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

Meeting Summary

July 13, 2001

Council members present: Senator Toni Harp (Chair), Rep. Vickie Nardello, Rose Ciarcia and James Gaito (DSS), Barbara Parks Wolf (OPM), Thomas Deasy (Comptroller's Office), Dorian Long (DCF), Janice Perkins, Patrick Carolan, Judith Solomon, Ellen Andrews, Dr. Wilfred Reguero, Dr. Leonard Banco, Lisa Sementilli-Dann, Jeffrey Walter.

Also Present: James Linnane, Martha Okafor, Mark Schaefer (DSS), Deborah Hine (Anthem BCFP), Sylvia Kelly (CHNCT), Catherine Jackson (Health Net), Jody Powel, Paula Armbruster, Debra Brackett (Qualidigm), Mariette McCourt (Council staff).

Senator Harp introduced Thomas Deasy from the Office of the Comptroller, who will be replacing Robert Gribbon on the Council. The Senator stated she appreciated Mr. Gribbon's regular attendance and participation in this Council.

Rose Ciarcia noted that James Gaito would be leaving the Department of Social Services July 20 to take a position with ValueOptions. Mr. Gaito has worked in DSS for 8 years and was a key person in developing the HUSKY managed care program. Since 1994 he has worked with the Council and subcommittees. Senator Harp presented Mr. Gaito with a legislative citation for his dedicated work and collaborative efforts that he brought to the HUSKY program and his work with the Council. The Council members wished Mr. Gaito well in his new position, acknowledging that his leaving would be a loss both to the Department and the Council.

Department of Social Services

James Linnane reviewed the quarterly data 2000 (4) report:

Well Child screens (EPSDT)

There has been an overall 3% increase in the EPSDT participation ratio in 2000(4) compared to 1999(4). By age, the greater increases (5-6%) in screens are seen in children five years and under. There has been a 1-3% increase for children aged 6 years and older, with minimal change (1%) seen for children aged 10-14 years.

Dental Care

The following table summarizes Full-Time Equivalent (member months divided by 3) HUSKY A members aged 3-20 receiving any dental service during the 4^th quarter 1999 and 2000:

The following table compares preventive and treatment services by age for the 4^th quarters of 1999 and 2000 for HUSKY A:

Behavioral Health Services

Over the last year, the utilization of mental health services has increased from 4. 56% to 5. 03% and substance abuse services increased from 0. 68% to 0. 88%. The overall behavioral health utilization in HUSKY A (5. 91%) is at a higher rate than the Medicaid fee-for-service (FFS) rate of 4. 75% for a similar population.

*Preferred One ambulatory MH & SA data appear incomplete, affecting their total service % numbers. Preferred One was purchased from HealthChoice effective October 1, 2000.

Prenatal/Postpartum Care 00(3)

· The incidence of low birth weight is 8. 1%, slightly higher than that of the statewide general population (7. 8%).

· The percentage of HUSKY members receiving care in the first trimester (61%) remains lower than the statewide rate of 88. 3%. This may in part be due to `under-reporting' in that 46% of mothers were enrolled in a plan in the first trimester; first trimester care outside of managed care cannot be captured in the data. DSS and DPH continue to work on a process to capture prenatal care from the Vital Records.

· There was an increase in postpartum visits (64. 1%) in 00(3) compared to 99(3) rates (59%) of women continuously enrolled in a plan 56 days postpartum. During this time period approximately 11% of women were not continuously enrolled; 89% were continuously enrolled. Notes accompanying the data indicate that the health plans reported additional women with postpartum visits that were outside the 21-56 day period or visits that had insufficient data or incorrect coding for a postpartum visit. The addition of 307 visits would increase the percentage of postpartum visits in HUSKY to 79. 2%.

Emergency Room visits

Compared to FFS (72), ED visits per 1000 Member Months remain significantly lower (49) in 00(4). The Department commented that this reduction in ED visits could be interpreted as a proxy for improved health care access through primary care rather than through ED services.

Inpatient Services

The hospital admissions/discharges (excluding behavioral health) were described as declining early in the managed care program compared to FSS, but now seem to be approaching FFS rates. Discharges, per 1000 member months were 9. 7 this quarter, 10. 6 in 00(3), 9. 7 in 99(4) compared with 19994 FFS rates of 11. The average length of stay was 3. 3 this quarter, 3. 4 in 99(4) compared to FFS 3. 5. Questions from the Council suggested closer scrutiny of this data is needed:

· Marie Roberto (DPH) questioned if data trends of inpatient diagnosis information are available as this data is crucial to the management of inpatient use and cost. Targeted prevention strategies for the population could be developed, based on the data.

o Health plans commented that the majority of inpatient days are due to deliveries, newborns in neonatal care, asthma and hypertension.

o Dr. Reguero noted that changes in labor and delivery medical practices increased LOS in some cases (i. e. C-sections for all breech deliveries and all HIV mothers).

· Senator Harp stated that determining the reasons for inpatient admissions in HUSKY is important in order to assess the quality of care in HUSKY from a public health perspective. Separating maternal health care from other admissions would provide the State and managed care organizations an opportunity to work in collaboration with DPH to consider targeting public health interventions appropriate to the HUSKY population as compared to commercial population initiatives. The Department of Social Services agreed that looking at admission diagnoses and trending data over 3 years is a good approach to assessing care and cost management, using a disease management structure. Senator Harp encouraged the Department, MCO's and the Department of Public Health to collaborate in addressing HUSKY inpatient care from a public health perspective.

Other Council comments related to the quarterly report focused on the overall low performance for HUSKY dental care access:

· Rep. Nardello inquired about the status of the Dental Advisory Council. {Public Act 00-2 (DSS `Implementer' bill passed in the June 2000 Special Session) established a Dental Advisory Council of appointed members that would review and make recommendations for Medicaid dental program fees, based on dental utilization in the annual HCFA reports, monitor the effects of any fee increases on dental access and provider participation, evaluate dental care pilot programs, enhance public and medical community awareness of dental access issues, identify private foundation support for public and non-profit entities providing dental services, and make recommendations concerning the expansion of access to dental care and increase dental utilization. This Council was to submit an interim report to the General Assembly by April 15, 2001, followed by a final report by January 1, 2002}. The Department of Social Services reported that the legislation did not establish a designated agency to call the Council; however both DSS and DPH will move ahead on this legislative mandate. Rep. Nardello noted that a report deadline has already been missed and urged both agencies to bring this Council together.

· The HCFA (now called the Centers for Medicare and Medicaid Services - CMS) report on State action plans for dental access has been sent in draft form to HCFA.

· Rep. Nardello noted that dental utilization in Hartford County decreased from 47% in 1999 to 34% in 2000. As chair of the Medicaid Council Public Health Subcommittee, Rep. Nardello will request health plans, Hartford dental providers and DSS to meet to identify the reasons for the utilization decrease, seen in the data, in a County that has generally led other areas of the State in dental access.

o Rep. Nardello reported that she understood that CCMC is now only taking Medicaid children <age 14 years that are referred by a health provider; this will further limit dental care access in Hartford.

(7/19/01 Addendum from Dr. Leonard Banco after conferring with Dr. Skinner, Director of CCMC Dental program: CCMC Pediatric Dental Clinic is open to see all children up to the age of 12. There is no need for referral by a physician. They do specialize in children with complex medical conditions and difficult diagnoses along with routine dental care for otherwise healthy kids. When a child over the age of 12 calls, they suggest calling dental clinics at Hartford Hospital, Saint Francis Hospital and UConn.

The reason for the age limit is the rapid growth in volume in the program. . . There has been a 30% increase in volume over the past year. Interestingly they have reduced their no-show rate from 60% (!) to 21% by institution of reminder calls, among other strategies. They see 7,500 kids a year. Dr. Skinner also noted that part of the increased demand has arisen from the decreasing participation of community dentists in Medicaid. He says that although the number of participating dentists was already limited, there are virtually no community dentists in the Hartford area still seeing any significant number of Medicaid patients. He feels this is all due to the extremely low fees paid by the plans. . . . ).

o Dental access data from the Children's Health Council identified that 40% of the encounters did not have a provider ID #. Rep. Nardello stressed it is important that dental providers give this information with their claims data. The Department stated that the Medicaid # is required; however the tax ID number is also allowed. Identifier numbers may not be missing; rather it becomes necessary to `cross-walk' identifier numbers, which the CHC may not be able to do.

o Changes in the procedure codes may be creating a problem with encounter data reporting. Deborah Hine (ABCFP) stated Anthem is reviewing their dental data and will resubmit the data.

o Pat Carolan (BeneCare) commented that data might have been lost with the Preferred One HealthChoice to FirstChoice transition in October 2000.

· Dr. Reguero observed that private provider dental care has not worked in Medicaid. The State needs to continue to support creative projects that provide dental services in the public sector. Pat Carolan stated that private providers are freezing their Medicaid practice numbers. This has been attributed to fees (payment is $ . 30-. 40/$ 1. 00) as well as a good economy in which consumers can afford out-of-pocket payment for services.

Department of Social Services Dental Action Plan

Martha Okafor presented an overview of DSS plans to increase dental access, and reduce the level of oral disease burden through oral health education and quality dental care through the promotion of best practices (see attached overview). Through collaboration with managed care organizations, HCFA, DPH and UCONN Health Center, the Medicaid Managed Care Council, Children's Health Council, Head Start, Community Health Centers and the CT Community Healthcare Initiative, targeted activities have been identified, including:

· Infrastructure development to improve the private provider network as well as strengthen the safety net capacity, link oral health programs across the ages including prenatal care and build a community/MCO coalition.

· Program development to improve access to preventive and restorative care, integrate oral health care with general health care, bring procedure codes up to date with current practices and address client missed appointment rates.

· Policies have been developed to simplify the Medicaid dental policy, and the dental hygienist regulations have been completed and approved by the legislature. Work is on going for the MCO's dental policy/procedure guide and oral health and anticipatory guidance guidelines for consumers and health providers.

There are current ongoing partnerships that address dental care that include:

· Dental hygienists, HUSKY managed care organizations and DSS worked with the Medicaid Council to develop informational grids for credentialing, claims and out-of-network services (see attached) that DSS will expand upon for dental provider information. Ms Okafor commented that the regulations for PA 99-197, which allows dental hygienists with two years clinical experience to practice in a public health setting without supervision of a licensed dentist, are in effect, having been approved by the Office of the Secretary of State.

· DSS and HCFA have developed a pilot project with a regional Head Start program and the CT Dental Society to address dental capacity, dental hygienist screens.

· The CHC has a pilot to guide Head Start programs in community outreach, modeled after a national program.

· The MCOs are collaborating with WIC sites, Head Start programs and School Based Health Clinic around dental care access.

HUSKY Managed Care Organizations' Dental Action Plans

Health Net, formerly PHS

Catherine Jackson, Director of CT Medicaid, Health Net of the Northeast, described the health plan's

dental access goals, objectives and status of these objectives:

Ongoing initiatives:

· Educate new members on the importance of preventive dental care with the first welcome call.

· Monitor initial well care dental appointment with new Primary Care Dentist within 6 months of enrollment in the plan.

· Enhance dental network to ensure sufficient access to services. Dental hygienists are critical to meeting this objective. Almost all the dental hygienists that have applied are enrolled.

· Design and develop a SBHC collaboration making new treatment available in Stamford schools.

Health Net is also developing a Memorandum of Understanding with WIC centers in Fairfield, New Haven and Litchfield counties for a pilot outreach initiative which will begin 9/01.

The Stamford SBHC is an example of collaboration among HUSKY managed care plans, the local health department, the education department and community-based programs, targeting both dental services and insurance access. The pilot dental screen and sealant program in grade 2 combines health care access by identifying uninsured children with preventive dental care. Dentists will volunteer to treat students at one of the schools. The MCO Dental Advisory Council will work with participating dentists to determine how these voluntary services can be billed so that the claims will be entered into the encounter data. Mr. Linnane (DSS) commented that free services such as vaccines and State lab lead tests do not incur a Medicaid managed care claim; hence the data for the service is not available for HUSKY data reports. Both DSS and DPH are working to match DPH data with Medicaid data in order to capture the information for CMS (HCFA) reports.

Senator Harp requested DSS take the lead in working with DPH and other entities to create an ongoing process that would capture free screens or services to Medicaid managed care enrollees that currently are outside the encounter data reports.

Health Net and Anthem BCFP have jointly purchased mobile equipment for Stamford. The two plans' dental vendors (Doral and DBP) accept electronic billing and the plans will work with SBHC's to use this media for claims submission. Martha Okafor commended Dr. Ardel Wilson (DPH) for facilitating a collaborative process with DPH, DSS, SBHC's and managed care organizations to assist the Centers in the MC claims process. The Centers are required to bill Medicaid as part of their DPH renewal grant; improvement in the claims process will provide more accurate encounter data that is used to evaluate access to and the quality of the HUSKY program as well as enhance clinic revenues for services provided under Medicaid.

The Council commended the creative collaborative efforts among the health plans and the community based agencies and organization in addressing both dental care and access to HUSKY.

BeneCare, dental vendor for CHNCT and FirstChoiceCT/Preferred One

Patrick Carolan and Tony Coletta (RDH, Benecare coordinator) presented three dental community outreach projects designed to meet the goals of providing comprehensive pediatric dental services in greater New Haven County, increasing community dentist participation, uniting educational and professional institutions and improving dental care access and the oral health of underserved children.

Project 1

Dental screening at the Yale New Haven Primary Care Center targeted children who have not received dental care within the past 1-2 years or never received dental care. The dental hygienist did on site (primary care clinic) dental screens. Approximately 478 children were screened that met the criteria for lack of recent dental care; 378 of these children screened kept appointments for dental treatment (80% show rate) and 192 returned for a 6-month follow up preventive appointment The appointment show rate was impressive, given that missed appointments account for 50-70% of the general pediatric scheduled visits.

Project II

BeneCare, with CHNCT and FirstChoice/Preferred One, collaborated with the University of New Haven School of Dental Hygiene, the West Haven Board of Education, the local Department of Public Health, regional DSS office and UCONN Health Systems to provide student dental education and screens in three elementary schools. The initiative was coordinated with HUSKY enrollment in that uninsured families were connected to Benova. BeneCare worked with the New Haven Dental Society to identify dentists willing to provide dental services in the clinic and agree to see children for their 6-month follow-up visit in the dentist's office.

· Dental education was provided to 5 schools (325 children).

· Dental education and screens were provided at 3 sites (630 children).

· BeneCare can determine past dental screens of these children while in BeneCare to reduce unnecessary screens.

· Of the pilot schools, Thompson school families (393) returned the permission forms (and insurance information): 324 children were screened (105 had no screen), with 201 needing only cleaning.

· 72 Preferred One and CHNCT families allowed dental screens.

· Of the 35 dental appointments that BeneCare scheduled, there were only 4 (11%) missed appointments.

· BeneCare's dental coordinator and the School Nurse referred children that were members of plans other than FirstChoiceCT/Preferred One and CHNCT to appropriate dental organizations.

Project III

Benecare is working with private dental offices in West Haven, Meriden, Hartford and Vernon to reduce the missed appointment rates. Benecare obtains the list of Medicaid appointments for CHNCT and P-1 patients, gives this to the two MCO's. The plan's staff call the family to remind them of the appointment and arrange for transportation, finding volunteer community chaperones for children <12 years as necessary and providing activities for the children while they wit for their appointment in the office.

Rep. Nardello applauded BeneCare's efforts to improve dental access through these initiatives. The pilots will afford the plans an opportunity to determine which efforts have positive results. Mr. Carolan stated that while the dental fee rates are a factor in dental participation, other issues such as missed appointments and available transportation contribute to inadequate dentist participation in the program and lower dental utilization. The UNH pilot includes a fee incentive of additional case management fees paid to providers.

Anthem BlueCare Family Plan/Dental Benefit Providers (DBP)

The objectives of the collaborative ABCFP and DBP dental action plan are enhancing member and provider education, improving access and developing benchmark and measurable outcomes. The initiatives include:

· Member outreach & education that focuses on two age groups: 2-5 and 10-14, with outbound calls to members due for a dental screen, reminder postcards and plan assistance with making and keeping appointments. The goal is to increase annual dental screens by 10% for children aged 2-5 years and 5% for children aged 10-14 years.

· Access Pilot includes educational information to members and on site member service and outreach staff at WIC centers and pediatrician's office to work with members to link them to appropriate services. Non-ABCFP members are referred to the member's plan for assistance. There will be a marketing campaign for dental services with member outbound calls and work with "grass roots" community groups. The results of this initiative will measure utilization against objectives, allowing adjustments in the plan's future activities.

· Appointment study will gather missed appointment data from Hartford-based providers, track the data, work with members who miss dental appointments and evaluate the results of this intervention.

· Current educational activities include modifying the welcome call script to emphasize the importance of dental exams and cleanings. A new dental corner has been added to the member news letter, educational brochures have been distributed to pediatricians, OB/GYN and WIC centers. Appointment keeping is being monitored and the plan is actively recruiting dental hygienists.

Sen. Harp thanked ABCFP and DBP for their efforts to improve dental access, commenting that it continues to be important to follow up with clients as to the reasons for missed appointments. Rep. Nardello stated that obtaining claims data is important and encouraged plans to work with providers to ensure accurate data submission.

Sen. Harp and Rep. Nardello thanked both Martha Okafor (DSS) for her leadership in bringing about the HUSKY health plans collaborative planning process and the health plans for their creative, collaborative efforts with each other, academia, providers and community groups to improve dental access within the HUSKY program. The Council looks forward to ongoing reports related to these initiatives.

Other Items

Resolution of behavioral health claims: the Department is continuing to work on the resolution of the mediated unpaid claims and will report on the status of these in September.

Medical `holds' for children with psychiatric diagnoses: Sen. Harp stated that she has met with providers, MCO's and State agencies regarding prolonged Emergency Department (ED) and medical unit stays for children with a primary psychiatric diagnosis because of difficulty securing inpatient beds. Senator Harp requested clarification from the HUSKY health plans regarding their responsibility for reimbursing ED stays beyond the 23-hour hold. Anthem BCFP was the only plan to comment that there is no mechanism to pay hospitals beyond the initial ED visit. While the plan is not financially responsible for the ED stay, Ms. Hine stated that the behavioral health vendor does work with the ED to find an appropriate place for the child. Mark Schaefer (DSS) stated that the department would be working with Mercer on data related to this issues and the freeing up of children's psychiatric beds. The department will look into the payment issues related to prolonged ED/medical unit placement of these children. A report will be made to the Behavioral Health Subcommittee and the Council.

DSS/MCO contract negotiations: the negotiations are finished and the contract has been sent to the MCO's for legal review, and will be reviewed by the Attorney General's Office. Capitation rates should be available to the MCO's by July 18, 2001.

Subcommittee Reports

Quality Assurance: Paula Armbruster reported the key areas that will be addressed are adolescent health, pediatric obesity and diabetes, HIV, adult health quality indicators. The Asthma work group and the smaller MCO/provider group have been working on streamlining the administrative processes in HUSKY and a more collaborative community and provider asthma management process.

Public Health subcommittee: Rep. Nardello will call the committee together to address dental care access in Hartford and follow up on the safety net provider issues raised in the survey done bay Barton Bracken and brought to the Council.

Consumer Access subcommittee: Senator Harp thanked Ellen Andrews for her work on the subcommittee and bringing forward important health care access issues. Ms. Andrews has resigned as chair. Senator Harp encouraged those interested in the Chair and CO-Chair positions to contact her.

The Council will not meet in August. The next Medicaid Managed Care Council meeting is scheduled for Friday September 14, 9: 30 AM in LOB RM 1D. The agenda will include a report from DSS on the contract amendments, and the report on psychotropic drug use among children in Connecticut's HUSKY A program.

Enjoy the rest of the summer.