nmss literature review june 2014 (autosaved)
TRANSCRIPT
The Move towards Medicaid Managed Care (MMC): Literature Review
Individuals Living with Disabilities and Chronic Illnesses in the Southeast U.S.
Zeeshan Haque
Index
1. Primer: Managed care delivery in Medicaid – pg. 3
2. Distinctions: Medicaid Managed care and people living with disabilities and chronic illnesses – pg. 8
3. Disposition: Medicaid Managed Care in Southeastern United States – pg. 16
a. Kentuckyb. Tennesseec. North Carolinad. South Carolinae. Floridaf. Mississippig. Alabamah. Georgia
4. Policy Recommendations – pg. 47
5. Resource Page – pg. 56
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Primer: Managed Care Delivery in Medicaid
Understanding the current standing of Medicaid concerning individuals living with
disabilities and chronic illnesses requires a fundamental background in the methodology behind
the organization, structure, and development of this government run entity, specifically the
concept of Managed care. Managed care represents a specific type of healthcare delivery system
in the United States that has gained traction over the past four decades. Today, managed care
represents the primary means through which both private and public sector healthcare plans, such
as Medicaid, are administered and provided to individuals. Overall, managed care seeks to
improve the functional efficiency and effectiveness of healthcare delivery through an integration
of the basic operations of the healthcare system, mechanisms controlling the utilization of
healthcare plans and caps to limit associated financial requirements for healthcare solutions and
providers.i These specific functional characteristics, designed to achieve the overarching goals of
improving quality and accessibility of healthcare services and solutions, improve endpoint and
patient outcomes, and limit healthcare spending, streamlining and facilitating a more integrated
approach to healthcare.ii
Current trends:
The most significant driving factor influencing the current trends and patterns in managed
care today, specifically in Medicare and public sector healthcare solutions, is the major
legislative reform, the Patient Protection and Affordable Care Act (ACA), signed into law in
2010. An October 2010 survey of all 50 states showed that every state, with the exceptions of
Alaska, New Hampshire, and Wyoming, reported having utilized Medicaid managed care
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programs.iii Figure one below gives a good representation of the influence managed care
solutions are currently having on the delivery of Medicaid services in states.
In addition, the figure below sheds further light below on the reliance of managed care systems
in state Medicaid programs.
4
For states that opted to expand Medicaid under the ACA, the expansion become effective on
January 1, 2014, hence the large upswing in the interest states have shown toward utilizing
managed care programs in Medicaid.iv The new provisions specifically call to expand Medicaid
to cover Americans (citizens) below 133% of the federal poverty line – these implications
amount to roughly an additional 16 million individuals, mainly adults, by the year 2019.v
Medicaid expansion will call for a “greater and larger role” for managed care in providing
healthcare solutions towards high-need populations. Many of these populations pose great health
and medical obstacles towards insuring proper care administration. Typically, characteristics of
Medicaid eligible individuals include persons with little to no income, either in fair or poor
health, having multiple chronic conditions, or mental illnesses, or in some cases substance abuse
issuesvi. Confounding this dilemma in Medicaid managed care expansion further is the fact that
many of these individuals have practically no experience using health insurance or managed care
systems, making market penetration that much more difficult.
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Given the high risk involved with these populations, managing the costs and needs of
these particular individuals, and even more so with individuals with disabilities and chronic
illnesses, becomes even more of a paramount challenge health policy makers must navigate and
solve – such issues will be touched upon later in the discussion. Figure 2 below gives a strong
indication regarding the state of these beneficiariesvii.
However, with the benefits of managed care established and proven in past case studies and
healthcare scenarios, states are determined to move forward with managed care delivery in
providing Medicaid solutions to these populations. States can take the proper steps to making
sure to best “coordinate and integrate care” towards populations with disabilities and chronic
illnesses. Many of these different tactics and strategic plans in managed care expansion,
illustrated below, highlight an increase emphasis in healthcare quality, outcomes, and long-term
care services.
6
While a proper critique of these strategies and decisions will come with time, there are specific
steps and considerations that all states should take into consideration when trying to configure
and create a most comprehensive Medicaid managed care package in serving individuals with
disabilities and chronic illnesses. These steps, considerations, and policy options are touched
upon in the complementing section.
Distinctions: Medicaid managed care and people living with disabilities and chronic illnesses
The healthcare needs and demands of individuals with disabilities and chronic illnesses
pose a new vantage from which Medicaid deliverance must be approached. These individuals all
have a varying degree of medical and healthcare needs that adds a new variable to consider when
providing Medicaid solutions through managed care. Essentially, there is “no single profile” of
Medicaid beneficiaries with disabilitiesviii, much like there is no single clinical profile for
individuals living with MS. The inherent diversity of this Medicaid enrollee population shown in
the chart and figure below highlights two important preliminary pieces of information – the
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complex nature of beneficiary medical needs and the variety of Medicaid spending for
individuals with disabilities and chronic illness.
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However, it is vital not to lose sight of the factors and considerations that should be made when
providing for these specific populations, specifically the underlying economic and social
backgrounds. The fact that economic background and status works against these populations
should only serve to exasperate the underlying disadvantages these individuals face, and thus,
require factors and considerations at the state and federal policy level to make accommodations
for such needs.
That background and context being established, the distinctions and factors needed to be taken
into account for the individuals with disabilities and chronic illnesses in Medicaid managed care
will be discussed in terms of payment and financial considerations, provider and delivery
considerations, and enrollee engagement considerations.
Payment and Financial Considerations:
Payment and cost considerations are extremely variable and dynamic in the light of a
patient pool with an array of disabilities and chronic illnesses. This makes the process of proper
financial assurances, evaluations, and payments much more difficult to navigate. In particular,
the concept of setting adequate capitation rates for healthcare providers. This type of payment
structure sets reimbursement rates for providers, where the provider is paid a fixed amount per
enrollee, referred to as a “per member, per month (PMPM) payment” – this holds regardless of
whether the enrollee decides to use the healthcare services at their disposal, or the quantity of
care providedix. That said, these rates must reflect the wide range and diversity of disabilities and
chronic illnesses that individuals have, calling for extremely specialized and specific healthcare
services and solutions.x It is a great task on the part of MCOs to set capitation rates for
individuals with disabilities and chronic illnesses at levels ensuring proper availability and
recruitment of the necessary physicians, providers, and specialists into the MCOs networks. In
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addition, associated secondary costs become an issue when dealing with this specific population
group. Specialized services, support mechanisms, and equipment for these enrollees will pose
other considerations for these fixed payment rates.xi It has been noted that while data analytics
and metrics are in place to ensure proper capitation rates, that getting an adequate sample size of
data and numerical evidences remains a challenge.
Nevertheless, patient empowerment and education remains just as vital. MCOs could
utilize capitation rates in additional function areas, such as providing healthcare education and
outreach efforts for individuals with disabilities and chronic illnesses. Provider rating and
accessible networks could also be funded for through these rates, offering patients the
opportunity to make informed decisions regarding their healthcare providers and services.xii A
final aspect of this consideration involves financial burdens and strains of offering Medicaid
towards individuals with disabilities and chronic illnesses under managed care. While this
integration of healthcare services is based around the premise of better involvement and input at
all levels of the healthcare cycle, implementing these initiatives often requires long-term
commitments, and this objective may run into direct opposition if managed care delivery systems
are in place primarily as a budget capping mechanism. Financial constrains may place a hold on
how involved or engaged these strategic plans in healthcare deliverance can feasibly be applied.
These conflicting goals within healthcare infrastructures may hinder the ability of MCOs to
achieve either of these goals of better-integrated care or a saving of financial resources in the
healthcare sphere. In sum, these considerations represent the financial and payment variables of
individuals with disabilities and chronic illnesses within the Medicaid managed care structures
that need to be accounted for at all times and cases.
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Provider and Delivery Considerations:
As mentioned in the section above, the healthcare and medical needs of individuals with
disabilities and chronic illnesses represents a significant obstacle in terms of proper delivery of
patient care. This consideration is brought even further to light within the context of Medicaid
managed care. That said, to properly serve Medicaid beneficiaries with disabilities and chronic
illnesses, MCOs will need broader provider networks to meet the healthcare and medical
demands and challenges of these enrollees.xiii This particular population will require a plethora of
healthcare services, including acute and long-term care. These necessary specialists and
providers may not be currently within the existing MCO provider networks and therefore, pose a
great barrier to adequate and proper healthcare services on the part of patients. As noted by a
comprehensive survey administered by the Kaiser Family Foundation in 2012, 25 states in total
reported that Medicaid beneficiaries experienced healthcare accessibility problems and issues to
meet their medical needs.xiv Moreover, these specific gaps in Medicaid coverage amongst MCOs,
will only prove to be an even greater issue for those individuals with more complex and intricate
medical needs and demands. Healthcare providers and specialists that are properly able to serve
and treat individuals with disabilities and chronic illnesses must be included in the policy
discussions about expanding MCO preferred provider networks. Without this variable taken
under serious consideration, utilizing a strictly cost savings approach in Medicaid would leave
enrollees with disabilities and chronic illnesses to fend for themselves without much in the way
of support. Such considerations and concerns are currently being brought up at the state level as
well, particularly in North Carolina, where a proposed regionalized approached to MCO
networks could threaten the ability of individuals to seek out their personal healthcare and
medical needs.
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In complementing this idea of the considerations of provider networks, ensuring proper
healthcare delivery for Medicaid enrollees with disabilities and chronic illnesses will also need to
account for logistical and geographic variables as well. There needs to be established travel and
waiting time lengths on the part of the enrollee that these patients should reasonable expect.
Oftentimes state statute or regulations puts caps on these time elapses, but given the wider need
of networks and providers that individuals with disabilities and chronic illnesses may need,
meeting these logistical standards may prove difficult to accomplish. Furthermore, specifically
for individuals with disabilities, timings and distances travelled may need specific cap
limitations, as these enrollees may need more frequent medical visits compared to other
individuals.xv In addition, geographic logistics may need to be taken into consideration as well, as
some enrollees reside in rural areas, where there often a shortage of necessary healthcare
specialists. In relation to this concept of logistical considerations, physical accessibility of MCO
network facilities should not prove to be a barrier for individual with disabilities and chronic
illnesses. There needs to be a standard of physical and mental accommodation and accessibility
within these provider facilities. This could potentially involve having proper communication
streams for individuals with disabilities and chronic illnesses, or making healthcare facilities
equipped with various instruments, structures, and devices, that allow enrollees to get to and
about their preferred healthcare facilities in an appropriate, efficient, and effective manner.xvi
Even something as simple as equipping clinics with automatic entry and exit doorways can go a
long way in achieving this goal. All of these often-overlooked aspects of the patient experience
really deserve a thorough reexamination and strategic plan in light of the diverse and specialized
needs of Medicaid enrollees with disabilities and chronic illnesses.
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Enrollee Engagement Considerations:
Medicaid managed care financial and provider network reforms and accountability, such
as those mentioned directly above can only be deemed a success and effective if Medicaid
managed care enrollees with specific conditions are properly guided, assured, and enlightened
toward their treatment and healthcare options. It is imperative that a personal touch and genuine
sense of trust and dependency is fostered within the patient-provider experience.xvii This
relationship is given even more importance and relevance in terms of individuals with disabilities
and chronic illnesses. Enrollee trust is a necessary component if provider networks and public
forums of health policy are to meet these individuals’ specific needs.xviii Giving these individuals
a robust and instrumental component in the design of their medical and healthcare strategies will
ensure properly directed care initiatives. Considering enrollee involvement in Medicaid managed
care, these individuals must have an array of tools at their disposal, such as varied
communication strategies, educational outreach, or social services, to understand how managed
care works and is organized, and be given vehicles and avenues within state Medicaid programs
to ensure their concerns are addressed.xix Individuals within Medicaid managed care programs,
and especially true of enrollees within the disability and chronic illnesses population, are
oftentimes at higher risk of poor health status and lower levels of educational attainment. These
two characteristics have been linked to lower levels of health literacy and educationxx, and
highlight the need for extensive pathways for patient education and outreach in the disability and
chronic illness communities within Medicaid managed care programs.
State Medicaid managed care programs must incorporate these enrollee engagement steps
and strategies to ensure the managed care models are meeting enrollee targets and objectives.
Without an accessible and informed arena of Medicaid managed care specifics and details,
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Medicaid managed care individuals with disabilities stand to miss significant opportunities to
tailor their healthcare services to their needs. Only then, will institutional reforms in financial
and provider networks result in positive changes in the manner and effectiveness in which
Medicaid managed care can serve the requirements of individuals with disabilities and chronic
illnesses.
i Shi, L., & Singh, D. A. (2005). Essentials of the US Health Care System. Sudbury, Massachusetts: Jones and Bartlett Publishers.
ii (February 2013). The History of Managed Care Organizations in the United States – Presentation Developed for the Academy of Managed Care Pharmacy (AMCP) (PowerPoint slides). Retrieved from http://amcp.org/WorkArea/DownloadAsset.aspx?id=16178
iii (February 2012). Medicaid Managed Care: Key Data, Trends, and Issues – Medicaid and the uninsured. Retrieved from: http://kff.org/medicaid/issue-brief/medicaid-and-managed-care-key-data-trends/
iv Paradise, P. (2013, 25 June). Trends in Risk-Based Medicaid Managed Care: A National Overview. Kaiser Commission on Medicaid and the Uninsured. (PowerPoint slides). Retrieved from: http://kff.org/medicaid/event/june-25-briefing-medicaid-managed-care-in-the-era-of-health-reform/
v (February 2012). Medicaid Managed Care: Key Data, Trends, and Issues – Medicaid and the uninsured. Retrieved from: http://kff.org/medicaid/issue-brief/medicaid-and-managed-care-key-data-trends/
vi Paradise, P. (2013, 25 June). Trends in Risk-Based Medicaid Managed Care: A National Overview. Kaiser Commission on Medicaid and the Uninsured. (PowerPoint slides). Retrieved from: http://kff.org/medicaid/event/june-25-briefing-medicaid-managed-care-in-the-era-of-health-reform/
vii Garfield, R., & Paradise, J. (2013, 2 August). What is Medicaid’s Impact on Access to Care, Health Outcomes, and Quality of Care? Setting the Record Straight on the Evidence – Kaiser Family Foundation. Retrieved from http://kff.org/medicaid/issue-brief/what-is-medicaids-impact-on-access-to-care-health-outcomes-and-quality-of-care-setting-the-record-straight-on-the-evidence/
viii Connolly, J., & Paradise, J. (2012, 1 February). People with disabilities and Medicaid Managed Care: Key Issues to Consider – Kaiser Commission on Medicaid and the Uninsured. Retrieved from: http://kff.org/medicaid/issue-brief/people-with-disabilities-and-medicaid-managed-care/
ix Shi, L., & Singh, D. A. (2005). Essentials of the US Health Care System. Sudbury, Massachusetts: Jones and Bartlett Publishers.
x Connolly, J., & Paradise, J. (2012, 1 February). People with disabilities and Medicaid Managed Care: Key Issues to Consider – Kaiser Commission on Medicaid and the Uninsured. Retrieved from: http://kff.org/medicaid/issue-brief/people-with-disabilities-and-medicaid-managed-care/
xi Connolly, J., & Paradise, J. (2012, 1 February). People with disabilities and Medicaid Managed Care: Key Issues to Consider – Kaiser Commission on Medicaid and the Uninsured. Retrieved from: http://kff.org/medicaid/issue-
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Utilizing national policy trends, implications and implementation considerations, the next
few sections will focus on Medicaid managed care programs in the Southeast United States. I
will focus on the current situation, outcomes and characteristics of these programs as they relate
to individuals living with disabilities and chronic illnesses.
brief/people-with-disabilities-and-medicaid-managed-care/
xii Connolly, J., & Paradise, J. (2012, 1 February). People with disabilities and Medicaid Managed Care: Key Issues to Consider – Kaiser Commission on Medicaid and the Uninsured. Retrieved from: http://kff.org/medicaid/issue-brief/people-with-disabilities-and-medicaid-managed-care/
xiii Gold, M., & Paradise, J. (2012, 1 September). Current and Emerging Issues in Medicaid Risk-Based Managed Care: Insights from an Expert Roundtable – Kaiser Commission on Medicaid and the Uninsured. Retrieved from: http://kff.org/health-reform/issue-brief/current-and-emerging-issues-in-medicaid-risk/
xiv Connolly, J., & Paradise, J. (2012, 1 February). People with disabilities and Medicaid Managed Care: Key Issues to Consider – Kaiser Commission on Medicaid and the Uninsured. Retrieved from: http://kff.org/medicaid/issue-brief/people-with-disabilities-and-medicaid-managed-care/
xv Connolly, J., & Paradise, J. (2012, 1 February). People with disabilities and Medicaid Managed Care: Key Issues to Consider – Kaiser Commission on Medicaid and the Uninsured. Retrieved from: http://kff.org/medicaid/issue-brief/people-with-disabilities-and-medicaid-managed-care/
xvi Connolly, J., & Paradise, J. (2012, 1 February). People with disabilities and Medicaid Managed Care: Key Issues to Consider – Kaiser Commission on Medicaid and the Uninsured. Retrieved from: http://kff.org/medicaid/issue-brief/people-with-disabilities-and-medicaid-managed-care/
xvii Gold, M., & Paradise, J. (2012, 1 September). Current and Emerging Issues in Medicaid Risk-Based Managed Care: Insights from an Expert Roundtable – Kaiser Commission on Medicaid and the Uninsured. Retrieved from: http://kff.org/health-reform/issue-brief/current-and-emerging-issues-in-medicaid-risk/
xviii Gold, M., & Paradise, J. (2012, 1 September). Current and Emerging Issues in Medicaid Risk-Based Managed Care: Insights from an Expert Roundtable – Kaiser Commission on Medicaid and the Uninsured. Retrieved from: http://kff.org/health-reform/issue-brief/current-and-emerging-issues-in-medicaid-risk/
xix Connolly, J., & Paradise, J. (2012, 1 February). People with disabilities and Medicaid Managed Care: Key Issues to Consider – Kaiser Commission on Medicaid and the Uninsured. Retrieved from: http://kff.org/medicaid/issue-brief/people-with-disabilities-and-medicaid-managed-care/
xx Hibbard J et al., Is the Informed-Choice Policy Approach Appropriate for Medicare Beneficiaries? Health Affairs2001 20(3): 199-203.
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Disposition: Medicaid Managed Care in Southeastern United States
Before beginning a state specific profile of each of the Medicaid Managed Care situations
and overviews, it is important to acknowledge the underlying challenges present in each location
that are ubiquitous and specific to no state. Certain population features and characteristics are
essentially universal in all of these states, and create for similar institutional challenges and
opportunities for both potential success and failure.xxi These major features are concerning rates
of poverty and disability amongst individuals. These states have the lowest rates of median
incomes amongst households, along with some of the highest rates of disability amongst the
population, which have lead to a challenging and difficult healthcare landscape for essentially all
programs in the southeast to manage and navigate. In a state-scorecard report generated by The
Commonwealth Fund, AARP, and The SCAN Foundation, each state’s long-term care and xxiReinhard, S.C., Kassner, E., Houser, A., Mollica, A., Raising Expectations: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers, AARP, The Commonwealth Fund, and The SCAN Foundation, September 2011
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service outcomes were ranked on a variety of indicators and variables, such as quality of life of
individuals with disabilities, accessibility and quality of care, amongst other factors. The states
finishing in the bottom quartile overall were overwhelming representing of states in the
southeastern United States – namely Alabama, Mississippi, Kentucky, Florida, Tennessee, and
Georgia.xxii The report’s evaluation of each state’s performance in individual quality of life and
quality of care showed no difference. Within this factor, the indicator of interest, quality of life
with individuals with disabilities, was represented by two quantitative measures relevant to our
literature review – the percentage of people with disabilities who are getting support and the
percentage of people with disabilities who are satisfied with life. The lowest performing states in
these indicators were all from the southeastern United States. The figure below paints an overall
situation regarding the health and medical outcomes of individuals with disabilities in these
locations.
xxiiReinhard, S.C., Kassner, E., Houser, A., Mollica, A. Raising Expectations: A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers, AARP, The Commonwealth Fund, and The SCAN Foundation, September 2011
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The important take away from this short primer is to understand that practically every
southeastern state is suffering from a great deal of patient difficulties and complications within
their state healthcare structure and programs, Medicaid being the most affected. All of these
states are struggling to address these concerns shown from constituents. Whether it involves
accessibility, patient satisfaction, or quality, each state will face the challenge of trying to devise
a proper response to the growing needs of its population, and most particularly with individuals
with disabilities and chronic illnesses. It remains to be seen whether state Medicaid managed
care programs can adopt and provide viable solutions. For explanatory purposes, since amongst
the states in the southeastern United States, Kentucky’s Medicaid Managed Care situation has
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given a greater level of analysis, emphasis, and spotlight, a majority of the details in this section
with focus specifically on this state.
- Kentucky:
o Kentucky represents the only state in the Southeast to accept federal dollars to
expand their Medicaid program to a larger population of Kentuckians. More than
410,000 Kentuckians have enrolled in new plans through Kynect, the state-based
health insurance exchange in Kentucky. Of those, more than 360,000 have qualified
for the Medicaid program. A yearly evaluation conducted by the Urban Institute, in
alliance with the University of Kentucky, describes this expansion both as a time of
“challenge and opportunity,” with monitoring accessibility to healthcare a forefront
issue, particularly for populations with behavioral and mental health needs.xxiii
However the state’s movement from a typical fee-for-service Medicaid program,
where providers are reimbursed on the number of services provided on a separate
basisxxiv, to a new statewide Medicaid managed care program in 2011, was far from
straightforward, and is still facing some setbacks and areas of inadequacy. The
quicker than anticipated shift toward the managed care model proved to be a
significant implementation challenge for state officials.xxv Kentucky’s
implementation timeframe was much too shortxxvi and a lack of proper
infrastructural initiatives and systems in place beforehand created a highly volatile
and complex Medicaid system for providers and patients alike. The main
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inadequacies during this transitioning period, patient networks and provider finances,
payments, and administrative logistics, are laid out in particulars below.
Patient networks: Kentucky’s switch to a managed care model resulted in
many patients being denied proper treatment and healthcare services for their
specific needs.xxvii Patients were forced to travel inconvenient distances to
reach their appointments, and this issue is even more pertinent towards
patients in needs of particular medical specialists, where a MCO may not
carry a specific provider in its network; the fact that Kentucky is mostly rural
only intensifies the situation.xxviii The contracting MCOs in Kentucky were
given roughly four months to establish healthcare services, operations - from
the time contracts were allocated and open enrollment periods began.xxix As
such, these MCOs hastily compiled a working group of employees, along
xxiiiHowell, E.M., Kenney, G.M., Palmer, A., etc. (2013, 20 December). Risk-Based Managed Care in Kentucky: A Second Year Implementation Assessment of Beneficiary Perceptions. Urban Institute. Retrieved from: http://www.urban.org/publications/412978.html
xxiv“Fee-for-service.” Medicaid.gov. Medicaid consumer information., n.d. Web. 2014, 2 February. Retrieved from: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Fee-for-Service.html
xxvBergal, J. Kentucky’s Rush Into Medicaid Managed Care: A Cautionary Tale for Other States. Kaiser Health News. Retrieved from: http://www.kaiserhealthnews.org/Stories/2013/July/14/kentucky-medicad-managed-care.aspx
xxvi Howell, E.M., Kenney, G.M., Palmer, A., etc. (2013, 20 December). Evaluation of Statewide Risk-Based Managed Care in Kentucky. Urban Institute. Retrieved from: http://www.urban.org/UploadedPDF/412702-Evaluation-of-Statewide-Risk-Based-Managed-Care-in-Kentucky.pdf
xxviiBergal, J. Kentucky’s Rush Into Medicaid Managed Care: A Cautionary Tale for Other States. Kaiser Health News. Retrieved from: http://www.kaiserhealthnews.org/Stories/2013/July/14/kentucky-medicad-managed-care.aspx
xxviiiBergal, J. Kentucky’s Rush Into Medicaid Managed Care: A Cautionary Tale for Other States. Kaiser Health News. Retrieved from: http://www.kaiserhealthnews.org/Stories/2013/July/14/kentucky-medicad-managed-care.aspx
xxix Carolina Journal Staff. (2013, 22 July). Report: N.C. Should Fare Better Than Kentucky on Medicaid Reform. Carolina Journal Online. Retrieved from: http://www.carolinajournal.com/exclusives/display_exclusive.html?id=10322
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with making bailout contracts, with new networks of doctors and hospitals
alike.xxx These haphazardly groups were in no position to establish
meaningful relationships with patient bases throughout the state of Kentucky,
whether it be regarding geographic locations or competencies of the actual
providers themselves. These networks have shown continual changes and
little to no stability in keeping the same group of providers for the long
term.xxxi The fact that Kentucky ranks amongst the worst states in terms of
population health only makes the situation that much more worrisome. Based
on the United Health Foundation policy report, Kentucky showed an overall
health ranking of 44th, 50th in smoking and cancer deaths, and 40th in obesity
ratesxxxii. However, overtime, these issues have become of less trouble, as
better implementation policies and strategies have allowed the state’s
Medicaid program to correct for issues.xxxiii In the second year of the managed
care transition, patients have given mainly positive reviews towards primary
care accessibility and quality. However, patients utilizing Medicaid for
physical and mental health needs demonstrated concerns in the ability to
see specialists, getting authorization for a needed medical service, and
xxx Bergal, J. Kentucky’s Rush Into Medicaid Managed Care: A Cautionary Tale for Other States. Kaiser Health News. Retrieved from: http://www.kaiserhealthnews.org/Stories/2013/July/14/kentucky-medicad-managed-care.aspx
xxxiHowell, E.M., Kenney, G.M., Palmer, A., etc. (2013, 20 December). Evaluation of Statewide Risk-Based Managed Care in Kentucky. Urban Institute. Retrieved from: http://www.urban.org/UploadedPDF/412702-Evaluation-of-Statewide-Risk-Based-Managed-Care-in-Kentucky.pdf
xxxiiBergal, J. Kentucky’s Rush Into Medicaid Managed Care: A Cautionary Tale for Other States. Kaiser Health News. Retrieved from: http://www.kaiserhealthnews.org/Stories/2013/July/14/kentucky-medicad-managed-care.aspx
xxxiiiHowell, E.M., Kenney, G.M., Palmer, A., etc. (2013, 20 December). Risk-Based Managed Care in Kentucky: A Second Year Implementation Assessment of Beneficiary Perceptions. Urban Institute. Retrieved from: http://www.urban.org/publications/412978.html
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not having a complete understanding of the managed care model. This is
specifically dealing with restricted access to pharmaceuticals, changes in
services provided, and the ability to see both physical and mental health
providers the same day. Fortunately, patients who are considered extreme
cases with greater needs have reported much higher levels of provider
satisfaction and accessibility.xxxiv
Provider finances, payments, and administrative logistics: Outside of the
patient perspective, the two overwhelming issues that plagued Medicaid
managed care’s transition in Kentucky were regarding provider payment
systems and administrative issues, such as claims processing and internal
coding issues for reimbursement purposes.xxxvxxxvi Providers in the state noted
difficulties in several key functioning areas of the Medicaid managed care
system. These specific areas included delays in service authorization, claims
denials (resulting in a higher level of appeals according to the state’s
Department of Insurance), and difficulty gathering coding systems in place,
along with necessary information to comprehend insurance plans.xxxvii
xxxiv Howell, E.M., Kenney, G.M., Palmer, A., etc. (2013, 20 December). Risk-Based Managed Care in Kentucky: A Second Year Implementation Assessment of Beneficiary Perceptions. Urban Institute. Retrieved from: http://www.urban.org/publications/412978.html
xxxvIngram, J., & Restrepo, K. (2013, July 10). Lessons Learned: How the Partnership for a Health North Carolina Avoids Kentucky’s Medicaid Reform Mistakes. John Locke Foundation. Retrieved from: http://www.johnlocke.org/acrobat/policyReports/LessonsLearned.pdf
xxxviHowell, E.M., Kenney, G.M., Palmer, A., etc. (2013, 20 December). Evaluation of Statewide Risk-Based Managed Care in Kentucky. Urban Institute. Retrieved from: http://www.urban.org/UploadedPDF/412702-Evaluation-of-Statewide-Risk-Based-Managed-Care-in-Kentucky.pdf
xxxvii Howell, E.M., Kenney, G.M., Palmer, A., etc. (2013, 20 December). Evaluation of Statewide Risk-Based Managed Care in Kentucky. Urban Institute. Retrieved from: http://www.urban.org/UploadedPDF/412702-Evaluation-of-Statewide-Risk-Based-Managed-Care-in-Kentucky.pdf
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Provider payment delays were in large part a result of a lack of preplanning
measures and infrastructure taken by the state of Kentucky to monitor
provider payment plans. In the early months of the transition, the Kentucky
Department of Insurance identified two of the three existing MCOs in the
area as not being able to meet payment requirement to network providers.xxxviii
These subsequently led to many appeals filed against these insurance
companies. These payment delays to the providers were in large part due to
the short periods MCOs were given to contract with providers before open
enrollment periods began to open for patient services. Due to a lack of a
properly devised implementation timeline, where enough time was devoted to
finalizing these contracts, frameworks and regulations regarding how to solve
payments delays, as well as create measurable metrics or formulas to
illustrate just how responsive MCOs were towards provider payments were
not created properly. In terms of administrative aspects of Kentucky’s
Medicaid Managed care system, the main dilemma was due to denied claims.
Again, likewise with the problems of delayed provider payments, a lack of
prior enrollment contact and sourcing with MCOs and health providers before
open enrollment periods set the stage for numerous administrative burdens on
the Medicaid system. The main issue here was claims processing.xxxix The
contracted MCOs for Kentucky’s Medicaid program utilized their own series
xxxviiiMusgrave, B. (2012). Complaints continue about delays in Medicaid payments. Lexington Herald-Leader. Retrieved from: http://www.kentucky.com/2012/12/11/2440057/complaints-continue-about-delays.html
xxxixIngram, J., & Restrepo, K. (2013, July 10). Lessons Learned: How the Partnership for a Health North Carolina Avoids Kentucky’s Medicaid Reform Mistakes. John Locke Foundation. Retrieved from: http://www.johnlocke.org/acrobat/policyReports/LessonsLearned.pdf
23
of specific coding and billing systems. These claims systems in place were
markedly different compared to the previous billing and coding system used
by providers for Kentucky’s Medicaid program. The main consequences
arriving from this confusion involving coding and billing procedures were
reimbursement and claims denials. It was a culmination of these processing
issues leading to many unnecessary obstacles in attaining proper
implementation of a managed care model in Kentucky’s Medicaid system.
However, through the next year of the implementation timeline, 2012, the
outlook for Medicaid in Kentucky has taken a turn for the better.
Based on both provider and patient observations and experiences, overall
performance, efficiency, and quality standards in Kentucky’s Medicaid
managed care system have all shown noticeable improvements.xl Overall, the
state has shown much initiative towards monitoring performance standards.
HEDIS scores know as Healthcare Effectiveness Dataset and Information set,
used for consumers to compare, rate, and report on healthcare plans, are now
being provided to allow for easier comparison between MCO plan
selections.xli This gives consumers a chance to make a much more informed
and involved decision regarding the plan best suited towards their needs.xlii xl Howell, E.M., Kenney, G.M., Palmer, A., etc. (2013, 20 December). Risk-Based Managed Care in Kentucky: A Second Year Implementation Assessment of Beneficiary Perceptions. Urban Institute. Retrieved from: http://www.urban.org/publications/412978.html
xliHowell, E.M., Kenney, G.M., Palmer, A., etc. (2013, 20 December). Risk-Based Managed Care in Kentucky: A Second Year Implementation Assessment of Beneficiary Perceptions. Urban Institute. Retrieved from: http://www.urban.org/publications/412978.html
xlii Howell, E.M., Kenney, G.M., Palmer, A., etc. (2013, 20 December). Risk-Based Managed Care in Kentucky: A Second Year Implementation Assessment of Beneficiary Perceptions. Urban Institute. Retrieved from: http://www.urban.org/publications/412978.html
24
Providers have indicated that they are now receiving much more timely
payments from MCOs, but the coding and billing obstacles have not all been
ironed out, as denied claims and authorization regulations have remained
issues of concern. From the patient perspective, primary care accessibility has
received positive reviews and primary care quality and patient outcomes were
at satisfactory levels as well. Other medical services such as dental, vision,
and emergency services were also received by patients as meeting adequate
standards in terms of quality, accessibility, and efficiency.xliii There are still
lingering areas of difficulty remaining for patients in Kentucky’s Medicaid
managed care system, particularly specialist availability, pharmaceutical
accessibility, and gaining authorization from a provider regarding a needed
medical service.xliv In the long run, it seems Kentucky will gain a handle on
both the patient and provider consequences that have spilled-over from the
short implementation timeline for its managed care system. Kentucky’s
Medicaid Commissioner Lawrence Kissner acknowledges it has been a trying
start the first few years for the state to adapt fully to the new Medicaid
deliverance system. Nevertheless, through different procedural changes, such
an “action plan” which requires the state Department of Insurance to conduct
audits on MCOs, or monthly reviews to ensure network accessibility to the
disabled and chronic illness populations, Kissner and state officials and
xliiiHowell, E.M., Kenney, G.M., Palmer, A., etc. (2013, 20 December). Risk-Based Managed Care in Kentucky: A Second Year Implementation Assessment of Beneficiary Perceptions. Urban Institute. Retrieved from: http://www.urban.org/publications/412978.html
xliv Howell, E.M., Kenney, G.M., Palmer, A., etc. (2013, 20 December). Risk-Based Managed Care in Kentucky: A Second Year Implementation Assessment of Beneficiary Perceptions. Urban Institute. Retrieved from: http://www.urban.org/publications/412978.html
25
representatives are ensuring the proper steps are being taken now to rectify
the Medicaid managed care situationxlv.
- Tennessee:
o Tennessee’s Medicaid program was one of the first in the United States to adopt a
managed care system of delivery – starting on January 1, 1994.xlvi The impetus for
this transition to a managed care model was to cut healthcare costs as well as provide
better coverage options for the serving demographic.xlvii Today, it represents the only
state program having its entire Medicaid population, including individuals with
disability or illness, enrolled into a managed care system, with as much as 12 MCOs
first contracted to provide these servicesxlviii. 2010 marked the year in which long-
term care needs for individuals with disabilities or chronic illnesses were brought
into the managed care umbrella, with the implementation of the TennCare Choices
program.xlix However, the early transition and current conditions of Tennessee’s
Medicaid system, despite being established in 1994, towards both individuals with
disabilities and chronic illnesses and the public remains functions notwithstanding its
xlvHowell, E.M., Kenney, G.M., Palmer, A., etc. (2013, 20 December). Risk-Based Managed Care in Kentucky: A Second Year Implementation Assessment of Beneficiary Perceptions. Urban Institute. Retrieved from: http://www.urban.org/publications/412978.html
xlvi “TennCare Overview.” tn.gov. TennCare News section., n.d. Web. 2014, 17 February. Retrieved from: http://www.tn.gov/tenncare/news-about.shtml
xlvii“Tenncare.” Tennesseeencyclopedia.net Tennessee Encyclopedia of History and Culture., n.d. Web. 2014, 16 February. Retrieved from: http://tennesseeencyclopedia.net/entry.php?rec=1307
xlviii“Tenncare.” Tennesseeencyclopedia.net Tennessee Encyclopedia of History and Culture., n.d. Web. 2014, 16 February. Retrieved from: http://tennesseeencyclopedia.net/entry.php?rec=1307
xlix “TennCare Overview.” tn.gov. TennCare News section., n.d. Web. 2014, 17 February. Retrieved from: http://www.tn.gov/tenncare/news-about.shtml
26
own flaws and obstacles. The main failings of TennCare in the developing stages
involved unsatisfactory reimbursement amounts to providers, as well as,
underfunding to provide satisfactory levels of care.l When individuals with
disabilities and chronic illnesses were first given coverage under Tennessee’s
Managed care system, many of these services exceeded reimbursement amounts,
leading to TennCare recovering $18 million out of the total $45 million owed to
providers across the state.li Furthermore, beyond administrative issues in covering
individuals with disabilities and chronic illnesses, physician networks were in no
position to provide medical services to patients. A lack of procedural rules and
regulations in MCOs in place meant that providers and hospitals alike were seeking
some form of patient adherence to approved lists of hospitals, specialists, and drugs.
Oftentimes, patients would try to see a specialist outside a given MCO network,
without having any prior knowledge of which providers and physicians are in their
preferred networks, and which are not.lii
o It was not until 2006 that the TennCare Managed Medicaid system ironed out a
majority of the underlying issues that came from its initial implementation back in
1994.liii However, enrollment totals during this time increased to the point that serious
financial complications put it in to jeopardy. With that, cuts were subsequently made
in enrollment totals and services offeredliv. These enrollment cuts were of particular
l“Tenncare.” Tennesseeencyclopedia.net Tennessee Encyclopedia of History and Culture., n.d. Web. 2014, 16 February. Retrieved from: http://tennesseeencyclopedia.net/entry.php?rec=1307
li “Tenncare.” Tennesseeencyclopedia.net Tennessee Encyclopedia of History and Culture., n.d. Web. 2014, 16 February. Retrieved from: http://tennesseeencyclopedia.net/entry.php?rec=1307
lii “Tenncare.” Tennesseeencyclopedia.net Tennessee Encyclopedia of History and Culture., n.d. Web. 2014, 16 February. Retrieved from: http://tennesseeencyclopedia.net/entry.php?rec=1307
27
interest to individuals with chronic illnesses and disabilities. While children and
mandatory adult populations were protected from these reductions, unfortunately for
individuals with disabilities and chronic illnesses, such was not the case. These
individuals saw the Medicaid program of Tennessee impose limitations on
prescription drugs and thereby affecting the MCO’s Preferred Drug Lists, and
subsequently restricting medication options for individuals in greatest need.lv Long
term and behavioral services were also impacted by budgetary cuts, as the state
sought long-term sustenance for Medicaid services. On a positive note, however;
healthcare quality monitoring and evaluation was reinforced in Tennessee’s Medicaid
system – as evident by the percent increase in TennCare Patient Satisfaction survey –
61% in 1994, compared to 87% in 2006lvi. In addition, TennCare became the first
Medicaid program in 2006 to require all providing MCOs to meet National
Committee for Quality Standards (NCQA) standardslvii. Inherently, while patient
outcomes where improving for individuals with chronic illnesses and disabilities –
the actual treatment options were facing limitations.
o In its current format and disposition, the TennCare system has shown a greater
degree of awareness and capability towards handling the diverse and ever-changing
needs of individuals with disabilities and chronic illnesses. In 2013, in order to
provide network stability for the servicing population, TennCare has reinforced and
extended its contracts with each MCO in the state. Provider volatility decreased, and
individuals in need of specialists have greater confidence in acquiring these
services.lviii In order to integrate all levels of Managed care, as well as the needs of
individuals with disabilities and chronic illnesses, in 2010 the TennCare CHOICES
28
program was established.lix While, only now on a national scale is Medicaid managed
care now being extended to populations with disabilities and chronic illnesses, the
TennCare CHOICES achieved this landmark proposition by providing long-term
Medicaid solutions for both elderly individuals and those with disabilities and
chronic illnesses. Now these individuals have the option of receiving integrated care
within the comfort of their own home or community. The integration of physical
health and behavioral health needs of individuals with chronic illnesses and
disabilities has a positive impact on care coordination across all stakeholders in the
TennCare system – from providers, patients, administrators, and, insurers.lx Today,
TennCare looks to have to turn the corner in righting the wrongs and mishaps
towards servicing individuals with disabilities and chronic illnesses. Many processes,
organizational, and functional improvements and alternations have led to a much
more responsive Medicaid system that is conducive to meeting the needs of a
dynamic state population. The graphic below illustrates specifically what these
liii“TennCare.” Virginia.gov. TennCare: Trends in Medicaid Managed Care – Virginia Medicaid Innovation and Reform Commission., n.d. Web. 2014, 27 February. Retrieved from: http://mirc.virginia.gov/documents/10-21-13/102113_No2_Gordon_MIRC.pdf
liv“TennCare.” Virginia.gov. TennCare: Trends in Medicaid Managed Care – Virginia Medicaid Innovation and Reform Commission., n.d. Web. 2014, 27 February. Retrieved from: http://mirc.virginia.gov/documents/10-21-13/102113_No2_Gordon_MIRC.pdf
lv “TennCare.” Virginia.gov. TennCare: Trends in Medicaid Managed Care – Virginia Medicaid Innovation and Reform Commission., n.d. Web. 2014, 27 February. Retrieved from: http://mirc.virginia.gov/documents/10-21-13/102113_No2_Gordon_MIRC.pdf
lvi “TennCare.” Virginia.gov. TennCare: Trends in Medicaid Managed Care – Virginia Medicaid Innovation and Reform Commission., n.d. Web. 2014, 27 February. Retrieved from: http://mirc.virginia.gov/documents/10-21-13/102113_No2_Gordon_MIRC.pdf
lvii“TennCare.” Virginia.gov. TennCare: Trends in Medicaid Managed Care – Virginia Medicaid Innovation and Reform Commission., n.d. Web. 2014, 27 February. Retrieved from: http://mirc.virginia.gov/documents/10-21-13/102113_No2_Gordon_MIRC.pdf
29
changes are. In addition, a subsequent illustration of the TennCare system identifies
the MCOs responsible for servicing each region of the state.
.
lviii“TennCare.” Virginia.gov. TennCare: Trends in Medicaid Managed Care – Virginia Medicaid Innovation and Reform Commission., n.d. Web. 2014, 27 February. Retrieved from: http://mirc.virginia.gov/documents/10-21-13/102113_No2_Gordon_MIRC.pdf
lix“TennCare.” Virginia.gov. TennCare: Trends in Medicaid Managed Care – Virginia Medicaid Innovation and Reform Commission., n.d. Web. 2014, 27 February. Retrieved from: http://mirc.virginia.gov/documents/10-21-13/102113_No2_Gordon_MIRC.pdf
lx“TennCare.” Virginia.gov. TennCare: Trends in Medicaid Managed Care – Virginia Medicaid Innovation and Reform Commission., n.d. Web. 2014, 27 February. Retrieved from: http://mirc.virginia.gov/documents/10-21-13/102113_No2_Gordon_MIRC.pdf
30
- North Carolina
o North Carolina’s Medicaid program is currently subject to drastic alternations in the
upcoming year due to changes in political power – in terms of both organization and
delivery – namely a switch to a managed care model, and changing of MCO
organization and servicing throughout the state. That said, an overview of the
Medicaid program will offer details and policy implementations and strategies the
state is likely to adopt would be discussed. While, eligibility standards for individuals
with disabilities and chronic illnesses has shown to be quite accommodating, due to
the sheer increase in the number of individuals in North Carolina’s Medicaid
program, program responsiveness towards individuals with disabilities and chronic
31
illnesses has been hindered to a great extent.lxi The figure below highlights just how
drastic Medicaid enrollment has increased in North Carolina over the past 15 years.
It becomes apparent through this graphic the impending consequences the variety of
issues the Medicaid system in North Carolina has been facing in recent years. Most
notably, quality measures and outcomes for patients with disabilities and chronic
illnesses have declined over the years, as well as an increase in associated healthcare
costs for the state.lxii Illustrating this pattern of healthcare spending in North Carolina
Medicaid is the graph below – North Carolina’s Medicaid spending has increased
over 90 percent in the past decade.lxiii
lxi Ingram, J., & Restrepo, K. (2013). The Partnership for a Healthy North Carolina – Medicaid Reform that Works for Patients, Providers, and Taxpayers Alike – John Locke Foundation. Retrieved from http://johnlocke.org/acrobat/policyReports/Partnership.pdf
32
However, simple increases in enrollment totals have not only lead to exorbitant
spending amounts, but per-enrollee spending has also contributed to this tendency, as
North Carolina has seen an increase across all Medicaid categories in per-enrollee
spending. For comparisons sake, amongst the states in the Southeast, North
Carolina in fact has the greatest levels of spending per person in Medicaid
services than any other state in the southeastern region.lxiv
lxii Ingram, J., & Restrepo, K. (2013). The Partnership for a Healthy North Carolina – Medicaid Reform that Works for Patients, Providers, and Taxpayers Alike – John Locke Foundation. Retrieved from http://johnlocke.org/acrobat/policyReports/Partnership.pdf
lxiii Ingram, J., & Restrepo, K. (2013). The Partnership for a Healthy North Carolina – Medicaid Reform that Works for Patients, Providers, and Taxpayers Alike – John Locke Foundation. Retrieved from http://johnlocke.org/acrobat/policyReports/Partnership.pdf
lxiv Ingram, J., & Restrepo, K. (2013). The Partnership for a Healthy North Carolina – Medicaid Reform that Works for Patients, Providers, and Taxpayers Alike – John Locke Foundation. Retrieved from http://johnlocke.org/acrobat/policyReports/Partnership.pdf
33
As touched upon earlier in this discussion of North Carolina’s Medicaid system,
patient quality indicators and outcomes have not been representative of Medicaid
spending in the state. North Carolina’s Healthcare Effectiveness Data and
Information Set (HEDIS) scores have indicated a decrease in quality metrics and
performance measures for the past years, and this is most notably true amongst
quality measures representing patient outcomes for disabilities and chronic
illnesses.lxv Furthermore, provider networks in North Carolina are severely limited,
and this causes many issues for individuals with disabilities and chronic illnesses to
have their healthcare needs met in a timely fashion. This is especially true in rural
and smaller communities throughout the state, where some physicians have shown
reluctance to accept new Medicaid patients all together. lxvi
Governor Pat McCrory’s newly established Medicaid Reform Advisory Group
represents the state’s proposed strategy towards insuring a Medicaid system focused
34
more heavily towards patient centered outcomes. This group will meet with various
stakeholders across North Carolina – Medicaid administrators, patients, providers,
and advocacy members – a chance to voice feedback and provide insights and
opinions regarding the current direction and organization of Medicaid services in
North Carolina.lxvii This proactive measure shows integration of policy
recommendations touched upon later in the literature review, namely the requirement
of states to utilize and seek out the expertise of multiple stakeholders outside state
Medicaid agencies, such as disability and chronic illnesses advocates and scientific
experts.
Governor McCrory’s reformation plan for Medicaid for North Carolina is titled
“Partnership for a Health North Carolina,”lxviii which emphasizes patient outcomes
and care quality with the goal of delivering more efficient Medicaid services to
enrollees.lxix The state has listed patient priority, budget predictability/cost
containments, and establishing Medicaid partnerships with the surrounding
lxv Ingram, J., & Restrepo, K. (2013). The Partnership for a Healthy North Carolina – Medicaid Reform that Works for Patients, Providers, and Taxpayers Alike – John Locke Foundation. Retrieved from http://johnlocke.org/acrobat/policyReports/Partnership.pdf
lxvi Ingram, J., & Restrepo, K. (2013). The Partnership for a Healthy North Carolina – Medicaid Reform that Works for Patients, Providers, and Taxpayers Alike – John Locke Foundation. Retrieved from http://johnlocke.org/acrobat/policyReports/Partnership.pdf
lxvii “N.C. Medicaid Reform Plan.” NC DHHS.gov NC Medicaid Reform n.d. Web. 2014, 27 February. Retrieved from: http://www.ncdhhs.gov/medicaidreform/
35
community, as the driving factors for influencing reform strategies.lxx The key
aspects of this reform strategy are detailed below, as well as their relation to
individuals with disabilities and chronic illnesses.
o The state plans to have both public and private comprehensive care entities (like an
MCO) submit bids to the state. North Carolina would then establish contracts with
selected MCOs to provide health plans and Medicaid services for eligible enrollees.
The organization behind the health plans is such that MCO providers have an
incentive to help treat and care for patients with greater health needs and focus
towards patient outcomes as well.lxxi In addition, providers will be motivated to treat
conditions faster and more efficiently and diagnosis patients in a more timely
fashion. The health plans would be paid at a flat, monthly rate, and would be risk-
adjusted based on the enrollee’s health status.lxxii North Carolina as a state would pay
this monthly rate in exchange for Medicaid services provided by the contracted
MCOs themselves, giving added responsibility for the contracted MCOs to make
lxviii Ingram, J., & Restrepo, K. (2013). The Partnership for a Healthy North Carolina – Medicaid Reform that Works for Patients, Providers, and Taxpayers Alike – John Locke Foundation. Retrieved from http://johnlocke.org/acrobat/policyReports/Partnership.pdf
lxix Pat McCrory, “Partnership for a Healthy North Carolina,” North Carolina Office of the Governor (2013), http://p1.governor.nc.gov/sites/default/files/partnershipforahealthynorthcarolina.pdf.
lxx Peal. M., (2014, 26 February). Medicaid Reform Scope and Principles – Medicaid Reform Advisory Group. N.C. Department of Health and Human Services. PowerPoint presentation. Retrieved from: http://www.ncdhhs.gov/medicaidreform/docs/meetings/140226/140226_Medicaid_Reform_Scope_Principles.pdf
lxxiIngram, J., & Restrepo, K. (2013). The Partnership for a Healthy North Carolina – Medicaid Reform that Works for Patients, Providers, and Taxpayers Alike – John Locke Foundation. Retrieved from http://johnlocke.org/acrobat/policyReports/Partnership.pdf
lxxii Ingram, J., & Restrepo, K. (2013). The Partnership for a Healthy North Carolina – Medicaid Reform that Works for Patients, Providers, and Taxpayers Alike – John Locke Foundation. Retrieved from http://johnlocke.org/acrobat/policyReports/Partnership.pdf
36
sure Medicaid services are delivered that are effective and worthwhile towards
patient outcomes. Further, in order to address many of the implementation and
administrative issues that were plaguing other state’s transitioning to a managed care
model, most notably Kentucky, North Carolina requires all contracted comprehensive
care entities to use the same financial vendor for physician reimbursement purposes,
insuring timely repayments are achieved and medical coding and billing issues are
not a problem.lxxiii
o However, while revised payment structures ensure providers are motivated to care
for all types of Medicaid enrollees, including individuals with disabilities and chronic
illnesses, there are still questions and concerns regarding the implementation of the
Partnership for a Healthy North Carolina plan. North Carolina Department of Health
and Human Service representatives and administrators have encouraged the idea of
dividing up the state’s servicing areas into seven distinct and unique regions across
the state. A map detailing this recommendation is shown below.
lxxiii Ingram, J., & Restrepo, K. (2013). The Partnership for a Healthy North Carolina – Medicaid Reform that Works for Patients, Providers, and Taxpayers Alike – John Locke Foundation. Retrieved from http://johnlocke.org/acrobat/policyReports/Partnership.pdf
37
The state is considering the idea of having each of these regions served by multiple
comprehensive care entities, with the belief that it easier for MCOs to provide services for a
localized region, compared to having statewide responsibility.lxxiv This is potentially troubling
news for individuals with disabilities and chronic illnesses. For these specific individuals, their
medical and healthcare needs are much more specialized and specific. That said, individuals with
these conditions will inevitably face difficulty with the proposed regionalized approach to
Medicaid services in North Carolina. Individuals with disabilities and chronic illnesses may be
living in a particular region where the best options for medical services are placed in another
region. Frustration has been voiced on the part of advocates of the disability and chronic illness
communities towards the idea of being forced to get care outside of their local management
entities (LMEs).lxxv Members of these communities point out that regionalized and localized
38
Medicaid services inherently take away an individual’s choice of hospitals, clinics, and doctors
best suited to meet their needs. An individual with a disability or chronic illness may not be able
to get the services a provider offers in another Medicaid region. Furthermore, moving residences
is often an impractical option. Many individuals with disabilities and chronic illnesses have
assigned places in Community Alternative Programs (CAP) whereby they can receive healthcare
and medical services at the convenience of their own homes.lxxvi However, this is contingent upon
where the individual is living – therefore, moving would require an individual relying upon CAP
services to give up that treatment service, further complicating access to care.
Overall, it seems North Carolina’s Medicaid managed care system has been able to recognize the
need for reform by providing more effective and efficient solutions towards its enrollee
population. The Partnership for a Healthy North Carolina appears to have started strong and is
moving toward addressing many of the implementation issues and concerns seen in other states.
Encouraging physicians and providers to seek out more patients to care, with an emphasis on
quality and patient outcomes, will give individuals with disabilities and chronic illnesses
Medicaid services, with their best interests in mind. North Carolina’s simplification of
reimbursement and provider repayment procedures addressed Administrative and operational
issues. However, the Department of Health and Human Service’s proposal to regionalize
Medicaid services for enrollees plants doubt that this method may be a practice in cost savings in lxxiv Hoban, R., (2013, 6 December). Advisoty Group Begins to Sketch Future of State Medicaid System. North Caroliina Health News. Retrieved from: http://www.northcarolinahealthnews.org/2013/12/06/advisory-group-begins-to-sketch-future-of-state-medicaid-system/
lxxv Hoban, R., (2013, 6 December). Advisoty Group Begins to Sketch Future of State Medicaid System. North Caroliina Health News. Retrieved from: http://www.northcarolinahealthnews.org/2013/12/06/advisory-group-begins-to-sketch-future-of-state-medicaid-system/
lxxvi Hoban, R., (2013, 6 December). Advisoty Group Begins to Sketch Future of State Medicaid System. North Caroliina Health News. Retrieved from: http://www.northcarolinahealthnews.org/2013/12/06/advisory-group-begins-to-sketch-future-of-state-medicaid-system/
39
lose disguise. Patient outcomes and autonomy have to be at the forefront of North Carolina
Medicaid reform in order for individuals with disabilities and chronic illnesses to receive
the best possible care in this state.
- South Carolina:
o Following suit with many states in this discussion, South Carolina has not decided to
pursue an expansion of eligibility requirements for its Medicaid program, mainly due
to concern of additional costs and potential inefficiency.lxxvii However, despite this
decision, the state’s agencies are predicting a 16 percent enrollment increase in
Medicaid.lxxviii Trends seen in increased Medicaid enrollee figures in South Carolina
mimic similar trends in other states, having to compensate for this issue. The
transition to a Managed Care model in South Carolina, particularly for individuals
with disabilities and chronic illnesses, has been relatively straightforward, especially
compared to other states. It has resulted in strong patient-centered outcomes and
standards that evidence the improved integration and resource efficiency that
managed care models deliver.
lxxvii Galewitz, Phil. (2013, 26 November). Even Without Expansion, S.C. Will See 16% Jump in Medicaid Enrollment. Kaiser Health News. Retrieved from http://www.kaiserhealthnews.org/stories/2013/november/26/south-carolina-medicaid-enrollment.aspx?referrer=search
lxxviii Galewitz, Phil. (2013, 26 November). Even Without Expansion, S.C. Will See 16% Jump in Medicaid Enrollment. Kaiser Health News. Retrieved from http://www.kaiserhealthnews.org/stories/2013/november/26/south-carolina-medicaid-enrollment.aspx?referrer=search
40
In October 2007, South Carolina implemented the Healthy Connections Choices
program in order to help alleviate the fiscal stresses that came with its Medicaid
program, and has proven to be quite successful given its relatively short timeframe
for implementation.lxxix This program implementation prompted a new wave of
enrollees into the South Carolina Medicaid program under the managed care model.
Two main delivery strategies utilized in the South Carolina Medicaid program are
managed care organizations (MCOs) and primary care case management
organizations (PCCM), although over 50% of Medicaid enrollees are in managed
care organization plans.lxxx
From the standpoint of evaluating the quality and efficiency of South Carolina’s
Medicaid managed care program towards individuals with disabilities and chronic
illnesses, in 2011, enrollment patterns in managed care programs was shifted beyond
typical population groups seen in Medicaid, such as certain economic groups and
children, to individuals with more complex conditions and needs. Many of these
individuals poised high health risks and procedural needs that quite often made
reimbursement for treating these individuals unique.lxxxi Despite serving a higher-
need population, HEDIS scores, as well as trends in a number of healthcare quality
measures showed positive gains.lxxxii This pattern indicates that South Carolina’s
Medicaid managed care system is able to effectively serve and provide care for
lxxix Tester. R & Madalena, M. (2010, October 1). Report to South Carolina Department of Health and Human Services – Medicaid Cost and Quality Effectiveness. – SCDHHS. Retrieved from http://www.scstatehouse.gov/archives/dhhs/MedicaidCostandQualityEffectiveness.pdf
lxxx Brantley. V., Lopez-De Fede, Ana., Mayfield-Smith, Kathy., etc. (2012 September). South Carolina Medicaid Health Care Performance CY 2011 – A report on quality, access to care, and consumer experience and satisfaction. Division of Policy and Research on Medicaid and Medicare. Retrieved from: https://www.scdhhs.gov/sites/default/files/CY2011SCMedicaidHealthCarePerformanceReportW.pdf
41
populations that are more complex. Managed care systems have continually
outperformed their previous fee-for-service counterparts across all health quality
indicators, as shown below, and this is expected to continue.lxxxiii
In addition, South Carolina’s managed care health plans have shown strong
performance within various behavioral measures and indicators as well.lxxxiv Measures
lxxxi Brantley. V., Lopez-De Fede, Ana., Mayfield-Smith, Kathy., etc. (2012 September). South Carolina Medicaid Health Care Performance CY 2011 – A report on quality, access to care, and consumer experience and satisfaction. Division of Policy and Research on Medicaid and Medicare. Retrieved from: https://www.scdhhs.gov/sites/default/files/CY2011SCMedicaidHealthCarePerformanceReportW.pdf
lxxxii Brantley. V., Lopez-De Fede, Ana., Mayfield-Smith, Kathy., etc. (2012 September). South Carolina Medicaid Health Care Performance CY 2011 – A report on quality, access to care, and consumer experience and satisfaction. Division of Policy and Research on Medicaid and Medicare. Retrieved from: https://www.scdhhs.gov/sites/default/files/CY2011SCMedicaidHealthCarePerformanceReportW.pdf
lxxxiii Brantley. V., Lopez-De Fede, Ana., Mayfield-Smith, Kathy., etc. (2012 September). South Carolina Medicaid Health Care Performance CY 2011 – A report on quality, access to care, and consumer experience and satisfaction. Division of Policy and Research on Medicaid and Medicare. Retrieved from: https://www.scdhhs.gov/sites/default/files/CY2011SCMedicaidHealthCarePerformanceReportW.pdf
lxxxiv Brantley. V., Lopez-De Fede, Ana., Mayfield-Smith, Kathy., etc. (2012 September). South Carolina Medicaid Health Care Performance CY 2011 – A report on quality, access to care, and consumer experience and satisfaction. Division of Policy and Research on Medicaid and Medicare. Retrieved from: https://www.scdhhs.gov/sites/default/files/CY2011SCMedicaidHealthCarePerformanceReportW.pdf
42
such as follow-up after inpatient hospitalizations for mental illnesses and various
behavioral conditions were all seen as strong point of emphasis and quality under the
managed care format, and support the notion towards patient centered medical homes
(PCMH) as a viable option for individuals with disabilities and chronic illnesses.
Overall, compared to its southeastern contemporaries, South Carolina’s
Medicaid managed care system has shown great promise and ability to handle
the public health challenges that come with opening Medicaid enrollment
towards individuals with disabilities and chronic illnesses.
- Florida:
o Medicaid managed care in Florida can be traced back to 2005, when the federal
government received a Medicaid waiver to allow for pilot programs in specific
counties to undergo evaluations under Medicaid reform strategies and plans under a
manager care model.lxxxv Since the pilot’s extension, the managed care model for
Florida’s Medicaid program was established by statewide legislation in 2011lxxxvi as a
two part program – a Long-Term Care managed care program (LTC) and a Managed
Medical Assistant program (MMA). A breakdown of these programs, comparing the
services and coverage, is shown below:
lxxxv Alker, J., & Hoadley, J. (2013, October). Medicaid Managed Care in Florida: Federal Waiver Approval and Implementation. Jessie Ball DuPont Fund. Retrieved from http://www.dupontfund.org/wp-content/uploads/2013/10/medicaid-brief-fall-2103.pdf
lxxxvi Summer, L. (2013, 11 December 2013). Medicaid Managed Long-Term Care in Florida: The New Program Launch and Lessons for Consideration. Georgetown University Health Policy Institute. PowerPoint slides. Retrieved from: http://hpi.georgetown.edu/floridamedicaid/
43
Having a comprehensive approach to its state’s Medicaid managed care program is
vital considering the demographic and needs of Florida’s population. To get a better
understanding regarding the great need for these various reforms shown above, just
looking at the number of uninsured individuals in the state itself paints a clear picture
of how significant these changes in Florida’s Medicaid could be.
44
In 2013, state legislation prompting a managed care model transitioned towards the
next phase in completely overhauling Medicaid enrollees into a managed care system
was passed. The Centers for Medicare and Medicaid Services (CMS) approved
Florida’s request to move almost its entire Medicaid program for acute care service
into managed care.lxxxvii
However, in the early and current stages of implementation of Florida’s reform
Medicaid system, there are quite a few issues and obstacles, which may hinder how
effective the managed care model in Florida will affect its stakeholders, particularly
individuals with chronic illnesses and disabilities. The highlighted issue amongst
these stakeholders is related to provider networks; many consumers, especially those
with disabilities and chronic illnesses, are having difficulty navigating the
complexities and differences amongst health plans (differences amongst HMOs lxxxvii Alker, J., & Hoadley, J. (2013, October). Medicaid Managed Care in Florida: Federal Waiver Approval and Implementation. Jessie Ball DuPont Fund. Retrieved from http://www.dupontfund.org/wp-content/uploads/2013/10/medicaid-brief-fall-2103.pdf
45
contracted with Florida, etc.) which is resulting in a lack of information for
consumers who are tasked with choosing their Medicaid options.lxxxviii An
independent analysis from the Georgetown Health Policy Institute found Florida’s
Medicaid managed care system to have incomplete information available to
consumers regarding provider networks and their specifics. In particular, issues like
provider network composition and the adequate handling of various health needs of
individuals with disabilities and chronic illnesses have yet to be solved. Provider
network shortages were a concern during the pilot program implementation back in
2005, and remain so today. Many individuals with disabilities and chronic illnesses
have questioned the availability and accessibility of providers within these HMO
networks, and the ability, skills, and expertise of these providers to be able to handle
the range of needs seen in the disability and chronic illness communities.lxxxix Other
issues within the topic of provider networks include provider reimbursement, as
many providers are finding that the MCOs contracted with the state were offering
lower rates than what these providers had been receiving before.xc Through the
implementation timeline, provider networks and the state’s ability to adopt physician
and consumer perspective towards a more informed and collaborative decision-
making process regarding Medicaid solutions will ultimately determine the success
of this transition to a managed care model in Florida’s Medicaid system. Policy
lxxxviii Summer, L. (2013, 11 December 2013). Medicaid Managed Long-Term Care in Florida: The New Program Launch and Lessons for Consideration. Georgetown University Health Policy Institute. PowerPoint slides. Retrieved from: http://hpi.georgetown.edu/floridamedicaid/
lxxxix Summer. L. (2013, December). Launch of Medicaid Managed Long-Term Care in Florida Yields Many Lessons for Consideration. Georgetown Health Policy Institute. Retrieved from: http://hpi.georgetown.edu/floridamedicaid/
xc Summer. L. (2013, December). Launch of Medicaid Managed Long-Term Care in Florida Yields Many Lessons for Consideration. Georgetown Health Policy Institute. Retrieved from: http://hpi.georgetown.edu/floridamedicaid/
46
recommendations from these early periods under the two-stage managed care
Medicaid model in Florida include a greater emphasis from state officials to provide
consumer outreach and counseling efforts. These initiatives specifically should allow
for greater transition periods when implementing and planning for future Medicaid
operational decisions – such as HMO contract agreements, monitoring of healthcare
quality, and training of staff and providers to meet the variety of needs of individuals
with disabilities and chronic illnesses.xci Taking these specific steps should help bring
about better patient and consumer experiences when navigating and experiencing
firsthand the new changes to Florida’s Medicaid managed care system.
- Mississippi:
o Mississippi’s Medicaid system faces the challenge of servicing one of the most
challenging populations in the United States. The state’s Medicaid executive director
David Dzielak echoes this widely believed sentiment, stating Mississippi has some of
“the most difficult patients to manage” under their Medicaid system.xcii Dzielak has
pushed for greater expansion of managed care models in Mississippi’s Medicaid
system, and results thus far have shown that utilizing this strategy has saved the state
roughly $40 million altogether.xciii Unlike other neighboring states, only roughly
22 percent of Mississippi’s Medicaid enrollees are under the managed care
xci Summer, L. (2013, 11 December 2013). Medicaid Managed Long-Term Care in Florida: The New Program Launch and Lessons for Consideration. Georgetown University Health Policy Institute. PowerPoint slides. Retrieved from: http://hpi.georgetown.edu/floridamedicaid/
xcii Harrison, B. (2013, 28 October). Managed care saving Medicaid money. DJournal.com local and state government news. Retrieved from: http://djournal.com/news/managed-care-saving-medicaid-money/
xciii Harrison, B. (2013, 28 October). Managed care saving Medicaid money. DJournal.com local and state government news. Retrieved from: http://djournal.com/news/managed-care-saving-medicaid-money/
47
model, and current legislation limits this percentage to only 45 percent of all
enrollees.xciv
However, while the managed care model is providing Mississippi with some needed
financial relief, patient and health outcomes are seeing minimal improvements of
such kind. The move to a managed care model in this state appears fueled by a costs
savings agenda above other considerations. This reinforced conclusion is through
broad inaccessibility to reliable healthcare services. State legislation, in exchange for
utilizing a managed care model, has had to ‘carve out’ many services available
through Medicaid. This is evidenced through the provider shortage seen in the state.
Roughly less than half of the state’s primary care physicians are even considering
providing services towards new Medicaid patients.xcv Mississippi has the fewest
number of primary care physicians per capita in the nation – there is one primary care
physician for every 1,463 citizens, and with only 678 clinics in the state, basic
healthcare accessibility is a challenge that the Medicaid system is hard pressed to
solve.xcvi Even in terms of infrastructure, reimbursement policies have not been
updated to common managed care practices – some hospitals still are reimbursed
through the old “fee for service model.”xcvii Accessibility and management of
xciv Harrison, B. (2013, 28 October). Managed care saving Medicaid money. DJournal.com local and state government news. Retrieved from: http://djournal.com/news/managed-care-saving-medicaid-money/
xcv Mitchell, J. (2014, March 30). Fewer physicians accepting Medicaid patients. Clarion-Ledger. Retrieved from: http://www.usatoday.com/story/news/nation/2014/03/30/in-miss-medicaid-patients-struggle-to-find-doctors/7069595/
xcvi Mitchell, J. (2014, March 30). Fewer physicians accepting Medicaid patients. Clarion-Ledger. Retrieved from: http://www.usatoday.com/story/news/nation/2014/03/30/in-miss-medicaid-patients-struggle-to-find-doctors/7069595/
xcvii Harrison, B. (2013, 28 October). Managed care saving Medicaid money. DJournal.com local and state government news. Retrieved from: http://djournal.com/news/managed-care-saving-medicaid-money/
48
Medicaid services in the state consistently rank amongst the worst the country – in all
facets of patient care, quality, accessibility, efficiency, individuals with disabilities
and chronic illnesses will continue to face trouble finding reliable health solutions for
their needs.
Overall, the outlook for Medicaid in Mississippi, regardless of the enrollees’ status as
being an individual with or without disabilities or chronic illnesses, remains
dependent on financial considerations more than anything else. Political agendas
hindered the ability of the state to opt into the federal expansion of Medicaid, and
have threatened clinics across the rural state to go out of operation.xcviii Not moving
forward with the provisions under the Affordable Care Act have left the state in
a no-win situation, with both fewer subsidies to write off uncompensated care at
hospitals – something quite common in Mississippi – as well as no additional
financial sources for the state’s Medicaid program. Simply, it is quite difficult to
see major improvements for individuals with disabilities and chronic illnesses in this
state unless major legislative alternations and political power has a shifting of
agendas.
- Alabama:
o Medicaid in Alabama has just been altered from a typical fee-for-service model seen
in past Medicaid systems into the managed care model. In May 2013, Governor
Bentley’s plan resulted in nearly 1 million Alabamians to receive Medicaid services
from entities titled Regional Care Organizations (RCOs).xcix According to state
xcviii Greenwood Commonwealth fund, (2014, 2 April). Medicaid decision hurting hospitals. Retrieved from: http://www.hattiesburgamerican.com/article/20140403/OPINION01/304030002/Medicaid-decision-hurting-hospitals
49
representatives, the switch to a managed care model is expected to save the state
close to 1 billion dollars over the next five years.c However, these RCOs have not
been established completely throughout the state (RCOs must be established by
October 1, 2014), and provision of care under this model set to begin only in 2016.ci
Therefore, while it is hard to gauge and make any definitive conclusions regarding
how Alabama’s Medicaid managed care system works towards individuals with
disabilities and chronic illnesses, financial considerations have played an
overwhelming role in influencing such a change in Medicaid structure. Cost
considerations have come into play moreover in Alabama than in most other states.cii
This is in large part due to growing demands placed on the state’s Medicaid system
across all enrollees, growing from 25 to 35 percent of the general budget from 2008
to 2013.ciii A variety of cost drivers have contributed to this increased financial
burden, from healthcare inflation to enrollment growth. That said, it becomes clear at
this early stage, that concerns regarding the fiscal health of the Alabama Medicaid
system has prompted a switch to a managed care model with more integration of
healthcare delivery at all points. But, that is not to say that limitations, and potential
concerns in the future, of how well Alabama’s Medicaid system will respond to
individuals with disabilities and chronic illnesses cannot already be forecasted.
Alabama’s Medicaid system, prior to the managed care switch, offers very little in
terms of additional healthcare solutions beyond the federal requirements. Some of the
mandatory Medicaid services shown below make an obvious talking point of
discussion for individuals with disabilities and chronic illnesses.civ
50
A limitation of services could obviously mean individuals with special healthcare
needs would face difficulty in getting the proper care and services needed. Again,
while it’s much too early to offer an evaluation of the managed care model in
Alabama, the policy recommendations listed later in this literature review provide a
xcix Bogard, H. & Fleming, K. (2014, 2 January). Alabama Medicaid: The Move to a Managed Care Program. Burr Forman. Retrieved from: http://www.burr.com/News-,-a-,-Resources/Resources/Alabama-Medicaid-The-Move-to-a-Managed-Care-Program.aspx#.Uz9K1lfmsdR
c Bogard, H. & Fleming, K. (2014, 2 January). Alabama Medicaid: The Move to a Managed Care Program. Burr Forman. Retrieved from: http://www.burr.com/News-,-a-,-Resources/Resources/Alabama-Medicaid-The-Move-to-a-Managed-Care-Program.aspx#.Uz9K1lfmsdR
ci Bogard, H. & Fleming, K. (2014, 2 January). Alabama Medicaid: The Move to a Managed Care Program. Burr Forman. Retrieved from: http://www.burr.com/News-,-a-,-Resources/Resources/Alabama-Medicaid-The-Move-to-a-Managed-Care-Program.aspx#.Uz9K1lfmsdR
cii Williamson, D. (2013 January). Report of the Alabama Medicaid Advisory Commission – State of Alabama. Retrieved from: http://www.medicaid.alabama.gov/documents/2.0_Newsroom/2.2_Boards_Committees/2.2.1_Med_Adv_Comission/2.2.1_Final_Commission_Report_1-31-13.pdf
ciii Williamson, D. (2013 January). Report of the Alabama Medicaid Advisory Commission – State of Alabama. Retrieved from: http://www.medicaid.alabama.gov/documents/2.0_Newsroom/2.2_Boards_Committees/2.2.1_Med_Adv_Comission/2.2.1_Final_Commission_Report_1-31-13.pdf
civ Williamson, D. (2013 January). Report of the Alabama Medicaid Advisory Commission – State of Alabama. Retrieved from: http://www.medicaid.alabama.gov/documents/2.0_Newsroom/2.2_Boards_Committees/2.2.1_Med_Adv_Comission/2.2.1_Final_Commission_Report_1-31-13.pdf
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good start from which implementation standards and Medicaid operations should
strive to focus on – namely patient-centered outcomes ahead of financial objectives.
- Georgia:
o The managed care model in Georgia has been slow to gain traction in terms of
servicing the entire state and all eligible enrollee groups. Doubts exist regarding the
ability of a managed care model to truly bring down costs and provide better patient
outcomes.cv An independent report commissioned by the state itself actually
recommended the switchover to a managed care model – including for the first time
in the state’s Medicaid implementation timeline, servicing individuals with
disabilities and chronic illnesses under a managed care system.cvi But, based on
financial figures provided by the state, Georgia could lose over $200 million in
federal funding if a managed care model was to be implemented for all Medicaid
enrollee groups.cvii While ongoing discussions and plans have been put into place,
there has not been a concrete or definitive managed care plan in place in Georgia’s
Medicaid system. What can be analyzed are the current efforts of the state to utilize a
Medicaid managed care model in specific population groups.
cv Miller, A. (2012, 30 May). State faces risk in Medicaid managed care switch. Georgia Health News. Retrieved from: http://www.georgiahealthnews.com/2012/05/state-faces-risk-medicaid-managed-care-switch/
cvi Miller, A. (2012, 30 May). State faces risk in Medicaid managed care switch. Georgia Health News. Retrieved from: http://www.georgiahealthnews.com/2012/05/state-faces-risk-medicaid-managed-care-switch/
cvii Miller, A. (2012, 30 May). State faces risk in Medicaid managed care switch. Georgia Health News. Retrieved from: http://www.georgiahealthnews.com/2012/05/state-faces-risk-medicaid-managed-care-switch/
52
Georgia is currently utilizing the managed care model in Medicaid in a few service
groups and demographics, namely children, under the PeachCare program, and low-
income pregnant women.cviii There are currently three MCOs in the state servicing
these populations, WellCare, Amerigroup, and Peach State.cix However, when the
PeachCare program was first established in 2006, the state lost millions in federal
funding. If history is to repeat itself, a switch to a managed care model would likely
result in adverse financial outcomes. How does the managed care model project to
impact individuals with disabilities and chronic illnesses is an entirely more
complicated question itself. Without any prior undertaking or initiative of using a
managed care model to service these particular Medicaid enrollees, patient centered
and healthcare quality need to be at the forefront of implementation if such a
transition were to take place. Advocacy and council groups within the state of
Georgia have weighed in on the potential shifting of individuals from a traditional
fee-for-service system to a managed care model. Many of these groups are concerned
that a managed care switch would be fiscally based on not focused on patient care.cx
In addition, there is a concern that the required individualized approach required to
adequately serving individuals living with disabilities and chronic illnesses would be
abandoned in favor of a more streamlined Medicaid system. For instance, managed
care organizations often rely upon commercial and industry standards to determine
the level of care to provide an individual. MCOs and other managed care companies
53
have a strong incentive to keep medical services to an absolute minimum, in line with
standard practices. However, with the unique nature of potential Medicaid enrollees
with disabilities and chronic illnesses, the managed care model may become a source
of remaining status quo rather than seeking out better patient outcomes – individuals
might not get better, but are remaining consistent in their wellness. This philosophy
is what drives some advocates and council groups away from the managed model
towards servicing individuals with disabilities and chronic illnesses. Ultimately, it
remains unanswered how Georgia’s Medicaid program responds to the needs of these
individuals, but it is guaranteed the future of Medicaid deliverance in the state will be
drastically changed in the near future.
Policy Recommendations
Examining the southeastern United States Medicaid Managed care dispositions and
current standings concerning individuals with disabilities and chronic illnesses has brought forth
patterns of similar themes and obstacles that all states seem to face. Issues of provider networks,
shortage of implementation timeframes and plans, lack of access to prescription medications, as
well as Medicaid managed care administrative and functionality issues have played significant
roles in leaving individuals with disabilities and chronic illnesses to struggle to find proper and
cviii Miller, A. (2012, 30 May). State faces risk in Medicaid managed care switch. Georgia Health News. Retrieved from: http://www.georgiahealthnews.com/2012/05/state-faces-risk-medicaid-managed-care-switch/
cix Associated Press ed. (2013, 18 July). Georgia plans managed care for children on Medicaid. OnlineAthens. Retrieved from: http://onlineathens.com/local-news/2013-07-18/georgia-plans-managed-care-children-medicaid
cx Lewis, B. (2012, 5 June). A look into Managed Care in Georgia from MAD Spring 2012. Georgia Council on Developmental Disabilities. Retrieved from http://www.gcdd.org/blogs/gcdd-blog/2308-managed-care-in-georgia.html
54
effective medical solutions for their needs.cxi This section seeks to remediate such findings
amongst the Medicaid Managed care systems in the southeastern United States through
suggesting various policy recommendations and alternatives in the different aspects of the patient
care experience.
Before venturing towards specific policy recommendations and alternatives, it is important to
understand the fundamental guiding principles that will ensure the correct motivation for
utilizing the managed care model in Medicaid towards providing services for individuals with
disabilities and chronic illnesses.cxii As adopted by the comprehensive policy report written by
the National Council of Disability (NCD) titled, Medicaid Managed Care for People with
Disabilities: Policy and Implementation Considerations for States and Federal Policymakers,
these listed principles are related to all aspects of the managed care deliverance system touched
upon before in the analysis of the southeastern United States. The NCD recognizes that these
motivating principles “be rigorously applied in designing and operating Medicaid managed
systems serving children and adults with chronic disabilities.”cxiii While there are numerous
principles listed, the following list will touch upon those concepts and ideals most pertinent to
the Medicaid Managed care cases of the southeastern United States.
- Principle 1: The central organizing goal of system reform must be to help people with disabilities to live full, healthy, participatory lives in the community.
cxi Gettings, R., Moseley, C., & Thaler, N. (2013, 18 March). Medicaid Managed Care for People with Disabilities – Policy and Implementation Considerations for State and Federal Policymakers – National Council on Disability. Retrieved from http://www.ncd.gov/publications/2013/20130315/
cxii Gettings, R., Moseley, C., & Thaler, N. (2013, 18 March). Medicaid Managed Care for People with Disabilities – Policy and Implementation Considerations for State and Federal Policymakers – National Council on Disability. Retrieved from http://www.ncd.gov/publications/2013/20130315/
cxiii Gettings, R., Moseley, C., & Thaler, N. (2013, 18 March). Medicaid Managed Care for People with Disabilities – Policy and Implementation Considerations for State and Federal Policymakers – National Council on Disability. Retrieved from http://www.ncd.gov/publications/2013/20130315/
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o State policymakers should view the usage of Managed care in Medicaid to assist individuals with disabilities and chronic illnesses to reach their individual potential. The integration of each step within the healthcare sector, from provision of services to reimbursement of services provided, should be seen not as a stop gap measure for cost containment, but rather a means of allowing individuals a better chance of living a more productive life.
- Principle 2: Families should receive the assistance they need to effectively support and
advocate on behalf of people with disabilities.
o The importance of advocacy work should be unquestioned and given great relevance when devising policy recommendations for states to better implement managed care within their Medicaid systems. Public arenas and discourse venues should serve as tools at the disposal of families to voice their opinions and concerns regarding the direction of Medicaid managed care for individuals with disabilities and chronic illnesses. This is especially true in cases where the individuals themselves are not in a position to contribute to these causes. In addition, state resources should be devoted towards providing supports and services at the comfort of the homes and communities of individuals living with disabilities and chronic illnesses. Long-term service solutions are vital in ensuring managed care policies in Medicaid can achieve Principle #1 mentioned above.
- Principle 3: States must ensure that key disability stakeholders are fully engaged in designing, implementing, and monitoring the outcomes and effectiveness of Medicaid managed care services
o This guiding perspective is related to the second principle of establishing family support systems. However, beyond the family, it is important that many nonprofit advocacy and research groups are also seen at panel discussions and deliberations of state Medicaid managed care system. Adding a further capable voice and key perspective, whose credentials are completely valid and legitimate, to the shaping of managed care systems in Medicaid will ensure that the best interests of individuals with disabilities and chronic illnesses, rather than just financial and monetary considerations and motivations.
- Principle 4: Managed care delivery systems must be capable of addressing the diverse needs of all plan enrollees on an individualized basis
o As touched upon before, the population of individuals with disabilities and chronic illnesses shows a varying level of disease and condition seriousness and prevalence. Many southeastern states, most notably Tennessee, were and are not prepared to meet the healthcare needs of these particular individuals. State Medicaid programs under a managed care model must ensure that serving MCOs understand the public health risk and undertaking involved when helping these individuals. If not, consequences
56
of providers refusing to see patients, and thereby denying needed services, could result. These needs should also not just be restricted to solely healthcare and medical needs as well. Issues such as logistical, administrative, and geographic factors of providing Medicaid services under a managed care model need to be given consideration and weight in devising an effective strategic plan for meeting individual needs.
- Principle 5: States should complete a readiness assessment before determining the subgroups of people with disabilities to be enrolled in a managed care plan
o This guiding principle relates to Principle #4 above, and addresses the issues of implementation obstacles. Kentucky remains the prominent case whereby a lack of preplanning measures in place seriously deterred the ability of MCOs to properly devise administrative codes and procedural rules to ensure a smooth transition from a traditional fee-for-service Medicaid system to a Managed care model. It is important for states to have a complete grasp and comprehension of the healthcare and financial implications and needs of specific populations before proceeding with any type of Medicaid transitioning.
- Principle 6: The provider network of each managed care organization should be sufficiently robust and diverse to meet the health care, behavioral health, and where applicable, long-term support needs of all enrollees with disabilities
o As mentioned before, the need for providers and specialists to meet the demands of individuals living with disabilities and chronic illnesses is crucial in ensuring the success of integrated MCOs within a state. States should hold off on financial considerations before proposing drastic changes in provider networks. Cutting off specialists for individuals with disabilities and chronic illnesses can result in greater expenses in the case of long-term care. This is where a state-wide preplanning assessment would really have great benefits in ensuring that a state’s MCO provider networks are up to the task of meeting the needs of individuals with disabilities and chronic illnesses.
These specific guiding principles serve as the foundational impetus and reasoning behind the
policy recommendations and alternatives needed for Medicaid managed care systems of the
southeastern United States. Now specific policy recommendations will be listed below:
- Recommendation 1: Southeastern states should be required to create a strategic long-term
document that reflects enrollee-centered outcomes and positive results for these individuals
that should come through the managed care system.cxiv
57
o Too often, states are quick to adopt the managed care model solely for cost cutting
mechanisms. A state’s strategy should reflect guiding principle #1 listed above, and
aim to create self-independence, an increase in productivity, and individual wellbeing
amongst individuals with disabilities and chronic illnesses. While the Federal
department of Health and Human Services requires state plans of each state, this
specific policy recommendation is more geared towards states being required to show
year-by-year steps in helping individuals living with disabilities and chronic illnesses
achieve lifestyle, living, and functional improvements and advancements. Under this
framework, disability and chronic illness advocacy groups, individuals living with
disabilities, their families, and state and federal policymakers, can better evaluate
quality standards and outcomes of state Medicaid managed care systems solely in
terms of public health impact and influence. Having the state requirement of
providing a year-by-year implementation strategy centered around Medicaid enrollee
benefits and outcomes ensures that the best interests of patients and families alike are
considered at the same time as the financial benefits of utilizing a managed care
model of Medicaid.
- Recommendation 2: Southeastern states should be required to enlist and utilize
nongovernmental stakeholders and representatives during the designing, implementing, and
operating Medicaid managed care systems towards individuals with disabilities and chronic
illnesses.cxv
o For many of the reasons involving outside parties and agencies, it is imperative that
the perspectives of individuals with disabilities and chronic illnesses and their
families are recognized. Issues such as provider networks and a lack of approved
58
prescription medicines (namely limiting pharmaceuticals and preferred drug lists)
could be addressed through involvement of stakeholders with enrollee centered
benefits and outcomes as their primary motivation. Beyond state department of
Health and Human Services representatives being engaged, individuals representing
disabilities and chronic illnesses provide both pragmatic, practical, and knowledge
insights and experiences that the southeastern states need to tap into in order to keep
individuals under Medicaid managed care systems satisfied and having their
healthcare and medical needs met. In addition, the involvement of disability and
chronic illness stakeholders and individuals should not be limited to just enrollment
and implementation phases of state Medicaid managed care systems. These
stakeholders should be actively present with shared opinions regarding evaluating,
maintaining, and providing constant feedback and constructive criticism of where
state managed care programs in Medicaid are succeeding and failing, such as care
quality, financial implications, and patient outcomes. Some alternatives to the
common practice of utilizing third-party mainstream consulting groups that are often
seen being relied upon by state Medicaid managed care programs, most notably
North Carolina and Kentucky, should be sought. Having a collection of experts and
recognized leaders in the disability and chronic illness communities, whether these
individuals be practitioners in the field or policy advocates, will help state officials in
developing and administering a Medicaid managed care program tailored for
individuals with disabilities and chronic illnesses in both the short and long terms.
- Recommendation 3: State officials should permit and require Medicaid managed care
administrators and representatives to have independent agencies and organizations provide
59
evaluative services to administer Medicaid managed care through MCO programs and
specific disability and chronic illness-specific state agencies.
o In states that transitioned to a managed care system of Medicaid from a traditional
fee-for-service system, state officials were left unprepared and unaware of how to
properly administer and analyze program performance, implementation, and
maintenance of the managed care model. This quandary was no more apparent than
in Kentucky, where a lack of preplanning and familiarity with the complexities that
come with the managed care model impeded on any progress in delivering a more
efficient and effective Medicaid system for individuals with disabilities and chronic
illnesses. To that point, overseeing the performance standards, quality outcomes, and
administrative and financial consequences of contracted MCOs calls for a different
set of skills than those of evaluating fee-for-service systems.cxvi State Medicaid
programs going to the managed care model should be required to seek the
involvement and insights of consulting personnel experienced with designing and
operating managed care models in state Medicaid programs. Particularly those
agencies that have shown experience in monitoring and handling MCO performance
measures and indicators, specifically of northeastern Medicaid managed care
programs, where patient outcomes and program performance has traditionally been
superior to any other region in the United States. Where there is an lack of a state
capacity and capability to perform tasks of MCO program evaluation, ceding
responsibility towards private contractors ensures that measures are being taken for
an efficient transitioning and long-term implementing of a managed care model in
Medicaid services for individuals with disabilities and chronic illnesses. This policy
60
recommendation complements the requirement of involving more disability and
chronic illness groups, experts, and stakeholders from recommendation 2, giving
state Medicaid agencies and administrators a broad and expansive range of expertise
and knowledge to move forward with a managed care model.
- Recommendation 4: States transitioning to the managed care model for Medicaid enrollees
with disabilities and chronic illnesses must administer and complete a pre-implementation
assessment of specific medical and health needs to identify and determine any barriers to
Medicaid enrollee care.
o Medicaid enrollees, particularly those with disabilities and chronic illnesses have a
wide range of health and long term needs that need to be recognized. The capacity of
states to address the health care needs of a variety of individuals varies significantly
from condition to condition, from patient to patient – even within constricted
geographic areas.cxvii Creating an assessment plan to determine the readiness and
preparedness of a state’s ability to handle multiple conditions and treatments will
give Medicaid administers and state officials time to establish a phase-in period,
whereby specific concerns associated with certain conditions are addressed. The most
imperative of these concerns are listed below:
The availability of reliable and adequate instruments to evaluate service and
support needs of specific population groups with disabilities and chronic
illnesses
Resources and expertise required to address behavioral and mental health
impacts from specific conditions, beyond medical care
61
An evaluation of each state’s strengths and weaknesses regarding its Home-
Community Based solutions in providing healthcare services on individual’s
needs and convenience
Community housing available capable of meeting the needs of individuals
with disabilities and chronic illnesses, particularly those who are transitioning
from institutions to community settings
Established plans for ensuring that Medicaid eligible enrollees with
disabilities and chronic illnesses have accessibility to prompt, comprehensive,
and relevant information regarding policies and procedures regarding
acquiring Medicaid services, as well the individual rights, privileges, and
obligations the individual has over a state’s Medicaid managed care program
An annual, evaluative report by outside parties and stakeholders (disability
stakeholders, consultants, etc.) that details Medicaid quality measures and
indicators to ensure patient outcomes, accessibility, and efficiency of the
managed care model
o These four specific policy recommendations cover the most pertinent issues seen
today in the situations of Medicaid managed care systems throughout the
southeastern United States. Issues of care quality, enrollment parameters, and
implementation and Medicaid program administration are all touched upon through
requiring states to engage in pre-planning requisites in ensuring a successful
transition from a fee-for-service model to a managed care model. Adopting a patient-
centered managed care model will increase the likelihood of better quality outcomes
62
and expedited patient transitioning from healthcare facilities to home-based care.
Ensuring these measures work, the pre-assessment plan requirement recommendation
will make sure cases such as Kentucky’s will not be repeated. Calculating the
capabilities and needs of the patient population pool fosters confidence within both
Medicaid and individuals with disabilities and chronic illnesses alike about what
operating, administrative, and medical concerns need to be addressed before
implementation.
o Moving forward, for purposes of consumer and patient empowerment and
knowledge, a listing of the entities responsible for Medicaid managed care services
for individuals with disabilities and chronic illnesses will be specified for each state
detailed. This listing will cover the essential contacts and parties responsible for
different facets of the Medicaid system, from contracted MCOs in a states, to state
Medicaid administers. State and National references and resources will also be listed
to ensure interested parties and groups have all the available information at their
disposal.
Resource Page
- National Level resources:
o Medicaid: http://www.medicaid.gov/
o Medicaid managed care: http://www.medicaid.gov/Medicaid-CHIP-Program-
Information/By-Topics/Delivery-Systems/Managed-Care/Managed-Care.html
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o Centers for Medicare and Medicaid: http://www.cms.gov/
o Health Maintenance Organization (HMO) information:
http://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-
advantage-plans/hmo-plans.html
o Medicaid Prescription Drug Programs: http://www.medicaid.gov/Medicaid-CHIP-
Program-Information/By-Topics/Benefits/Prescription-Drugs/Prescription-
Drugs.html
- State-based resources:
o Kentucky
Medicaid: http://www.chfs.ky.gov/dms
Managed Care Organizations in Kentucky: http://www.kcnpnm.org/?MCO
Kentucky Preferred Drug Lists (PDL):
https://kentucky.magellanmedicaid.com/RemoteFiles/PROD/PDL/KY_PDL.p
df
Kentucky Department of Insurance: https://insurance.ky.gov/
o Tennessee
Medicaid: http://www.tn.gov/tenncare/
Department of Human Services:
http://www.tn.gov/humanserv/adfam/afs_med.html
64
Managed Care Organizations in Tennessee: https://www.tn.gov/tenncare/pro-
mcos.shtml
Tennessee Preferred Drug Lists (PDL):
https://tenncare.magellanhealth.com/static/docs/Preferred_Drug_List_and_Dr
ug_Criteria/TennCare_PDL.pdf
Tennessee Department of Insurance: http://www.state.tn.us/commerce/
o North Carolina (MCOs are still being determined)
Medicaid: http://www.ncdhhs.gov/dma/medicaid/
Department of Health and Human Services:
http://www.ncdhhs.gov/index.htm
North Carolina Preferred Drug Lists (PDL):
http://www.ncdhhs.gov/dma/pharmacy/pdl.pdf
North Carolina Department of Insurance: http://www.ncdoi.com/
o South Carolina
Medicaid: https://www.scdhhs.gov/Getting-Started
Department of Health and Human Services: https://www.scdhhs.gov/
65
Managed Care Organizations in South Carolina:
https://www.scdhhs.gov/press-release/managed-care-organizations-mcos-and-
behavioral-health
South Carolina Preferred Drug Lists (PDL):
http://southcarolina.fhsc.com/Downloads/provider/SCpdl_listing_20140101.p
df
South Carolina Department of Insurance: http://www.doi.sc.gov/
o Florida
Medicaid: http://www.fdhc.state.fl.us/medicaid/
Department of Health and Human Services: http://www.floridahealth.gov/
Managed Care Organizations in Florida:
http://ahca.myflorida.com/MCHQ/Managed_Health_Care/MHMO/docs/MC
AID/LIST_MEDICAID_HMOs.pdf
Florida Preferred Drug Lists (PDL):
http://ahca.myflorida.com/medicaid/prescribed_drug/pharm_thera/pdf/
PDL_03-13-14.pdf
Florida Department of Insurance: http://www.floir.com/
o Mississippi:
Medicaid: https://www.medicaid.ms.gov/
66
Department of Health and Human Services: http://www.mdhs.state.ms.us/
Managed Care Organizations in Mississippi:
https://www.medicaid.ms.gov/mscan/Welcome.aspx
Mississippi Preferred Drug Lists (PDL):
http://www.medicaid.ms.gov/Documents/Pharmacy/PreferredDrugList.pdf
Mississippi Department of Insurance: http://www.mid.ms.gov/
o Alabama (Managed care transition is still underway – RCOs not completely
determined)
Medicaid: http://www.medicaid.alabama.gov/
Department of Health and Human Services: http://www.adph.org/
Alabama Preferred Drug Lists (PDL):
http://medicaid.alabama.gov/documents/4.0_Programs/4.5_Pharmacy_Servic
es/4.5.12_PDL/4.5.12_PDL_List_Therapeutic_4-1-14.pdf
Alabama Department of Insurance: http://www.aldoi.gov/
o Georgia
Medicaid: https://dch.georgia.gov/medicaid
Department of Health and Human Services: https://dhs.georgia.gov/
67
Georgia Managed Care Organizations: https://dch.georgia.gov/care-
management-organizations-cmo
Review of Managed Care Organizations: https://dch.georgia.gov/cmo-
reviews-and-reports
Georgia Preferred Drug Lists (PDL): http://dch.georgia.gov/preferred-drug-
lists
Georgia Department of Insurance: http://www.oci.ga.gov/
Acknowledgements and thanks
- Kara Hinkley, Manager of Southeast Advocacy, National Multiple Sclerosis Society
- Paula Lipford, Director of Volunteer Engagement, National Multiple Sclerosis Society
68
Image citations (listed by chronological appearance in literature review)
1) Kaiser Family Foundation. (2011). (Graphical map of Medicaid Managed Care presence
in each state). Retrieved from: http://kff.org/medicaid/slide/comprehensive-medicaid-
managed-care-penetration/
2) Virginia Medicaid Innovation and Reform Commission. (2013). Trends in Medicaid
Managed Care. (Graphical map of changes in Medicaid Managed Care state presence
over time). Retrieved from: http://mirc.virginia.gov/documents/10-21-
13/102113_No2_Gordon_MIRC.pdf
3) Kaiser Family Foundation. (2013). What is Medicaid’s Impact on Access to Care, Health
Outcomes, and Quality of Care? Setting the Record Straight on the Evidence. (Bar graph
health outcomes of individuals with Medicaid, private insurance, no insurance).
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is-medicaids-impact-on-access-to-care1.pdf
4) Kaiser Commission on Medicaid and the Uninsured. (2013). Paradise, P. (2013, 25 June).
Trends in Risk-Based Medicaid Managed Care: A National Overview. (PowerPoint
slides). (Bar graph representing state action/plans expanding managed care). Retrieved
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of-health-reform/
5) Kaiser Family Foundation. Connolly, J., & Paradise, J. (2012, 1 February). People with
disabilities and Medicaid Managed Care: Key Issues to Consider – Kaiser Commission
on Medicaid and the Uninsured. Retrieved from:
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69
6) Kaiser Family Foundation. Connolly, J., & Paradise, J. (2012, 1 February). People with
disabilities and Medicaid Managed Care: Key Issues to Consider – Kaiser Commission
on Medicaid and the Uninsured. Pie chart of Medicaid spending by disability. Retrieved
from: http://kff.org/medicaid/issue-brief/people-with-disabilities-and-medicaid-managed-
care/
7) AARP. Reinhard, S.C., Kassner, E., Houser, A., Mollica, A. (2011, September). Raising
Expectations: A State Scorecard on Long-Term Services and Supports for Older Adults,
People with Physical Disabilities, and Family Caregivers. AARP, The Commonwealth
Fund, and The SCAN Foundation. State-wide graphical representation of health
outcomes (Long-Term Services and Supports for Older Adults, People with Physical
Disabilities, and Family caregivers). Retrieved from:
http://www.longtermscorecard.org/~/link.aspx?
_id=DCD2C261D26D414C971D574D577A78FE&_z=z#.U8RVlrEto3w
8) Virginia Medicaid Innovation and Reform Commission. (2014, February). “TennCare.”
TennCare: Trends in Medicaid Managed Care – Virginia Medicaid Innovation and
Reform Commission., n.d. Web. 2014, 27 February. Retrieved from:
http://mirc.virginia.gov/documents/10-21-13/102113_No2_Gordon_MIRC.pdf
9) TennCare. (2014, January). TennCare 101: Explaining the basics of Medicaid in
Tennessee. Graphical representation of Tennessee MCOs by region. Retrieved from:
http://www.tn.gov/tenncare/forms/tenncareoverview.pdf
10) John Locke Foundation. (2013). Ingram, J., & Restrepo, K. The Partnership for a
Healthy North Carolina – Medicaid Reform that Works for Patients, Providers, and
70
Taxpayers Alike. Bar graph of time-elapsed North Carolina Medicaid enrollment.
Retrieved from http://johnlocke.org/acrobat/policyReports/Partnership.pdf
11) John Locke Foundation. (2013). Ingram, J., & Restrepo, K. The Partnership for a
Healthy North Carolina – Medicaid Reform that Works for Patients, Providers, and
Taxpayers Alike. Bar graph of time-elapsed North Carolina Medicaid spending. Retrieved
from http://johnlocke.org/acrobat/policyReports/Partnership.pdf
12) John Locke Foundation. (2013). Ingram, J., & Restrepo, K. The Partnership for a
Healthy North Carolina – Medicaid Reform that Works for Patients, Providers, and
Taxpayers Alike. Retrieved from:
http://johnlocke.org/acrobat/policyReports/Partnership.pdf
13) North Carolina Health News. (2013, December). Advisory Group Begins to Sketch Future
of State Medicaid System. Retrieved from:
http://www.northcarolinahealthnews.org/2013/12/06/advisory-group-begins-to-sketch-
future-of-state-medicaid-system/
14) South Carolina Department of Health and Human Services. (2012, September). Brantley,
V., Lopez-De Fede, Ana, Mayfield-Smith, Kathy., etc. South Carolina Medicaid Health
Care Performance CY 2011 – A report on quality, access to care, and consumer
experience and satisfaction. Division of Policy and Research on Medicaid and Medicare.
Bar graph comparing health outcomes of South Carolina MCOs and FFS organizations
Retrieved from:
https://www.scdhhs.gov/sites/default/files/CY2011SCMedicaidHealthCarePerformanceR
eportW.pdf
71
15) Georgetown University Health Policy Institute. (2013, December). Summer, L. Medicaid
Managed Long-Term Care in Florida: The New Program Launch and Lessons for
Consideration. PowerPoint slides. Retrieved from:
http://hpi.georgetown.edu/floridamedicaid/
16) Georgetown University Health Policy Institute. (2013, February). Alker, J. Florida’s
Medicaid Choice: Options and Implications. Bar graph of Florida and United State
uninsured rates. Retrieved from:
http://ccf.georgetown.edu/wp-content/uploads/2014/02/florida.pdf
17) Georgetown University Health Policy Institute. (2013, February). Alker, J. Florida’s
Medicaid Choice: Options and Implications. Bar graph of Florida’s uninsured adult rates.
Retrieved from: http://ccf.georgetown.edu/wp-content/uploads/2014/02/florida.pdf
18) Alabama Medicaid Agency. (2013, January). Report of the Alabama Medicaid Advisory
Commission – State of Alabama. List of Medicaid services. Retrieved from:
http://www.medicaid.alabama.gov/documents/2.0_Newsroom/2.2_Boards_Committees/
2.2.1_Med_Adv_Comission/2.2.1_Final_Commission_Report_1-31-13.pdf
72
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