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Designing Healthcare Systems That Work for People With Chronic Illnesses and Disabilities
People with Special Needs
Deirdre Duzor, M.A., Director, Division of Quality Systems Management,
Center for Medicaid and State Operations, Health Care Financing Administration (HRSA), Department of Health & Human Services (HHS), Baltimore, MD.
The Balanced Budget Act of 1997 required a report to Congress on safeguards/protections
needed for people with special healthcare needs enrolled in Medicaid managed
care. The study was done internally by the Health Care Financing Administration (HCFA) using existing research.
The National Academy for State Health Policy was asked to convene a group
of approximately 20 stakeholders; the group met in March and July, 1999.
The report's targeted issues are:
- Identification, including the need for communication between
States and Managed Care Organizations (MCOs) (e.g., identifying Supplemental Security Income [SSI] beneficiaries).
- Stakeholder education and involvement, noting that consumers
and providers need to understand the Medicaid system.
- Matching services to needs, encouraging flexibility, individualized
beneficiary assessments, and medical necessity determinations.
- Coordination and continuity of care, noting that care coordinators
will not be successful if they have responsibility without authority,
and that States may need to take responsibility to fill in gaps in services.
- Use of experienced providers, as evidenced by hands-on experience
more than credentialing (e.g., HIV-experienced physicians, who have
no formal credentialing process).
- Quality monitoring, noting that methodological difficulties
exist in developing tools with statistical significance for the small
populations of people with disabilities enrolled.
- Payment approaches.
When asked what would happen in Washington once the report became public,
Ms. Duzor noted that congressional representatives may turn some of the
recommendations into proposed legislation, but eventual passage could
not be predicted. Many of the recommendations could be implemented by
HCFA through proposed regulations, without the need for legislation.