Hello and welcome to another edition of Tuesdays with Liz: Disability Policy for All.
Today we're going to be interviewing John Tschida who is the associate executive director
here at AUCD for research and policy.
Today we are going to be interviewing John about managed care.
So welcome John.
Thanks, Liz.
The first question is: What is managed care and why is it important for people with disabilities.
Great question.
Managed care actually is a concept that started almost 50 years ago in my home state of Minnesota.
There was a doctor there who dealt with patients who had polio and post-polio syndrome at a
place called the Sister Kinney Institute and he saw that in his work as a pediatric neurologist
that the hospital wasn't making decisions that were in the best interest of the patient.
They were actually making decisions in the best interest of the hospital.
So managed care started as a way to really put the patient at the center of all of the
healthcare services that they were receiving.
This was back in the early 1970's.
Today as a strategy it's not necessarily being used that way and if you look on the CMS website
they talk about managed care as doing really three things.
So if you think about it as a three-legged stool.
You have cost, wanting to control cost.
We have service use or utilization.
So making sure services are being coordinated and that they aren't being duplicated in any
way and finally it's about quality.
So those three legs of that stool if you will, looking at the cost of services, looking at
what services are being delivered and what's the quality of those services.
So trying to develop strategies and ways of managing care for those individuals is really
what managed care has become today.
OK.
For our audience, who might not know what CMS is, can you just?
Sure, CMS is a federal government agency that funds and really controls the policies related
to the two main public health programs.
So Medicaid, which provides medical health services and home and community based services
and also the Medicare program which provides medical services mostly for people over the
age of 65 but also for about 9 million people under the age of 65 who have disabilities.
So that's the federal agency that coordinates those programs.
OK, thank you.
The next question is: Are managed care and Medicaid connected, and if so, how?
Increasingly Medicaid and managed care are very connected.
And that can be challenging for people with disabilities.
What I talked about in the history of managed care and where it got started, people were
only looking at medical services.
So if you were getting care in a hospital or an outpatient clinic or even going back
to the hospital to get services for a condition or challenge that you were having, from a
health perspective, so really only focusing on the medical.
But with Medicaid, we're seeing increasingly that states are making decisions about home
and community based services, so non-medical services.
Things like care coordination or home based services or even day programs that people
with developmental disabilities might go to.
And putting that in a managed care context where they're looking at yes, quality, and
yes what services are being provided, but it's really the third leg of that stool that
I talked about that's often a major concern for states and that's the cost.
So, are we doing what's in the best interest of individuals on the Medicaid program in
a managed care context?
I think that's possible.
But we need to look at and ask questions as a community: Are these decisions about managing
the care, and in some cases that means making decisions for people, especially people on
the Medicaid and people with disabilities, but are we also making decisions with people
and in the best interest of individuals with disabilities in particular in a way that honors
the history of managed care and where it got started almost 50 years ago.
We have a couple of dozen states now who aren't just using managed care for the medical services
I talked about, but also for those home and community based services as well.
So in an organization that is often primarily medically focused, are people making decisions
who have a good understanding of those home and community based services.
Do they understand the importance of those home and community based services?
And we know that often it's getting access to those home and community based services
that keeps people healthy and active in their communities and saves money where we don't
need or use the medical services.
Thank you.
Can I ask another question that I might not have thought about before?
Sure.
But I think it relates with all this issue around Medicaid and the issue around fighting
and saving Medicaid.
If Medicaid should be taken away, would that matter to managed care?
I think some of the changes they are proposing for the Medicaid program would result in fewer
people being served by the Medicaid program.
Remember that today Medicaid is what we call an entitlement program.
Now that's a fancy word.
What that really means is, if you're eligible for the program you have a right to enroll
in the program and get served by the program.
Some of the changes that are being proposed today would say that it's no longer an entitlement
or not everyone qualified for the program would be qualified to get services in the
program and states would have the choice to decide how much money they spent on the program.
So that's important to remember.
Managed care as a strategy under that scenario I don't think would go away.
I think many states, the majority of states, are now using managed care as a strategy to
make sure that services aren't being duplicated, that people are getting the services that
they need, not always the services that they may want.
And measuring the quality of those services, which is critically important.
OK, thank you.
And the last question is, is there anything else that would be helpful for the audience
to know about managed care and living in the community?
I think the most important thing about managed care and if managed care is to again, fulfill
the promise of where it started almost 50 years ago, people with disabilities need to
be front and center in creating their own plans and setting their own goals, not just
for those medical services but especially those home and community based services.
as well.
If the managed care plan, and these are being provided by insurance companies, is the one
who's in charge of developing that plan and responsible financially for the care that's
being delivered under that insurance plan.
So it's about personal control, it's about personal choices, putting people with disabilities
at the center of their care, whether that's medical or community based, so that we all
can live as independent and productive lives as we want to in the community.
It sounds to me like self determination.
You're exactly right.
And there are some managed care plans that do that well.
Not all managed care plans do that well.
So as advocates, we need to continue to educate them and coach them so that managed care can
work as a strategy for people with disabilities.
Thank you, and if you have any questions about this or any policy issues, please go to the
AUCD webpage and look for this week's InBrief and if you have any questions or comments
about this week's Tuesdays with Liz, please leave them in the space below.
Thanks again, John.
Thank you, Liz.
Bye.
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