Article by Kimberly Hines, MSL Leadership Team

The meeting today talked about Medicaid expenditures for both the special needs and behavioral health (BH) populations. 2016 costs for both populations were discussed and projected costs were estimated, both with and without the implementation of managed care. Please note that “halo costs” are described as costs that are above and beyond regular care, such as additional hospital admissions or ER visits. Tier III care is defined as inpatient treatment requiring 24/7 care (these are the Medicaid users that are the most expensive).
The possibility of combining both the special needs and BH populations into one managed care program was the main discussion today.

This concerns me on so many different levels. First and foremost, these two populations of patients are entirely different and should not fit under one umbrella. While the pediatric special needs population (generally speaking) have caregivers/parents to make sure they get the health care and therapy services they need, the BH population is entirely different. From a population health management standpoint, increased BH costs are commonly a result of non-compliance with medications (whether that be an inability to afford medications or a patient opting not to take them). Non-compliance can sometimes lead to an acute inpatient admission or decline in health status due to other underlying health conditions that are not managed by the patient. Another issue many BH patients experience is the lack of care access – there simply are not enough health providers for BH services. BH providers are very limited and are more apt to accept a private commercial insurance. Those BH providers that do have open Medicaid slots for new patients sometimes have a six-month waiting list. Another reason for this lack of access to adult BH care providers is due to the cost difference that Medicaid pays to providers. Medicaid reimburses physicians/providers much more substantially for the pediatric population, opposed to the adult population.

I did try to ask Dennis (the presenter) why they wanted to combine the two populations into one managed care program since the two are so different. The response I received was that this was just a preliminary planning stage and nothing was set in stone.

I also asked if they had made any cost projections that indicated how much more tier III patients with a special needs would cost them long-term if they were to decrease therapy services for special needs children now, while they are at their most rapid level of development. Dennis said they had not completed these types of projections.

I think the important thing we need to advocate for is making sure that these two populations are considered SEPARATELY. I will say that above all managed care for the BH population due to lack of access and other issues I mentioned may benefit these patients. That being said, I do not feel managed care would at all help the special needs pediatric population when you look at the reduction of therapy services to cover the costs of managed care.

If you would like to contact your representative about this, you can find more information here.