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.