Case management strategies faltering in New York state Medicaid programs
While the private sector has embraced case management and disease management as ways to promote better health while holding down costs, New York State’s Medicaid managed care plans are experiencing difficulties, according to a study by the United Hospital Fund, and the problems may affect other states’ Medicaid programs.
Timothy Prinz, United Health Fund senior health policy analyst, tells State Health Watch that enrollment difficulties play a major role in making it difficult for plans to implement case management programs.
Making it work
"Plans have difficulty keeping patients for an extended period, and that’s really what’s needed for case management to work. The classic example is pregnancy," he says. "You really want to have the woman in a case management program for the entire time, but often there are gaps in coverage. It’s not that plans don’t want to do case management. It’s that it’s more difficult for them to accomplish it."
United Hospital Fund’s Medicaid Managed Care Plan Survey 2000, with data from 1999, collected information on five types of case management programs:
• asthma;
• diabetes;
• HIV;
• hypertension;
• pregnancy.
Mr. Prinz says many plans also reported operating other types of programs, such as mental health, obesity, pediatrics, and preventive care.
"The most common case management programs focus on asthma treatment and pregnancy," according to the study report.
Most New York Medicaid managed care plans said they had few enrollees in their case management programs. For instance, the number of beneficiaries enrolled in asthma programs ranged from four to 1,700; for diabetes from four to 5,035.
Pregnancy and HIV program enrollment was more uniform, ranging from two to 210 and from one to 258, respectively. The report says that case management programs "are still in the early stages of program implementation, and it may take some time for them to systematically identify, enroll, and retain eligible members."
Mr. Prinz’s analysis found modest variations in program frequency between New York City and the rest of the state. Results from the survey indicated that plans serving the rest of New York State generally have more extensive and diverse case management programs in place.
Patterns and needs
Some 66% of plans serving the rest of the state had diabetic programs, for example, compared with only 37% of plans in the city. Notably, the portion of plans that have implemented asthma programs for Medicaid beneficiaries in both the city and the rest of the state is high — 100% and 84%, respectively. The proportion of city-based plans with HIV programs significantly exceeds that of plans serving the rest of the state (90% to 33%), a trend that fits with disease patterns and medical needs in the state, Mr. Prinz explains.
The survey indicated that all plans except one rely on some combination of plan staff and providers to administer case management programs. Mr. Prinz says such shared responsibility underscores the importance of facilitating a free exchange of information among patients, plans, and providers for the successful operation of case management.
He says the problem is not only getting people enrolled with managed care plans, but also keeping them enrolled with their plan.
"Patients need to stay with a plan if we’re going to expect that plan to manage their care. Continuous enrollment is important, and it’s not unrealistic to expect patients to stay in one plan, Mr. Prinz says. "There are problems but no insurmountable barriers. We’ve heard of success stories when patients have found a medical home and have gained benefit from that. But both outcomes and cost savings are difficult to see at the outset."
Who is responsible?
Mr. Prinz says there have been debates over whether the state, the city, or the plans should bear major responsibility for who should be resolving the problems that are slowing enrollment in case management.
"In some respects, part of the problem is that these are government programs that try to mimic the private sector, and in such a situation, the question of responsibility can fall through the cracks," he says. "There should be more patient education about the need to stick with one plan. The question is whether the state or the plans should be doing that education. It can be resource-intensive to fix.
"Everyone knows the value of patient education, but it’s hard to know who should do it and who should finance it. Plans might be willing to do more patient education if the state realized and acknowledged that it is resource intensive and the plans need money," Mr. Prinz explains.
[Contact Mr. Prinz at (212) 494-0746.]
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content