Beyond the Water's Edge: Charting the Course of Managed Care for People with Disabilities - Conference Resource Book. The Managed Care Enhancement Project for Children with Special Health Care Needs

11/01/1996

Deborah Allen
As the Director of the Division for Children with Special Health Care Needs of the Massachusetts Department of Public Health, Deborah Allen is responsible for assuring family-centered, community-based care for children with special health care needs and their families. Her division is the lead agency for implementation of Part H of the IDEA in Massachusetts and for the provision of case management services to SSI-eligible children. Ms. Allen is the Principal Investigator for the federally funded Managed Care Enhancement Project for Children with Special Health Care Needs. She is also responsible for two grants funded by Title IV of the Ryan White Care Act: MassCARE (Massachusetts Community AIDS Resource Enhancement), which focuses on pediatric and family care needs, and MCAP (the Massachusetts Women's HIV Care and Advocacy Project), which promotes identification and care of women with HIV prior to or early in pregnancy.

Ms. Allen has master's degrees in Health Policy and Management and Maternal and Child Health from the Harvard School of Public Health and is, as we speak, in the final stages of her doctoral research on "Predictors of Voluntary HIV Testing During Pregnancy," also at Harvard. She is absolutely committed to making this the last formal education she ever undertakes.

OUTLINE OF PRESENTATION

  • Health care in Massachusetts
  • MassHealth Managed Care
  • The Managed Care Enhancement Project
  • Needs assessment
  • Interventions
  • Evaluation
  • Concluding thoughts

HEALTH CARE IN MASSACHUSETTS--A WHIRLWIND TOUR

  • Extensive tertiary medical system
  • Widespread influence of academic medicine
  • Extensive CHC network
  • Extensive HMO penetration
  • No county health departments
  • Limited clinical role of local health departments
  • Comprehensive Medicaid program

MASSHEALTH OVERVIEW

  • Target population - 450,000 Medicaid recipients
  • All Medicaid clients except:
    • Individuals with private insurance and Medicaid
    • Individuals with Medicare and Medicaid
  • Enrollment started April, 1992

SSI RECIPIENTS IN MASSHEALTH

  • Special procedures for
    • Outreach
    • Enrollment
    • Assignment
  • For adults and children on SSI

MASSHEALTH COMPONENTS

  • Health Benefits Advisor Program
  • Primary Care Clinician Program
  • Mental Health/Substance Abuse Program
  • HMO Program

PCC PROGRAM

  • Approximately 1300 practices
  • Almost 2500 physicians
  • Eligible providers are:
    • Internists
    • Pediatricians
    • Family practitioners
    • Ob-gyns
    • Nurse practitioners

PCC PROGRAM OPERATIONS

  • No capitation at present
  • PCC receives $10 bonus per primary or preventive visit
  • PCC responsible for:
    • Primary care
    • Specialty referrals
    • Authorization of most medical services
  • Mental health, substance abuse do not require PCC authorization

PCC PROGRAM ENROLLMENT

  • Current enrollment approximately 290,000
  • 80% of Medicaid enrollees in PCC program
  • 80% of children with special health care needs in PCC program

HMO PROGRAM

  • 8 vendors statewide
  • 1 special contract for disabled individuals
  • Enrollment is voluntary
  • Current enrollment 81,000

MANAGED CARE ENHANCEMENT PROJECT OVERVIEW

  • Four year grant ending Sept. 1997
  • Funded by HRSA--Maternal and Child Health Bureau
  • Joint Title V--Division of Medical Assistance administration
  • Active, diverse advisory committee

MCEP GOALS

  • Improve health status of children with special health care needs in MassHealth
  • Improve quality of life for families of children with special health care needs in MassHealth
  • Increase appropriate use of health resources for care of children with special health care needs while averting unnecessary costs
  • Enhance understanding of optimal systems of care for children with special health care needs

MCEP NEEDS ASSESSMENT

  • Utilization data
  • Family survey
  • Provider survey
  • Family focus groups
  • Provider focus groups
  • National key informant interviews

FINDINGS ON UTILIZATION

  • CSHCN claims reveal:
    • Equal or greater use of primary care
    • More use of
      • Inpatient care
      • Home health care
      • Prescriptions
      • DME
    • Less use of
      • Dental
  • Than other children in MassHealth Managed Care

FAMILY SURVEY METHODS

  • Inclusion criteria
    • SSI enrollment or at least one EI claim
    • At least one full year of Medicaid with < 45 day interruption
  • Sample
    • 1,000 families chosen at random
    • Overselection of Spanish-speaking families
  • Implementation
    • Two mailings in English and Spanish
    • 800 number for questions or if phone administration preferred
  • Response
    • 32% response rate
    • 254 English surveys returned or completed by phone
    • 67 Spanish surveys returned or completed by phone

FAMILY SURVEY FINDINGS

  • High level of general satisfaction
  • Areas for improvement
    • Access to information
    • Family supports
    • Coordination of services
  • Survey also revealed weak links between primary care and
    • Schools
    • Discharge planning
    • Home care

PROVIDER SURVEY METHODS

  • Target population
    • Pediatricians, family practitioners
    • Participating in Primary Care Clinician Plan
  • Sample
    • 906 physicians
  • Implementation
    • Initial attempt at phone administration
    • Shift to administration by mail
  • Response
    • 31% response rate
    • 196 surveys completed by mail
    • 89 surveys completed by phone

PROVIDER SURVEY FINDINGS

  • High level of general satisfaction
  • Some areas of provider concern
    • Coordination of care
    • Information needs
    • Time constraints

OTHER NEEDS ASSESSMENT STRATEGIES

  • Confirmed and expanded upon needs assessment findings
  • Identified possible interventions

INTERVENTIONS

  • Special Care Coordinator
    • 4 sites
    • 3.5 FTE's
  • Parent manual
    • Focus on system "how to's"
    • Parent role in writing, editing
  • Enhanced provider education
  • Enhanced customer service
  • Enhanced PCC/case management linkage

EVALUATION OF SCC INTERVENTION

  • Parent questionnaires
    • Two points in time
    • Comparison group
    • Child functional status
    • Family functional status
    • Parent satisfaction
  • Utilization
    • Admissions
    • ER use
    • EPSDT compliance
    • Over one year relative to comparison group
  • Post-implementation PCC review
    • Qualitative interviews at 4 sites

EVALUATION OF MANUAL

  • Parent survey
    • Use
    • Strengths and weaknesses
    • Usefulness
  • Provider survey
    • Use
    • Strengths and weaknesses
    • Impact on practice

CONCLUDING THOUGHTS

  • Medicaid managed care offers opportunities to change system for the better
  • To seize that opportunity must have relevant players in a given state at the table listening to each other
  • Key elements to make managed care work for cshcn are being to emerge
  • These elements must be addressed at each stage of implementation, from early planning to final evaluation
TABLE 1. Costs of Care for CSHCN
Average per member per month
   CSHSN
   Other children in MassHealth
$360
$58
Maximum per member per month
   CSHSN
   Other children in MassHealth
$26,519
$12,769

 

TABLE 2. Service Types as Percent of Total Cost for CSHCN
Home health 23%
Inpatient care 22%
Prescriptions 13%
DME 6%
Primary care visits 6%
Specialty visits 6%
ER, transportation, dental <2%
Other 13%

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