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The American Journal of Managed Care April 2018
Delivering on the Value Proposition of Precision Medicine: The View From Healthcare Payers
Jane Null Kogan, PhD; Philip Empey, PharmD, PhD; Justin Kanter, MA; Donna J. Keyser, PhD, MBA; and William H. Shrank, MD, MSHS
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Care Coordination for Children With Special Needs in Medicaid: Lessons From Medicare
Kate A. Stewart, PhD, MS; Katharine W.V. Bradley, PhD, MBA; Joseph S. Zickafoose, MD, MS; Rachel Hildrich, BS; Henry T. Ireys, PhD; and Randall S. Brown, PhD
The Well-Being of Long-Term Cancer Survivors
Jeffrey Sullivan, MS; Julia Thornton Snider, PhD; Emma van Eijndhoven, MS, MA; Tony Okoro, PharmD, MPH; Katharine Batt, MD, MSc; and Thomas DeLeire, PhD
A Payer–Provider Partnership for Integrated Care of Patients Receiving Dialysis
Justin Kindy, FSA, MAAA; David Roer, MD; Robert Wanovich, PharmD; and Stephen McMurray, MD
Financial Burden of Healthcare Utilization in Consumer-Directed Health Plans
Xinke Zhang, PhD; Erin Trish, PhD; and Neeraj Sood, PhD
Progress of Diabetes Severity Associated With Severe Hypoglycemia in Taiwan
Edy Kornelius, MD; Yi-Sun Yang, MD; Shih-Chang Lo, MD; Chiung-Huei Peng, DDS, PhD; Yung-Rung Lai, PharmD; Jeng-Yuan Chiou, PhD; and Chien-Ning Huang, MD, PhD
Physician and Patient Tools to Improve Chronic Kidney Disease Care
Thomas D. Sequist, MD, MPH; Alison M. Holliday, MPH; E. John Orav, PhD; David W. Bates, MD, MSc; and Bradley M. Denker, MD
Limited Distribution Networks Stifle Competition in the Generic and Biosimilar Drug Industries
Laura Karas, MD, MPH; Kenneth M. Shermock, PharmD, PhD; Celia Proctor, PharmD, MBA; Mariana Socal, MD, PhD; and Gerard F. Anderson, PhD
Provider and Patient Burdens of Obtaining Oral Anticancer Medications
Daniel M. Geynisman, MD; Caitlin R. Meeker, MPH; Jamie L. Doyle, MPH; Elizabeth A. Handorf, PhD; Marijo Bilusic, MD, PhD; Elizabeth R. Plimack, MD, MS; and Yu-Ning Wong, MD, MSCE

Care Coordination for Children With Special Needs in Medicaid: Lessons From Medicare

Kate A. Stewart, PhD, MS; Katharine W.V. Bradley, PhD, MBA; Joseph S. Zickafoose, MD, MS; Rachel Hildrich, BS; Henry T. Ireys, PhD; and Randall S. Brown, PhD
As increasing numbers of children with special healthcare needs move into Medicaid managed care, health plans can improve care coordination using evidence from Medicare.
ABSTRACT

Objectives: To provide actionable recommendations for improving care coordination programs for children with special healthcare needs (CSHCN) in Medicaid managed care.

Study Design: Literature review and interviews with stakeholders and policy experts to adapt lessons learned from Medicare care coordination programs for CSHCN in Medicaid managed care.

Methods: We reviewed syntheses of research on Medicare care coordination programs to identify lessons learned from successful programs. We adapted findings from Medicare to CSHCN in Medicaid based on an environmental scan and discussions with experts. The scan focused on Medicaid financing and eligibility for care coordination and how these intersect with Medicaid managed care. The expert discussions included pediatricians, Medicaid policy experts, Medicaid medical directors, and a former managed care executive, all experienced in care coordination for CSHCN. 

Results: We found 6 elements that are consistently associated with improved outcomes from Medicare care coordination programs and relevant to CSHCN in Medicaid: 1) identifying and targeting high-risk patients, 2) clearly articulating what outcomes programs are likely to improve, 3) encouraging active engagement between care coordinators and primary care providers, 4) requiring some in-person contact between care coordinators and patients, 5) facilitating information sharing among providers, and 6) supplementing care coordinators’ expertise with that of other clinical experts.

Conclusions: States and Medicaid managed care organizations have many options for designing effective care coordination programs for CSHCN. Their choices should account for the diversity of conditions among CSHCN, families’ capacity to coordinate care, and social determinants of health.

Am J Manag Care. 2018;24(4):197-202
Takeaway Points

This study describes 6 attributes of care coordination programs associated with improved outcomes among Medicare beneficiaries with chronic illnesses that are applicable to children with special healthcare needs (CSHCN) in Medicaid managed care. These findings may help managed care decision-makers implement and improve care coordination programs for CSHCN by: 
  • Identifying children who might benefit from care coordination. 
  • Specifying program goals and metrics. 
  • Developing requirements for care coordinators’ activities while allowing them to draw on their clinical expertise and judgment. 
  • Identifying other professionals (eg, clinical pharmacologists) who should team with care coordinators.
Care coordination has the potential to improve care and reduce costs for children with special healthcare needs (CSHCN) enrolled in Medicaid.1-3 CSHCN are defined broadly as children who “have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”4 This group includes children with the most intensive and challenging healthcare needs, increasingly referred to as children with medical complexity. In addition to accounting for a large proportion of Medicaid spending, CSHCN are at risk for preventable hospitalizations and emergency care resulting from poor coordination among families, medical care providers, schools, and other community-based programs.3

The pediatric community has emphasized the importance of care coordination for CSHCN for decades, but limited infrastructure and accountability have slowed implementation.1,2,5 This issue has become even more salient in Medicaid as state policy makers look to use resources more efficiently and shift more Medicaid-enrolled CSHCN into managed care plans. However, states provide Medicaid managed care organizations (MMCOs) with little guidance on how to implement effective care coordination programs for CSHCN.6 Furthermore, despite an extensive literature on care coordination for CSHCN,7-19 it is challenging to draw conclusions about design features of effective programs because existing studies often lack methodological rigor and vary widely in their underlying conceptual frameworks.

Given the paucity of reliable evidence on children’s programs, how should states and MMCOs design and implement care coordination for CSHCN? Research on care coordination interventions for Medicare beneficiaries is a potential source of insights. Although CSHCN and elderly Medicare beneficiaries may have very different healthcare and nonhealthcare needs, the goals and design elements of care coordination programs may be similar. In contrast to the CSHCN literature, there is a rigorous evidence base on care coordination for Medicare enrollees, including numerous experimental and quasi-experimental analyses of care coordination demonstrations funded by federal agencies and other organizations.20-29 We sought to identify characteristics of successful Medicare care coordination programs and the extent to which they might be applicable to Medicaid-enrolled CSHCN, with the goal of providing actionable recommendations for state policy makers and MMCOs.

METHODS

For this study, we reviewed evidence on Medicare care coordination programs to describe the attributes of successful programs and then assessed the applicability of those findings to CSHCN in Medicaid. Regardless of whether these studies used the terms care coordination or care management, we focused on programs that perform coordination functions, such as organizing or linking multiple services and engaging the patient.30

We began our review of the Medicare literature with research syntheses that described findings across multiple federally funded care coordination demonstrations for community-dwelling Medicare fee-for-service beneficiaries. The syntheses were derived from randomized controlled trials and quasi-experimental analyses.20,31,32 We supplemented these syntheses with additional studies of care coordination programs targeted to Medicare beneficiaries that had equally strong research designs and were published in the last 10 years. These were primarily identified through summary articles on other care coordination programs targeted to Medicare beneficiaries in primary care practices which were included in a recent National Academy of Medicine workshop, “Models of Care for High-Need Patients.”20,29,33-39 We reviewed the original research cited in the syntheses and summary articles for additional detail on program characteristics and outcomes, as needed. 

Second, we conducted an environmental scan of the Medicaid financing and eligibility mechanisms through which states may provide care coordination to CSHCN, and we examined the extent to which existing programs rely on or interact with Medicaid managed care. We began the scan by reviewing articles that described existing programsand additional materials on the programs contained in those compilations.6,40-43 We also performed internet searches for Medicaidchildren, and care coordination (or care management or case management), using several search terms for care coordination because it is not defined in Medicaid regulations and, in practice, exists in Medicaid under multiple programs.43 We also reviewed Medicaid law and federal guidance for clarification of the financing and eligibility options available to states interested in providing care coordination through Medicaid managed care.

Finally, we translated common characteristics of successful Medicare care coordination programs into program design considerations for CSHCN in Medicaid. Adapting evidence from Medicare for pediatric populations requires attention to unique characteristics of children’s health, such as the need for parental support, developmental trajectories, and differences in treatments for serious illnesses compared with such treatments in adults. We then refined our recommendations with the help of experts in children’s healthcare. We gathered feedback from 11 outside experts, including 5 Medicaid medical directors, 3 practicing pediatric clinicians, 1 former managed care executive, and 2 policy professionals well-versed in the research on Medicaid, care coordination, and CSHCN. 

RESULTS

We reviewed 30 publications, including syntheses, summary articles, and individual studies of Medicare care coordination programs. Twenty-four of these publications reported evidence on impacts from rigorous studies and were included in this study. Nearly all of the Medicare care coordination programs used nurses as care coordinators. The goals of the Medicare care coordination programs were to reduce beneficiaries’ need for emergency department (ED) and inpatient care and to lower overall Medicare spending. Several studies also reported effects on mortality,22-24,29,44 patient functional status,26-28 patient satisfaction,26 and provider job satisfaction.45 We refer readers to summary articles for descriptions of the various care coordination interventions.20,21,31-36,38,39

We identified 6 design elements common among programs that were successful in reducing healthcare utilization or Medicare spending. Each of these has potential value for care coordination programs for CSHCN in Medicaid, but each requires adaptation to account for differences between the populations, funding sources, and programmatic constraints. In the remainder of this section, we discuss these 6 program design considerations and their relevance to CSHCN in Medicaid, noting particular challenges in adapting evidence from Medicare for pediatric populations. We provide additional detail in the eAppendix30 (available at ajmc.com). 

1. Identify and target specific subgroups. Medicare care coordination programs that had positive impacts tended to focus on specific subpopulations. These included beneficiaries with particular chronic conditions and comorbidities and those projected to have high medical care use and spending.22,23,25-29,37,44-46 Even among programs with favorable overall effects, impacts were often concentrated in, or larger for, a higher-risk subpopulation of their enrollees.20,27,28,37 Similarly, among care coordination interventions that did not demonstrate overall impacts, several had positive effects for a subset of higher-risk enrollees.20

States and MMCOs may well benefit from strategies similar to those used in many Medicare programs to identify beneficiaries with either high recent utilization of EDs or inpatient care or high predicted future medical care spending, in addition to or instead of condition-based criteria. In the Medicaid context, social determinants of health and behavioral health comorbidities are additional factors that may help states and MMCOs identify children who are at especially high risk. 

Medicaid-specific programmatic and care delivery factors may also drive, or limit, the targeting of care coordination programs for children. Several states combine Medicaid managed care with other Medicaid financing and eligibility pathways to care coordination that inherently target medically complex populations (eg, managed long-term services and supports for children covered by 1915[c] waivers and targeted case management delivered through managed care). States may also limit certain programs, such as targeted case management and home- and community-based benefits, to specific geographic areas, which may preclude targeting to all CSHCN who would benefit from care coordination. Likewise, the settings in which CSHCN receive care may inform targeting decisions. For example, CSHCN who receive care at tertiary care hospital outpatient clinics may be an easily identifiable high-risk target population, although targeting such CSHCN may exclude those who live far away from the selected clinics. In contrast, it may require more effort (eg, examination of diagnoses in encounter data) to identify CSHCN treated by primary care providers in the community who are most likely to benefit from care coordination.

2. Set clear goals for outcomes that are feasible to achieve within the time period examined. Few Medicare care coordination programs led to significantly lower Medicare spending,21-23,25,44 although some programs’ care coordination costs were offset by reductions in spending on inpatient or ED care.20,21,31 More commonly, interventions showed evidence of reduced hospitalizations,20,22,23,25,31,37 ED use,22,25,27,28 mortality,22-24,29,44 and other types of utilization,26,45,46 as well as improved functional outcomes27,28 and process of care quality measures.25,27,28

These findings underscore the importance of specifying explicit goals in advance and developing logic models that connect care coordination activities to intended outcomes. States and MMCOs whose goals focus on improved well-being and functional status should not be surprised if their care coordination efforts actually increase net Medicaid spending. For states and MMCOs whose goals focus on reducing utilization and Medicaid spending, care coordination may initially increase healthcare utilization and spending before reducing the use of avoidable expensive services. Moreover, some positive outcomes of care coordination for CSHCN in Medicaid will not accrue to Medicaid programs, such as increases in parents’ labor force participation or children’s eventual success as independent adults. States and MMCOs must be realistic about expected outcomes specific to CSHCN and the time periods necessary to achieve them. 

 
Copyright AJMC 2006-2018 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
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