Health-Based Payment for HIV/AIDS in Medicaid Managed Care Programs

Health Care Financing Review, Spring, 1998 by Richard Conviser, Sandy Gamliel, Lynda Honberg

* Designing MCO contracts that limit the State's liability.

NOTE: MCO is managed care organization.

SOURCE: (Conviser et al., 1997a).

Figure 2 Managed Care Organization Concerns

* Maintaining profitability while assuring protection against undue financial risk.

* Pacing managed care implementation to allow for the development of adequate provider networks, referral patterns, information systems, and member services.

* Having to collect and use data in unaccustomed ways.

* Limiting the administrative burdens associated with developing and maintaining management information systems (to collect encounter and other data).

* Developing ways to identify enrollees eligible for enhanced capitation rates while maintaining enrollee confidentiality.

* Monitoring data to ensure that clinical conditions related to disabilities appear in encounter records (where they are often currently taken for granted).

SOURCE: (Conviser et al., 1997a).

Figure 3 Provider Concerns

* Adapting to changes in the business and care environments.

* Negotiating payments that will protect their financial viability without compromising the quality of care or imposing undue administrative burdens.

* Having payment mechanisms flexible enough to cover the costs of new medications and other emerging modalities of care.

* Creating linkages with culturally diverse patient (psychosocial) support systems to draw and keep enrollees in care.

* Obtaining and using management information systems to assess cost-effectiveness and treatment outcomes.

* Developing standardized measures to allow for the evaluation of care quality.

* Receiving adequate information to keep up with rapid changes in HIV care.

NOTE: HIV is human immunodeficiency virus.

SOURCE: (Conviser et al., 1997a),

Figure 4 Consumer and Consumer Advocate Concerns

* Ensuring consumer input into the design of Medicaid managed care programs.

* Having access to experienced HIV providers as principal care providers.

* Timely access to specialty and ancillary services and investigational therapies.

* Coordination of health services with necessary social services.

* Unbiased information to help choose among MCOs and identify experienced providers.

* Culturally competent educational materials about using managed care systems.

* Timely external grievance processes to ensure MCO accountability to enrollees.

* Having MCOs develop appropriate ways (e.g., protocols and unique patient identifiers) for sharing necessary information among providers while ensuring enrollee confidentiality.

* Access to out-of-network providers in rural areas.

NOTES: HIV is human immunodeficiency virus. MCO is managed care organization.

SOURCE: (Conviser et al., 1997a).

VARIATIONS IN MEDICAID CARE COSTS

Medicaid managed care programs serve diverse subpopulations, including families with children--through Aid to Families with Dependent Children (AFDC), now replaced by Temporary Aid to Needy Families (TANF)--an d people with chronic illnesses and disabilities, typically through Supplemental Security Income (SSI) programs. The costs of care for these two subpopulations are quite different. "[P]oor families with children ... [account nationally] for 72 percent of Medicaid recipients but [incur] only 29 percent of Medicaid expenditures. Services to elderly and disabled persons account for 59 percent of Medicaid expenditures" (Bodenheimer, 1997).