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Hello and welcome to another episode of the Disabilities Rights Center Presents...
I'm your host Cindy Robertson
and today's topic is Medicaid managed care
you've heard in the news lately about health care the future of
health care in New Hampshire
and I've got two guests with me today to talk about managed care
one is Michelle Winchester she's representing the Institute for Health
Law and Ethics at UNH School of Law
and Deb Fournier Policy Analyst for New Hampshire Fiscal Policy Institute so
welcome you both for joining us today I appreciate your time thank you
I think we're going to have a good conversation today about managed care
we thought it was important to sort of address this topic now because
we know that's the direction New Hampshire's moving in and and we also
recognize that the legislature and
Health and Human Services is really involved right now and is sort of putting
together the whole program
so he wanted to give people an opportunity to learn a little bit about it
on today's show with the intent it would just be a primer
just basics nothing too complicated because they know
even your titles are complicated very complicated
so can you just and we're gonna do this sort of informally just jump in,
have a conversation
Can you give us some idea about what managed care is
just very broadly what it is
Want me to go ahead?
managed care is a really big term
and its used in a lot of different ways
primarily it is a way of organizing how health care is paid for and how it's
delivered
and
the most
frequent
way that
managed care's organized
the way most people frequently refer to it is a
capitated system
that's a really big word and what it means is that
there's a payment made
for every person in the group
and it's the same payment
per person
no matter what services they use or what services they don't okay so for example
as a very simple example
they'll say we will give you one hundred dollars for each person
in the group and there's twenty people in the group
if person one only needs three dollars worth of services it doesn't matter you
still get your hundred dollars and if person two needs a thousand dollars worth
of it doesn't matter you still get a hundred dollars correct ok exactly now
very quickly how is that different than what we've got right now in
place? So right now another term is fee for service is how we
right now pay for health care
and that means that a provider gets paid
for every service that that provider gives to every patient
so if the patient
comes in
three times
for three different things a provider gets paid
three different times for three different things. So if one costs
ten dollars and one costs a thousand dollars and one costs thirty dollars they're gonna
get
each the full amount for each one of those
Right and under this other system
the provider gets a uniform payment for every person no matter how much or
how little
health care that person obtains or uses during the course of a
time period
like a year or
whatever the contract says
so I know that New Hampshire's only one of three states that does not
have
managed care at this point for its Medicaid program that's right
So what are the advantages of why would people why would the state
want to go into managed care versus keeping it fee for service
well
one of the obvious advantages is that it makes the costs very predictable
once the contract is agreed on and the rate that this
this uniform payment rate this capitated rate is agreed on
than the state knows based on how many people it's covering
what it's bill is going to be
for that group of people
also obviously
health-care costs are increasing
everywhere
for every population and this is
often seen as a way to control costs
whether or not it actually will or can is the larger question
but that's usually
the driving factor and New Hampshire like almost every other state in the nation
has seen
big gaps in its budgets in the last few years especially because of the
economic downturn
and so lawmakers are
pushing really hard to find ways to control costs because health care costs
are such a huge part of the state budget
so other New England states obviously have
have this in place right now
and so I know that in Connecticut for example they've had it for quite a
while but how is it working in other states
Well Connceticut has
had it for awhile and has now
left it
but it only had one population
instead of saying
our whole Medicaid population is going into managed care it's limited to one part of
the population and it picked one
which
was not made up
of people with disabilities the elderly who need long-term care
so probably
you could characterize it as the healthiest population
what they found is that they really didn't save a lot of money
and decided that there's
probably another way of doing this that
was advisable and so they have backed off
and started working again on a new plan
to move forward bringing the whole population hopefully
that's kind of interesting because
I know one of the goals of this is to save money
is to keep the cost down
but for Connecticut as an example
they take what should be the easiest or maybe cheapest
population
and attempt to see if it works and it
either doesn't work or they don't save the money that they thought they were gonna save
on what should be the cheapest population it's interesting now in New Hampshire my understanding is
it is the entire Medicaid population that is going to be
involved in our managed care is that right? Right.
so like Michellle you said it's not just the healthiest or maybe the least risky
or the cheapest medical cost people it's it's everybody so it's
people with development disabilities, mental health issues, elders
that require long term care is you're actually looking at to include the
most expensive where the highest need categories as well
that's correct
what you usually see in states that they're establishing managed care programs in, as they have
established them over the years is they started with that healthy
population and then gradually brought in the disability population and gradually
brought in
long term care
if they bring in long term care at all
so both conflict
in the fall
the Kaiser Family Foundation
released a report surveying all of the states and one of the things that they did find
when they talk about the states that had managed care programs is that all these managed
care programs look very different it's hard to compare one to the other but what
they did find when they talked to them was that only about half of them actually
saved any money so
there is no
absolutes
to prove that that's going to happen
even in New Hampshire
all you have to do is listen to Katie Dunn who is the Director
of Medicaid at Health and Human Services and she has actually brought this to the
legislature explaining to them that we have already implemented a lot of care
management type
programs
and
so we're questioning and the Department is questioning whether
there really is money to be saved
in the general medical services population so the question really
lingers as to maybe the savings could come in long term care but
long-term care programs really are not developed throughout the country so we
don't know what the experience has been there
we don't have a lot to build on from there
so the whole cost savings piece really is up in the air we don't know
it's a little bit experimental. absolutely this is a little different
from the
managed care methods the state currently uses because
right now
the state administers the Medicaid program
right it does eligibility and enrollment and it pays the bills when they come in
and it negotiates with
the providers to make sure that
they have providers that they can send the medicaid patients to
or members to
and they currently utilize
things that are managed care tools
like reviewing an expensive service before it's permanent
or saying, putting in service limits, saying how you can only
go see this type of specialist so many times
throughout a year
and the department already utilizes several managed care tools
to control its costs
what is different is
the way in
which New Hampshire doesn't have a formal managed care
arrangement
and it doesn't have contacts with managed care organizations
that are then in charge
administering the medicaid program for medicaid members
so if this were to go in place we won't have Health and Human Services
managing it
we'll have this organization or this company or this
agency or whatever it's going to be or multiple companies
coming in and doing that
that's right and the Department will go
into a mode more of managing that big contact with that vendor or
those vendors -sort of oversight - yes and then keeping them accountable and saying
that they're compliant with
or that they stick to the terms of the contract
which is actually a very important role
the monitoring is a very important role if there's anything learned from the other
states that have undertaken managed care it is that it's very important for the
state agency to continue to monitor those contracts and make sure the managed
care companies are doing exactly what they were asked to do
and what we are seeing though are in the states where budgets
have started to diminish the staffs
in in the agencies
we're seeing that
it's harder for them to do that monitoring
and those states are the states that are seeing are not necessarily seeing the savings we don't
know if we should be we don't have the staff to monitor so just an important lesson for
New Hampshire to remember
that we don't ratchet down our staff
to such a degree that they can't actually do that very important monitoring yes they're
responsible for making sure that quality
the quality standards are met that the standards that are put in place for the
types of
doctors and other providers are met
and that if there are grievances
by members there's an appropriate way for members to express their
grievance and to get their problem resolved with the managed care
organizations so there are
I agree with Michelle completely there are many several
iomportant oversight functions that the state will be undertaking
So let's take the audience back OK so
the legislature actually passed a law saying
you're gonna do this, this is going to be done
and they set down a timeframe here's when it has to be done by certain phases
and the issue what was first called the
RFP
and just for the audience that is basically sort of they lay out the information
and
people who
are these agencies or organizations have an opportunity to take a look at what it
is that they think they
want to do
and bid on it or say we're interested very simple terms of we're interested and
we might want to do this work
but before they so they issue the RFP but
there was also a process put in place to sort of get public input
and can you tell the audience a little bit about what the Health and Human Services
did
to try to figure out what it is that we want our medicaid managed care program to
look like, maybe we're different than Connecticut maybe we're different than
Massachusetts
you know we've got a lot of rural
pieces of New Hampshire not a lot of transportation not a lot of
providers up in the North Country
so its unique we know we're not Hartford
you know and
so that was things that had to be taken into consideration but how did they
get public input on this?
The state was actually under a very aggressive timeline
the bill was signed into law in early June
and the commissioner had to present a plan to some of the legislative
bodies by the middle of july
and so then
I believe in September if I remember correctly
they initiated a number of regional forums
and
there were a number of them five or six I believe
and
they were asked a number of questions about their
concerns about managed care what would make them
want to cooperate with the managed care arrangement what would make them
less cooperative with the managed care arrangement
and what they thought would help such an arrangement to succeed
and those happened all over the state
in five or six
different settings
and then in addition to that
there were
focus groups that were conducted by invitation only
with representatives of several different populations that are currently
within the Medicaid program
I had actually attended one of the public forums
and they put us into groups and it was a series of questions that you had
to answer it was very much, they wanted people to say okay right now
what is it
about the services you get that you would like to make sure you can continue
to get in the future what is it that you like now and it was
interesting because there were a lot of like you say say there was a lot of public there
not providers just actual consumers if I can use that term
and people were concerned about the quality am I still going to have the same quality of care
am I still going to be able to see my same doctors am I still going to have my same
case manager
am I still going to be able to work with
you know Community Bridges or Riverbend
or very very specific
detailed questions that nobody has any answers to those
but people were very concerned about that I know
we've talked before about people that
are in the developmentally disabled populations have some real
worries about what this might look like once it gets in place
are they going to lose all their services
so they did get this public input and then I presume they took
that information and did what with it?
It's actually an addendum
I believe to it's an attachment to the request for proposal
I think we have yet to see
how those responses were incorporated into
whatever contractual arrangements the department's making with the members that are selected
and I also know that through the process
the bidders had questions
before they would bid they had the opportunity to say oh yeah but
what about this what do you mean by that
it's all written in this
very vague technical terms and just so the audience knows all the
information is actually on the Health and Human Services web site if you have
access to a computer
you can get on there you can see the bidder's questions you can see the department's
response
I'm not sure how informative it is but it's there if you want to look at it
so they got all this information and they created this
RFP and they had a number of organizations
submit an interest
and then the selected just recently what, three?
agencies? organizations?
so we actually don't know
I thought we knew there was three - no we
actually don't know
how many bids were actually finally accepted
It's my understanding that there were fifteen vendors that expressed interest
the state has moved forward with
actual bids
word on the street is that there are five or six vendors that submitted bids
the deadline did just pass for when the Department was to select those vendors and there is no
requirement in the statute that they publicize
who those vendors are
right, so that information hasn't been made public yet
we could just speculate
under federal requirements they have to choose at least two
right because people have the right to choose they have a choice right
and i think in recent press reports there was some indication that there
were two maybe three
but we don't know the identity of who
those organizations are
so has
anybody seen the contract what it looks like?
No. The contracts are
we are assuming are being written at this point in time and we're in the write the
contract
execute the contract
period and
they're due to go to Governor and Council by March 15.
So until that point in time
we're in the dark.
right, basically
and Governor and Council has a meeting on March 28
there's every expectation that
those contracts will be on the agenda
for that meeting
So March 15 is the date, will the public have access, will we have access to
them say March 16, March 17?
What's the expectation and will they be posted on the website or
I think that for presenting contracts to the Governor and Council that
the
usual format is that
whatever is to be presented to Governor and Council
is made public the Friday before
that meeting
so I suspect that they will follow the procedure that they follow
for all of their contracts and so
that last meeting is the 28th
and that's a Wednesday
then whatever the Friday before is,
the 23rd of March maybe? OK, might have a chance to see it then
would be my guess
and if everything stays on schedule it's July 1st
It's supposed to go into effect
yes enrollment in
this new managed care system,
the target date for beginning that
process is July first
okay before we get to talk to what populations who is actually going to be
first affected
is there a possibility it wouldn't started by July first I mean is
there something some flexility there or...
there are a number of things
that could go wrong between now and then. One, we're in a very hasty period
no other state really has done it
like this and a very very short amount of time
so most states have taken
a year, two years just to prep
to go into this and we're doing it
in under a year.
so
we not only have to get contracts in place but we also probably have to have
waivers from the centers for Medicare and Medicaid services which are
complicated matters and probably are going to be back-and-forth discussions
for a significant period of time.
When you look at what most states have their waiver's just being authorized
most of them have gone a year
or even more in getting that place so if New Hampshire can do contracts
get the contracts approved, get a waiver through between now and July first
I'd say
it's doing a remarkable job.
Especially including the whole entire medicaid population again
and also
the submission of contracts to the Governor and Council
isn't necessarily a done deal - that's right - Governor and Council - they could turn
it down - may have questions, may want to table the matter while they
review them i mean there's any number of
things that could happen at that stage alone and that's the middle of March.
yes so there's nothing in stone yet
So let's talk about because I know people are concerned about you know
if i'm on the DD waiver, July first comes, Bam! July 2nd I have nothing or
Bam! I have completely new provid... I have everything
but it's not it's gonna
be phased in, different phases so who's, do you know who's in the first
phase, let's say they
do manage to get through all this
anyway now it's July first let's just say
who's the first ones who are gonna get their notice saying
here's the change?
so what's sometimes a little confusing about the way this has been put together is that
all populations
are covered by this requirement
but the phases are broken up by services
so the first phase will affect what's considered
mandatory and and a lot of the optional Medicaid like the really
what
we think of as acute care,
short term medical
care
inpatient hospital
outpatient
fairly, what what a lot of
people would consider fairly traditional
health care services
will be in the first
phase so
regardless
what that does not mean
- sorry -
what will not be included
necessarily are the waivered services will not be
different as of July first
but it's hard because when you start talking about the different populations
and the different services
things often
get muddled.
right. right.
because again we've talked about Medicaid on the show before but it
is very complicated but just as a you know
tiny tiny refresher
there are plenty of people who get state Medicaid benefits that are not on the
waiver program - correct -
and so
that sort of, the medical, acute care the hospitalizations,
physical therapy that sort of stuff and people on waivers
get acute care, get short term health care services. Right exactly
so
yeah it isn't necessarily
split up in a way that makes sense to people who get medicaid benefits
right
you know Medicaid
mostly, So Medicaid serves
lower-income children
and some of their parents
seniors
and this very broadly speaking and people with disabilities
Those are the folks that are covered
when we think of
you know acute care services
almost always think of the kids in there
and their parents
right short term medical care
the folks with more complicated needs like seniors and people with
disabilities
many are on waivered programs and
many are not so
you know it's a complicated
way, the way they split up the phases doesn't necessarily make sense to
folks who are
on a waiver right now
and what's the expectation let's say you are just state Medicaid plan not waiver
how would these people be informed of when now the medicaid managed
care plan is in effect
is a written notice? Is it just simply you nothing gets and then when you go to
the doctor the doctor says oh and by the way you've now used your
fifteenth time, how do people know?
There will be lots of notices and they will all be in writing
If people are going to have to pick a plan to go on, this is going to be, the
first phase is really going to be like
picking an insurance plan
which one works for you
probably what people are going to need most help
with up front is
what are they looking for when they decide to pick a plan what's
important to you and
so that's one of the big public education pieces that probably going to
have to be in place
around that time. But they're going to have plenty of notice of that
and right now it's just picking that health insurance plan
they're not stuck with it
once they get in they'll have
you know a little period where they'll be able to just back out if they don't like
this particular plan if it's not working for them
the you have to pick a different plan - and they'll have to pick a different plan.
There are people who
won't even have to do this if you're somebody for example in the first phase
if you're somebody who is on Medicare you won't have to
be on a managed care plan
if you're a child on the Katie Beckett option you won't have to be on this
so there are some people who will not
be mandated to do this at least at phase one
okay now I'm going to have to move along really quickly this always happens
so let's just jump really quick so we've got the second phase
anticipated to kick in 2013 - yes -
and that is the waiver
populations: long-term care, the DD mental health
and nursing homes so again they will have notification and they will
be selecting
the plans and
will there be an opportunity well let me ask you this first I'm running out of time here
the
agencies that bid
right now
are they also bidding for phase 2 and phase 3? so right now okay I
can handle the hospitals, I can handle the physical therapy but I'm also gonna have
to be able to handle the waiver
population so that's gonna be the exact same thing, no separate
bidding process no separate agencies
and what about the
public input
Is there going to be another round of public input for people who are on the waiver after
they've seen with the first year what it's like on the
acute care?
or we don't know?
we have been told that
there will be some input or some opportunity to talk we don't know if it will be any broader than the focus groups and regional forums that were held the last time.
again this is
very different from what most states do, most states have had advisory councils, they've had
long meetings, long discussions with the public
it could be
something more like that for the long-term care portion
or just
like we did in the first round.
The RFP does say that the
department
will engage with the managed care organizations and all the stakeholders to
develop
and design the phase two
systems
or plans
but Michelle's right other than that and some
indications by department officials to the same
we don't have any more details about what that's gonna look like
when that's going to occur or how rigorous or how
long-term or how in depth that
process is going to be - right -
and then just for the audience's sake there's a phase three but that's the
expanded affordable care act population we're not going to get into too much of that
right now but it sounds like there are a lot of steps as we sit here right here on
January 25th 2012 there's a lot we don't know
what this is gonna look like, how it's actually going to be implemented
put into effect
how it's actually going to impact individuals that are going to be on it, we don't know any of that yet
we're sort of hoping to find that out in the near future so I know we have talked earlier
we thought that maybe we'd do other shows
and one show might be after we actually get our hands on the contract to sort of
take a look at
now that we'll know more what the contract looks like
and we talked about Michelle coming back on and doing how to pick the
plan after we see what the different plans look like so our audience that
would help them a lot
maybe a year later what the effects
have been the first year we take a look at that
okay I've completely run out of time but I appreciate you both coming
it's been really informative and hopefully you'll both come back and help
with the future shows - absolutely - yes get you on tape
commiting OK true lawyers thank you thank you very much