Conference room E-275C, Lowrise
John F. Kennedy
Federal Building
100 Cambridge Street
Boston, Massachusetts
DR. IEZZONI: Good morning. My name is Lisa Iezzoni. I'm with the Beth Israel Medical Center. I Chair for the Subcommittee on Population-Specific Issues, National Committee on Vital and Health Statistics. We are happy to have everybody here today for a second day of hearings for people in Massachusetts about Medicaid managed care.
What I'd like to do is go around the room and have the subcommittee members and members of the audience introduce themselves. And then each of the panelists, if you give your talk, please introduce yourselves. Since the morning is packed, I think you were instructed on 15 minutes, and we should try to hold to that so we can have a chance for interaction at the end of the presentation.
Carolyn? Most of you have talked to her. She is the person that put this meeting together.
MS. RIMES: I'm Carolyn Rimes.
MS. COLTIN: I'm Kathryn Coltin, Harvard Pilgrim Health Care.
MR. FRIEDMAN: Dan Friedman with the Massachusetts Department of Public Health.
MS. GREENBERG: Marjorie Greenburg from the National Committee on Vital and Health Statistics.
DR. IEZZONI: There's a lot of feedback on this microphone system. So what I'd like to do is if anybody wants to make a comment, they need do it like this (demonstrating). It would help the transcriptionist, who will have a very hard job today.
MS. WARD: Elizabeth Ward from the Washington State Department of Health.
MR. VAN AMBURG: George Van Amburg, National Public Health Institute.
DR. NEWACHECK: Paul Newacheck from the University of California.
MS. MOIEN: Marry Moien, contractor working on a report from all these hearings.
MR. HITCHCOCK: I'm Dale Hitchcock from the Division of Data Policy Office, staff to this committee.
MS. ARAKI: Lanette Oroki, National Center for Health Statistics.
MR. ROBINS: I'm Tony Robins, Manager of Public Health Reports.
DR. IEZZONI: Did I cover everybody? Jason and Gretchen are not in the room, but they have helped us manage today's program and yesterday's program.
DR. IEZZONI: I'd like to get started with the panel this morning. Sally Bachman? Hi. Why don't you tell us a little bit about yourself.
MS. BACHMAN: Good morning. I'm happy to be here this morning. I am on the faculty at the Boston University School of Social Work. I have been working in the area of Medicaid managed care for a very long time, as Dan Friedman will attest. It's been close to 20 years in Massachusetts Medicaid working there and then doing health policy research. I have been full time at Boston University just the last year having been active at the Med Stat group for the last several years. I'm happy to go ahead and start if that's what you want me to do. I want to make five points to you today. I know you're supposed to do three, but I'll do five, so brace yourself. The first is that I have a particular policy context that I would like to put forward as one way to view the issues that need to be considered around Medicaid managed care and the data that are required for research, management, policy analysis. I'd like to talk about some of the issues that I have encountered when talking with states about collecting encounter data. I would like to talk about issues that states are facing when it comes to analysis of the data. The fourth issue I would like to talk about briefly is the question of alliance, specifically with respect to how Medicaid managed data care fits into a new landscape. And, finally, I have kind of a catchall category that I'll call "other key issues". I look at Medicaid managed care and the vast growth and emphasis on using Medicaid managed care as akin to a privatization question. What Medicaid programs are doing is paying managed care plans, very often mainstream, private managed care plans, capitation rate, and in exchange for the capitation rate asking the plans to provide a comprehensive benefit package. Traditionally, the only piece of information that Medicaid has kept about this transaction is the record of the monthly payment. There are very few states that are actually getting encounter data which gives a window to what is actually happening to Medicaid recipients inside the plan. There are a lot of reasons for state policy makers to want to do this in addition to sort of the politically correct atmosphere of using Medicaid managed care plans. This type of privatization off-loads both financial risk and responsibility to a private organization. This type of privatization is something that we have seen for years in government, the provision of government services, but I think the risk involved in this situation needs to be examined a little more carefully. By off-loading risk and responsibility to managed care plans, Medicaid policy makers get administrative (not recorded), they get to mainstream their Medicaid recipients, which is a good thing, and they also get to off-load some of the thorny policy decision making that has caused issues for Medicaid policy makers for years. This isn't necessarily a bad thing, but I would like to view the question of data collection in that context because there is a tension around how much do Medicaid policy makers really want to know and how responsible should they be? Sometimes tough decisions need to be made by Medicaid policy makers around benefit packages, around costs, around monitoring quality. And sometimes it's easier to use managed care plans to make those decisions. Very often, I don't mean to imply there are bad decisions being made, but I would like to view this discussion as how much data do Medicaid policy makers need in order to stay on top of what is happening in that transaction. One of the ways that this struggle plays out is through data, how much data do Medicaid policy makers need, how far are they willing to push the plans in order to get those data? What I'd like to do is just briefly go through some of the different types of data that are available to Medicaid policy makers now and talk about the issues around using each of those types of data. I think there are six types of data. You might disagree with me, but since I'm at the microphone, I'll keep going. The first is fee for service based claims data. These are the traditional claims data that Medicaid programs have used to keep track of what is happening in the Medicaid program.
There is a link to eligibility systems, and the point to remember about this source of data is that the MMIS hasn't always worked flawlessly in the past and we are not starting from necessarily a good place. And there's a lot of animosity that's been built up over the years around this and how well or how poorly that system has worked.
So when Medicaid programs go to providers and say, Okay, now we are going to go to the next level of data collection, often times there's residual anger and lots of other feelings and issues about that because of this poor history.
The second type of data, encounter data, many plans already gather encounter data. Theoretically, Medicaid programs should be able to access those data. There seems to be a lot of issues in transmitting those data to Medicaid in a format that Medicaid can use, issues like comparability, accuracy, completeness, system compatibility, how Medicaid programs should process those data once they get them.
So we have this situation where the data are probably out there, but it's creating the link and getting them into Medicaid in a form that can be used that creates problems. There are issues around linking up multiple provider sites, even though plans are merging, changing organizational structure all the time. So this creates complications about how to get the data into Medicaid.
There are issues for the plans in this context of a fee for service system that hasn't worked well. What information do we need to give Medicaid, how much energy should we expend in order to do this when we are not sure that it's going to work well once it gets there anyway.
There's a real issue about labor within Medicaid programs to analyze the data once the data gets into Medicaid. It's a new way of approaching data analysis. Potentially there could be mountains of data poured onto Medicaid programs. Who is going to look at these data and what kinds of staff are going to be hired to do that?
A third type of data are HEDIS data. And for Medicaid programs there are a number of issues around using those data, the quality of the data, the validity of the data, the utility of this type of data for populations that are important for Medicaid, long-time care populations, people with disabilities and chronic conditions.
And then there's another issue of plans performing to the HEDIS measurements. So plans bring people in for mammograms because they are measured about how well they will do on mammography screens. So while it's a useful source of data, I would tend to be inclined to look other places for a fuller picture of what is going on.
Another type of data are medical records, and there are Medicaid programs that are doing medical record audits that provide valuable information, but it's very expensive and there are labor issues for Medicaid programs about getting folks who are qualified to do this, how many medical records can you really audit, what should we be looking for?
Another type of data are consumer surveys. I'm optimistic about the CAPS survey that is being developed and fielded. There are many subsets of the CAPS survey that will be targeted to populations that are of importance to Medicaid, the Mount Auburn substance abuse subset, a subset for people with chronic conditions, and also the Medicaid subset.
I'm hopeful that Medicaid programs will look to consumer surveys as an important place to get information about what is happening in the program. It's not typically where Medicaid programs have turned in the past, and perhaps there will be some benefit from the interest that's being shown more broadly about the CAPS survey.
Then there are other types of data which could be gathered in a Medicaid managed care environment but aren't on the top of the list, information about transportation, home health, long- term care, services provided by other state agencies. There are all these other types of data that could play into an understanding of what is happening in Medicaid managed care plans.
Obviously, once all these types of data are gathered, the hope is that the state agency would be able to use them. But in work that I've been doing, it doesn't appear that this is as easy as you might think. There needs to be staffing in the Medicaid agencies more sophisticated enough to analyze the data, there needs to be a clearer understanding about the purpose of such data analysis -- what is the data analysis going to be used for, monitoring quality, monitoring access, program planning, plan compliance, regulatory purposes and so on. There's a long list of reasons for data analysis. And there needs to be better clarity about the purpose of the analysis.
Another question is, Who should see the results of the data analysis? Would this be kept within the Medicaid agency, would the state Medicaid agency share this information with advocacy groups, with the plans, with the providers? Minnesota has told us they are treating their analysis as public information, so folks can call the Medicaid agency and ask for data analysis runs to be completed as a public information request.
So there's a broad range for how that issue of sharing results could be approached. Plans have said that they don't want to submit data that aren't going to be used, which seems like a reasonable thing to me. Medicaid agencies, on the other hand, are thinking I'm not sure what it’s going to be used for so I had better ask for anything. So somewhere in that tension there needs to be a minimum data set that will be collected for a specified purpose that will then get analyzed and the results will be used. On the question of alliance, this whole issue of Medicaid managed care data, how it is going to be collected, how it's going to be used, becomes even more important in the context of 1115 waivers. Medicaid financing has become a cornerstone of state health reform efforts. So now we are creating linkages between Medicaid agencies and other state agencies that are more powerful than they have ever have been.
In our state, we have a children's medical security plan that has been moved to Medicaid. We have a senior pharmacy program that is jointly managed by Medicaid and Elder Affairs. The linkages between Medicaid and these other state agencies are becoming stronger and more important. This raises the question of who has access to these data and how can Medicaid data be used by other state agencies to cope, manage a program?
So data needs are not determined only by what Medicaid needs to know but by what other state agencies need to know and by what legislators need to know about legislative reforms that they have implemented. And I believe you are hearing from a Massachusetts legislator this afternoon, and it will be interesting to see what she has to say about this issue.
So linkage with the rehab departments, public health departments, mental health departments, mental retardation departments and others are going to become increasingly more important. How can these more micro Medicaid encounter data issues be addressed in this context where things are changing and more and more people are looking to Medicaid for good information.
Finally, some key points that I want to make. The questions about Medicaid managed care encounter data are embedded in larger questions, which I think are privatization and what are the limits of privatization and what is government's responsibility to keep information even as it's off-loading risk and responsibility for service delivery. And secondly, where is the state going its overall health reform efforts and how is Medicaid data going to be viewed in that larger context?
It's expensive and labor intensive to get adequate data. It's expensive and labor intensive to analyze the data. So the decision should not be taken lightly. It's expensive for the plans, it's expensive for the state, and it's going to be expensive for other state agencies to react to these decisions. Where do safety net providers who are very important players in the context of Medicaid managed care get the resources and the support to provide data that are going to be mandated or requested by state agencies?
This is a key question, because in every state, no matter how much we mainstream Medicaid recipients into private managed care plans, there are going to be safety net plans. And they have been arriving here in Massachusetts at Boston Medical Center. Those need additional support in order to create, sometimes maybe for the first time, automated data systems in order to manage their new managed care plan.
We need to be thinking about standardizing data requirements. We need to be thinking more about very micro level decisions that could be made about the requirements of the data elements and inside those data elements specifications that are going to be requested across states.
And, finally, we need to be very thoughtful about what the mandates are going to be. And then once the mandates are set, follow through, make sure the data are collected and support organizations that are going to need it in order to provide the data that are going to be used for program management.
I’ll be happy to answer questions now or later.
DR. IEZZONI: Thank you for a very thorough presentation. What I'd like to do is hold questions until after we hear from the other panelists if we have time at the end. Debbie Thompson?
MS. THOMPSTON: My name is Debbie Thompson. I'm director of public policy for the Alzheimer's Association. By training I'm a lawyer, by predilection I'm an advocate. I cannot give you the academic approach to quality care, but I can give you a consumer-driven approach. And it is certainly a topic that we approach with passion and commitment because it's important to the people we serve that they receive quality health care.
At the Alzheimer's Association, most of the folks I deal with are elderly. There is a subset that is a younger disabled population, but most of our folks are elderly. In Massachusetts, the elderly have been included from the Medicaid managed care system, as have institutionalized people.
There is an experiment underway now, an 1115 waiver proposal combined with the Medicaid proposal, that would enroll a subset of duly eligible people in managed care plans that would be funded by both Medicare and Medicaid. And I presume that some of the Medicaid presenters can tell you more about this proposal, but I think right now that for us it's the duly eligible population that we need to focus on in terms of looking at managed care quality and data collection issues.
When I first started thinking about what quality measures would be appropriate in the context of the duly eligible waiver proposal the state was working on with HIPAA, it came clear to me there is little out there in terms of quality measures for long-term care. I think that we had need to look at that in this context with this population as ever more people will be served with chronic illnesses in a long-term care setting.
When I say long-term care, I mean in-home services as well as institutional services. I think that in order to appropriately measure quality and collect data we do need to look at structured process and outcomes, but I think in particular the outcome measures have been neglected for this population, particularly in long-term care.
The HEDIS measurements that we have seen primarily deal with medical care services. I know that HEDIS now has some Medicare managed care measures which are a little better, but still they really neglect chronic illness and long-term care service settings. So I would encourage the government and this group to look at how we can effectively measure care in the long-term setting.
And I think to do that we need to create and devise new measures for quality beyond that that exist. It's my impression that there is a lack of data on managed care services for the disabled in general which results in difficulties in setting accurate capitation rates.
So I think we need to figure out ways to include the disabled in the development of these measures, and I think it's very difficult for the duly eligible population to accurately measure quality of care across the spectrum of services, primarily because Medicare and Medicaid are very separate systems.
We have Medicaid managed care plans, Medicaid, fee for service right now, as well as Medicare fee for service. And how do you combine and capture a spectrum of services and try to measure quality when there's different systems in effect? It's hard. Medicaid has taken a first step at that in terms of developing into 1115 waiver by getting data, combining data from both HIPAA on Medicare usage and combining it with Medicaid usage for duly eligible people and trying to project an accurate pattern of usage for this population.
They are using this in determining their capitation rates for their waiver proposal. I believe that this is really the first time that this has been done on a large scale, and hopefully the integration of this data will be a model for future use in other parts of the country.
Many of the points that Sally mentioned are things that I think are very important in terms of looking at the duly eligible populations and trying to standardize quality. I think we need to ensure that data collection is standard across managed care plans.
I think this will become more of a problem in the near future as Medicare Plus choice plans come on the marketplace where you will have a number of new models of Medicare managed care.
It's not clear to me what oversight, monitoring, measures and assessments will be required of these plans.
But for people who are duly eligible, there needs to be some thought given as to how we can model managed care to be integrated with Medicaid. And I think we need active assessment of data by both the state and federal government for this population. I think the involvement of HIPAA and data collection is very helpful in the context that waivers are required. And I would again encourage the involvement of external review entities in order to assess and measure quality. Let me tell you a little bit about how consumers look at quality and how they look at the collection of data.
First of all, I think we need to develop measure which are specific to the duly eligible population. We need to be functional as well as medical. A great deal of quality of life, quality of care for duly eligible people depends on the social support that they may receive from other state programs, the informal family support they receive. It's not just a question of medical services that are provided.
We need to devise some way of capturing the totality of services that people need. We also need to focus on the provision of services that allows the maximum amount of independence for this population. These people are by definition disabled and elderly. They have care needs that are in most cases chronic, and it's very important to most people to remain in their own homes as long as possible and receive care in a setting that allows them maximum independence.
So I think we need to look at that as one measure of quality and we need to look at rates of institutionalization, levels of services provided in the home, as ways to capture quality and managed care. As I said, I think long-term care quality measures do include both functional outcome measures as well as medical measures in a variety of settings.
We now have a minimum data set for nursing homes, which I think is limited, but it's a first step in trying to standardize and collect data in a nursing home setting. I think we need to press forward and develop more measures for capturing quality of care in the in-home setting.
Consumers need to be a source of data collection and quality measures as well. There has been some movement on the Medicare side right now. I think that's a good first step, but I think we also need to include family members in determining what the quality of care is for these people, particularly caregivers for people with disabilities or elders.
We need to involve them in the quality measurement process, and I think we need to assess what barriers are out there for quality. For instance, our Medicaid to access quality care. It would be a lack of social support for individuals that is making it difficult for them to receive care. These are issues which need to be captured and measured.
And again, I couldn't begin to tell you what data measures you'll want them to collect to try to get a fix on these issues, but those are important issues. I think we need to look at more objective measures of consumer satisfaction as well, including why people disenroll as well as the rates of grievances and appeals. Grievances and appeals I don't feel is by itself a good measure because often the bureaucratic barriers for using them are sufficient to discourage people.
But in that regard, I would recommend that plans include ombudsman, perhaps internal and external ombudsman, that would enable people to access the grievance and appeals processes. I think we need to look at specialized services for identifying groups as a quality measure. People in managed care programs have access to special care programs, nursing homes to dementia day care with specified programing and staffing for these populations. There are many other populations that need specialized services, and are they being provided in managed care? Again, in program and institutional settings, I think staffing is a critical measure of quality. I think it's fair to say that in most nursing homes today across the country staffing levels are an issue. We need to ensure that staffing is adequate to provide quality care to give people what they need, to provide specialized services when necessary.
I think there is a definite connection between what providers get paid and the quality of care they provide. While it's not a direct dollar to dollar connection, it is there. I think it's time to capture the relationship of good care and quality.
An area for the duly eligible population that I don't think gets enough allocation is mental health. Many elders are depressed. It is quite a common quality to the elderly and frail and those with chronic illness. It frequently does not get diagnosed. We need to develop measures to ensure that mental health needs are properly screened for and treated when they are identified.
I also believe that integration of mental health services is a more effective model for seniors and disabled people who need extensive care planning and management. It is very difficult to have managed for a specific set of services. I think as matter of just the development of those models those services tend to be sidelined and not as integrated as the other services in the managed care planning process.
I think we need on-going consumer involvement in managed care organizations in their operation. I think we need advisory groups. I think we need government board participation. We need to provide a feedback group for consumers who are in managed care plans, and we need to have vehicles in order to make their feelings about quality known. And I think we also need to look at on-going care plans as a quality measure. The population that we are talking about needs on- going assessment, adjustment of care plans. Somebody needs to be looking at the population before they are in crisis providing preventative services, social support services.
There has to be a mechanism in place that screens for and allows on-going care planning. And also, I believe a choice of provider is a very important quality measures. It's one thing I hear more about than any other issue is that they want to have an adequate choice of providers. So I think an important measure of quality is to look at the depth of provider panels and the look at the choices that are provided among different providers.
I think that it's important, as Sally mentioned, to have some mechanism for reporting quality assessment and data collection measures to the public. Recently, in Massachusetts, the Department of Public Health has implemented a nursing home report card. While there may be some issues about the kind of data that's been reported in the report card, the agency has been swamped with calls from consumers who want some information on nursing homes because it is so difficult to determine what quality of care is like in institutional settings.
So I think we need to look at more measures like that, ways of getting usable quality information back to the public so that they can make informed choices. Finally, as I said, I think the future challenge for dual eligible populations is going to be for Medicare Plus choice plans that I expect will very soon be on the market and will provide a new array of benefits, combinations of premiums and co-pays and additional services.
And it's not clear to me at this point, I'm not sure if it's clear exactly what those plans are going to look like and how they will be monitored and how quality will be measured, but how are those plans going to be integrated with Medicaid managed care? I think that's a real challenge for the future, and I thinks we can all work together on it.
DR. IEZZONI: Thank you very much. We'll get back to you with questions. Zolia? We need you to speak into a microphone.
MS. FELDMAN: Good morning. My name is Zolia Feldman, and I am the director of the Great Brook Valley Health Center in Worcester, Massachusetts. While I'll be using some examples specifically to our health center, I speak for the health centers in general. (Speaker was not able to be transcribed due to poor audio and heavy accent.)
DR. IEZZONI: Thank you for a very interesting presentation. Lise Federman?
MS. FEDERMAN: I'm Lise Federman. I'm right now the chief financial officer of Neighborhood Health Plan, which is a 50,000 member HMO that is predominantly Medicaid. (Additional qualifications not recorded due to poor audio.)
DR. IEZZONI: You need to talk a little closer to the mike.
MS. FEDERMAN: Sorry. My comments will probably be a little (not recorded). Some are from the plan standpoint and some are more public policy I think. From my experience overall in the last five or six years, I think Medicaid managed care needs adequate funding for HMOs to do well.
I think a significant piece of the data related to that underlines the federal upper payment methodology as in each state you calculate what the fee for service average would have been before you go into managed care. And I think data collection on that going forward is fairly important in determining whether the methodology actually works.
If you look at it, it's sort of a somewhat unclear methodology and it's been used in different ways, in different states. And as you go forward, the more you move people into managed care, the more unclear it becomes as a methodology. And I think it's hard for both states and plans to work on adequate funding around that. So collection of data and then the experience of HMOs I think is working. Because I think if people are going to receive adequate health care, the funding will be critical.
And to the extent that states have tried to use savings for managed care as part of the financing, you have to reinvest the savings. And I think the analysis underlying both those pieces is pretty important. And I think probably, I'm not sure the relationship between the federal agencies, but I think a lot of the work needs to be done on the federal level.
The second thing I think that's important, as we've moved into expanding managed care, it's difficult for both the state and for the HMOs to sort out the impact on the new population coming in, and it's also difficult for us to get experience from other states. One of the particular difficulties we have in looking at other state data is most of the state programs are so different. The benefits are different, the age structure is different.
And I think to the extent that people could find ways to standardize the indicators without using the Medicaid benefit program from each state, it would make it possible for state agencies and the HMOs to work so that you could understand data. Generally, when you look at the HIPAA data or data reported, it's so hard to understand who's in the data that you really can't use it in a constructive fashion.
I think the effect of expanding managed care on the uninsured population remains in the uninsured, especially for the safety net HMOs and the providers because we are all having trouble assessing who is left. I think we have also a small commercial population. I think to the extent that Medicaid expands into that, having some understanding of the impact of that on who is left in the work force and how it affects low income work people who are employed by companies who have fringe employees, I think it's important for us to watch going forward.
And I think folks at a national level are a better place to look at than an individual HMO. And it's one of the issues we are sort of struggling with now as Medicaid is expanding. On the HEDIS indicators and things like that, in Massachusetts here I think it's been pretty inventive and they have been extremely sympathetic to the issues of safety health net providers.
If you predominantly serve a very low income population, you tend not to generate the resources, and you're being compared to enormous firms who have a lot of resources who have invested in the market to sustain their commercial business and national competition.
And I think what ends up happening frequently is some of the indicators are more geared to the commercial market, but it's the resource issues of some of the providers in our number. For example, they don't necessarily have the resources to devote to a particular indicator. They need to devote more limited resources to a different set of health care services.
But as people continually use some of the HEDIS measures, that whole issue and how it affects, how the plans look and as people try to standardize reporting to HMOs, that definitely feels like it's an issue for us and how people use those indicators. And looking at finding ways to truly make it a reasonable comparison but not unreasonable seems important.
One of the major issues that we have as a health plan, we serve a lot of urban people. We get almost no information from Medicaid on who the disabled are. And it may not be true, it doesn't appear that SSI has an easy time releasing that data. And Medicaid also has a difficult time. But you have to expend a lot of time finding the particular person. Not that we shouldn't do it, but to the extent people could make available data in a confidential way through the Medicaid agency more accessible, you could be much more protective with the disabled. And we have an active disabled population and really can't access that now.
And the state is working on it to find a way to both make available -- the other thing I think that the federal agencies would do is significant work trying to explain to the HMOs how the disabling conditions that people have fully effect their -- because one of the things we find is we have an awful lot of people and there's only a small population that use it. And to the extent people could support or could provide additional information within the HMO, I think that would be helpful to us.
I think my only other comments on the sanctions to the extent that it was a question, one place where we find sanctions difficult is to some of our other providers that don't have a lot of money and sanctions become difficult for us to use with them. And again, I think for large Medicaid HMOs, additional sanctions become another resource issue in the context of relatively even funding to the extent it's adequate. Most providers don't have access to additional funds. So I would say sanctions would need to be carefully thought out.
DR. IEZZONI: We've learned a huge amount from you. Very diverse but interesting panel. Thank you. Committee members, are there any questions, comments?
MR. FRIEDMAN: The question for you, you talked about the capacity of health centers to analyze and use Medicaid managed care the analysis that you presented. Were those done in house?
MS. FELDMAN: No, it was done by for us by the neighborhood health plan. I think that we do, however, do a lot of things like that in the health center in that we have, I can't say how many track systems we have, you know. We believe that a great deal of what we give them is based on that. We are looking forward to trying to implement a medical records system, but we have been actually looking for resources for five years. (Additional comments not recorded due to audio and heavy accent.)
DR. NEWACHECK: To what extent is data collection that you're doing a financial burden for you and who do you think should be paying for it as required under Medicaid managed care?
MS. FELDMAN: If we look at our Medicaid population, it is only about 32 percent of our population. Forty-four percent of our clients you are uninsured. I don't think I can say that Medicaid is in fact the agency that is responsible for funding in fairness.
I think that it is a federal and state responsibility. It's hard to say. I mean, on the other hand, you know, the investment that Medicaid could make on that would in the long run end up benefiting Medicaid as well. Because if the clients go to the hospital instead of us, the expenses are going to be very high.
DR. NEWACHECK: It sounds from your perspective you're interested in the data and do you feel other health centers in the area are able to use data adequately? Do they find it to be burdensome?
MS. FELDMAN: I think clinicians, the reality is that from when we are speaking, we are speaking about what the conditions are able to do. And I should expand that by I'm not talking physicians but I'm talking about psychologists, dentists, etcetera, to be able to track information, being able to track information on performance.
They are trained to respond to information that comes back in. That is the training that they have received. The physicians in particular who have chosen to work at community health centers have not chosen to work there because they want to make a difference to particular individuals that they come in, they are committed to the population of medicine.
They are committed to make a difference. And therefore, the information that they need is not just individual data, it's aggregate data. Yes, I think there is a uniform commitment of clinicians to benefit from that.
DR. IEZZONI: I'd like to make Paul's question a little more specific both for Zolia and Lisa. Do you know about the standards for data transmission, electric data transmission, that were promulgated under HIPAA, and are you putting mechanisms into place to use those standards?
MS. FELDMAN: I think when we looked at, in going to the process of looking with vendors, we accessed some resources from our local community hospital to look at all the requirements that needed to be met. And they assisted us in making sure that all the vendors that we were talking to had an understanding about what the requirements were.
DR. IEZZONI: Lisa, what seems to be happening in the neighborhood health center?
MS. FEDERMAN: We are just starting to look at it. We should be able to use most of the definitions, and we are at this point in time upgrading our entire management information systems. It's not clear to me yet whether there are reporting requirements from our providers.
And to the extent there are, I would be concerned. Just as an example, right now, probably because of the diversity of the health center's resources, we don't have an interactive connecting network with all the health centers, which is where we are trying to get to.
To the extent they would need to change the systems, that would be a significant issue for the health centers. It would be less for hospitals.
DR. IEZZONI: Hortensia?
MS. AMARO: I was wondering whether you could comment on issues of behavioral health care and what kinds of -- I guess you would comment on several levels. Several of you mentioned the need for appropriated rates of reimbursement and calculations for costs, you know, based on the population that's being served as opposed to some other population.
It would be that or in terms of what kind of outcome measures or performance measures you would think would be important to keep track of your population in terms of behavioral health care specifically.
DR. IEZZONI: Could we also hear Sally? I was wondering whether you would have some comments on that?
MS. FELDMAN: On mental health, I think depending on the diagnostic categories there are different outcomes and performance measures. We have not necessarily had a problem with the methodology that Medicaid has used. I disagree that integration is really more desirable. And it's very difficult to deal with different entities and different measures because we use an integrated model. I think with the chronically mentally ill, one of the areas where we have been able to -- we have not been able to gather the information, but it has been gathered I believe on Medicaid and analyzed by looking at the cost effectiveness of medication and case management for the chronically mental ill.
Again, the issue I think many times is being able to get involved in the diagnostic category appropriately but to be also able to do managed care of those individuals. The benefit again on Medicaid managed care is that we are able to track them as a group as well as individually. In substance abuse, I think we have a lot to do. I don't think we have adequate access to services. I think, you know, and some it I think in terms of financing, I think it has much more to do with the level of financing but also with the contracting. We do not have enough competent providers in a number of slots. There's a lot of work to be done there.
MS. BACHMAN: Where to begin? I've done a little bit of work on carve out arrangements. And in general, state policy makers that I've spoken to are thinking integration long term. Eventually, I think they have an image that all services will be integrated under one capitated arrangement and that this type of arrangement would apply for most populations.
Carve outs seem to be kind of a step along the way that many states get stopped in. The carve out arises because of advocacy, because of concerns about making sure that you have appropriate infrastructure for behavior health services and worries about safety net providers who are often involved in providing behavioral health services to Medicaid recipients.
What has happened in this state is kind of interesting. We have a statewide carve out for behavioral health services in which mental health and substance abuse services are provided to people enrolled in our fee for service managed care plan. Then there are mainstream plans that integrate mental health services like Harvard and Pilgrim.
And I believe neighborhood health plan has a carve out within a capitated arrangement. We are getting these kind of variations blooming, but ironically we are not actually moving closer to integration, so I'm not sure where we are going to end up with that.
I think in terms of outcome measures that could be gathered, there could be some very basic outcome measures that could be gathered that would give a sense about what is happening to individuals who are receiving behavioral health services. And there has been some work done toward identifying what those measures are.
It's not so much the identification of measures, but I think what happens is we get caught up in all these other issues about how much data to require and how are we going to get that data flowing back and forth and how is it going to be used. In this state, the partnership has data. It has data about services that are provided to Medicaid recipients. So a partnership in that sense is just another plan so that the issues become the same.
DR. IEZZONI: Lise?
MS. FELDMAN: We do have an integrated system and also we have a vendor. And I think integration works particularly because it's possible for the clinicians to talk relatively rapidly. And that's the one thing that, at least so far, partly I think because of the experience of the partnership and sometimes it's more difficult for those communications to happen when people don't know each other.
We do joint case management. And I think in terms of data collection, I agree it's relatively simple, but standard measures would be helpful. The two areas that I see sort of issues, one is there's frequently such a focus on chronically mentally ill that one of the concerns that I have is we have a very large population and they have AIDS, substance abuse, they have a lot of social issues and need a lot of support.
And I think underutilization in that population is the most likely thing and I think some way of monitoring that would be very helpful. It's just it's so easy to focus on recognizable needs. The second thing I would say, the dual diagnosis situation, I think people of medical, and it's hard for plans to understand how those two relate in terms of utilization and management to the extent people can get information and a better understanding of dual diagnosis within the disabled.
For example, we have a lot of very high substance abuse pregnant women who have a lot of services and have ended up needing to back into care management around those women. That's the more clearly recognized problem. The other kind of problem, it's much less clear and I think collection on that would be very helpful, particularly fee for service system. A link to that would be very helpful.
DR. IEZZONI: Thank you. Kathy?
MS. COTTIN: We have an integrated system, so we have the advantages of having complete data across our population for both mental health and non-mental health services. But when I hear all the time from plans that don't have that, and for Medicaid we don't have that, that's the one for Medicaid we do but a lot of the plans do not, that they don't have that capability to link.
And one of the issues that comes is that these are particularly sensitive data, and we've heard from others who are testified around privacy and confidentiality issues that the mental health and substance abuse data are particularly sensitive. So when the health plan does not have a relationship with the carve out vendor when the carve out is occurring at the level of the purchaser, in this case Medicaid, as opposed to at the level of the plan where you do have a relationship and you can make it part of your contract that you share that information, you don't have that ability when the carve out is happening at the level of the purchaser.
There's no formal relationship between the plan and the carve out vendor and therefore no obligation for the carve out vendor necessarily to share information, particularly sensitive and confidential information. And the informal communication among the caregivers that's so vital is also compromised because in most carve outs the patient sees an intake care coordinator and they do some sort of assessment of their needs and make a referral to a particular provider.
And the plan may not even know that, the primary provider may not know who the individual provider is who the patient is seeing. So informal communication is sometimes difficult to establish as well in coordinating the care, whereas when it happens within the system you have that ability to have the caregivers directly communicate with one another around what is going on with the patient.
DR. IEZZONI: I actually want to ask Debbie question that draws on that question about confidentiality and sensitive information, and I think because of the historical stigma that the issues around protecting privacy and confidentiality are more acute and more something that people talk about.
But we've also heard from some family members, for example, in testimony that Elizabeth recalled yesterday that family members as they begin to get increased numbers of requests from plans, etcetera, for information about the functional status of their person with disabilities within their family, that they are becoming increasingly concerned about responding honestly to those kinds of requests, concerned that they might have certain services denied, for example, or might be dropped from a plan based on disability.
Is that something that you're hearing from any of the folks that you're representing? Is that a concern for you?
MS. THOMPSON: We have not heard it in the context of people being concerned that they will be dropped. I think what actually most of our folks are struggling with now is cutbacks in Medicare home health services which are directly based on a number of the things we are talking about. That is a real problem. I think the problem for caregivers who are not necessarily sophisticated in eligibility criteria, under either Medicaid or whatever it might happen to be, is what should they be saying? They may answer to the best of their ability, and the answer may be subjective and result in a denial of services.
For instance, they may not know that somebody needs skilled observation which qualifies them for a home health service. And this is true in Medicaid as well. And if they are answering on behalf of someone who cannot answer for themselves, their answer may result in a termination of services when it's not what they intended at all. Then they are stuck with the process of trying to get the services reinstated, which is difficult and time consuming and rather unsuccessful.
We have heard, yes, that family members are being asked questions that they don't necessarily know how to answer. That is more of a concern, I think, than being afraid to answer. They want to give the right information.
DR. IEZZONI: Do you have any suggestions? Because I hear exactly what you're saying, especially around home health eligibility. Do you have any suggestions for how to deal with that, getting the information that people need?
MS. THOMPSON: Well, there are certainly a number of screening tools out there that I think we should look at that would provide a standardized way of collecting data about functionability and reporting. Frequently with seniors, the problem we have is the assessor will come out and say, Can you dress yourself, and they say yes, when in fact they can't. So there's a certain level of pride that mixes into this.
I think it does come down to having an accurate assessment tool and having an assessor who is trained to work with these populations and understand where they are coming from. And I think also when you add in the socio-economic factors with Medicaid, there may be ethnic issues around how particular disabilities are viewed. People may be ashamed that they can't do certain things. I think you really need to have someone culturally sensitive to determine what is appropriate.
DR. IEZZONI: That's an excellent answer. Does anybody else on the panel want to comment?
MS. BACHMAN: There's been a lot of struggling about the issue of assessing individuals as they are enrolling in managed care plans for fear that that information would be used for the purposes that you're describing. There are a couple of examples of managed care plan that have instituted assessment systems.
One plan in particular is called the Intermountain Health Plan in Utah. They have an enrollment and assessment system that is linked. And then when individuals are assessed, they are triaged into three or four different models of support and health care that are responsive to their functional status.
So that the negative side of assessment seems to have become less important in this plan. And the plans are able to use the information to develop care plans that reflect the individual's need for services. The individual is participating in a routinized system so that they are not being red lined or identified in some way for disenrollment or whatever the concerns might be.
So there are only a few plans that I'm aware of that have developed these systems, but I think there are models that would be looked to for positive use of this type of information and could back away from the fear so many have of it.
DR. IEZZONI: Thank you. I'd like to break a little bit early so we can have a break before the next session. Are there anymore questions. Kathy?
MS. COTTIN: Sally, you talked about the limits of the privatization and also about the state's responsibility around a benefit package design in particular. And Debbie talked about wanting to see measures of long-term care and managed care, mental health and managed care, specialized services.
Can you talk a little about the interplay about where the locus of responsibility would reside for data collection and for data analysis depending on what decisions are made on benefit packages?
MS. BACHMAN: To my way of thinking, there is some amount of responsibility that must reside at the state level, responsibility for being clear about what is being asked for, responsibility for being clear about how it's going to be used and responsibility for monitoring health plans.
The flip side of that is that there are definitely advantages to state policy makers to use managed care plans because they can introduce increased flexibility in their benefit packages. So it seems to me that there needs to be additional dialogue between the plans and the state about benefit exceptions, the type of creative care plans that could be developed through a managed care plan because they are not tied in the same way to restrictions that a Medicaid program might be.
I would be in favor of flexibility. Sometimes, we've all probably heard stories about very small benefit changes that made a huge difference to an individual. The problem with that is it's hard to legislate and hard to say in advance what those changes may be. It seems to me you would work out a system where there would be reasonable benefit changes that would be allowed in order for the managed care plan to do what it can probably do very well, which is try and look at a person holistically and integrate services.
I'm not aware of a state that has developed that kind of a system that could look at benefit changes or benefit plans in that type of way, but I think it's worth thinking about.
MS. THOMPSON: I would note that the duly eligible waiver that Massachusetts is now developing provides discretion for plans to provide additional services which are not normally included, the idea being that as long as they stay within their capitation rates, etcetera, they are best positioned to know what kinds of services people need and so I think that kind of flexibility is very desirable.
MS. FELDMAN: I want to make a comment about the benefit package. (Testimony not recorded due to poor audio and heavy accent.)
DR. IEZZONI: I would like to thank our panelists for an excellent series of presentations.
(Short recess.)
MS. TOBIAS: There are a lot of different questions that the panel is interested in. I'll just speak very briefly about what some of the kinds of data is we looked at and used.
We have done a lot of work with Medicaid claims data and have been working to develop risk adjustment payment systems for people with disabilities over 65. We have done some analysis that sheds light on management care of that population as well as worked on developing different iterations of health base payments.
One of the biggest shortcomings in the data that we look at in most of the work is that we lack any information on functional status. Well were just talking about that earlier. It makes it difficult as you think about trying to develop payment systems for people with disabilities when you don't have any information on functional status but just have claims data.
The other kind of data we collect and work with is with consumer interviews. We do a lot of in person and telephone interviews with people, particularly people with developmental disabilities, physical disabilities, about their access to health care services, their experience with different kind of care and delivery systems, their satisfaction with care and how they perceive their health status. Those are the two forms of data with which we are most familiar.
Our perspective on the issues raised by the panel is more national than local because we work with programs with the state, and our focus is on the under 65 population with people with disabilities with adult children. The first question, what are the most important issues that Medicaid managed care spans, I think there are so many different ways to talk about that I have chosen three to focus on. One is on the benefits and service utilization issues. The second is the cost experience of health plans, what is happening to health plans that serve these populations? And thirdly, are there some simple steps that we can take right away that piggyback on other states adopting quality for the general population that will have slightly more relevance to people with disabilities.
I don't think that's enough, but it's an initial step that hasn't been taken in too many places. To look at the issue of benefits and utilization, one of the biggest issues that we've encountered in working with states and plans in developing managed care programs is how do you know if people with disabilities, with life-long chronic needs, are getting access to the right amount and type of benefits they need to have? What kind of data is being collected to look at this, what are people finding?
The Medicaid benefit package is so different from any other kind of insurance. Medicare is different from any kind of commercial insurance both in its scope of coverage for certain kinds of benefits, such as durable medical equipment, rehabilitation therapy, mental health services and also in the kinds of long-term benefits that people use. So when states begin contracting primarily with health plans to serve people with disabilities, the scope of these benefits and the utilization is going to be very, very different among this population than anything the health plans have ever experienced in servicing AFDC or servicing commercially insured population. So how that communication takes place is essential and how information is communicated to consumers it essential, and then what is done to monitor this process to make sure people aren't getting shortchanged as this occurs.
I want to give a couple of examples of situations where good oversight, good data collection, and I don't know all the details of how it was done, led to the identification of problems quickly and their resolution. One is in the state of Oregon which contracted with managed care plans to serve the elderly.
Whatever monitoring system they had set up with the data collection system came to identify very quickly that the health plans had no experience with the provision of medical supplies, and furthermore, no intention of delivering them. This was just not something they had done, and they were able intervene in that situation and address it and make sure people got access to the medical supplies.
The second situation occurred here in Massachusetts, and you can ask them how that occurred, but they discovered that mental health and substance abuse treatment utilization among HMOs serving Medicaid recipients with people with disabilities was much lower than what they were expecting. This experience is being repeated all over the country as people with disabilities enter managed care.
I don't believe most states have the monitoring system and data collection tools necessary to identify things as quickly as Oregon and Massachusetts did, but I think it's essential. The second issue I want to address is the issue of capitation rates and financing of care for these populations. I see from other people on the panel that more rate setting issues, so I won't go into the details, but there have been a number of distances around the country recently where programs have either fallen apart or at risk of falling apart.
Our states are being sued because the health plan for people with disabilities are far lower than what they need to actually adequately care for people. I think we can expect perhaps to see this get worse, not better, in the coming months and years because states are getting more sophisticated about knowing what to ask for and making demands for the plans and they have got to have the resources to do that.
There are three cases that I can think of, one in Pennsylvania recently, where the state had a legislative commission that required an audit of the way the rates were set for people with disabilities, the state of Washington which has just withdrawn its program for serving people with disabilities because the HMOs basically withdrew from the program saying they are not getting paid enough, and an on-going struggle that we are having with a plan in Wisconsin constantly experiencing cost overruns and there's a big debate.
The issue is, Do we really know why this is happening, are we collecting the data that we need to collect to understand why is it happening? There are many possible reasons. It can be the rates were wrong to begin with. But it could also be because of adverse selection. It could be because -- one of the things I've heard from the state of Washington is that the health plans went out and did a big need of assessment and began to give primary care and dental services that they never received before.
And, hey, guess what? That wasn't in the capitation rate. The fourth reason could be because the health plans aren't capable of managing the care of its populations. I'm not sure we have done the kind of evaluation and we need to understand why this is happening. These are early warning signals as we move ahead.
The last point is about data collection for Medicaid managed care and is there any way to piggyback on things that are being done currently for other Medicaid populations to address people with disabilities? Bruce will talk more about a study we conducted about a year and a half ago, so I won't steal his thunder.
But we did ask one question about what are you doing about monitoring the quality of care for people with disabilities? And basically we got back that, Well, we haven't got to that yet. And we interviewed every state with people with disabilities in managed care and some of them have just started doing it.
Some of the very early steps I think that could be taken is that as states are collecting data about how many people are getting mammograms and how many people are getting immunizations, to collect this information separately for people with disabilities. It's really important to know how many people in their 50's with disabilities are getting mammograms, because it's a huge issue. It really important to know how many children with disabilities are getting immunizations. To know that you have to look at it separately. There's man other things that need to be done, but that would take another panel.
DR. IEZZONI: Thanks. Stick around. We'll probably have some questions for you. Representative Chandler?
MS. CHANDLER: If you don't mind, I think it would be valuable to hear others first. I can stay.
DR. IEZZONI: Bruce, has just ran out to photocopy your slides, but let me tell the committee we will be having paper copies of Bruce's slides.
MR. LANDON: Thanks for having me here. My name is Bruce Landon. I work with the Department of Health Care Policy at Harvard Medical School as well as at Beth Israel Deaconess Medical Center. Again, I thank you for having me here.
I first want to provide a brief overview of what I'm going to be talking about. Traditional fee for service Medicaid is disappearing. I think that's the reason we are talking about managed care here. Medicaid offers a lot of opportunity but it also offers some problems. We'll talk about them for a couple of seconds.
I think there's a lot of variability across states in the implementation of managed care programs. I'm going to share some data with you on what we collected from states having to do with what plans are doing and how they are implementing the programs. I think I will draw on some themes that Carol raised about data collection tools and monitoring of data within health plans that is really falling on states and that states really need to do the job on. I'll show you some data on what they are doing now and what they hope to do in the future.
States are planning to do more, and they are planning to do things in a standardized way and think of ways to disseminate data. There seems to be a need from states for technical assistance in this area. I'm just going to put this up for a second.
Everybody knows that enrollment is really increasing very quickly. As of 1997 we were just at about 50 percent of the Medicaid population covered by managed care plans. My guess is we are over 50 percent right now. One thing we should remember is that all managed care is not alike. There is primary care case management, which is what I think we are focusing on here, and virtually all the growth is in this capitated plans. Managed care is clearly a significant benefit for Medicaid beneficiaries. (Testimony not recorded of slide presentation.)
DR. IEZZONI: Thanks. Do you want to go now?
MS. CHANDLER: I do. I guess you would put me last for a very real reason and a very good reason, because I'm the case study. I provide where the rubber meets the road, and I can only speak from my experience as the Chair of the Joint Committee on Health Care here in Massachusetts, but I wonder whether we are so different from other states?
First of all, you're asking about data and our concerns about collecting data. I must with some embarrassment tell you that we do not as a legislative body collect data, so we depend on our data from other sources. We unfortunately find that there is so little data being collected that we are often forced to make policy. In fact, generally forced to make policy based on anecdotal information.
It is (not recorded) policy that we make because we are never quite sure. Let me give you an example of that. I think perhaps Diane Flanders will probably supplement what I'm saying. Two years ago we developed a program where we attempted to provide prescription assistance to seniors. It was an extraordinary program, at least we thought it was when we initially embarked on this program.
However, we thought there were some 60,000 seniors who were not eligible for Medicaid who did not currently have health care insurance. And we thought the target group was around 60,000. The first year we had some 12,000 apply for the program. We are still kind of wandering in the dark.
We increased the requirement of what the poverty line had to be. We increased whether initially it was just chronic maintenance drugs and we increased that to all drugs. We increased the amount that we would offer from 500 to $750, and we are still struggling to bring our numbers up. I believe we have something like 22 or 23,000 now. But this is not the way to make policy. We have $30 million sitting, waiting for people that we hope we can identify. So that's a real issue.
Another example of this is that when we expanded Medicaid this year for the kiddie-care program, when we extended that program, we think we are hitting it correctly and we think we have the right number but we are not sure. Again, it's not good policy.
More and more as the federal government will put more demands and more responsibilities on the states, the need for data becomes more important. So we look to our own Medicaid agency, our own department of medical assistance, who we have great confidence in, but I think they are probably going to be overworked in trying to provide the issues that we require information about.
You are asking a difficult question today because we as a state are really in the infancy of a Medicaid managed care program. We have all of our non-elderly, except for the disabled, who have Medicare -- excuse me, all of our non-elderly are on managed care Medicaid. However, for our elderly, we only have 800 so far, and that's in the Pace program. Let me back up a little bit.
One of the concerns that we have as a state is that we are a very heavily penetrated managed care state. And as such, we are for the first time in 22 years looking at our managed care companies and trying to provide shall we say some reforms that reflect consumer input in the process of managed care.
If we are going to put substantial numbers of the population into managed care through the Medicaid program, first of all, the base of that managed care has got to be very straight. We have to be on a very solid basis. So we would like to make sure that there are notifications if there are going to be denials, and they should be in writing. Things that are very clear and very simple but are really problematic at this point.
So these are some of the issues we are straightening out at this time, making the necessary corrections in our own managed care program. Now, onto that level you have the Medicaid program, which we have, I think, administered with great skill in this state. And I say that not to pamper anybody, but I think we are one of the shining lights.
We are looking now at a real crisis. And our crisis in Massachusetts is not unlike the crisis that other states are feeling. We are very concerned as we follow what is happening at the federal level with Medicare. The cuts in Medicare that we have seen are going to have incredible effects here in Massachusetts, and in fact every state.
I say that because that has become, I think that 1998 will be the year of the crisis in Medicare for us, which will in turn become a crisis in Medicaid. I don't have to tell you what the relationship between the two is. I don't have to tell you that the concerns that we have in home health services are reaching somewhat monumental proportions.
We are getting calls, these people have no where to turn. They don't no where to go and they have no place else to turn. And they call our office, they call Consumer Affairs. They probably are calling the Division of Medical Assistance. They are calling all over the place because they have no where to go. They are seeing that their own health cares are going to be budgeted, and I think that's a very kind word, rationed is a fair word for it, and we are concerned about the impact this is going to have in our hospital costs.
We are concerned about the impact this will have in Massachusetts on our nursing home costs. We are concerned about what this will mean in terms of our residency programs. We are proud of the number of teaching hospitals and the quality of them, but a great deal is dependent on funding through the Medicare program. This will be a trickle down effect on our state that will take one of the shining lights and perhaps diminish it to a degree that we don't even want to consider at this point in time.
What does this mean for many of the people that we are seeing on a regular basis? I participated yesterday in a panel discussion on the impact of Medicare on managed care and the seniors are very concerned. These are seniors who had hoped to live the rest of their days with some sense of independence and dignity.
And because of the Balanced Budget Act, they are going to have those Golden Years, they are going to find that the Balanced Budget Act has been transacted on the backs of some of our most vulnerable members of our population. And they are very concerned.
We are seeing in Massachusetts that, a survey of 40 home health agencies found that 60 percent of the agencies said they expect to lay off staff within the year. About 10 percent said they have already initiated layoffs. In my own community of Worcester, the second largest city in the Commonwealth and in New England, we have already been told of one provider who is no longer going to be able to make it.
This industry employees approximately 18,000 people in Massachusetts, and it stands to lose $100 million a year in cutbacks. The Medicare cutbacks for us represent 1.5 million visits a year for Massachusetts alone. That is very substantial. That means people who normally would have been able to stay in their homes are going to start looking for other sources and that other source is ultimately going to be looking at going into nursing homes far earlier and putting pressure on the Medicaid funds that we have. And we are already beginning to feel that, putting pressure also on the Medicaid home health care funds that are available. We are already beginning to feel that. So we are in a bit of crisis here, and I think that we are not too different from other states in this situation. We, I think, are doing a good job as we move into Medicaid managed care.
But I can't really tell you that with any certainty because we are really on the cusp, we are in our infancy. We have a report card, I believe, that has been issued, which is wonderful because we are treating our Medicaid population with the dignity I think they deserve to make choices, that they are capable of information that will give them the opportunity to make good choices.
We have to make sure that we preserve the confidentiality of the medical records that are developed here. It's a worry because we worry about the confidentiality issue right across the board. Medical health records are a problem. There is no such thing as true confidentiality and anonymity in medical records. And we are working to try to provide a bill here in Massachusetts to provide that.
We are worried about how it plays out in the mental health area, another area of grave concern to us. We are worried how it will play out in terms of substance abuse issues. Capitation is an issue for us. One of the concerns is we don't really know what the impact of capitation is versus fee for service.
One of the things that we have attempted to do in Massachusetts in our managed care bill is to look at -- we can't make any decisions about is capitation better than fee for service, so we are attempting to do a bi-annual survey that will look at doctors and the medical care they give in terms of patient satisfaction and in terms of outcomes.
We need to do a great deal more with outcomes because most of our information, most of our surveys are at the moment really slanted toward patient satisfaction. We need to educate the patient population in terms of what are the kind of things other than just sort of feel good kind of things they can expect in their medical care.
We need to be aware are the rates are high enough, because one of my concerns, before coming to the Legislature I was president of a long-term care facility that ran a day health center, what I thought was a very important resource for the community. And we only had three in the full community of Worcester servicing 300,000 people in the greater area. And we had to close last year our senior day health center because, frankly, we could not run the center on the rates that we were getting.
That is a serious, serious issue. I am tired as a legislator of saying that I want to keep seniors, and I'm heading there myself so I'm worried about me, but we want to keep seniors independent and we want to keep them at home as long as we can. But you can't do that with talk.
You have to provide money to make that happen.
You have to have rates that allow that to happen.
You have to have services that permit it to happen.
And so if I can leave with you only one thing, I think that we need your help, we need your data, we need your information. And together with your data and a better understanding of the populations we serve and the needs that they have, I think we can as we move into the 21st century do the job that needs to be done here.
DR. IEZZONI: Thank you. Why don't we take about ten minutes now to see whether there are any questions.
DR. AMARO: Thank you for coming. It's great to have you here. I was wondering from the legislature's perspective what kind of data would the legislature find useful in its assessment of the performance of Medicaid managed care in general?
MS. CHANDLER: You need outcome studies.
MS. AMARO: I want to ask if you could comment or any additions related to specific mental health and substance abuse treatment which are generally left out of the picture.
MS. CHANDLER: It's very definitely left out of the picture. What we use, I mean, I'm embarrassed to tell you that we are totally reliant on the sources of self-serving agencies because we have no objective data at this point in time.
This is particularly true of mental health. We have a major bill that is going through the legislature now in terms of mental health care and another one that's about to deal with mental health and the Medicaid managed care area. So we are going to be doing that bill I believe based solely on a knee jerk reaction. And that's not good.
We don't have enough data internally in terms of our own state, and we don't have enough comparative data to know what other states are doing in this area. I think a national standard would be a great help to us so that we are comparing apple and apples rather than apples and watermelons at times. We know how to use the data, it's just a question of having it available to us.
MS. WARD: I just want to clarify something I think I heard you say, and that was that for states that have had managed care for some time that the introduction of the Medicaid managed care was in fact a vehicle for potentially a better oversight and management of just managed care period?
MS. CHANDLER: I don't know whether that is really true. I would say to you that I feel very comfortable that with Medicaid and entering the managed care world that they will have high standards and provide enough of a critical mass so that there will be attention paid to the Medicaid patients.
I think I say that based on the fact that one of the things that one needs in working effectively in managed care is a critical mass so that attention is paid. I wish I didn't have to say that. But we at the same time without really any discussions about, with the DMA here, began to do our own analysis of what we needed to do with managed care.
The two really are separate, but I look upon the introduction of Medicaid in the picture as a partner in this process.
MS. COTTIN: I know that in Massachusetts we are really just beginning on the journey of collecting encounter data from managed care plans, and I'm sure that we will be looking to other states who have experience in doing that as we think how the data needs to be provided and whether it should be provided in the standard format, and this will make the basis if we can standardize what actually gets collected.
But one of the questions I have came up from talking with folks in Arizona who have been collecting encounter data for a long time. And they talked about the staffing at the state Medicaid agency and their ability to actually mind the data, be able to analyze it and to provide the information necessary to inform policy, to perform monitoring and surveillance and so forth.
And I know that in the Medicare program at the federal level they have been able to benefit greatly by make public use data tapes available to researchers to help inform policy and to expand the resources that are available to analyze the data. And I know you've been talking about the confidentiality issues, but has the state given any thought whatsoever to thinking about public use data tapes, you know, with identifiers that could be used by researchers to help the state Medicaid agencies expand the resources they have available to analyze the data and inform policy?
MS. CHANDLER: I can answer that in several ways. I think the first answer to that is that we discovered last year in the process of this confidentiality bill that our group insurance commission, which is something all of our state employees belong to, had been giving or selling aggregate data from the group insurance program. And an absolute panic began.
The thought was, my God, if they are doing it with the group insurance commission, what in the world must be happening in Medicaid, because that was of major concern. I think the confidentiality issue is so enormous in that it is not easily bridged.
However, you also said something else that I found interesting. We have a history in Massachusetts, a history of about four years, of having our large purchasers of health insurance, managed care, have gotten together using the HEDIS data, and they have developed I would call it a report card, you would call it a report card, it talks about satisfaction and outcomes. It's a very good instrument.
They survey one year, and the second year they work with the companies, work with the plans to increase their scores in those areas that they are weak. They are large purchasers. Medicaid would be a large purchaser. They have enormous clout with those plans. And I have watched -- I mean, I wasn't a believer, but I have watched what has happened. And because they are such large purchasers, the plans have been incredibly responsive.
Now, we are going to build on that. We are going to have report cards for managed care that will be available to everyone in our state, much the way Maryland has done, New Jersey has done, Minnesota, Pennsylvania. We are going to do the same thing with the understanding that we can get that kind of clout and improve the quality.
This is why I say critical mass is very important here. And Medicaid, knowing their exacting standards, I think we can expect to see some improvements right across the board.
MS WARD: I think you're right about that, but I think what people are concerned about now is moving the populations into managed care that haven't been in managed care and where we don't have quality indicators that are being reported. So there are no quality indicators for the SSI population, for instance, in managed care.
One of the problems with trying to implement that is within a plan the critical mass of members on which to make measurement as well. One of the problems we are stuck with is that as we embark onto something, we don't have the critical mass, we don't have the data to know what the impact is going to be and it's awhile before we fully get it. And by the time we do, you know, we may find there's a problem.
Really, the encounter data may be able to serve as a warning system for that kind of thing because you can look at cross plans and develop a critical mass.
MS. CHANDLER: I think I have to know more about the encounter data and how it's developed, how it's taken before I could really comment on it. I do know that the confidentiality issue would be a problem. If that could be in some way resolved, I think that perhaps it would work.
But we are having our own problems of getting this new population into Medicaid and into managed care. I do believe that it will be a very wise thing. I believe the capitation and Medicaid plans will work well.
MS. THOMPSON: You have three experts coming this afternoon who will probably be exactly who you can address that question to. They are the HMO people and they would be very interested in your question.
MR. VAN AMBURG: One of the things that has occurred over the years is that states have really not invested in health information systems, data systems, as extensively as per capita as private industry has done. Do you see the states, and Massachusetts in particular, willing to invest enough money in their information systems and in the analysis of the data to answer the questions that need to be answered on Medicaid managed care?
MS. CHANDLER: I think we do. I think the resolve is there in Massachusetts. I know you are either going to hear or have already heard Elliot Stone, the executive director and CEO of the Massachusetts Health Data Consortium. I had the opportunity to speak last year and just a few weeks ago to the consortium and to talk to the CIOs of the consortium, and I know they have great concern.
We are coming into the 20th century, we are not quite into the 21st yet, but we are computerizing and we are investing money in this.
DR. IEZZONI: Can I follow up on this? I know what Elliot does since I live in Massachusetts. We heard from Neighborhood Health Centers this morning who said that they don't even have computers that necessarily are up to speed. So I think that Elliot is kind of an end user, he's on the food chain way up here. What we are talking about is the absolute bottom people that are being eaten --
MS. CHANDLER: And they are not.
DR. IEZZONI: True. They don't have the capacity. It kind of gets into what you were talking about in terms of having the rates payment for Medicaid being adequate to support not only the care that's given to patients but also documenting some things about what happens to them.
MS. CHANDLER: That's a very good point. I'm very familiar with him because I know how concerned we are in terms of having the right wiring and to be able to interact with hospitals, etcetera. That is a critical issue. It's almost as though we haven't quite gotten it yet as a state legislature.
We are just, we just computerized the state legislature two years ago. Understand where we are. Our hospitals are computerized. This is the home of community health centers, the birthplace. And clearly with the Medicaid population as well as those that are uninsured, it is critical we provide the same data that we provide elsewhere. So, yes, I would agree with your comment.
We are not quite there yet because I don't think that the need has really been articulated enough with everybody's attention focused on it. We've been focused on other things. Maybe it's just about time for that, because we are beginning to understand -- Elliot's group is doing his thing, and there is clearly going to be a time when the managed care companies are going to need to interact directly, communicate directly with the community health centers. And at the moment they can't do that.
So I think the issue will be raised but the rates become a very important thing.
DR. NEWACHECK: My question is related to George's. In your remarks, you prefaced them by saying you don't have adequate information now to make informed policy decisions. In thinking about improved data systems, can you tell us a little about what you think should be the responsibilities and goals of the state as opposed to the federal government in creating that kind of a system?
MS. CHANDLER: I really would have to think about that a great deal. I think if the federal government is going to put as much of the responsibility on the states as we are beginning to see happen, then we are going to have to, we are going to need some assistance in being able to do this data collection. We cannot do it on our state budgets.
I've spent some time telling you about what is happening to our state budget as a result of the Medicare cuts. To expect that responsibility of the states, to sort of dump it on the states and not help us is to be the same kind of agency that would at one in the same time suggest that people should be independent and living at home and not in any way make that possible for them to do so.
I think at some point you have to put your money where your mouth is, and we have to see more of that from the federal government.
DR. IEZZONI: I'll ask the final question. Back to the confidentiality issue, we know Massachusetts is a state where this is let's say at the top of many people's agendas. But we also heard this morning very compelling testimony from advocates for patients with disabilities that people outside of the direct care delivery system for certain patients need to have access to information about them so they can plan for services, not necessarily for Mrs. Jones or Mr. Smith but for the group of people, the Mrs. Jones and Mr. Smiths altogether. And that means having some information about people that some strict privacy act advocates would feel uncomfortable with. How is the legislature going to balance the need to plan for effective service delivery by having information about people's health status and at the same time appropriately protecting privacy and confidentiality?
And is the state legislature working with people who might know how to safeguard privacy and confidentiality a little bit better so there isn't the knee jerk response that we can't possibly give the data because there's privacy concerns? I think that there are ways to better safeguard privacy and confidentiality to get data to people who need it.
MS. CHANDLER: I think that makes good sense. We have been working for almost ten months on a confidentiality bill. Let me just tell you that it began initially with an ACLU kind of all bells and whistles that that required every time you took a breath there would be informed consent required. Even the sponsor of the bill understood that.
We brought together a working committee that has been meeting every two weeks, in fact this afternoon, and it represents everything from state government to insurance companies, to physicians who work in paperless offices, to physicians who operate out of cardboard boxes, to researchers. I mean, it's the whole gamut. And we added, and we added to it a computer scientist who could help us to bring the technology to the problem that needed to be matched with it. We are almost at the end of our work, and there are safeguards. Is it 100 percent, would the absolute virtuous person who wants to assure confidentiality be satisfied? Probably not, because there is no such thing as totally anonymous data. But what it would give us is the opportunity, it would give the patient the opportunity to feel that if the record was tampered with that the patient would know that we would not have blanket informed consent that most us have now, which is a problem, because with that blanket consent you give away forever any control over the information that is released.
So that we would do away with that, and we would very specifically enumerate the conditions under which informed consent would be required. We leave that to the beginning of concern. We feel that managed care companies really don't need too much more than billing information which is not going into the record and finding all the intricate details of the nervous breakdown you had, which might be used against you by your employer.
We also felt that if we did it this way we would be able to provide the provider, and we are concerned about that because they have had reached the point that they are not noting all the data on the patient's record. When they have hundreds of patients, they can't always remember. And that is no way to handle a patient-doctor relationship. So we have to help the provider as much as possible.
We also have to deal with the kinds of issues that allows the company, a plan, to be able, and an employer, in this case Medicaid, to make decisions about whether there is instances of Medicaid fraud going on here. So there's a balance here. But I think as the technology develops and as our sophistication develops, I think that we can have at least a modicum of confidence that we are just not sort of giving it all away, because that would be a terrible thing to do. In this state I don't think it would be tolerated.
(Final round table discussion not recorded.)
DR. IEZZONI: Thank you. We will break for lunch. I want to thank the panelists, it was great. Thank you for taking the time. We'll reconvene so we can start promptly.
( Whereupon the hearing was suspended at 12:30 p.m.)
COPLEY COURT REPORTING
C E R T I F I C A T E COMMONWEALTH OF MASSACHUSETTS
PLYMOUTH, SS.
I, Patricia M. Haynes, a Notary Public in and for the Commonwealth of Massachusetts, do hereby certify:
That the testimony hereinbefore set forth is an accurate record of my stenotype notes taken in the foregoing matter, to the best of my knowledge, skill and ability.
IN WITNESS WHEREOF, I have hereunto set my hand and Notarial Seal this day of June 1998.
--------------------------------
PATRICIA M. HAYNES, CSR,
Notary Public
My commission expires, August 14, 2003
COPLEY COURT REPORTING