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.
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