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Designing Healthcare Systems That Work for People With Chronic Illnesses and Disabilities
Innovations Without Waivers
Gino A. Nalli, M.P.H., Project Director, MaineNet,
Bureau of Elderly and Adult Services, and Muskie School of Public Service, Portland, ME.
MaineNet is an emerging model for coordinating Medicare and Medicaid benefits for older adults and disabled younger adults living in the community. This program is designed to augment, rather than replace, the State's existing long-term care system in which one contracted entity conducts assessments and develops care plans and another contracted care coordination organization implements and monitors the care plans. The State avoided the waiver process by making enrollment voluntary and the program nonpunitive for members not complying with rules. The expected start will be in the first quarter of 2000, approximately 90-120 days after the rules are finalized.
MaineNet's original approach was to contract with a Managed Care Organization (MCO) for capitated Medicaid and Medicare services within the pilot catchment area. Members would be covered from cradle to grave. However, by the summer of 1998 it became apparent that this approach would not work, as Maine has an absence of viable MCOs (the State only has a 30-percent managed care penetration rate and has only one MCO serving the Medicaid population), skepticism as to financing arrangements, and little interest in making investments.
In the revised approach, MaineNet links primary care physicians and the State's community-based long-term care system through case management. Primary care physicians (PCPs) receive monthly primary care case manager (PCCM) fees for coordinating Medicaid and Medicare services. (There is no change in how PCPs bill Medicare and
Medicaid fee-for-service for direct service provision.)
For consumers receiving home and community-based services through the waiver or the State plan (known as Partnership members), PCPs coordinate primary and acute services while long-term services are coordinated by registered nurses (RNs) located in the physicians' offices and employed by the care coordination organization. (Mr. Nalli emphasized the importance of having the care coordinator accountable to the care coordination organization rather than to the PCP or the organization employing the PCP, in order to avoid conflicts of interest.)
Due to the increased complexity and acuity of needs of the Partnership members, PCPs receive $20 per member per month (PMPM) as PCCM fees; they receive $5 PMPM for "regular" MaineNet members. The incremental costs for the RN case managers (above the costs the State pays to the care coordination organization for long-term care coordination) run $25,000-$30,000 per site. The relationship between the physician and the care coordinator is expected to be the key to the program's success.
Physician sites are chosen for the number of eligible clients currently served, interest in being involved, and willingness to live by the program's rules. Three pilot sites are currently on board, with discussions underway with another three sites.
MaineNet Partnership. Pilot program. Portland (ME): Bureau of Elderly and Adult Services; 1999.
Schore J, Brown R, Cheh V, Schneider B. Costs and consequences of case management for Medicare beneficiaries: Final report. Princeton (NJ): Mathematica Policy Research, Inc.,
NASI Study Panel in Fee-for-Service Medicare. From a generation behind to a generation ahead: transforming traditional Medicare. Washington (DC): National Academy of Social
Insurance (NASI), 1998 Jan.
Presidential National Economics Council. The president's plan to modernize and strengthen Medicare for the 21st century. Washington (DC): The White House, 1999 Jul.
Fox PD. Applying managed care techniques in traditional Medicare. Health Aff 1997 Sep/Oct;16(5):44-57.