Background:
While the State of Michigan has made a full transition to managed care for the general Medicaid population, there are a number of unresolved issues that affect the quality of services being delivered. The oversight and authority of the Michigan Legislature can dramatically improve the access to health care services for this at-risk population.
Primary among the concerns in the Medicaid managed care program is the financing structure. The capitated system places primary and preventive services at risk, by creating disincentives to providing the preventive care. The concept of a medical home benefits all patients, and especially Medicaid consumers. However, the low reimbursement rates for the Medicaid population requires participating health plans with medical loss ratios over 90% to reduce access to services. Medicaid has reduced funding in the last two budgets by over $200 million. Often times, the services reduced are the preventive and primary services that lessens the need for more costly acute care services!
The components of the Early and Periodic Screening, Diagnosis and Treatment program (EPSDT) are just some of the services that are being neglected in the rationing of dollars. Created to ensure all children in Medicaid receive the necessary preventive screenings and follow-up care, EPSDT rates have actually declined in Michigan in recent years, both before and after the application of managed care with this population. (See attachment) EPSDT must be maintained and strengthened within the managed care system. Other states like New York meet the federal target of 80%, while Michigan languishes with less than 50% of the eligible served.
Maternal Support Services and Infant Support Services (MSS/ISS) are also seeing sharp decreases in access in the transition to managed care for the Medicaid population. These programs, along with services such as transportation, outreach and nutrition counseling, are essential components in the improvement of pregnancy and birth outcomes and the reduction of infant morbidity and mortality. Managed care organizations that do not understand the benefits of these programs are drastically limiting access to the services, in an effort to reduce costs. The Legislature can assure MSS/ISS will continue to be protected in the managed care system, by assuring access to the services through a change to a performance based reimbursement system for prevention services (see principals attached).
The frantic pace of moving the Medicaid population into managed care is another reason that access to services has suffered. Again, using EPSDT and MSS/ISS as examples, the managed care organizations which have become responsible for the care of this population had little to no understanding of the programs, their purposes, and the components that make them
successful. EPSDT and MSS/ISS were begun at a time when Medicaid patients were often cared for by local public health departments. Now, with the entire responsibility for care shifted to managed care organizations, there has been little or no explanation of the structure of EPSDT or MSS/ISS, and little thought by the state as to their responsibility to assure the continuation of, and access to, preventive services in the transition process. Local health departments and the clients they served have suffered and paid the cost with decreased access.
Recommendations:
Access to Health Care Data Fact Sheet
PRINCIPLES FOR DEALING WITH EPSDT AND MSS/ISS
Additional Resources:
Gerard Breitzer, D.O., M.S., F.A.A.P
Michigan Chapter, American Academy of Pediatrics
517/353-3100
Joe Moore, M.D.
Michigan State Medical Society
616/391-2851
Ann Marston
Michigan League for Human Services
517/487-5436
Sharon Claytor Peters
Michigan's Children
517/485-3500
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