The Kaiser Commission on Medicaid and the Uninsured, June 2013
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* Incomplete or out-of-date contact information for SPDs was an obstacle to notifying beneficiaries of the transition to MMC.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 coordination.
* The mental health services “carve-out” poses barriers to care coordination.
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.
http://kaiserfamilyfoundation.files.wordpress.com/2013/06/8453-transitioning-beneficiaries-with-complex-care-needs.pdf
Comment:
By Don McCanne, M.D.
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.
