Quote-of-the-day mailing list
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Subject: qotd: Transferring patients to Medicaid managed care
Date: Wed, 3 Jul 2013 12:24:12 -0700
From: Don McCanne <firstname.lastname@example.org>
To: Quote-of-the-Day <email@example.com>
The Kaiser Commission on Medicaid and the Uninsured
Transitioning Beneficiaries with Complex Care Needs to Medicaid Managed
Care: Insights from California
Between June 2011 and May 2012, the California Medicaid program (known
as Medi-Cal) transitioned just under 240,000 seniors and persons with
disabilities (SPDs) from fee-for-service to mandatory Medicaid managed
care (MMC) as part of its "Bridge to Reform" Medicaid Waiver. Goals of
the transition were to increase plan and provider accountability and
oversight, improve beneficiary access to care, and make costs more
predictable. This study examined how health service providers, plan
administrators, and community-based organizations (CBOs) in Contra
Costa, Kern, and Los Angeles counties experienced the transition of SPDs
to MMC. Below are some key study findings that may help inform future
transitions to managed care for populations with complex health needs.
TRANSITION READINESS: BENEFICIARY DATA AND INFORMATION SHARING
* Incomplete or out-of-date contact information for SPDs was an obstacle
to notifying beneficiaries of the transition to MMC.
* Health plans experienced barriers contacting beneficiaries by phone to
complete Health Risk Assessments.
* The transfer of health and prescription history information from the
state to health plans and providers was not timely.
* The delay in obtaining medical records also made it harder for
providers to effectively care for new patients.
* Delegation to other health plans or IPAs sometimes caused further
delays in data transfer as well as confusion about which entity was
responsible for covering certain types of care.
* The SPD transition disrupted established communication channels
between primary and specialty care providers.
PROVIDER NETWORKS: BUILDING ADEQUATE CAPACITY
* Health plans experienced barriers recruiting primary care providers
with expertise in complex care management.
* Health plans faced challenges recruiting specialty care providers,
particularly given the wide range of conditions among the SPD population.
* The reluctance of FFS providers to join plan networks was a major
barrier to network expansion.
CARE COORDINATION: NEW RESPONSIBILITIES AND EXPECTATIONS
* Primary care providers have more responsibility for care coordination
for SPDs patients but feel unprepared and untrained for this activity.
* Health plans are providing care coordination to SPD who called the
member services line up to 4 times as often as other beneficiaries.
* While care coordination has expanded on all fronts, the transition to
managed care added complexities that generated even greater need for
* The mental health services "carve-out" poses barriers to care
ORGANIZATIONAL RESOURCES: ENSURING ADEQUATE TRANSITION SUPPORT
* Providers reported that the SPD transition taxed their staff resources.
* Providers reported providing unreimbursed care during the transition
to prevent potentially dangerous disruptions in care.
* Some plans reported that Medi-Cal capitation rates for SPDs do not
account for the much higher utilization rates of the population.
* Community-based organizations (CBOs) used resources to assist SPDs
with the transition to managed care.
The usage of Medicaid managed care delivery models have been increasing
nationally, a trend which is likely to continue due to the coverage
expansion under the ACA. Even when steps are taken to mitigate
anticipated issues and concerns prior to the transition, as was the case
with California, unanticipated challenges are likely to arise. Learning
from California's experience with their SPD transition, this brief
presents considerations for states, health plans, CBOs, and providers as
they prepare for managed care expansions. Particularly salient are the
findings around timing, communication, and coordination, including the
establishment of partnerships that enable plans and providers to deliver
efficient and effective care that meets beneficiaries' health care needs.
Comment: Although transferring patients to Medicaid managed care plans
is supposed to improve access to care, this report shows that access was
impaired as patients lost the choice of their health care providers, and
experienced disruption in the continuity of their care. Although some of
the problems were transitional, many represent substantial impairment in
the quality and delivery of health care services. It's disgraceful.
We need to return these patients to the health care professionals and
institutions of their choice, while providing first dollar coverage for
their care. In fact, we need to do that for all of us. Think single payer.