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Providing High-Quality Services to Children with Special Health Care Needs (CSHCN) Under Managed Care

Primary Care Case Management Systems

Serving Children with Special Health Care Needs

Presenters:

Phyllis J. Siderits, R.N., M.P.A., Assistant Health Officer, Children's Medical Services, Florida Department of Health and Rehabilitative Services, Tallahassee, FL.

Cassie Lauver, A.C.S.W., Director, Bureau for Children, Youth and Families, Kansas Department of Health and Environment, Topeka, KS.


Although States traditionally have chosen to exempt CSHCN from managed care arrangements due to concerns over quality and financing, many are now including this population in managed care systems through the use of primary care case management (PCCM) strategies. These systems preserve the fee-for-service payment structure while offering the benefits of a consistent source of primary care and case management.

In this session, Phyllis Siderits, Assistant Health Officer for the Children's Medical Services in the State of Florida, and Cassie Lauver, Director of the Bureau of Children, Youth and Families in the State of Kansas, shared their States' experiences with implementing this model for CSHCN, and discussed the designs of their systems, the policy decisions involved in choosing this model for the care of CSHCN, and the strengths and weaknesses of the primary care case management approach.

In Florida, according to Ms. Siderits, the Medicaid program offers two options to its enrollees: MediPass, a primary care case management model, or a prepaid health maintenance organization (HMO) option. However, the State is starting to implement a new program within the PCCM option that utilizes what they call an "Alternative Service Network" for CSHCN, which will offer a continuum of coordinated, comprehensive, non-risk bearing managed care.

The challenges for this new program include:

  • Enhancing data systems.
  • Developing a centralized provider network
  • Developing standards and Request for Proposals (RFPs) for providers.

However, there are a number of opportunities posed by the program, such as retaining a Statewide system of care for CSHCN, reducing the adverse impacts of risk-bearing arrangements, and providing families with a broad range of provider and plan choices.

In the State of Kansas, children , including CSHCN, have been a part of a Medicaid PCCM program for a decade. According to Ms. Lauver, there have been a number of benefits to the inclusion of CSHCN in a PCCM system, including increased access to primary care as well as specialty care; better communication between primary care and specialty care providers; and improvement in primary care providers' skills in caring for CSHCN.

References

Children's Medical Services Program: The Alternative Service Network, Implementation Policies: 1997.

Section from State of Kansas Interagency Agreement between the Department of Health and the Environment and the Department of Social Rehabilitation Services.


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