Transitioning Beneficiaries with Complex Care Needs to Medicaid Managed Care: Insights from California

Graham C, Kurtovich E, Taube S, Ray L, Arguello R
Publication Year: 2013
Patient Need Addressed: Care Coordination/Management
Population Focus: Medicaid beneficiaries, Vulnerable/disadvantaged
Demographic Group: Adult
Intervention Type: Staff design and care management
Study Design: Other Study Design
Type of Literature: Grey

This brief examines how health service providers, plan administrators, and community-based organizations in Contra Costa, Kern, and Los Angeles Counties experienced the transition of Medi-Cal-only seniors and persons with disabilities (SPDs) to managed care as part of the state’s “Bridge to Reform” Medicaid waiver. Findings presented may inform similar transitions of high-need beneficiaries in other states and coverage expansions in 2014 under the Affordable Care Act. The paper was first released in conjunction with a briefing on Medicaid managed care in the era of health reform.

Insights Results

Overview of brief

  • Between June 2011 and May 2012, the California Medicaid program (known as Medi-Cal) transitioned just under 240,000 seniors and persons with disabilities (SPDs) from fee-for-service to mandatory Medicaid managed care (MMC)as part of its “Bridge to Reform”. SPDs in California account for a disproportionately high share of the state’s Medicaid spending. Medi-Cal-only SPDs represent 40% of the state’s total SPD population and comprise mostly individuals with disabilities. Goals of the transition were to increase plan and provider accountability and oversight, improve beneficiary access to care, and make costs more predictable. This study examined how health service providers, plan administrators, and community-based organizations (CBOs) in Contra Costa, Kern, and Los Angeles counties experienced the transition of SPDs to MMC

    Key takeaways/implications

    • The following are relevant key study findings that may help inform future transitions to managed care for populations with complex health needs: 1) The SPD transition necessitated information sharing across many entities, including the state, health plans, CBOs, providers, and beneficiaries, and was key to improving plan and provider readiness for the transition. Challenges to efficient data transfers included incomplete or out-of-date beneficiary contact information and patient privacy provisions that prevented plans and providers from timely access to beneficiary medical records. Potential strategies to overcome these barriers include engaging groups familiar with the SPD population to help disseminate information, working directly with county social services, or using pharmacy data for beneficiary information; 2) Providing coordinated care for SPD beneficiaries was a primary goal of the transition and a requirement of the Medicaid waiver. SPDs had more complex and frequent care coordination needs and primary care providers reported insufficient training in care coordination. Potential strategies include creating care coordination teams, providing ongoing provider and staff trainings, and contracting with CBOs to assist with care coordination; and 3) The transition had a substantial impact on health plan and providers’ organizational structures and resources. Providers reported delivering unreimbursed care and plans reported that Medi-Cal capitation rates did not cover actual SPD costs. Potential strategies include collaborating with CBOs for assistance during the transition and developing a methodology designed specifically to pay for care delivered during the transition
    • It is important to highlight that providing coordinated care for SPD beneficiaries was a primary goal of the transition of SPDs to managed care and a requirement stipulated in the Section 1115 waiver. Lack of coordinated delivery in FFS Medi-Cal has been identified as a key contributor to poor access to care, more duplication in care, and higher costs for SPD beneficiaries. Managed care delivery systems in which primary care providers act as the single point of entry, have the potential to increase the number of beneficiaries with a usual source of care, improve access to appropriate services, reduce duplicative care, and lower costs. Since the SPD transition to managed care, health plans, providers, and CBOs all report significantly increasing their efforts to coordinate care across settings for SPD beneficiaries
    • This brief also explains that it is important to understand impact on organizational structures that this transition causes and what can be done to minimize the strain. Specifically, Community-based organizations (CBOs) used resources to assist SPDs with the transition to managed care. Organizations such as Independent Living Centers, advocacy groups, and Regional Centers for people with developmental disabilities are organizations with a great deal of direct contact with certain segments of the SPD population
    • Overall, this brief presents considerations for states, health plans, CBOs, and providers as they prepare for managed care expansions. Particularly salient are the findings around timing, communication, and coordination, including the establishment of partnerships that enable plans and providers to deliver efficient and effective care that meets beneficiaries’ healthcare needs