Pediatric Annals

Pediatricians Partnering With States To Assure That Children With Special Health Needs Are Provided Appropriate Services: The Vermont Experience With Managed Medicaid

Richard M Narkewicz, MD, FAAP; Paula Duncan, MD, FAAP; Carol Hassler, MD; Nancy Menard, BSN, MSA

Abstract

The state of Vermont is noted for its commitment to positioning the family at the center of care for children with special healthcare needs (CSHCN). The emergence of managed Medicaid systems raised concerns that these new systems could potentially be divisive for the family's relationship with their primary care provider (PCPs)1 and could prove to be unwieldy and confusing for the PCPs. This article describes the results of an intense effort by policymakers, pediatricians, family practitioners, and the State Health Department to build a managed care system for CSHCN in Vermont. The objective of this program is to keep the family at the center of care, retain the excellent pediatrie multidisciplinary specialty care services, manage resources, and preserve the medical home for these children.

VERMONT CHILDREN WITH SPECIAL HEALTHCARE NEEDS HEALTHCARE SYSTEM PRIOR TO MANAGED CARE

Children with special healthcare needs programs, from their beginnings in 1914 as an "after care department" for home treatment of children with polio, have been based on three principles:

1. Partnership between providers of specialty pediatrie care and public health.

2. Models that serve all children with need regardless of family resources or insurance status, and

3. Collaboration with community services and primary care.

The Vermont Health Department's CSHCN programs serve a statewide population of children with chronic conditions or disabilities, without respect to family size or income. A combination of strategies is employed to assure families of a comprehensive, family-centered system, including multidisciplinary specialty clinic teams, regionally based nurses and social workers, a statewide network of mutual parent support, and the use of state and Title V resources to help fill funding gaps.

WAIVER APPLICATION PROCESS: DESIGN OE THE FUTURE

Faced with escalating healthcare costs and a desire to provide health insurance for more uninsured Vermonters, the state of Vermont decided in 1995 to apply for an 1115 Research and Demonstration Waiver and develop systems to integrate the population with Medicaid insurance into managed care. A Medicaid Advisory Committee (which included representatives from, the Vermont Medicaid Division, Department of Health, Department of Mental Health, practicing pediatricians, families, and representatives from managed care and other state professional groups) was instrumental in the waiver design and was interested in developing a unique and special system for the CSHCN in Vermont.

After reviewing the potential advantages and disadvantages of managed care systems for CSHCN (Table 1), the decision was made to include most CSHCN in a managed care program. The 100 children enrolled in the comprehensive high-tech program were excluded.

IMPLEMENTATION AND MAKING IT WORK

Three managed care organizations (MCOs) bid, and as soon as one MCO's bid was accepted, a work group was formed to write an agreement for service coordination and integration between the MCO and the Vermont Department of Health. This group included the MCO's pediatrie medical director, a utilization management specialist, the MCO director of Medicaid programs, the Vermont Medicaid Director and Medicaid Program Director, the Department of Health CSHCN Director, the Maternal and Child Health (MCH) Director and, as needed, the administrator of the CSHCN programs. Other managed care staff, such as fiscal and data managers, attended as necessary.

This group set out with five goals for CSHCN in our new Vermont system:

1 . A seamless transition for parents, with no disruption of services

2. No barriers to access to care (ie, no disincentive for referral of a child to a specialist in a CSHCN Clinic Team setting when needed)

Table

An important element in implementing this portion of the contract negotiation was a recognition that there were many problems in other states' systems where subspecialists who were supplying expert…

The state of Vermont is noted for its commitment to positioning the family at the center of care for children with special healthcare needs (CSHCN). The emergence of managed Medicaid systems raised concerns that these new systems could potentially be divisive for the family's relationship with their primary care provider (PCPs)1 and could prove to be unwieldy and confusing for the PCPs. This article describes the results of an intense effort by policymakers, pediatricians, family practitioners, and the State Health Department to build a managed care system for CSHCN in Vermont. The objective of this program is to keep the family at the center of care, retain the excellent pediatrie multidisciplinary specialty care services, manage resources, and preserve the medical home for these children.

VERMONT CHILDREN WITH SPECIAL HEALTHCARE NEEDS HEALTHCARE SYSTEM PRIOR TO MANAGED CARE

Children with special healthcare needs programs, from their beginnings in 1914 as an "after care department" for home treatment of children with polio, have been based on three principles:

1. Partnership between providers of specialty pediatrie care and public health.

2. Models that serve all children with need regardless of family resources or insurance status, and

3. Collaboration with community services and primary care.

The Vermont Health Department's CSHCN programs serve a statewide population of children with chronic conditions or disabilities, without respect to family size or income. A combination of strategies is employed to assure families of a comprehensive, family-centered system, including multidisciplinary specialty clinic teams, regionally based nurses and social workers, a statewide network of mutual parent support, and the use of state and Title V resources to help fill funding gaps.

WAIVER APPLICATION PROCESS: DESIGN OE THE FUTURE

Faced with escalating healthcare costs and a desire to provide health insurance for more uninsured Vermonters, the state of Vermont decided in 1995 to apply for an 1115 Research and Demonstration Waiver and develop systems to integrate the population with Medicaid insurance into managed care. A Medicaid Advisory Committee (which included representatives from, the Vermont Medicaid Division, Department of Health, Department of Mental Health, practicing pediatricians, families, and representatives from managed care and other state professional groups) was instrumental in the waiver design and was interested in developing a unique and special system for the CSHCN in Vermont.

After reviewing the potential advantages and disadvantages of managed care systems for CSHCN (Table 1), the decision was made to include most CSHCN in a managed care program. The 100 children enrolled in the comprehensive high-tech program were excluded.

IMPLEMENTATION AND MAKING IT WORK

Three managed care organizations (MCOs) bid, and as soon as one MCO's bid was accepted, a work group was formed to write an agreement for service coordination and integration between the MCO and the Vermont Department of Health. This group included the MCO's pediatrie medical director, a utilization management specialist, the MCO director of Medicaid programs, the Vermont Medicaid Director and Medicaid Program Director, the Department of Health CSHCN Director, the Maternal and Child Health (MCH) Director and, as needed, the administrator of the CSHCN programs. Other managed care staff, such as fiscal and data managers, attended as necessary.

This group set out with five goals for CSHCN in our new Vermont system:

1 . A seamless transition for parents, with no disruption of services

2. No barriers to access to care (ie, no disincentive for referral of a child to a specialist in a CSHCN Clinic Team setting when needed)

Table

TABLE 1Potential Impact of Managed Care Systems on Children With Special Healthcare Needs

TABLE 1

Potential Impact of Managed Care Systems on Children With Special Healthcare Needs

3. Family-centered care

4. The preservation of the traditional, strong bond between the family and the PCP in the medical home concept

5. A need to manage all resources (because this was the primary reason seen by most lawmakers and policymakers to institute managed Medicaid)

After agreeing on the goals, the group focused on gaining an understanding of the intricacies of CSHCN clinic funding and managed care fiscal responsibilities under the waiver agreement. Although the services provided by the state and the cadre of pediatrie subspecialists were of high quality, this project sought ways to improve the management of these services. Although the MCO was obviously respected for its ability to manage these resources, to their credit, they agreed to share the management with the state of Vermont, particularly those resources that the state managed well. This decision was the seminal beginning of the breakthrough for the Vermont program.

Critical elements in the success of this process were the commitment to the children and their families, an honest, mutual respect for each organization's talents and constraints, and the willingness of all the group participants to alter their schedules so that they could attend all the meetings, often on short notice. A subgroup of the work group (MCO, CSHCN, Medicaid representatives) began having meetings with parent groups, such as Parent to Parent and the CSHCN Advisory Council, so that each step in the process could be developed with parent input.

Table

TABLE 2Orthopedic Clinics

TABLE 2

Orthopedic Clinics

A description of the current systems and a roster of the current specialty clinics, along with the physicians' services, clinic-related services, and other services and referrals on that site were developed. On a service-by-service basis, the group discussed each item, and it was agreed that the Vermont Health Department would continue to pay for certain services with state and MCH Block Grant Funding, Medicaid would cover certain services directly, and the MCO would pay for other services (see example in Table 2, orthopedic clinic).

Table

TABLE 3Challenges for the Future for the Vermont Children With Special Healthcare Needs System

TABLE 3

Challenges for the Future for the Vermont Children With Special Healthcare Needs System

An important element in implementing this portion of the contract negotiation was a recognition that there were many problems in other states' systems where subspecialists who were supplying expert care for CSHCN were not credentialed or certified by the MCOs. This was quickly overcome by the MCO accepting all the pediatrie subspecialists within the Health Department's system and appropriately credentialing them to the managed care organization. The other key was to give "prior authorizations" for necessary services and tests that were essential for the diagnosis and treatment in the various subspecialty clinics.

A material agreement was reached between the MCO and the Health Department to ensure that "always needed" services were given automatic approval, te, did not require a referral from the PCP. These services were considered to be "prior authorized." Any service over and above these specifically listed "prior-authorized" would need PCP approval. In addition, as part of the MCO's case management service, each CSHCN is assigned a nurse case manager to contact the family and facilitate the coordination of care and appropriate authorizations. This greatly facilitates the MCO as user-friendly by the primary care doctors and helps eliminate some of the confusion and delay over appropriate referrals.

With these discussions concluded, the new Vermont system was ready for implementation. The MCO had agreed to provide a medical home, routine medical care, preventative measures, necessary medical services, continuity of care, case management, and participation in care planning, and would authorize medical necessity for those services that were identified during the course of the clinic setting. On the other hand, the Department of Health would continue to provide multidisciplinary clinics, care coordination, written reports to the primary care doctors, and the wrap-around services necessary, and would continue to provide treatment in many cases that could not be authorized by the managed care system's contract.

CONCLUSION

The Vermont public-private partnership for CSHCN could be useful in other states. It facilitates a mechanism for PCPs to provide a medical home for CSHCN. It provides an opportunity for parents of CSHCN to continue with specialized diagnostic services and care under managed care in a familiar surrounding with the support of both the Health Department and the managed care company. It is a win-win situation for families, providers, the Department of Health, and managed care.

It is too early to include any meaningful outcome data; however, we will be working on the challenges for the future (Table 3).

BIBLIOGRAPHY

Epstein SG. Taylor AB. Halberg AS, Gam« JD, Walker DtC, Cracker AC. Enhancing Quality: Standards and Indicaron of Quality Core for Children nith Special Health Care Ntak - Bascan, Mass: New England SERVE Regional Task Force on Quality Assurance, an MCHB-SPRANS grant project; i989.

Family Voices (a national grassroots network of families and friends speaking on behalf of children with special health care needs, PO Box 769, Algodones, NM 87001). Children uilh Spedo! HeaIA Can Needs tn Managed Cart: Questioni lo Asie and Answer.

Newacheck PW, Stein REK, Walker KD, Gorrmaker SL, Kuhlchau K. Pcrin JM. Monitoring and evaluating managed care for children with chronic illnesses and disabilities. Pattarne!. 1996;9952-958.

State of Vermont. Vermont Health Acce« Plan: Return far In/ormeoon. Office of Vermont Health Accesi. Department of Social Welfare, Agency of Human Services, 103 South Main St, Waterbury, VT0567MZ01; 1995.

ADDITIONAL RESOURCES

Children midi Spedai Health Care Needs in Managed Cart Oijaniamons; Definition! and identtfkaaon, Family Participation, Capuaoon and Risk Adjustment, Quality of Care (J996). Summaries of work group available from the Division of Services for Children with Special Health Care Needs, Maternal and Child Health Bureau. Department of Health and Human Service«, 5600 Fishers Lane, Room 18?27, Roclmlle, MD 20857.

Fox HB, McManus MA. Medtcaid-Managed Care for Children with Chronic m Disabling Conditioni: Improved SiroKgies forSunti and Pions (1996). Available from Maternal and Child Health Policy Research Center, Maternal and Child Health Bureau. Department of Health and Human Service«, 5600 Fishers Lane, Room 1SA27, Rockville. MD 20857.

Medicaid Managed Care: Serving the Disabled Challenges Stole Programs - Report to the Chairman and ranking minority member. Subcommittee on Medicaid and Health Care for Low-Income Families, Committee on Finance, US Senate. Available through the GAO. United States General Accounting Office, Washington, DC 20548; 1996.

TABLE 1

Potential Impact of Managed Care Systems on Children With Special Healthcare Needs

TABLE 2

Orthopedic Clinics

TABLE 3

Challenges for the Future for the Vermont Children With Special Healthcare Needs System

10.3928/0090-4481-19971101-08

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