Designing Healthcare Systems That Work for People With Chronic Illnesses and Disabilities

Care Coordination

People with Special Needs

Presenter: Deirdre Duzor, M.A., Director, Division of Quality Systems Management, Center for Medicaid and State Operations, Health Care Financing Administration (HRSA), Department of Health & Human Services (HHS), Baltimore, MD.

The Balanced Budget Act of 1997 required a report to Congress on safeguards/protections needed for people with special healthcare needs enrolled in Medicaid managed care. The study was done internally by the Health Care Financing Administration (HCFA) using existing research.

The National Academy for State Health Policy was asked to convene a group of approximately 20 stakeholders; the group met in March and July, 1999.

The report's targeted issues are:

• Identification, including the need for communication between States and Managed Care Organizations (MCOs) (e.g., identifying Supplemental Security Income [SSI] beneficiaries).
• Stakeholder education and involvement, noting that consumers and providers need to understand the Medicaid system.
• Matching services to needs, encouraging flexibility, individualized beneficiary assessments, and medical necessity determinations.
• Coordination and continuity of care, noting that care coordinators will not be successful if they have responsibility without authority, and that States may need to take responsibility to fill in gaps in services.
• Use of experienced providers, as evidenced by hands-on experience more than credentialing (e.g., HIV-experienced physicians, who have no formal credentialing process).
• Quality monitoring, noting that methodological difficulties exist in developing tools with statistical significance for the small populations of people with disabilities enrolled.
• Payment approaches.

When asked what would happen in Washington once the report became public, Ms. Duzor noted that congressional representatives may turn some of the recommendations into proposed legislation, but eventual passage could not be predicted. Many of the recommendations could be implemented by HCFA through proposed regulations, without the need for legislation.

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