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Children with Special Healthcare Needs

Alternative Delivery Systems


Richard Aronson, M.D., M.P.H., Chief Medical Officer for Family and Community Health, Wisconsin Division of Public Health.

Susan Tucker, M.P.H., M.B.A., Assistant Director, Medical Assistance, Maryland Department of Health and Mental Hygiene.

Maude Holt, M.B.A., Health Systems Administrator, Medical Assistance Division, District of Columbia Department of Health.

Louise Novak, M.P.H., Research Consultant, Child Health Institute.

This session was designed to discuss various State approaches to fostering the development of service delivery systems that meet the complex needs of children with special health care needs (CSHCN) and their families.

Richard Aronson discussed some of the ways that collaboration can be effective in making systems of care work for CSHCN. He provided an overview of the comprehensive approach that Wisconsin has utilized in an effort to improve service delivery availability.

Some of the challenges, benefits, and lessons that Wisconsin has experienced include:

  • The considerable time that it takes to make comprehensive systematic change.
  • The necessity of establishing and building trust with all constituencies throughout the process.
  • The benefits of establishing long-term change for providing care to CSHCN.

Susan Tucker, Assistant Director of the Department of Medical Assistance for the Maryland Department of Health and Mental Hygiene, discussed the mainstream model that has been established in Maryland for CSHCN. She discussed key design decisions that the State made in program implementation, including the decision to include most Medicaid recipients and services in the mandatory managed care program, with the following exceptions:

  • Dually eligible persons, people with spend-down coverage, and institutionalized individuals in the mandatory Managed Care Organization programs (MCOs).
  • Specialty mental health services, medical day care services for children and adults, and certain services provided by MCOs.

In addition, Ms. Tucker discussed Maryland's rate-setting methodology—a payment system designed to reimburse at a higher rate those MCOs that care for sicker patients. This rate-setting program has developed special carve-out payments for individuals with legislatively determined "rare and expensive" diseases.

Maryland has also designed quality provisions, ongoing oversight by a special advisory committee, and special complaint procedures. Ms. Tucker emphasized the importance of education and collaboration with local health departments for the provision of an adequate service delivery system for CSHCN.

Maude Holt, Health Systems Administrator for the District of Columbia, discussed the specialty care model that the District has put in place for CSHCN. In 1994, the District of Columbia embarked upon public-private partnerships to provide care for CSHCN. Currently, only children enrolled under Supplemental Security Income are eligible for this non-mandatory program.

With this program, the District of Columbia has been able to define an expert provider network and has been able to provide service to the population most at risk while reducing inappropriate hospital stays. Over the next year, the level of service provided by the District will be maintained; however, enrollment will become mandatory and members will be able to choose from two different MCOs for service.

Louise Novak, M.P.H., then spoke about Agency for Healthcare Research and Quality (AHRQ)-sponsored research being conducted at the University of Washington's Child Health Institute. This research is designed to detect whether certain features of managed care positively or negatively affect the care of children with chronic health conditions. This study focuses on the features of insurance products that may affect the quality of care for children with chronic conditions, measures the features of practices and providers that are providing care to this population, and defines and measures quality care for four chronic conditions. Results of this study are expected over the next 3 years.

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