Policy Issues

“Adults with Disabilities in Medi-Cal Managed Care: Lessons from Other States” – Medi-Cal Policy Institute, prepared by Center for Health Care Strategies, September, 2003, 48 p. Nikki Highsmith, M.P.A., and Stephen Somers, Ph.D.

Examines how well managed care programs for people with chronic illnesses and disabilities served people in other states: Massachusetts, New Jersey, Oregon and Pennsylvania. Interviews were conducted with senior state Medicaid officials, health plan executives, and leaders from consumer organizations. Also mentioned in the report are the experiences of other states the authors knew had developed programs in this area. Key findings are:

  • building a comprehensive and responsive model of managed care takes time but offers greater opportunities for coordination and can assist people with disabilities despite the complexity and heterogeneity of their conditions
  • states can maximize consumer choice in the enrollment process by systematically engaging disability organizations, consumers, and family members
  • short-term savings are difficult to achieve due to high initial utilizations, difficulty in setting accurate capitation rates, and up front administrative costs, yet longer-term savings are achievable through more effective clinical management and care coordination programs. “A high tolerance for deferred gratification with respect to cost savings is critical.”
  • traditional network adequacy standards offer little guidance for people with disabilities and their care needs; states need to be more flexible to develop network capacity
  • effective care coordination goes beyond medical models of case management; successful programs address medical and psycho-social needs, focus on wellness and prevention, managing both covered and uncovered services
  • managed care offers greater capacity to measure performance and so quality measures must be modified to reflect the complexity of chronic conditions among people with disabilities.

“Making Tough Choices: Adults with Disabilities Prioritize their Medi-Cal Options” – California Healthcare Foundation, December, 2004, 38 p. Marjorie Ginsburg and Kathy Glasmire, Sacramento Healthcare Decisions, Inc.

Using a computerized tool and interactive group process called CHAT (Choosing Healthplans All Together), 12 separate groups in urban, suburban and rural settings designed their Medi-Cal benefits by making choices from 14 categories of service. Participants (131 total) were given a limited budget and had to prioritize services most vital. This paper is a full report of the process, the types of participants and their disabilities, and its findings:

  • adults with disabilities are often highly dependent on medical and supportive services
  • most important to them is maintaining a full range of Medi-Cal services
  • also essential are sufficient choices and availability of providers; choice of physicians is especially important
  • three categories needed greater coverage: doctor care, dental care, and equipment
  • to maintain a full range of services, CHAT participants most often limited the scope of drugs (brand), enrollment (eligibility), and personal care to reduce costs.
  • pleased with the opportunity to voice their opinions, 78% of CHAT participants thought that the process was a good way for others to understand views and priorities of those using Medi-Cal services.

“Medi-Cal Beneficiaries with Disabilities: Comparing Managed Care with Fee-for-Service Systems” – California HealthCare Foundation Issue Brief, August, 2005, 12 p.  Lisa Chimento, Moira Forbes, and Any Sander, The Lewin Group; June Isaacson Kailes, Brenda Premo, and Curtis Richards, The Center for Disability Issues and Health Professions, Western University for the Health Sciences; and Chris Perrone, California HealthCare Foundation

Brief paper synthesizes recent research about the experiences of non-elderly beneficiaries with disabilities in managed care and fee-for-service systems in California and other states. The purpose of this review is to help policymakers understand and evaluate options for changing service and payment systems under Medi-Cal. Key findings:

  • data determining how people with disabilities will fare in Medicaid managed care is limited; in California, among other states, assessing quality of care has been poor
  • a recent national study found that there was no significant difference between Medicaid beneficiaries in managed care and those in fee-for-service on most measures of access and quality
  • California managed care enrollees have fewer preventable hospitalization than fee-for-service user; however, users of both systems have trouble finding physicians, communicating effectively with providers and with physical access
  • Californians who have experienced mandatory managed care through Medi-Cal have had difficulties during the transition period, with both counties and health plans
  • several options for increasing managed care participation do not rely on mandatory enrollment.

Makes recommendations to strengthen the Medi-Cal program’s performance, measurements, public reporting, reimbursement systems, and coordination across programs. Tables and graphs enhance the narrative.