Preparing for a Changing Healthcare Marketplace Lessons from the Field (1993) / Chapter Skim
Currently Skimming:
Managed Care and Vulnerable Populations
Managed Care and Vulnerable Populations
Pages 40-77
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From page 40... ...
Although the topic tonight is managed care and all vulnerable populations, I am going to focus specifically on Medicaid recipients as a type of vulnerable population. I think the things we talk about here can also be applied to Medicare, but since I have a ~ 5-minute time restriction, I will limit my comments to Medicaid and I will try to give you an overview.
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From page 41... ...
Traditional fee-for-service floes not exist for Medicaid patients in the HealthPASS demonstration area. There are approximately 1 10,000 Medicaid recipients in the demonstration area, and there are three health plan options that a Medicaid recipient can choose: two commercial HMOs and the HealthPASS Program, which is a stateowned program managed by a private contractor.
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From page 42... ...
Oxford has set up its Medicaid line of business as a totally separate and distinct cost center. That is extremely important if one is really going to make a difference when serving Medicaid recipients and if one is really going to be accountable.
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From page 43... ...
As regards lack of access, New York City Medicaid recipients could not get care from private practitioners anywhere because fee schedules had deteriorated so badly that an office visit was reimbursed at $12 and yet it cost the physicians more than $12 to collect the fee. As a result, recipients had to go to Medicaid mills, hospital emergency rooms, or hospital clinics, if they could go anyplace at all.
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From page 44... ...
, continuing out to commercial HMOs, which manage the Medicaid population within the framework of their commercial population. Then farthest out on the line of effective managed care models is the specialized comprehensive program, whether it be a Medicaid-only managed care program or a commercial HMO that has isolated the Medicaid line of business and whose employees focus on the unique needs of the Medicaid population, giving them as much attention as others give their commercial population.
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From page 45... ...
In addition, education levels are a barrier. Commercial HMOs that do not know the literacy levels of Medicaid recipients often hand out the commercial population literature to their Me(licaid recipients, not recognizing or acknowledging that the material should be written at a third or fourth grade rea(ling level if the material is to hit home.
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From page 46... ...
The only way to elevate consciousness regarding health status is to deal with some of these other high-priority items. So, effective managed care programs that link with community agencies and fund programs that deal with these traditionally non-health-care issues are the ones that ultimately save health care clolIars, and in addition successfully elevate the quality of life and the health status of the vulnerable population they are serving.
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From page 47... ...
A health plan cannot do it when it has a base of only 5,000 members, but as Medicaid managed care programs get larger, it is amazing what creative activities are going on out there in the country. Also amazing is the willingness of the private sector to invest in the health care
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From page 48... ...
We saw tremendously high levels of teen pregnancy, substance abuse, and learning deficits as a result of violence in the community, unstable family structures, and other problems that made it very difficult for students to learn. This investment in school-based health will bring tremendous positive results to the west Philadelphia community.
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From page 50... ...
I am concerned that the best practices outlined earlier in this talk will be impossible to implement in a massive health alliance environment. Another concern is whether these massive health alliances will be able to determine who is serving vulnerable populations well and whether they will be able to measure performance in this area.
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From page 51... ...
DAVID SNOW, JR. 51 A final concern is that a massive push for national reform could actually stall the Medicaid managed care revolution taking place at the state level while we wait for federal initiatives to be implemented.
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From page 52... ...
So, I am absolutely delighted to be able to talk to you about how vulnerable populations are going to fare under health care reform. I was struck by the topic for this presentation: striking the right balance between access and efficiency.
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From page 53... ...
In this presentation I would like to discuss three topics: Medicaid managed care in Minnesota, Medica's evolutionary involvement in that program, and what an organization like Medica views as major concerns in looking at health care reform and vulnerable populations. My work in medical assistance started, as I said, in the early l9SOs and involved designing the first Medicaid demonstration project.
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From page 54... ...
The county describes the managed care options that are available to individuals when they enroll in medical assistance. Medica became involved in managed care for Medicaid recipients in the mid-l98Os with the other health plans.
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From page 55... ...
Who are we to sit here in a lofty environment and talk about what is wrong with our medical assistance population and medical assistance programs? " So, we came up with what I think was a novel idea, at least for us.
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From page 56... ...
We learned that, yes, the medical assistance population uses the emergency room at basically the same rate as our commercial population. But then we asked, "Have you ever been hospitalized after you have been in the emergency room?
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From page 57... ...
First, to not recognize the difference in providing health care services to vulnerable populations is to ignore reality. If we cannot identify ant!
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From page 58... ...
The second point is that much of the health care reform rhetoric depends on a technology that I think is still in the Mode! T stage of development and this scares the hell out of me.
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From page 59... ...
The reason he needs me as a primary care doctor is that the insurance company told him he has to have a primary care doctor and his wife's coverage (loesn't cover anyone in that neighboring institution because they only cto tertiary and quaternary care. So, my job with him will be to write as many letters as possible to his other doctors to authorize him to go on seeing them.
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From page 60... ...
She is a single mother, living in South Boston, covered by a Medicaid managed care program. She has four kids.
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From page 61... ...
The Harvard Community Health Plan is just down the street. They have hundreds of thousands of patients.
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From page 62... ...
They are marching like mad into Lexington, Massachusetts, where I live, and setting up primary care programs in well-heeled communities. I clo not see them rushing headlong into Roxbury or Dorchester where the underserved are.
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From page 63... ...
LOIS WATTMANo We not only function on a capitated basis at Medica with our Medicaid population, we also have 45,000 enrollees in our Medicare program who are also capitated. However, we treat these two groups very differently.
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From page 64... ...
We have a long history of institutions of lesser quality being available to indigent populations and other vulnerable populations. So, the combination of quality in providers, hospitals, and related institutions is crucial to our being able to solve this problem.
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From page 65... ...
We also bring in other providers who only serve Medicaid and meet our credentialing criteria, such as community health centers and hospitalsponsored primary care centers. As to quality: we do not compromise our credentialing process to serve the Medicaid population.
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From page 66... ...
And we have expanded significantly the options for where Medicaid recipients can receive their care. I would say generally that this situation holds true for most of the Medicaid managed care programs I am familiar with throughout the country.
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From page 67... ...
Does that mean those other alternatives are not working? The answer is no, because clearly you give that health plan some time, and the population they attracted who were healthy when they enrolled will ultimately start looking like the overall population.
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From page 68... ...
We are going to be hiring social workers on our staff so that our physicians can, in fact, access those social workers to deal with the multiplicity of needs that are presented when that individual comes into the office. So, we try to replicate at the plan level the kinds of services that are necessary.
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From page 69... ...
John Eisenberg, now head of medicine at Georgetown University Medical School, used to always say to me that when he was in HealthPASS there were addicts whom he would see once a year, and it was delightful because he would get all the capitation payment for that patient and, yet the cost for that patient was extremely low. So, vulnerable populations have this paradox about them, that if one, in fact, delivers goo(l service to them, they do cost more, but, indeed, frequently if you look at their use pattern, which sometimes is the best predictor actually of the cost of services from a risk assessment point of view, you will find that they underuse services and the result is that they are the low-cost group.
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From page 70... ...
Secondly, Lois, I was really interested in how we get managed care organizations to deal with the vulnerable populations if they are not paid more? You said that 10 percent of the population was enrolled in managed care, but they are 12 percent of your budget.
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From page 71... ...
And the results, although not scientific, can lead one to believe that over time, as people get use(1 to a manage(1 care system, they are better off. I think more should be done to study better the outcomes from care delivered through managed care entities, especially to vulnerable populations.
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From page 72... ...
health plan Group Health which has about 580,000 enrollees, has 2,000 medical assistance enrollees. We are challenging our sister plans to say come on in.
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From page 73... ...
This leads me to the one major point I want to make, which is a plea for us not to loose sight in Washington, D.C., of the single-payer option, which, aider all, will render the financing side of this more or less moot, as far as I am concerned, and will let us all then conduct our various demonstrations. Another comment about the managed care option and at-r~sk populations: based on my considerable experience, I don't know whether the number is 75 percent, 80 percent, or 85 percent of families in the inner city are every bit as mi(l(lle class, anti have the same aspirations, as every one of us sitting in this room, and we must not lose sight of that as we talk about the at-risk nature anti the special populations that we are talking about.
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From page 74... ...
I am with the American Psychological Association. Most of what we have talked about tonight in terms of vulnerable populations has focused on the poor.
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From page 75... ...
At Oxford, when a person is diagnosed with a catastrophic or chronic illness that clearly requires specialist care, we do not make our member go to a primary care doctor every single time they need to access that specialist. We link that member to a specialist and that specialist keeps the primary physician informed because, should that member develop an unrelated illness, you want the primary physician in the loop.
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From page 76... ...
I am Alan Bergman with the Uniter} Cerebral Palsy Association. As we have looked at the research and the data and perhaps we didn't have yours most of the managed care programs in this country that have operated under Medicaid specifically have excluded SSI recipients because the managed care system didn't have the research base, didn't have the data, didn't want to get into the risk business to see how much more on the average these folks were going to cost.
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From page 77... ...
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