Local health departments assume role as watchdogs of Medicaid managed care
Medicaid Managed Care
Local health departments in Maryland and in other states are becoming the watchdogs of Medicaid managed care, with responsibilities ranging from assisting in enrollment, to resolving disputes between enrollees and plans, to tracking down non-compliant enrollees and showing them how to navigate the managed care system.
When Maryland implements its 1115 waiver for mandatory Medicaid managed care on June 1, local health departments will have a number of special roles:
• Do eligibility and income determinations for pregnant women and their children under the Pregnant Women and Children’s (PWC) program and the Maryland Kids Count program. The PWC program offers expanded Medicaid eligibility to pregnant women and their children up until the birth of the baby, and the Kids Count program picks up for children under one year when the PW coverage ends. a primary care benefits program for pregnant women and children who are not in the Medicaid program.
• Do client and provider outreach and education to communicate what changes will take place under Medicaid managed care and what recipients must do to enroll in plans;
• Perform one-on-one case management with non-compliant recipients and members of special populations. If patients do not enroll or keep scheduled appointments, the local health department will do home visits to help resolve the problem.
• Act as ombudsman to resolve disputes between health plans and recipients, and educate recipients on how to use their plan’s grievance process.
Says Frances Phillips, health officer for the Anne Arundel County Health Department in Maryland: "Our vision is getting out of direct service provision and into enabling services and quality assurance and monitoring."
Health plans in Maryland will be required to report encounter data, says Ms. Phillips, so that health departments will be able to help monitor quality of care in areas such as prenatal care, where the health departments have a proven track record. Data will have to be made available so that it can be broken out by jurisdiction. Ms. Phillips would like to convene HMO medical directors to discuss the most reliable ways for reducing low birthweight and infant mortality.
"Our success has not just been in providing good OB care, but in dealing with issues such as transportation and domestic violence counseling. Outcomes will fall if HMOs don’t do these things," she adds.
Core public health functions
In Onondaga County in upstate New York, health departments have signed agreements with the four managed care plans serving Medicaid clients there that specify what responsibilities they have for core public health functions. The plans must provide data on preventive services, particularly immunization and perinatal care, so that the health departments can monitor the provision of these services. The health departments will still provide some services directly, including home visits for high-risk pregnant women and for children with elevated blood lead levels, and all tuberculosis care. The plans will reimburse the health department on a fee-for-service basis for these services.
Plans agreed to this arrangement, says Gary Urquhart, deputy commissioner of health for the county, because they saw the ultimate financial benefit of putting more resources into prevention rather than treatment. "We’re kind of amazed they all agreed to do this. Likewise, they were astounded that someone put something on the table for them to look at."
Educational role
In Arkansas, health departments helped bring down inappropriate emergency room use by Medicaid recipients by 68% from the first quarter to the fourth quarter of 1996 by taking on an aggressive educational role. Last spring, the state health department launched an initiative called Connect Care to increase enrollment in the state’s primary care case management (PCCM) program and to discourage inappropriate use of services. The state had been using a PCCM model since April 1994, but enrollment was lagging behind expectations.
The department of health has developed a major media campaign focusing on enrollment and appropriate use of services. The campaign includes television spots, dissemination of written material, and use of a 24-hour 800 number to respond to questions, complaints, and enrollment issues. Ron Stark, program manager for Medicaid outreach and education at the Arkansas Department of Health, gauges the success of the media campaign by the fact that his own acquaintances are now familiar with his job. "People I know now know what I’m doing, which has never happened before," he jokes.
While enrollment in the PCCM program has not increased "as fast as we’d like" — Mr. Stark estimates that there are 30,000 recipients who still need to enroll — the program has had a dramatic impact impact on inappropriate emergency room visits and per person health care expenditures. Costs per PCCM member were $85 per month in the first quarter of 1996, and $73 per member per month in the third quarter, a savings largely attributable to the reduction in ER usage. However, usage of other services, such as outpatient and inpatient services, has declined as well. Conversely, visits to PCCM physicians are going up, says Mr. Stark.
The state health department also monitors primary care physicians’ compliance with their PCCM obligations
When a Medicaid patient presents at the ER and does not have a PCCM physician, the hospital can enroll the person at that time. If a PCCM physician does not respond when called from the ER, the hospital alerts the health department, which follows up to determine whether the physician is complying with PCCM rules.
The Connect Care budget for the 15 months from March 1996 to June 1997 is $1.2 million, says Mr. Stark, "but I don’t think we’ve spent near that." He points out that the money saved in inappropriate ER visits "more than paid for the program." The program is funded by a 50/50 state/federal Medicaid match.
Most health plans seem to welcome the input of the public health community on serving the Medicaid population, but they are less certain about allowing health departments to stipulate data requirements or to approve contracts.
In Minnesota, public health departments may soon be able to give a thumbs up or down to managed care plans that want to serve Medicaid recipients in their counties under bipartisan legislation introduced in early March. Although the final decision would rest with the state’s commissioner of health, a vote of "no" from the health departments would carry significant weight. Counties would evaluate managed care plans’ contracts with the state based on whether the plan is fulfilling its public health responsibilities and other considerations such as provider networks, says Robert Fulton, director of the Ramsey County Department of Public Health in St. Paul. "We wanted to have some ability to influence the delivery system and quality provision," says Mr. Fulton. "This gives us enough clout to do that." In addition, the legislation would allow public health departments to contract with the state to become full-fledged Medicaid managed care providers in their respective counties.
"The bill is too ambiguous with respect to the public health provisions," says Andrea Walsh, senior vice president for HealthPartners, a Medicaid managed care plan. She is concerned that it could create "unfunded public health mandates on health plans far beyond what is expected of health plans today."
In addition, plans believe that if public health departments contract with the state to provide Medicaid services to their populations, they should be regulated like any other health plan, says Ghita Worcester, vice president of UCare, a group of family physicians affiliated with the University of Minnesota. "That part really concerns us — the whole issue of whether counties have to follow the same regulatory requirements as health plans."
—Jana Sansbury
Contact Ms. Phillips 410-222-7375, Mr. Urquhart at 315-435-3252, Mr. Stark 501-661-2251, Mr. Fulton at 612-266-2424, Ms. Walsh at 612-883-5088 or Ms. Worcester at 612-603-5381.
Local health departments assume role as watchdogs of Medicaid managed care
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