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![]() ![]() Public Health Departments Adapt to Medicaid Managed CareIssue Brief No. 16
Medicaid Managed Care
In recent years, however, nearly every state has moved or plans to move its Medicaid population into managed care. As a result, Medicaid recipients are more likely to obtain primary care services from private providers in their managed care network than from public health departments. As Medicaid beneficiaries have more choices of where to obtain care, health departments risk losing - or, at best, sharing - a substantial number of Medicaid clients and the revenue that comes with them. The impact of this policy shift has varied in type and intensity around the country, for example:
As these examples illustrate, states have pursued different approaches with respect to integrating health departments into the provision of services for Medicaid beneficiaries.
State Contracts Lack Clarity
State Medicaid contracts generally encourage health plans to form relationships with a wide variety of public health agencies, including school health clinics, homeless health providers and state senior services. But rarely do the states set specific requirements for comprehensive involvement of the public health departments. For example, in several states, Medicaid contracts allow referrals to "any qualified family planning provider," but do not specifically name public health departments. Some state contracts are more likely to spell out a role for local health departments on a service-by-service basis, particularly infectious diseases. In California, for example, the state contract specifies that tuberculosis patients requiring directly observed therapy be referred to the local health department. But in general, with respect to both care for and control of communicable diseases, contracts between plans and the states reflect a clear shifting of the responsibility and the revenue stream from health departments to health plans. Contracts generally specify that prevention and treatment be included in the Medicaid managed care benefit package, but again, the role of local health departments is not clearly spelled out. Primarily, plans are required to report instances of diseases back to the local health department. EPSDT services have proven to be an especially tricky component of the state/health department/health plan relationship. These include a wide range of screening services aimed at marking critical stages of childhood development, including immunization, vision and hearing exams, mental health screening and lead poisoning screening. Historically central to the health department mission in most places, EPSDT services have been largely shifted to health plans under Medicaid managed care. Coordination between health plans and local health departments in the delivery of some EPSDT services is important because health plans do not always have the systems necessary for meeting all EPSDT requirements, such as those associated with responding to positive lead poisoning screens. Many contracts are similarly vague with respect to how health departments might get paid for services rendered for which primary responsibility has shifted to managed care providers. Where payment is specified, health departments often must receive prior authorization from the plan before services are administered. It is not surprising that states have not thought about specific roles for health departments as Medicaid managed care has become more the norm. Even under fee-for-service, states have not done particularly well at coordinating care between different entities and different types of providers. Now, some states are concerned about having different delivery systems for the same clients. Moreover, other states have not generally thought of public health services as a part of the traditional package of health care services that need to be purchased, and some states do not believe that health departments should be involved in the delivery of any kind of direct clinical services.
Three Partnerships Close Up
Dade County, Miami. An MOA between the state, Miamis Dade County Health Department (DCHD) and 10 participating health maintenance organizations (HMOs) emphasizes the responsibilities of each partner, a reimbursement system for services provided by the DCHD and the means of exchanging information between the HMOs and the health department. DCHD remains responsible for promoting the publics health, controlling and eradicating preventable diseases and providing primary health care for special populations. The HMOs are specified as subcontractors to the Florida State Agency for Health Care Administration (which administers the Medicaid program). The HMOs pay the DCHD for immunization services, family planning services and related medications and diagnostic and treatment services for communicable diseases, including STDs. These services may be given without prior authorization. HMOs are also required to help eligible beneficiaries make contact with the DCHD for services they need. For example, plans must refer all eligible women to DCHD for Healthy Start pre- and postnatal screening. Provisions governing the exchange of information between plans and the county health department involve a tremendous amount of detail. Among other requirements, the DCHD must try to notify the HMO before providing care for its members (for administrative purposes such as quality reporting, not for prior authorization), and it agrees to quickly provide the HMO with immunization records for plan members. Meanwhile, the HMO must provide the health department with any records that will assist in the latters effort to track and prevent communicable diseases. Onondaga County, Syracuse. In Syracuse, N.Y., where 50 percent of Medicaid beneficiaries are in managed care and where there is a declining public health department role in clinical service delivery, MOAs were executed with four health plans. The goal, according to the Onondaga County Health Department (OCHD), is to provide an integrated system of high-quality, cost-effective public health and managed care services. Under the agreement, OCHD has three basic functions:
Tuberculosis control is a key part of the joint agreement that relates to communicable diseases. Participating Syracuse health plans are required to refer all active and suspected TB cases to the health department. From that point, care of TB cases becomes a collaborative effort, with the OCHD carefully monitoring the health plans treatment and even developing schedules for medication and home visits. The protocol for care does not depart from established health department procedures, but the innovative aspect of the MOA is that the OCHD is reimbursed by the plan for providing population-based services and surveillance as well as disease control. Some aspects of the MOA go beyond the public health programs provided by OCHD. Participating Syracuse health plans, for example, are required to refer children who are not gaining weight and developing properly to the New York State Department of Healths Infants-Child Health Assessment Program. To meet the requirements of this program, these health plans engage the services of public health nurses, who conduct home visits and administer a range of clinical and educational services to the children who fall into high-risk groups. Orange County. CalOPTIMA, a public agency, contracts with providers and health plans in Orange County for Californias Medicaid program, called Medi-Cal. The Orange County Health Care Agency (HCA), facing losses in patient visits and revenue to Medi-Cal managed care plans, developed a series of MOAs with CalOPTIMA to delineate the responsibilities of each organization in coordinating care for the Medi-Cal population. Twelve specific areas of service are covered in these MOAs, including HIV programs, pulmonary diseases, childrens health and disability prevention, lead poisoning control and epidemiology. The MOA governing HIV control is particularly detailed and explicit. It describes the responsibilities of HCA and CalOPTIMA as they affect the testing, detection, reporting, care, education and prevention of HIV. CalOPTIMA is responsible for ensuring that its HIV-infected clients receive appropriate care. HCA, meanwhile, is responsible for public education and tracking down partners of infected individuals to notify them that they should be tested for HIV, and for providing HIV ambulatory care services for non-Medicaid clients.
Finding Their Own Way
Researchers are now going back into the field to better understand a number of issues, including:
Careful scrutiny of the successes and challenges posed by these emerging partnerships should prove valuable to local public health departments that are only now formulating a new posture for the changing health care environment, as well as to their plan partners and to policy makers at the state and federal levels.
Study Methodology
The survey is an adjunct to HSCs Community Tracking Study, a longitudinal study that focuses on changes in the health system in 60 sites that are representative of the nation. Site visits and more in-depth surveys are conducted in the same 12 communities covered in this Issue Brief. Mathematica gathered data through on-site interviews and from surveys by the National Association of County and City Health Officials and the National Association of Local Boards of Health. Mathematica also drew from a report by the George Washington University Center for Health Policy that details Medicaid managed care contracts in 36 states plus the District of Columbia, including nine of the 12 study sites.
Health Departments Participating in the StudyPhoenix, Ariz., Maricopa County Department of Public Health Little Rock, Ark., Pulaski Central Health Unit Orange County, Calif., Health Care Agency of Orange County Miami, Fla., Dade County Health Department Indianapolis, Ind., Marion County Health Department Boston, Mass., Boston Public Health Commission Lansing, Mich., Ingham County Health Department Newark, N.J., Newark Department of Health and Human Services Syracuse, N.Y., Onondaga County Health Department Cleveland, Ohio, Cuyahoga County Board of Health Greenville, S.C., Appalachia II Public Health District Seattle, Wash., Seattle-King County Health Department
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