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MANAGED CARE
AND
PEOPLE WITH DISABILITIES
Robyn I. Stone
Deputy Assistant Secretary
for Disability, Aging and
Long-Term Care Policy/ASPE
Presentation to
Appointees with Disabilities
March 15, 1996
What is
Managed Care?
Integrating the financing
and/or delivery of health
care services.
Some form of
capitation.
Emphasis on primary
and preventive care
services.
Disincentives for
unnecessary
hospitalization and
institutionalization.
Types of
Managed Care
Primary care case
management.
Risk-based models.
Primary and acute care
only (e.g., Medicare HMOs,
Medicare Select, Evercare,
Community Medical
Alliance).
Long-term care only (CNO).
Integration of primary,
acute and long-term care
(PACE, SHMO II, ALTCS "for
MR/DD").
Managed Care's Great
Promise for People
with Disabilities
Expanded services.
Protection from high
copayments and
deductibles.
Increased coordination and
case management.
Continuity of care.
Less restrictive forms of
care.
More prevention and
primary care.
Reduced incentives for
institutional care.
Potential Disadvantages
for Older Persons
and Persons with
Disabilities
Risk selection.
Inadequate access to
specialty care.
Gate keepers
Defined provider networks
Decreased access to
core services.
Home health care
Rehabilitation
Potential Disadvantages
(Continued)
Disruption of important
care relationships.
"Medicalization" of
long-term care.
Greater use of nursing
homes.
Barriers to
Development of
Managed Care for
Elderly and Disabled
Fragmentation of
funding source.
Risk issues.
Lack of comprehensive
service coverage.
Fragmented service
delivery system.
Lack of education and
training.
Key Design Issues
Target population.
Generic versus specialty
plans.
Which disabilities to
include?
Degree of financial
integration.
Service coverage.
Primary, acute, post acute,
long-term care.
Integration versus
coordination.
Case management.
Key Design Issues
(continued)
System organization
(horizontal versus
vertical).
Degree of consumer
choice.
Voluntary versus
mandatory.
Choice among plans.
Choice of practitioners/
services.
Consumer role in decision
making.
Information systems
development.
Quality assurance.
Medicaid Beneficiaries
Enrolled in Managed Care
40
30
In millions
20
10
0
1991
1992
1993
1994
Enrolled in Managed Care
Total Medicaid enrollment
SOURCE: HCFA, Office of the Actuary
115H\pe9195-c
Percent of SSI Disabled Enrolled in
Managed Care
100%
87.6%
80%
67.5%
60%
50.3%
39.8%
40%
38.5%
20%
13.5%
3.2%
4.7%
0.4%
0.3%
0%
AZ
CA
CO
FL
KS
MA
MI
NJ
NM
SC
SOURCE: Institute for Health Policy, Brandeis University, August 1994.
Managed Care and
People with Disabilities
Joint Research Agenda
Planned
Ongoing
Managed Care for Disabled Elderly
Models of Managed Care for
Children with Disabilities
Study of Dually Eligible
Health and Expenditure Patterns of
Children with Disabilities
DC Waiver Evaluation
Innovative Practices and Plans
Project
Disability Survey Analysis
Disability Supplement
Interdisciplinary Training Project
Statewide Evaluations
(HCFA & ASPE)
Employer-Based Study
Managed Care Grant
National Conference
(HCFA & ASPE)
Synthesis of HHS Related Managed
Care Research
1994/1995
Disability Survey
Phase /: Collect disability
information on 250,000
persons nationally; data
available June 1996.
Phase It: Collect detailed
medical and nonmedical
information on service use,
housing, transportation,
employment, etc. for 40,000
persons with disabilities.
Results: Detailed information on
cost, coverage, satisfaction,
functioning, health care access.
Analyses: Over a dozen papers
planned; session scheduled at
APHA.
Project on Health and
Expenditure Patterns for
Children with Disabilities
Measuring disabilities by
diagnosis as well as
disabling condition under
SSI.
Analyzing utilization and
expenditure patterns
under Medicaid.
Comparing analyses with
private employer data
bases.
Project on Model Managed
Care Systems for
Children with Disabilities
Examine innovative models
serving children with
disabilities.
Identify and explore
financing arrangements,
quality assurance
activities, organizational
models, benefits and
coverage.
Data/information collected
and summarized from four
States.
Final report due by May.
Project on Innovative
Practices and Plans Serving
Disabled Populations
Areas of interest include:
Risk management strategies.
Provider training models.
Quality assurance activities.
Enrollment and marketing
practices.
Consumer participation.
Provider recruitment and
retention.
Interdisciplinary
Education and
Team Training Task
Case studies to identify
and describe
interdisciplinary training
programs.
Review and synthesize
literature on
interprofessional and
team training.
Medicaid 1115 Waiver
Evaluation Supplements
Oregon and Tennessee.
Pre/post comparisons
(access, quality, cost,
outcomes).
Linking Medicaid claims data
with Social Security files and
State functional data when
available.
Descriptive case studies
(infrastructure, delivery
systems, provider training...)
Baseline and follow-up
satisfaction survey of
consumers and providers.
Employer-Based Study
Identify employers/payers
interested in sharing data on
disabled.
Develop methodology to
identify people with disabilities
using MCOs in large private
payers.
Supplement existing employer
data base(s), and data
collection instruments.
Track enrollment, utilization
and cost data on people with
disabilities in managed care.
Analyze data from employers.
National Conference on
Research on Managed Care
and People with Disabilities
Scheduled for November 1996.
Interdepartmental planning
group.
To synthesize and share
research results on the impact
of managed care on people
with disabilities.
To disseminate information on
successful practices of
managed care plans and
providers serving the disabled.
To stimulate debates on the
implications of research and
practice for policy development
around managed care and
disability.
Managed Care
Research Grants
Comparative study of FFS
and HMO use by
nonelderly Medicare
disabled (Fallon Health
Care and Kaiser in
Portland, Oregon)
Managed care models for
children with special
needs in Florida.
Risk adjustment for people
with disabilities in
managed care (with
NIDRR).
Projects Planned
for 1996-1997
Medicare managed care
for people with
disabilities.
Delivery of Medicare and
Medicaid services to the
dually eligible.
Early implementation
evaluation of the DC 1115
waiver.
Providing acute and long-term
care to children with
disabilities.
Ongoing analyses of the
Disability Survey.
HCFA INITIATIVES RELATED TO
MANAGED CARE AND PERSONS WITH DISABILITIES
DEMONSTRATION PROJECTS
Program of All-Inclusive Care for the Elderly (PACE)
The Program of All-inclusive Care for the Elderly (PACE) demonstration is a fully
integrated model that incorporates all acute and long term care services available through
Medicare and Medicaid under full provider financial risk. Enrollment is limited to the frail
elderly who are either dually entitled or who have the financial resources to pay a premium
equal to the Medicaid capitation rate. Nine sites are currently operational, and additional
sites are under development. Reflective of an interest in identifying broad, common
solutions to service delivery across the disability spectrum, several PACE sites are
currently receiving funds from the Robert Wood Johnson Foundation (RWJF) to
determine whether a PACE-like model can be tailored to meet the service and financing
needs of various non-elderly disabled groups. Efforts are focused toward persons with
AIDS (East Boston, Massachusetts), children with severe disabilities (Columbia, South
Carolina), and the non-elderly, primarily physically disabled (Bronx, New York and
Madison, Wisconsin) [HCFA Lead Contact: Steve Miller, ORD, (410) 786-6656]
Social Health Maintenance Organization (Social HMO)
The Social Health Maintenance Organization (Social HMO) demonstration supplements
the existing Medicare benefit package available through TEFRA-risk HMOs with
expanded benefits such as prescription drugs and long term care benefits such as
homemaker, transportation, and home health services. Financing is accomplished through
prepaid capitation, pooling funds from Medicare, member premiums, and Medicaid (for
the limited number of Medicaid eligible enrollees). Three sites are currently operational.
HCFA recently selected six organizations to participate in the second generation Social
HMO. Social HMO II will focus on refining the targeting and financing methodologies
and benefit design of a Social HMO, with an emphasis on geriatric care and the expansion
of the model to special populations, including the non-elderly disabled, beneficiaries living
in rural settings, and those who are dually entitled to Medicare and Medicaid.
Approximately 85,000 individuals are expected to enroll in Social HMO II. [HCFA Lead
Contact: Melissa McNiff Hulbert, ORD, (410) 786-8494 and Dennis Nugent, ORD, (410)
786-6663]
End Stage Renal Disease Managed Care Demonstration
The Deficit Reduction Act of 1984 authorized Social HMO demonstrations and the
Omnibus Budget Reconciliation Act of 1990 authorized additional sites, including a
1
project to provide integrated acute and chronic care management of ESRD beneficiaries.
Prior work included a Rand study to design an ESRD capitation rate-setting method,
based on whether the patient receives maintenance dialysis, has transplant surgery, or
remains Medicare-eligible with a functioning graft. For the current project, Brandeis
University's Institute for Health Policy is assisting HCFA with the further development of
concepts for an ESRD Managed Care Demonstration solicitation [Lead Contact: Paul
Eggers, ORD, (410) 786-6691]
MAINE-NET
The State of Maine was recently awarded a grant to develop a Medicare and Medicaid
managed care program for the elderly and physically disabled. Entitled MAINE-NET, the
project is designed to demonstrate integrated models for the financing and delivery of
managed health care and social services for Medicare and Medicaid elderly and physically
disabled. The project seeks to promote the development of regional service delivery
networks or health plans, particularly in rural areas of the State, that would be responsible
for the management, coordination and integration of services including multi-disciplinary
approaches to care planning and service delivery. The demonstration will provide a
comprehensive package of primary, acute and long term care (institutional and
noninstitutional) services as part of a prepaid capitated health plan for the target
populations. The State expects to implement MAINE-NET in January 1997, following a
2-year development period. [HCFA Lead Contact: Kay Lewandowski, ORD, (410) 786-
6657]
Minnesota Long-Term Options Project
The State of Minnesota has received approval for a waiver proposal entitled the Long-
Term Care Options Project (LTCOP). The LTCOP is a 5-year demonstration designed to
test delivery systems which integrate long-term care and acute care services for elderly
dual eligibles. All services provided under Medicare Parts A and B, Minnesota's current
Medicaid program, and the State's current Elderly Waiver (1915c waiver) will be
provided under LTCOP. The integrated service delivery system is expected to facilitate
more efficient and economical clinical approaches for services to the elderly which will
result in the same or lower costs than the current system. The LTCOP demonstration will
begin on January, 1996 and continue through December, 2000. [HCFA Lead Contact:
Melissa McNiff Hulbert, ORD, (410) 786-8494]
Rhode Island CHOICES
The State of Rhode Island was recently awarded a grant to develop an 1115 waiver
project to serve adults with developmental disabilities using a managed care network.
Under the Rhode Island CHOICES waiver program, the State intends to consolidate all
current State and Federal funding streams for approximately 4,000 adults with
developmental disabilities under one managed care Title XIX waiver program. Each
eligible person will be enrolled in a private health maintenance organization or approved
health plan for acute health care and a clinical management system will also assist
2
individuals in obtaining long-term supports. For long-term care services, the State will
assess each eligible person's needs and past service use and ascribe a dollar amount for the
procurement of long-term care services. Each eligible person will then, with technical
assistance from a broker or other source, choose to manage the long-term care cap
amount directly themselves via a voucher or choose an agency that can support a person's
needs within the identified resources available. Rhode Island believes this approach
represents an opportunity to transform the current provider driven system to a consumer
driven model. [HCFA Lead Contact: Thomas Theis, ORD, (410) 786-6654]
Health Services for Children with Special Needs, Inc. (HSCSN)
HCFA approved a waiver to the District of Columbia to enroll in a managed care program
Medicaid-eligible children who are disabled and youth with special needs. The District
will sponsor the demonstration through Health Services for Children with Special Needs,
Inc. (HSCSN), a non-profit managed care corporation established for the purpose of
coordinating care for children who are disabled and youth with special needs who are
eligible for Medicaid. HSCSN will contract with physicians as primary care case managers
to coordinate care. Other case managers employed by HSCSN will develop expertise in
managing care for specific sub-populations, such as children with spina bifida or those
who are dependent upon technology. The District hopes to use the program to eliminate
both barriers to access and other health care delivery problems that children who are
disabled and their families encounter in the current Medicaid fee-for-service system.
Approximately 3,600 children are targeted for enrollment, with implementation planned
for 1995. [HCFA Lead Contact: Phyllis Nagy, ORD, (410) 786-6646]
Wisconsin Special Care Initiative.
HCFA is supporting, with the Pew Charitable Trusts, RWJ Foundation, and the Medicaid
Working Group, a demonstration initiative to develop integrated care models primarily for
non-elderly persons with disabilities, all of whom are eligible for Medicaid, and about 40%
of whom are dually entitled. Initiatives are in various phases in the States of Wisconsin,
Missouri, New York and Ohio. The most fully developed of these initiatives is the
Wisconsin Special Care Initiative.
Focusing on the SSI population, this demonstration is designed to provide Medicaid-
covered medical services and additional social services such as respite, family training,
long-term planning, referral and medication services to up to 3,000 Medicaid eligible SSI
recipients in Milwaukee County. About 75 percent of projected enrollees are between 21
and 64 years of age, most have never been employed, and many receive some form of day
programming either through the Milwaukee Public schools (if school-aged) or through a
community-based organization. Capitation payments are being made to an HMO-like
provider for these services. Central to the model is a physician panel of experienced
providers, case management services through a multi-disciplinary team, and specialized
clinics. Enrollment in the 3-year demonstration began in July 1994, and in January,
enrollment was approximately 1,500 individuals. [HCFA Lead Contact: Sam Brown,
3
ORD, (410) 786-6667]
Evaluation of the Community Supported Living Arrangements (CSLA) Program
The CSLA program is designed to test the effectiveness of developing a continuum of care
concept as an alternative to the Medicaid-funded residential services provided to
individuals with mental retardation and related conditions as an optional State Plan
service. CSLA was implemented in 8 States. The evaluation of the CSLA program will
assist HCFA and the Congress in considering the policy options regarding the continuation
and expansion of the Medicaid State Plan optional service. [HCFA Lead Contact: Sam
Brown, ORD, (410) 786-6667]
Arizona Long Term Care System
Arizona has implemented an innovative program to provide Medicaid long term care
services in a managed care environment. The project, called the Arizona Long Term Care
System (ALTCS), is the long term care component of the Arizona Health Care Cost
Containment System (AHCCCS), the State's Medicaid demonstration implemented in
1982. AHCCCS began phasing in long term care services for persons with mental
retardation and developmental disabilities (MR/DD) in December, 1988, and for the
elderly and physically disabled (EPD) in January, 1989. The Arizona Department of
Economic Security provides services to the MR/DD population, and Program Contractors
provide services to the EPD population. All long term care, acute care, and behavioral
health services are included as part of a single capitation rate. Approximately 60 percent
of the EPD population are institutionalized; 40 percent receive home and community-
based services (HCBS). The MR/DD clients are almost completely de-institutionalized--
over 95 percent receive HCBS. The ALTCS program has produced substantial cost
savings compared to the estimated cost of a traditional Medicaid program in Arizona.
Oregon Health Plan
The Oregon Health Plan, which has been operational since February, 1994, enrolls
Medicaid-eligible individuals and persons living below the poverty level into managed care
programs and offers benefits according to a prioritized list of services. In January, 1995
the State began Phase II of the program, integrating the aged, disabled, foster children into
the demonstration. The aged, disabled, and foster children will receive the same benefit
package that was offered in Phase I, plus enhanced services as appropriate. These
additional services include long-term care and home and community-based waiver
services; institutional care in State facilities; community mental health program care;
personal care in residential settings; and case management services. Phase II population
members can enroll in a State-approved managed care plan or with a primary care case
manager. Additional safeguards have also been implemented for this populations, such as
medical case management services, ombudsman services, and exceptional needs case
management.
4
RESEARCH PROJECTS
Medicaid-Capitated Managed Care Program for the Supplemental Security Income
Disabled.
This project is a case study of eight States that provide Medicaid managed care programs
to working age persons eligible for SSI, and a survey of health plan administrators who
manage capitated plans in the States where they are offered. The draft final report has
been submitted to HCFA and reports on such issues as: implications for collaborations
among existing community-based service systems and mainstream managed care
programs; effects of gate-keeping approaches on access and health/social outcomes; and
rate structure and payment mechanisms that will provide incentives to serve special
populations. [HCFA Lead Contact: Rose Hatten, ORD, (410) 786-6630]
Working-Age Persons With Disabilities
The proposed study will use the Medicare Current Beneficiary Survey (MCBS) to
examine various target populations of working-age persons with disabilities. The goals of
this study are to (1) describe the health care utilization experience of the working-age
population; (2) to evaluate the working-age disabled population's access to health care
services; (3) to evaluate the extent and adequacy of health insurance coverage for
working-age disabled persons from both public and private sector sources; and (4) to
consider the implications of this research for the future of health services policy. [HCFA
Lead Contact: Sam Brown, ORD, (410) 786-6667]
Access in Managed Care
ORD will be conducting a study to address the issues relevant to measuring access in
managed care. The principal goal of this project is to develop and test a framework for
monitoring access in the managed care sector. These access measures will incorporate
aspects of quality and outcomes of care. Ultimately, this framework could be used to
measure whether vulnerable segments of the Medicare population, such as the disabled
enrolled in managed care plans, experience access problems. [HCFA Lead Contact: Renee
Mentnech (410) 786-6692]
WORKGROUPS AND COMMISSIONS
National Steering Committee on Managed Care for Older Persons and Persons with
Disabilities
Kathy Buto and Sally Richardson represent HCFA on this Committee convened by the
National Academy for State Health Policy. Many states are turning their attention to
expanding managed care for Medicaid beneficiaries who are elderly or have disabilities,
now that they have some experience with AFDC beneficiaries in managed care. The
group was convened to assess and advance the state-of-the-art regarding managed care
for persons who need primary, acute, and long-term health services. The Committee is
5
focusing some of its efforts on examining the barriers to managed care for dually-eligible
beneficiaries. [HCFA Contacts: Kathy Buto, AAP, (202) 690-7063; and Sally Richardson,
MB, (410) 786-3230]
Dual Eligibles
The Office of Managed Care has formed a workgroup to develop policy on managed care
for dual-eligibles. The purpose is to create a managed care environment in which dual-
eligibles will be identified, access to care enhanced, and the efficient and appropriate use
of Federal funds ensured. The workgroup is comprised of representatives from four OMC
Teams (Beneficiary Access and Education, Data Development and Support, Medicaid
Managed Care, and Program Policy and Improvement), ORD, and Regions I, III, and X).
The dually-eligible beneficiaries are entitled to Medicare and Medicaid and typically
include the elderly and disadvantaged, or disabled and low-income beneficiaries. However,
the workgroup is focusing specifically on the Qualified Medicare Beneficiaries (QMB)
who are in managed care programs because the States want to impose cost-sharing
incentives on the QMBs under managed care waiver programs (using Section 1915(b) and
1115 waiver authority). [HCFA Lead Contact: Melodie Janes, OMC (410) 786-7614]
OUTREACH ACTIVITIES
ADAPT Initiative
This initiative is a joint effort between HCFA Central offices and the Regional offices.
This initiative began last May, when both the Secretary and the Administrator met with
representatives of the advocacy group ADAPT. The Administrator agreed to a number of
action steps to improve relations with ADAPT. These activities include:
Holding quarterly meetings with ADAPT (the last meeting was held on November
8, 1995).
Every HCFA regional office has identified staff to serve as coordinators for the
ADAPT initiative, as well as to work on outreach to other disabled populations.
All the regions have held meetings with local ADAPT chapters in order to identify
issues of concern to their constituency. A summary of all the meetings was
compiled into a national report. The chart outlines each issue, indicates the states
where the issue was raised, and states what action was taken, either by HCFA
regional offices or HCFA central headquarters, or other entities. The chart is used
to track progress on issues critical to ADAPT.
Provide ADAPT with copies of HCFA issuances which have an impact on the
disabled.
Provide opportunities for ADAPT to comment or participate in discussion on
policy development in areas related to the disabled community.
[HCFA Lead Contacts: Dave Selleck, Denver Regional Office (303) 844-2121 X375,
6
Paul Mendelsohn, OBS, (410) 786-3213, and Tom Hoyer, BPD, (410) 786-5661]
Beneficiary Outreach Focus Groups
HCFA's Office of the Associate Administrator for Policy has been coordinating a series of
focus-group style meetings with beneficiary advocacy groups, with each meeting centered
on specific policy topics. The first meeting, held in September 1995, was coordinated
with HCFA Region VIII in Denver, Colorado and HCFA's Office of Beneficiary Services,
and was with local disability advocacy groups and beneficiaries with disabilities. The
topics addressed at the meeting were mangaged care for people with disabilities and
assistive technology coverage issues. One of the goals of the meeting was to learn about
the experiences of disabled populations and their advocates in dealing with managed care
plans and the types of suggestions they may have to improve the responsiveness of
managed care programs for disabled beneficiaries. [AAP Contact: Margie Davis, (202)
690-7864]
HCFA customer disability awareness, sensitivity, and outreach issues.
The Office of the Associate Administrator for External Affairs is charged with the
coordination of HCFA customer disability awareness, sensitivity, and outreach issues. As
part of this activity, AAEA assures that all publications are available in formats which can
be used by the visually impaired and the deaf-blind. This includes the production of
materials in large print, WordPerfect diskette, audiocassette, and braille. All new HCFA
publications are being designed to be sensitive to color blindness. All videocassettes
produced by HCFA are captioned. In addition, most materials will be available in Spanish,
and special requests for other foreign languages can be met.
AAEA has a direct TDD access number -- 410-966-7581 -- which is answered by Paul
Mendelsohn, of the Office of Beneficiary Services, and has a voice message capability.
[AAEA Contact: Paul Mendelsohn, (410) 786-3213.]
HCFA Hotline
HCFA has established a new 800 Medicare hotline number, 1-800-820-1202, for use by
persons with hearing and/or speech impairment. The voice hotline number has been
sensitized to better serve persons with disabilities, particularly those with visual
impairments. HCFA is required by law [Section 1882 (42 U.S.C. 1395)] to operate this
toll-free telephone hotline for receiving beneficiary complaints of Medigap sales practices.
Also, the Omnibus Budget Reconciliation Act of 1990 requires HCFA to provide
information to beneficiaries to assist in selecting Medigap policies. The Office of the
Inspector General (OIG) takes complaints of suspected Medicare fraud, abuse and waste,
but has requested that HCFA first screen the calls and eliminate those that can be handled
by Medicare carriers and intermediaries before referring the calls to the OIG. Calls to the
agency regarding second opinions for surgery had been taken on a HCFA contractor-
operated hotline for the past 11 years. Although these are now being referred to Medicare
carriers, many public information materials still carry the old hotline number, and the
7
agency still receives many of these calls.
For individuals who are hearing impaired, deaf and speech impaired, the contractor must
provide access for computer and TDD (Telephone Device for the Deaf) phone calls. This
may require a separate telephone number and specialized computer hardware and
software. This system must provide services similar to the general system.
For those who are visually impaired or blind, copies of material in large print and
audiocassette (provided to Contractor by Project Officer) shall be offered and mailed out
on request by the contractor.
Information, Counseling, and Assistance Grants Program
The Office of the Associate Administrator for External Affairs administers the ICA Grants
program which has a specific charge to focus on special needs populations. HCFA is
authorized to make grants to States for health insurance advisory services programs for
Medicare beneficiaries. The grants are available to support information, counseling, and
assistance activities relating to Medicare and Medicaid as well as Medicare supplemental
policies, long-term care insurance and other health insurance benefit information.
The purpose of the ICA Grants Program is to strengthen the capability of States to
provide Medicare beneficiaries with information, counseling, and assistance on adequate
and appropriate health insurance coverage. Some areas of special focus are Medicare
physician payment reform, Medicare Secondary Payer, Qualified Medicare Beneficiaries,
information, counseling, and assistance in rural areas, and coordinated care options for
Medicare beneficiaries. ICA Grant funds are intended to help States plan, develop, and
implement programs designed to provide those services. While the programs strive to
serve the various minority and hard to reach populations through outreach activities, there
is no measure of the proportion of individuals with disabilities served. [AAEA Contact:
Paul Mendelsohn, (410) 786-3213.]
8