A look into Managed Care in Georgia from MAD Spring 2012
Managed Care in Georgia: Options, Concerns, Direction
By Bill Lewis
Right now, there is a lot of discussion surrounding the issue of managed care. But what actually is it? Managed care is a system of healthcare which organizes doctors, hospitals, insurance companies and other providers into groups with the aim of enhancing the quality and cost-effectiveness of healthcare. The cost of treatment is monitored by a managing company, and the patient relies on a primary care physician to serve as a gatekeeper for them to receive other health services such as specialty medical care, surgery or physical therapy.
Generally, there are three types of managed healthcare plans: PPOs (Preferred Provider Organizations), HMOs (Health Maintenance Organizations) and POS (Point of Service) organizations. You may very well be enrolled in one of these healthcare plans now.
Managed healthcare was at the core of the debate in Congress recently when the Affordable Healthcare for America Act was being discussed. Supporters of the measure believe some form of managed healthcare should be available to everyone, with the government as the fallback guarantor of payment. Its critics argue that this will be a step toward the government being a singlepayer source, which they feel is not the best course for American medicine to pursue, fearing among other things, that it may lead to rationed care.
Healthcare vs Social Services
The entire Affordable Healthcare for America Act has yet to be implemented and much remains to be seen as to how it will affect managed medical care. There is another component to managed care, though, that seldom gets as much attention as healthcare: social services. That includes services needed by the disability community such as finding housing or jobs, creating recreational activities, providing personal care services and others that are not usually part of healthcare and are not typically addressed since they are not needed by the population as a whole as much as general healthcare, which tends to be universal. Generally, managed healthcare organizations don’t even have much experience in providing those social services.
Who then provides these vital social services for individuals with disabilities? According to the Georgia Council on Developmental Disabilities’ (GCDD) Executive Director Eric Jacobson, “Those kinds of issues have really emerged as a system of service that is provided by Medicaid and other state government services at this point.”
Costs for all managed care continue to rise. And it’s primarily because of that reason that the State of Georgia has “decided that they want to look at putting everybody who is categorized as aged, blind or with disabilities into managed care,” adds Jacobson. “This also includes children with disabilities.”
Reform Initiative by DCH
The Georgia Department of Community Health (DCH) has recently undertaken a reform initiative to investigate the possibility of creating a broad-based managed care program. Some states have put partial
managed care programs into place, but Georgia would be the first to bring every service and every eligible person (aged, blind or those with disabilities – adults and children) under a more broad-based, state-planned system.
As you might imagine, there are a lot of emotional and practical considerations involved. Last August, DCH engaged an outside company to investigate current programs in other areas of the country, as well as assess Georgia’s existing plans. Now, the Department is in phase two, which is to digest the report and gather input from many other sources.
Broad-based Support Needed
Many advocacy groups around the State are weighing in on the situation. As a whole, it’s probably safe to say they would all only agree on the idea that while managed care may have some good attributes, any overall proposal must include safeguards for a variety of potential users.
Jacobson believes there are some good things that can come out of this. But, there are some cautions that need to be out there as well. “If you look at what other states have at least thought about through a managed care system, the major advantage is that there would not be a waiting list for services. Anybody who is eligible for Medicaid would be required to get the services,” he points out.
“Essentially, there would be no waivers. It would all become state-planned services instead of a waiver, and the waiting list would potentially be eliminated for home and community-based services. That’s a good thing, as long as there are enough providers who can offer those services,” he adds. “In theory, you would be able to increase access and quality to services by eliminating or increasing the number of local providers across the State. But in reality, can that really happen?”
Children’s Issues
Children with disabilities represent another group whose advocates are very vocal in making sure any managed care program includes individualized possibilities.
“My concern is for children with chronic health issues and developmental disabilities. Our goal is to keep them in their homes and thriving with their families and there is a certain level of support that will be needed to do that, often well into adulthood,” says Karl Lehman, CEO and president of Childkind. “So a concern with managed care is that if the medical model says the individual will get
better and services will taper off, there could quite possibly be a collision of philosophies down the line. There could be a model that says these people should have gotten better and be off the roles by a certain time. The program cannot be a one size fits all. It has to be based on individual needs.”
Jeff Cornett, director of training, research and advocacy for Hemophilia of Georgia, says that for children with hemophilia, there is already an effective comprehensive care system that has been in place for almost 40 years. Funded originally by the federal government, the clinics are now mainly supported by Hemophilia of Georgia. “Over the years, research has shown that patients who go to one of the comprehensive hemophiliac centers live longer than those who don’t. So most people go there,” says Cornett.
Hemophilia is very expensive to treat. “Depending on weight, it can cost $30,000 to $300,000 a year just for medications,” Cornett adds. Putting those children in a capitated (a defined limited dollar amount) managed care plan “becomes very scary.”
“Our concern with managed care is that the focus has been on managing costs, not care,” says Cornett. “We have found that Care Management Organizations (CMOs) seek to reduce costs by reducing care. It’s been a constant struggle for our patients in existing managed care programs. I really worry about the other children that have developmental disabilities and other complex chronic problems. If you have a child who deviates from the normal care for anything, that’s a trigger that you’re going to have problems.”
Mental Illness
Ellyn Jeager, director of public policy for Mental Health America of Georgia, has expressed concern about the impact managed care would have on those with mental illness.
“Managed care right now is not set up to handle people with mental illness. For those who want to live in recovery, it’s more than healthcare. It’s jobs, transportation and housing,” she notes. “I think certain populations are at a disadvantage in the managed care system. People with mental health illness and developmental disabilities would be at a disadvantage. Also the aging population.”
What does she see happening on the managed care front? “I don’t know. But, we are being asked our opinion by DCH and I appreciate that. In writing a contract though, to be effective, it would have to include a social model and not just a medical model. It all comes down to the contract. If it’s not in there, it doesn’t have to happen.”
Managed Care Elsewhere
Some managed long-term care programs have been tried in other states. In Wisconsin, one component is the Family Care Initiative that is being phased in as a replacement for state/county long-term care programs. “Family Care is designed as a capitated, managed long-term support and health care management program to serve adults with developmental disabilities, adults with physical disabilities and frail elders,” says spokesperson Dennis Harkins. “The goal is to focus on the individual. When and where it works as it is intended, it allows each person to be a full partner with the Managed Care Organization (MCO) in deciding where and with whom to live, to make decisions regarding supports and services, how to spend each day doing things they believe are important and in essence supporting people to live fulfilling lives in their communities.”
Wisconsin’s Family Care has been in effect since it began as a pilot in 2000. “The state reports that members are satisfied in meeting their desired outcomes,” says Harkins. “Overall, per person Medicaid costs (longterm care and acute) are decreasing compared to the previous system and nursing home usage is decreasing.”
However, Harkins comments that the program has not been without growing pains. “The rapid expansion has led to concerns over a growing segregation and congregation of services, provider rate-cutting and service reduction. Too often, care managers’ ideas of what is best for a person hold more weight than the person’s desired outcomes, despite our rhetoric to the contrary. That is definitely something that most of the Family Care programs are working on.”
Harkins suggests that key elements to making this work are being clear up front about the values that guide the funding; having an Independent Ombudsman (oversight structure) that people can contact; requiring all MCOs to give people the option of using the principles of self-determination to develop their own plan for supports and services; and requiring the MCO to include, and if necessary, develop providers of highly individualized services.
“It’s a very complex system and needs continual oversight and engagement by those who rely upon it,” says Harkins. “If done well, it can support people in having fulfilling lives; if done poorly it can maintain or even increase the segregation and devaluation of the people it is designed to support.”
Georgia’s Version
The question though, is would managed care work in Georgia? Government Affairs Consultant Tom Bauer works with several advocacy groups, and he has a concern shared by many others that under a managed care system children and adults with disabilities, the blind and aged populations will have a much more difficult time getting the care they need.
“The managed care system basically uses a payment approach in which the managed care provider receives the same amount of money regardless of the amount of services provided,” Bauer shares. “Therefore there is a built-in incentive to save money, and there may be some evidence that an approach like that might work for healthy people, but it leaves a lot to be desired for those with disabilities because they probably need more individualized care.”
Bauer also adds, “Managed care frequently uses commercial standards to determine how much care to give someone. Customary therapy, for example, might be set at twice a month. But a doctor or therapist might decide that a child with disabilities needs therapy once a week. Managed care companies have an incentive to rely on the commercial standards to minimize the amount or frequency of care. Their approach is to approve treatment as long as a child makes progress, but some children with disabilities may only be able to maintain their condition.”
“What we’re saying is, before you take people out of their current healthcare plans, before you change a system that still takes individual cases into account, you have to make sure managed care will take care of them.”
Nevertheless, some think managed care has come a long way. According to Kay Nelson, an occupational therapist who represents the Georgia Occupational Therapy Association, “When they first started, there were a lot of problems. There are still issues to work through, but we’ve seen some improvements.”
“I think the biggest problem we run into is delays in services. If a child needs therapy or medical services, you have to apply to the managed care organization and sometimes there’s a delay in getting that organization to respond,” she says.
What safeguards should a managed care system going forward have? Nelson says, “An oversight structure to make sure service is timely is very important. Another thing is that currently only one of the CMOs is electronic-based. The others are paper-based and that creates delays. In a new system, everything needs to be electronic-based.”
DCH Task Forces
In February of this year, DCH convened two advisory task forces: a Provider Task Force and an Aged, Blind and Disabled (ABD) Task Force. These task forces will provide input into the Medicaid and CHIP Redesign Initiative, and a third task force will discuss Children and Family Services.
GCDD Deputy Director Pat Nobbie, Ph.D., says there is a group of advocates about 45 people strong including dental and pediatric representatives, meeting fairly regularly. “Well informed people are out there watching this very closely,” she says. They have created a 10-point guide for the new program that has been forwarded to DCH. (See listing of guidelines below in sidebar.)
“People with disabilities and their families need to have access to comprehensive health and long-term support services and those services need to be provided on the basis of need, preference and choice,” says Nobbie. “In our language, that means things like making sure self-directed services are still an option for people so they can make the choice of what services they are getting and what providers they are using. That means things like person-centered planning, and access to the system recognizes individual issues.”
As with every program, money becomes a big issue. “Providers need to be reimbursed at an adequate level,” says Nobbie. “A huge issue right now is that rates are too low already. If
you add a middleman, essentially, that will impact rates even more and then could there be an issue around quality of care.”
Sidebar
Guidelines for DCH Task Forces
1. Re-order the priorities.
2. Establish a values base.
3. Slow down and create a meaningful planning process.
4. Establish quality measures.
5. Adopt standards of care consistent with the mandates of the Medicaid Act and the Americans with Disabilities Act.
6. Engage stakeholders.
7. Establish independent review.
8. Keep the big picture in the forefront.
9. Do more of what works, less of what doesn’t.
10. Pilot services for new populations.
The Big Issue:Quality of Care
For virtually everyone involved with the managed care debate, what trumps the money issue though, is the quality of care.
Director of Health Policy at the Georgia Budget and Policy Institute, Tim Sweeney voiced what many think about managed care as a concept, “I generally don’t feel that it is inherently good or bad. It’s the way you organize the program. I don’t think budgetary savings should be a driving factor as the State moves toward re-designing the managed care program.”
Sweeney adds, “Every program can’t be designed to fix everything. It’s a perfect comparison to think about medical vs social populations; however, there are some populations we’re providing medical services for, but we don’t want to miss the boat on social services. Case management becomes even more important to other audiences.”
“In designing a service, the most important aspects are what services are available to the enrollee, how easily accessible are those services and if they are high quality services that are meeting their needs and helping them get the right care.”
DCH Timing
The current schedule for recommendations from DCH is to have a managed care proposal finalized this summer. At that time, managed care companies will have the opportunity to bid on requests for proposals. Those then will be reviewed with selected providers and are due by January 2013. With the providers in place, the new programs would then begin in January 2014.
Right now, probably the only thing that is certain is that managed care in Georgia would bring a change in the way healthcare and social services would be available to all citizens, especially people with disabilities. The most important thing an individual can do is to become informed and stay informed. Knowing what is coming can help make any change easier to comprehend and deal with as it occurs.
