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Medicaid MC moves from its "gatekeeper" reputation
In previous years, there was a widespread perception that the reason managed care was cost-effective was that services were restricted, according to Alice R. Lind, RN, MPH, senior clinical officer at the Center for Health Care Strategies (CHCS) in Hamilton, NJ. This was a largely undeserved reputation, she says, but it worked against managed care expansion.
"It's taken a long time to make the case that managed care is able to assist people in both getting the right preventive care as well as coordinating care more effectively," says Ms. Lind. "That can lower costs without providers in any gatekeeping role."
California Medicaid sees managed care expansion for its Seniors and Persons with Disabilities (SPD) beneficiaries as a way to improve quality and access while containing cost growth, says Ms. Lind. Managed care clients will be in a health home, with better coordination of services and one person to call for health care needs, she says, whether a primary care physician or care manager.
The rates that California Medicaid is proposing to pay the managed care plans assume a reduction in emergency room and hospital use, adds Ms. Lind. The health plans and the Department of Health Care Services discussed this back and forth, she says.
"Plans initially took a look at those rates and said that they cannot achieve changes in behavior on the very first day of enrollment," says Ms. Lind. "But the plans are very comfortable assuming those changes will happen over time."
Access is an issue
For a subset of the SPD population with rare conditions, there may not be a single health plan that contracts with all the subspecialty providers that the individual needs, says Ms. Lind. Also, many SPD beneficiaries will have anywhere from three to nine different conditions, she adds.
"Finding the right set of providers who can see them for a broad range of conditions can be a challenge," she says.
Over time, in Medicaid programs across the country, managed care has moved away from the gatekeeper role that used to be assigned to the primary care provider, adds Ms. Lind.
"When states first started using managed care for the [Temporary Assistance for Needy Families] population, you would have to clear it through the primary care provider for every single referral," she says. "That doesn't work for this population with chronic and complex needs."
This is because seniors and adults with disabilities typically have long-standing relationships with an array of providers, says Ms. Lind, so it is no longer in the health plan's interest to require referrals. "The main thing that advocates and clients worry about is access to care," she says.