Providing High-Quality Services to Children with Special Health Care Needs Under Managed Care

Summary of a Workshop for Senior State and Local Health Officials

This workshop addressed the information needs of public officials striving to ensure that the trend to managed care translates into access to high-quality care for children with special health care needs, including the important roles that public programs play in assuring access to quality health care services for this population and the challenges and opportunities that managed care presents. It was held in San Diego, California, September 10-12, 1997.

About the Workshop Sponsor.

Overview

As the trend toward enrolling Medicaid-eligible populations in managed care continues, States have begun to address the potential challenges involved in providing coordinated, high-quality care to high-risk or high-cost populations through managed care arrangements. Of particular concern in many States is the population of children with special health care needs (CSHCN), many of whom are enrolled in Medicaid. This population may include children with chronic illnesses, physical disabilities, or serious emotional disturbance.

Structuring a health care system to effectively provide high-quality services to children with special health care needs requires many considerations:

• First, such a system needs to provide CSHCN with access to the full range of specialty and support services and technologies that they need to treat their chronic conditions and prevent further disability.
• In addition, such a system must not lose sight of the fact that CSHCN, like all children, need access to routine preventive and primary care to detect and treat the common illnesses of childhood.
• Finally, to coordinate this array of services, CSHCN and their families commonly need intensive case management to assist them with arranging, organizing and advocating for care.

Meeting these needs within a managed care environment represents an even more complex challenge. On one hand, managed care's fundamental principles of assigning all enrollees to a primary care "medical home" and integrating service delivery offer great promise for CSHCN. On the other hand, important uncertainties remain regarding whether or not managed care systems can adequately meet the needs of children with higher ongoing medical costs. The incentives involved in capitated arrangements raise the concern that children with complex conditions may not receive all of the services they need.

In addition, not all managed care plans have the capacity to serve CSHCN; it is not uncommon for managed care organizations' panels of physicians and ancillary providers to not include all of the specialists, therapists, and other support providers needed to appropriately serve CSHCN. The challenge for State officials, therefore, is to design systems of services for CSHCN enrolled in managed care plans that will provide access to the wide range of services needed by this population.

Developing approaches to ensure that high quality care is provided to CSHCN served under managed care arrangements represents a significant challenge. Both systems that monitor the process of care and those that measure the outcome of care are important in the development of a comprehensive quality assurance system for the care of CSHCN. However, while the public and private sectors are in the process of developing systems to monitor the quality of care provided to children and families under managed care, systems for assuring the quality of care provided to CSHCN specifically are still in the early stages of development. Current research and demonstration efforts do, however, offer hope for the future.

Objectives

The major objectives of this workshop were to:

• Provide participants with an opportunity to obtain an overview of the needs of the CSHCN population and the implications of those needs for managed care systems.
• Benefit from other States' experience in designing strategies to serve this population under managed care.
• Discuss emerging approaches for measuring and monitoring the quality of and access to care provided under managed care systems.

Through this workshop, important information from the health services and financing research fields and from State practices was shared with public policymakers and program administrators. This workshop covered four major health care policy concerns:

• The issues and challenges involved in defining the population of children with special health care needs, as well as the range of services and service delivery systems they need.
• The potential challenges raised by the introduction of CSHCN into managed care, with a particular focus on the development of payment mechanisms for this population.
• Potential policy design options that a State may use in designing managed care systems to serve CSHCN.
• The latest trends in the development of approaches to measure and monitor the quality of care provided to CSHCN under managed care arrangements.

Participants

This workshop was intended for State and local government officials concerned with the design, financing, and administration of appropriate health care and accompanying quality assurance systems for children, particularly children with special health care needs. The participants included officials from State agencies for Maternal and Child Health, State Medicaid officials, health policy researchers, nurse consultants, State legislators, and several local health officials.

Workshop Sessions

• Challenges in Health Services Research
• Defining the Population
• Reimbursing Managed Care Organizations (MCOs)
• Designing Managed Care Systems
• Expanding Health Insurance Coverage
• Primary Care Case Management Systems
• Fully-Capitated Managed Care Arrangements
• Providing Selected Services Outside Managed Care
• Measuring and Monitoring Quality of Care
• Measuring Consumer Satisfaction
• Structuring Contracts

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