Connecticut
Medicaid Managed Care Council
Legislative Office Building Room 3000, Hartford CT 06106
(860) 240-0321 Info Line (860) 240-8329 FAX (860) 240-8307
www.cga.state.ct.us/ph/medicaid
(Next meeting:
Friday June 4, 9:30 AM LOB RM 1D)
Present: Sen. Toni Harp, Rep. Vickie Nardello, David Parrella & Rose Ciarcia (DSS), Ardel Wilson & Martha Okafor (DPH), Dr Victoria Niman & Naidia Arcenes (DCF), Dr Wilfred Reguero, Ellen Andrews, Marjorie Eichler, Dr. Edward Kamens, Janice Perkins & Linda Pierce (MCOs), Dr. Alex Geertsma, Jeffrey Walter.
Also Present: Mark Schaefer (DSS), William Diamond (ACS), Judith Solomon, Deb Poeria, Paula Armbruster, Paula Smyth (Anthem BCFP), Sylvia Kelly (CHNCT), Douglas Hayward & James Gaito (Preferred One), Dr. Alan Kazdin (Yale Univ.), Dr. Paule Couture, Denise Stevens (Matrix), M. McCourt (staff).
·
Co-payments are eliminated for HUSKY A, Medicaid
and SAGA adults effective July 1, 2004 (PA 04-258). (Premiums {Sept SS, PA03-1, Sec 11} for non-managed care
Medicaid clients were also eliminated).
Public notice and consumer, health providers and HUSKY MCOs notification
of the changes will be done by June 1, followed by changes to the State Medicaid
Plan.
·
Money was included in the budget for
parent/caregivers with earned income (16,000 adults) to continue enrollment in
Medicaid for the second year of the TMA period ending April 1, 2005.
This was based on the recent 2nd Court of Appeals decision.
·
While imposition of new and increased premiums for
HUSKY B band 1 and 2 continue, members will not be dis-enrolled in May 2004.
The Department will submit a report to the legislative Committees of
Cognizance by June 1, 2004, which will indicate how the DSS plans to proceed
with this issue after June 1, 2004 (HB 5801, Sec 107).
Approximately 2000 children are in families that have not paid premiums
and could potentially be dis-enrolled from HUSKY B.
·
The DSS may move pharmacy benefits for HUSKY
and Medicaid to a separate contract with a Pharmacy Benefit Manager (PBM) or
within the DSS Preferred Drug List. (PA 04-258, Sec. 7, effective July 1,
2004). The carve-out decision
has not been made nor is DSS certain about the impact of this provision in
relation to the timing of the DSS/MCO contract cycle.
The DSS complimented the Council members and BH Subcommittee on their
continued work toward streamlining the existing HUSKY formulary operations.
HUSKY
service carve-out status was reviewed:
·
The DSS intends to implement the Dental service
carve-out October 1, 2004. This change would be part of the next DSS/MCO
contract cycle. All four MCOs have
signed a current contract extension through September 30, 2004.
·
The BH service carve-out remains uncertain,
although the DSS is looking toward the possibility of carving out BH services
within HUSKY. The 2004 legislation
did not authorize the creation of a full Behavioral Health Partnership (BHP)
with BHP dollars within separate agency (DSS, DCF & DMHAS) accounts.
·
No decision has been reached on a pharmacy
carve-out (see above).
Comment/questions
from the Council included:
·
Regarding the dental carve-out, the DSS is close to
making the decision on the dental ASO and will communicate the decision in
writing to the Council.
·
Regarding HUSKY B premiums, the DSS stated ACS, the
enrollment broker, has anecdotal information from follow-up reminder calls: some
families have declined continued coverage, perhaps returning to employer-based
insurance when the HUSKY B cost share increased, and some families have paid in
response to the calls. Dr. Reguero
stated there is concern that over 2100 children could be uninsured as some
hospitals are reluctant to take non-emergency free ambulatory care for the
uninsured due to their budgetary constraints.
The DSS is aware of the serious impact of cost sharing on children’s
insurance and will consider that as the agency makes the policy decisions.
The June 1 report will outline the HUSKY B DSS policy for FY05.
·
Behavioral health services:
o
Changing the delivery model for BH Services in
HUSKY A & B would require an amendment to the 1915(b) waiver with revision
of the actuarial soundness of the MCO capitation rates and State Plan changes.
Both require CMS and legislative committee approval. These changes would also
significantly impact the MCO per member per month capitation rates.
o
The BHP collaborative spirit continues with the
three agencies working together. However reaching consensus on major issues such
as operational responsibility and provider reimbursement is difficult to achieve
between the two branches of government. The DSS commented that the current
system does not work well because of structural barriers rather than the fault
of providers or clients.
o
The time line for implementing a HUSKY BH carve-out
may go beyond 2004 because it is a lengthy process.
o
Sen. Harp asked how we moved from the original
KidCare legislation three years ago that created collaboration between DSS and
DCF to the three agency BHP. Dr.
Mark Schaefer stated that administrative costs associated with implementing
KidCare alone exceeded the available appropriations.
At the time that KidCare was developing, DMHAS began discussions with DSS
on adult mental health. There seemed to be common goals (administrative
efficiency and clinical management by the specific agencies) for child and adult
BH services. The BHP was thought to
respond to the need for administrative efficiency through a single
administrative (ASO) entity, which would provide service integration across ages
among the three agencies. Currently
one possibility is to implement KidCare through a BH carve-out with an ASO,
implement the structural changes to the administrative operations and build
credibility and trust among stakeholders as community alternatives to
institutional care are expanded and/or developed.
·
Regarding the possible pharmacy carve-out, Rep.
Nardello encouraged the DSS to make the financial basis for any decision for a
different delivery model transparent, given national attention to PBM issues.
·
The DSS stated, in response to Rep. Nardello’s
question, that the State is not pursuing the HIFA waiver nor any form of a
Medicaid block grant approach for HUSKY A (HB 5801, Sec.106).
ü
Overall
the May HUSKY A enrollment increased by 1521 members (average monthly increases
have been 1000 members). Within
HUSKY A, adult enrollment increased by 627 (monthly increases average 4-500
members), those <19 years enrollment increased by 894 (monthly average
increases are 500/month).
ü
HUSKY
B enrollment peaked in October 2003 (15,241), leveling to the low to mid
14,00’s since October 03. In May,
HUSKY B enrollment increased by 257. The
number of HUSKY B families that did not renew their coverage peaked in March
2004 (382), but fell to 246 in April. The increases in premiums began February
1, 2004.
ü
Since
October 2003 the number of non-renewals per month climbed to >250/month while
this number remained about 150 or less May-September 2003.
ü
Consistently,
approximately 45% of all applications and renewals received by ACS are referred
to DSS regional offices for HUSKY A determinations.
The
Department was asked to report on monthly enrollment losses, reasons for dis-enrollment
and the percentage of those dis-enrolled that were enrolled in the following
month (RWJ grant).
The
Council had been asked to review the information about on-line eligibility
applications established by other states provided to members after the April
Council meeting in order to vote on the recommendation from the Consumer Access
Subcommittee. Prior to considering
the recommendations, Sen. Harp asked the MCOs if they had noted any impact on
their operations that potentially could be related to delays in eligibility
determinations. Mr. Hayward (POne) stated they have seen a higher percentage of
pregnant women enrolled in their plan in the 3rd trimester in 2004
compared to 2003. Many premature
deliveries are associated with late enrollments. Whether the delays are due to eligibility delays is unknown
at this time. Sen. Harp asked the
health plans to review this, perhaps focusing on pregnant women’s timely entry
into their plans. Agency early
retirements and staff layoffs have significantly impacted the staffing resources
at the regional offices.
The
recommendation that the DSS implement on-line applications for Medicaid and
HUSKY was approved, with the DSS abstention.
Sen. Harp stated that while no new money was attached to this provision
in the budget (PA 04-216, Sec. 26, subsection d), the DSS was asked to
look at the process and parameters for on-line applications, reporting back to
the Council in several months. Sen.
Harp noted that a later recommendation could be entertained for OPM to include a
budget option in the next budget year.
Dr.
Alan Kazdin, Yale University School of Medicine, the evaluator for the BH
Outcomes study that focused on outpatient care, reviewed the study findings with
the Council. The intent of this
study, initiated by the Medicaid Council in collaboration with the DSS,
was to examine the impact of treatment on a child’s functioning,
comparing pre and post treatment assessments of multiple characteristics of
children and families as well the broad types of BH services provided.
Of the anticipated 4000 completed forms (based on a percentage of
outpatient (OP) BH service utilization for children in HUSKY A), 893 completed
pre and post forms were available for the study.
The
key findings were:
ü
Children
in OP treatment demonstrated statistically significant improvement; however the
magnitude of change, measured by global functioning (GAF) and reduction in
mental, emotional, medical/health and role performance impairment, was
relatively small.
ü
Most
children received multiple and diverse combinations of treatment, with some type
of individual and family therapy being the most common combinations.
ü
Treatment
outcome was influenced by socioeconomic (SES) disadvantage and severity of
initial impairment. Greater SES
disadvantage and severity of the presenting impairment was predictive of less
improvement.
ü
Family
involvement in treatment influenced change and the parent’s rating on desired
treatment outcomes met; more family involvement in treatment was associated with
greater change in the children post treatment.
ü
There
were few differences in treatment outcomes that were associated with the health
plans, whether or not these differences were controlled.
Council
comments:
·
This study is an important step in beginning to
evaluate outcomes. Going
forward, it is important to evaluate treatment modalities, which are evidenced
based and associated with what outcomes. Evaluation
and identification of effective treatments in the face of limited resources is
crucial to making informed policy decisions.
Dr. Kazdin stated there is growing evidence on BH techniques that impact
the most people, some of which may be less costly
yet widely disseminated. (i.e.
parent training videos are available: parent intervention is key to managing
aggression, oppositional disorders, which account for about 50% of BH
referrals). Dr. Niman (DCF) stated
she would like to work with Dr. Kazdin regarding parent training for foster
families.
·
How can outcome information be obtained in the
future? Dr. Kazdin stated that the
current measures could be streamlined and put into a provider-friendly form that
would lend it to be more easily coded.
·
Clinician training is an important part of the
process of applying evidenced- based practices.
o
Yale Child Studies Center works with three levels
of trainees in clinical skills development and appropriate use of
evidenced-based interventions.
o
Dr. Schaefer (DSS) stated that evidenced-based
practice is crucial to the BHP, in
improving system efficacy and efficiency as well as promoting continued
clinician education. The proposal for ‘enhanced clinics’ that could receive
financial incentives, provides an opportunity for applying these concepts and
evaluating how to promote best practices throughout the system of care.
o
The State and/or credentialing boards require
certain health care specialties to maintain certification through continuous
education credits (CEU). This may be a mechanism in the future that could be
applied to other disciplines to maintain knowledge of “what works and for
whom”.
Jeffrey
Walter, Chair of the BH subcommittee, stated the subcommittee would further
discuss the study and findings. Sen.
Harp and Rep. Nardello thanked Dr. Kazdin for his work with the Medicaid Council
on this project and look forward to continuing this work with him in the future.
Department of Public Health: Medical Homes Prove Quality
Care to Children with Special Health Care Needs (CSHCN) (see
accompanying power point doc)
Martha
Okafor introduced Denise Stevens, from Matrix that assessed family and provider
perspective on needs related to CSHCN and the effectiveness of “medical
homes” for families and CSHCN.
Approximately
10-43% of families reported needing but not receiving services for their child
with special needs. The key
obstacles reported were insurance coverage and access to resource information
and care coordination.
Pediatricians
described obstacles to providing effective care for CSHCN.
These included insurance issues, coordination of services and family
issues.
Case
managers for CSHCN identify and help families access appropriate services, thus
reducing redundancy and more costly interventions. Evidence is emerging that the medical home model,
which encompasses primary care provider (PCP) family-centered, comprehensive,
coordinated and continuous care, are associated with better health outcomes and
lower care costs. Annualized costs for care coordination in a community-based
pediatric practice providing 774 visits for 444 patients ranged from $22,809 –
33,048 (see the May 2004 supplemental issue of the journal Pediatrics
for more information)
The
major barrier to the development of medical homes is the increased use of
provider/staff time that is not associated with increased reimbursement.
Effective coordinated care is associated with longer office visits, care
coordination with multiple payer systems and consultation with multiple
specialty services that is only partially reimbursed, if at all.
Dr.
Paule Couture, a pediatrician in a private practice of 15,000 patients that
include Medicaid and ethnically diverse families, participated with her staff as
one of the three practice sites in the CT medical
home collaborative. The practice
screened children for special needs, developed a care plan with the family and
coordinated care, linking state systems and medical specialty systems into a
coordinated treatment approach with the family.
The most beneficial and powerful change, from practice perspective, was
the inclusion of parents in care planning through review of the pre-visit
questionnaire and development of a treatment plan.
The
DPH currently is expanding the medical home collaborative in CT to a total of 10
practices, identifying CT pediatricians interested in becoming a medical home
(44 CT practices), soliciting proposals for Regional Medical Home Support
Centers that will provide technical assistance, family support and care
coordination to medical homes in their region and creating a curriculum of a CT
Medical Home Academy in partnership with the CT AAP Association.
The DPH would support a QA improvement project by partnering with key
stakeholders to establish medical homes and monitor the performance provided.
Council
members commended the DPH and practitioner efforts to implement a more
coordinated approach to care for CSHCN at the practitioner level and the Matrix
report on medical homes. What is
needed is identification of the interface between practice care coordination vs.
more distant coordination, identification of appropriate care coordination
codes, uniform criteria for care coordination and intensity of need and
integration of medical and behavioral health services for this population.
Since the BH subcommittee had previously worked with DSS and the MCOs to
create criteria for reimbursed provider-based case management for children with
complex MH needs, Sen. Harp requested DPH, DSS, the HUSKY MCOs, Jeffrey Walter
and Dr. Geertsma meet as an ad hoc group to address this and other issues
related to the above identified areas.
Next
Council meeting is on Friday June 4 at 9:30 AM, in LOB RM 1D (note
room change)