Children With Special Health Care Needs and Managed Care

To the Editor.—As California pediatricians specializing in treatment of children with special health care needs (CSHCN) in a state with extremely high managed care penetration, we were very interested in the recent Pediatricsarticle “Do Children Receiving Supplemental Security Income Who Are Enrolled in Medicaid Fare Better Under a Fee-for-Service or Comprehensive Capitation Model?”1The article concludes that CSHCN in managed care fare better that those in fee-for-service plans. However, our close reading of the article offers potential explanations for discrepancies between our experiences and those of the families we serve and the authors’ conclusions. Based on these explanations, we urge great caution in extrapolating the results to support enrollment of CSHCN in typical Medicaid managed care plans elsewhere.First, a bit of background: California’s state program for low-income CSHCN serves children with diagnostic conditions that are disabling, potentially disabling, or life threatening and require access to pediatric subspecialty care (eg,cerebral palsy, leukemia and other cancers, congenital heart conditions, sickle cell disease, cystic fibrosis, complications of premature birth). Although most of these children are enrolled in capitated Medicaid managed care plans for their nonspecialty care,treatment related to their special health care needs is carved out and handled through a statewide program established >75 years ago that manages their specialty care and related needs. County-based physicians and nurse case managers preauthorize and manage children’s access to appropriate specialty care, pharmaceuticals,durable medical equipment, and physical therapy. The program pays its network of credentialed providers on a fee-for-service basis. Children enrolled in this “specialty care managed care plan”have access to a full array of pediatric providers across the state,based on their specialty medical needs. Although there certainly are ways in which access and the program itself could be improved,the state’s pediatric community generally supports the program. Our experience with children with similar conditions who are enrolled in private-sector managed care plans yields very different results from those presented by Mitchell and Gaskin. Both physicians and families report difficulties accessing such necessary elements of care as pediatric subspecialists, pediatric durable medical equipment,off-formulary pharmaceuticals, and physical/occupational therapy. We suspect that these problems are the result of low payment rates,including capitation rates that do not reflect the costs of care for higher-need children, and the fact that the plans are designed for large, essentially healthy populations rather than for CSHCN or, for that matter, adults with disabilities or other special needs.The Washington, DC, plan studied by Mitchell and Gaskin more closely resembles California’s program for CSHCN than a typical Medicaid managed care plan. Most importantly, the plan, a nonprofit organization in collaboration with the DC Medicaid program, was designed specifically for CSHCN. In an effort to ensure that the plan could meet its mission to serve children with Supplemental Security Income, it has been willing to make substantial changes in that design, for example,by modifying its original fully capitated financing system. As the authors tell us, as of 1999 the plan retains only partial risk for the direct costs of medical services, with Medicaid accepting overall financial risk. In addition, providers are not at risk for services to their patients and receive rates higher than for Medicaid fee-for-service patients. The important factor here seems to be the conscious design of the plan for the population to be served.Although we found the article to be an interesting description of how managed care approaches can be designed and tweaked to serve complex populations such as CSHCN, we think the title and some of the conclusions are ultimately misleading and perhaps even dangerous for the children we serve. Perhaps a better title would have been“Can Children With Special Needs Fare Better Under a Specifically Designed Managed Care Approach Than Under Typical Medicaid Fee-for-Service or Managed Care Arrangements?” That’s a question we’d like to see addressed.