III.
Leadership Workshops on Managed Care and
Child Health
What did States choose to discuss?
The design of the Leadership Workshop
project offered States considerable flexibility
in defining
the topics they wished to discuss. For
example, the project brochure suggested
topics such as:
- How
to promote the highest quality of health
care through the managed care contracting
process.
-
How to use the pediatric purchasing
specifications as a tool to improve
managed care
contracts and ensure the inclusion of
Title V services and comprehensive child-focused
benefits— i.e., Early Periodic
Screening and Diagnostic Treatment (EPSDT).
- What
key terms and elements to look for when
negotiating a fiscally sound managed
care
contract.
- How
to evaluate contract provisions using
practical checklists.
How to foster contractual relationships
with managed care organizations and provider
groups and Medicaid/SCHIP agencies.
-
How to negotiate provider network specifications
to ensure adequate access to primary
care
pediatric providers and to increase
provider participation in the Vaccines
for Children (VFC)
program.
-
How purchasing specifications can be
used to tailor contracts to ensure quality
health care for
children with special health care needs.
The five States which held workshops selected
an array of issues and topics that reflect
some of
the current challenges and unmet needs
in maternal and child health. (Note that
Pennsylvania
held two workshops, the first and last
in the series.) The issue “briefing
sheets” contained in
appendices 1-5 describe these issues in
some detail. Table 3 summarizes the issues.
Three
checks show States that gave priority
to an issue (i.e., made it a focal point
of their agenda,
briefing papers, and discussions). When
an issue was identified as a subtopic
in the briefing
sheets, two checks are shown. Those discussed
but not identified as a priority by the
planning
group have one check.
Children’s mental health, particularly
early childhood mental health, was a topic
of discussion in
every workshop. Mental health was one
of the three priority issues in some States,
and a lesser
point of discussion in others. In Connecticut,
the discussion of early childhood mental
health
was linked to planning under the MCHB
State Early Childhood Comprehensive System
grant.
In Wisconsin, the topic of managed care
purchasing for children in out-of-home
placement
necessitated discussion of mental health
services across children and adolescents.
Leadership
Workshop participants in each State expressed
concerns about the provider supply, screening,
referrals, and mechanisms to “carve-out”
or “carve-in” this population.
Another
topic identified in all five States was
children with special health care needs.
In some
States, these discussions focused more
specifically on children with mental health
needs, in outof-
home placement, and with developmental
delays, but also addressed general concerns
about
linkages between Title V Maternal and
Child Health Agencies and managed care
providers. In
Connecticut, Ohio, Pennsylvania, and Wisconsin,
participants described initiatives to
ensure that
each child with special health care needs
has a medical home. Some had concerns
that too little
had been done to engage the MCOs and their
providers in efforts to ensure medical
homes for
children.
As a result of projects funded by the
Commonwealth Fund, the MCHB State Early
Childhood
Comprehensive System grants, and other
initiatives, many States are looking at
opportunities to
finance services that promote child development
with Medicaid and SCHIP. In their Leadership
Workshops, Connecticut and Ohio gave particular
attention to these issues. Screening and
referral mechanisms, provider training,
and finance mechanisms were discussed.
[D]
Administrative issues also were on States’
agendas, particularly those related to
collaboration
among Title V, child welfare, and Medicaid
agencies. Representatives for local public
health
attended each meeting and expressed concerns
about relationships with MCOs. While GWU
research suggests that States have made
considerable progress in defining such
relationships in
managed care contracts, local public health
leaders from Pennsylvania and other States
identified
ongoing issues of concern.
What did States’ leaders
hope to do?
Several strategies related to improving
Medicaid and SCHIP managed care contracts
and
practices emerged from the discussions
at these five State Leadership Workshops.
First and
foremost, participants expressed enthusiasm
for meeting as an interagency and public-private
sector group. This enabled these State
and local leaders to discuss cross-cutting
issues, debate
alternatives, and identify possible action
steps requiring collaboration. In four
out of five of the
States, some or all of the participating
leaders reconvened to further advance
their discussions
and strategies. While the workshop process
was not formally evaluated, the enthusiasm
of
participants and the initial action steps
taken since the workshops indicate that
these were useful
discussions.
Specific and actionable strategies include:
Reviewing and monitoring the system of
care
-
Review the State’s Medicaid and/or
SCHIP managed care contracts using the
GWU
purchasing specifications and other
tools.
-
Develop a system or finance map to show
the relationships among agencies and
the flow of
funds for specific priorities such as
early childhood mental health or child
development.
-
Identify gaps in provider networks between
Medicaid and SCHIP have been widely
reported. States could use geo-mapping
or similar approaches to identify specific
areas in
need of improvement.
-
Revise care coordination or case management
strategies, after identifying duplication
of
effort, overlapping service areas, and
targeting funding opportunities.
MCO practices
-
Determine the best use for and the best
practices of MCO special units for children
with
special health care needs, pregnant
women, EPSDT, and so forth.
-
Make greater use, through contracts,
of performance monitoring, quality studies,
child health
indicators, and similar quality improvement
mechanisms.
-
Require, through contracts, relationships
between MCOs and local public health
and other
child serving agencies.
-
Adopt pay-for-performance strategies
to maximize existing dollars and health
provider
capacity.
Special populations
-
Consider special issues related to adolescent
health, including confidentiality, individual
cards, and services in transition to
adult years.\
-
Clarify contract language and service
strategies with regard to child Medicaid
beneficiaries
in out-of-home placement, including
those identified through the Child Abuse
Prevention
and Treatment Act (CAPTA).
-
Clarify periodic and interperiodic screening
under EPSDT, particularly related to
children at
risk for mental and behavioral health
problems, developmental delays, and
other special
health care needs.
-
Clarify the definition of child development
services (e.g., screening versus diagnostic
assessment) under Medicaid’s child
health component, EPSDT.
-
Adopt contract language to encourage
MCOs and their providers to adopt a
medical home
approach, building on best practices
from the demonstration projects.
-
Improve care coordination for CSHCN,
particularly for those children who
have care plans
in multiple systems of care (e.g., health,
child welfare, special education, early
intervention).
-
Refine the approach to serving children
with or at risk for mental health problems,
including
revised billing codes, service definitions,
and referral mechanisms.
Financing mechanisms
-
Use Title V block grant funding as “glue”
to hold together various services, case
management, and care coordination approaches,
as well as to fill gaps.
-
Enhance capitation fees for medical
home providers of children with special
health care
needs and/or adopt Medicaid managed
care payment adjustments based on pediatric
patient
acuity.
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