodelsofmanagedcareandtheirability toprovideintegratedservicestoCSHCNandtheirfamilies. II. MedicaidManagedCareModelsandtheStudyStates ThreebasicmodelsofmanagedcarehavebeenemployedbystateMedicaidprograms. Typically,usingstatutorywaiverauthorityunderSections1115(a)and1915(b)ofTitleXIXof theSocialSecurityAct,stateshaveimplemented: Fully-capitatedprograms,throughwhichcontractedhealthplansreceiveafixed monthlyfeeperenrolleeinreturnforacceptingfiillriskforthedeliveryofa comprehensiverangeofbenefits; Partially-capitatedprograms,throughwhichplanscontractandareatriskfora morelimitedscopeofservices(e.g.,ambulatorycareonly)andMedicaid providesfee-for-servicereimbursementforcarenotincludedinthecapitation;^ and PrimaryCareCaseManagement(PCCM)systems,inwhichaprimarycare physicianagreestoprovideandarrangeallofapatient'scare,servingasa "gatekeeper"toapproveandmonitorallserviceprovision. Thesephysiciansdo notacceptanyfinancialrisk;rather,theyarepaidonafee-for-servicebasisfor Whilepopularamongstatesinthe1980s,fewerstatesaretodayoperatingpartially-capitatedmanaged careprograms. HealthSystemsResearch,Inc. SynthesisofStudyResults Page6 theservicestheyrenderandacceptanadditionalper-patient-per-month managementfee. AsstatedinSectionIofthisreport,stateshavedesignedandimplementednumerousvariations onthesethreemodels. Tostudytheeffectsofalternativemodelsonserviceintegrationfor CSHCN,wewereparticularlyinterestedinidentifyingandstudyingstatesthatenrolledthese childreninto: Fully-capitated"mainstream"plansthatservethegeneralMedicaidpopulation (toobservetheextenttowhichtheyincorporatedanyspecialdesignsor provisionsaimedatimprovingthecoordination,integration,andqualityofcare forCSHCN); Fully-capitatedprogramsthat"carveout"certaintypesofcarethatare commonlyusedbyCSHCN,suchasmentalhealth(toobservehowtheseexplicit divisionsofresponsibilityamongsystemseitherimprovedorhinderedcross- systemintegration); Fully-capitatedprogramsthatarespeciallydesignedtomeettheneedsof CSHCN(topermitadetailedcomparisonwith"mainstream"plans);and Primarycarecasemanagementprogramsthatuseamanagedfee-for-service structuretoprovidefortheneedsofCSHCN. Finally,asacomparisontothesemodels,wealsoincludedastatethathaschosentoexclude CSHCNfrommanagedcarearrangements,undertheassumptionthatdoingsowouldallow thesechildrenandtheirfamiliestomaintainexistingproviderrelationshipsinthefee-for-service "system." Basedonthesegoals,weselectedasampleofeightstates:Arizona,theDistrictofColumbia, Florida,Maryland,Michigan,Minnesota,Oregon,andTermessee. Briefsummariesofthese states'modelsandhowtheyfittheaboveschemaareprovidedbelow. Arizona. Arizona'sMedicaidprogram,theArizonaHealthCareCost ContainmentSystem(AHCCCS),beganonOctober1,1982undera1115(a) researchanddemonstrationwaiverapprovedbythefederalHealthCare FinancingAdministration(HCFA). TheAHC—CCSmodelmandatesthatall Medicaid-eligiblechildren,includingCSHCN definedasthoseeligibleforSSI HealthSystemsResearch,Inc. SynthesisofStudyResults Page7 orChildren'sRehabilitativeServices(CRS)underthestate'sTitleV program—enrollinAHCCCS'capitatedhealthplans. AHCCCShealthplansare responsibleforprovidingallprimaryandacutecareservices,whilespecialtycare rtoeltahteedCtRoSquaanldifRyeinggioCnRalSBceohnadviitoiroanlsHaenadlmtehnAtuatlhohreiatlyth(sRerBvHiAce)ssayrest"ecmasr,vedout" respectively. Inaddition,aseparatemanagedcareprogramcalledtheArizona LongTermCareSystem(ALTCS)providescomprehensiveservicesforadults andchildrenwithdevelopmentalandphysicaldisabilitieswhoareatriskof institutionalization. mfDiarsontmarigHcetCdoFfcAaCroeolfpuramobwgiaraia.vmerIdnepseliiatmgeinte1td9i9ns5pg,etcthihfeeiMcDaeildslityrcifacoitrdocpfhirCloodglrreuanmmbenitroaoilrlmeepcdleieivmneeSdnStIa.p^aprsUopvneacdilearl theprogram,childrenonSSIhavetheoptionofenrollinginthenewhealthplan orremaininginthetraditionalfee-for-servicesystem. TheDistricthas implementedthewaiverthroughacontractwithoneprivatenon-profitmanaged careplan.HealthServicesforChildrenwithSpecialNeeds,Inc.(HSCSN), whichprovidesacomprehensivearrayofservicesforenrolledchildren,including primaryandspecialtymedicalcare,mentalhealth,andabroadrangeofancillary andsupportservices,inreturnforcapitatedfees. HSCSN,inturn,contracts withabroadarrayofproviderstodeliverservicestoplanenrollees,while oHuStCreSaNc.handcasemanagementservicesareprovidedbyin-housestaffof Florida. BuildingonitsstrongstateTitleV/Children'sMedicalServices(CMS) systemandhistoryofservingMedicaidrecipientsthroughmanagedcare tairmreanogfemtieinistss,tutdhye,StthaeteCoMfSFlNoertidwaorlkauwnacsheadPthCeCCMMSprNoegrtawmorfkorinMe1d9i9c6a.idA-tthe eligiblechildrenwithspecialhealthcareneedsoperatedbythestate'sCMS program.'' ChildreneligiblefortheCMSNetworkreceivetheircarefroma specialnetworkofprimarycareandspecialtyphysicians(andotherhospital- basedproviders)credentialedbyandincludedwithinthestate'sTitleV/CMS system. Allenrolledchildrenarelinkedwithaprimarycareproviderwhois responsibleforprovidingallpreventiveandprimarycareservices,aswellas managingreferralsforspecialtyandancillarycare. Primarycarephysiciansare reimbursedonafee-for-servicebasisforthecaretheyrenderandpaidamonthly administrativefeeforcaremanagement. Specialtyprovidersarelikewise reimbursedonafee-for-servicebasisforthecaretiieyprovide. Intensivecase managementservicesareprovidedbylocalareaCMSnurseswhoassistclientsin receivingneededservicesinanintegratedmannerandworktoensurethatCMS 1998—al^tThhoeugohriagionnael-wyaeiavreerxwteanssiaopnprtohvreoudgfhorNoavtehrmebee-yrea1r99p9erwiaosdr—efcreonmtlDyegcreanmtbeed.r1995toNovember Medicaid^-InanJdulTyit1l9e9X9X,It-heeliCgiMbSleNCeStHwoCrNk,wwililthbethceonstvaetretCedMtSoaagfeulnlc-yristkocsaeprivteataesdtmheodreislk-abveaairlianbgleenttoitbyo.th HealthSystemsResearch,Inc. SynthesisofStudyResults Page8