reports

The faces of Medicaid: the complexities of caring for people with chronic illnesses and disabilities

Hamilton, NJ, USA: Center for Health Care Strategies.

Center for Health Care Strategies, Hamilton, NJ, USA

A complex question has persisted in our minds since the Center  for Health Care Strategies (CHCS) opened its doors in 1995 to  direct The Robert Wood Johnson Foundation’s Medicaid  Managed Care Program: why doesn’t anyone know how many Medicaid  recipients have what chronic illnesses and disabilities requiring what  array of medical and social services? Without an answer to this question,  it would seem self-evident that state Medicaid agencies, health plans,  and consumer groups—the stakeholders—are severely limited in their  efforts to design high quality managed care programs for a substantial  number of beneficiaries —not only those eligible by virtue of SSI, but  also many AFDC/TANF recipients with chronic, complex needs.  Without data identifying these conditions, their comorbidities, and  their prevalence, how could enrollment approaches be designed,  provider networks be developed, rates be set (and risk adjusted), and  quality be monitored? In short, how could contracts be written?
As an initial step toward helping states, managed care organizations and  consumer groups to answer these questions, CHCS prepared The Faces  of Medicaid: The Complexities of Caring for People with Chronic Illnesses  and Disabilities. The goals of this report are to begin to identify populations  with special health care needs in Medicaid and now State  Children’s Health Insurance Programs, describe the severity of some of  their primary and secondary conditions, and highlight a subset of the  clinical and fiscal policy issues faced by states and health plans enrolling  these populations in managed care.
The CHCS team accomplished these goals through an analysis of claims  data from four states, supplemented by other national data sources,  exhaustive literature reviews, and interviews with consumers and other  experts in the field. The report highlights best practices and policy  implications for further discussion, including: adjusting covered  benefits and rates, reimbursing family caregivers, providing adequate  transportation for people with disabilities, and altering the definition of  medical necessity to accommodate chronic conditions.
The Center for Health Care Strategies is a nonprofit, policy resource  center that promotes high quality health care services for low-income  populations and people with chronic illnesses and disabilities. Initiatives  at CHCS are organized around four organizing principles: informed  purchasing, consumer action, integrated systems of care, and managed  care best practices. The Faces of Medicaid addresses all these issues.