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CURIE: Perils of one-size-fits-all Medicaid

States racing to managed care risk endangering most vulnerable

As states rush headlong into managed care in the name of "in- tegration" and cost savings, those most vulnerable among us are standing on the sidelines and are most likely to become victims of a public-health-policy offensive.

In these challenging economic times, Kentucky, New Hampshire, Kansas and Louisiana have moved aggressively toward mandatory managed care within the past six months as a way to address their expanding state Medicaid budget burdens. Other states, including Florida and Georgia, are poised to move quickly in the same direction. Still others are making incremental progress toward the same end. These dramatic policy shifts have not been without major controversy and provider and service disruptions.

Some of our nation's most vulnerable (and largely voiceless) people receive their health care through state Medicaid and safety-net programs. Proposed Medicaid reforms for managed care will thrust these people - including ones with serious mental illnesses, children in foster care, physically and developmentally disabled (including those with autism) and many in nursing homes - into managed health care.

While state leaders endeavor to reform their Medicaid systems, the choices to which they are defaulting will place the consideration and decisions for the care of vulnerable people with special needs in the hands of impassive monolithic health plans. Just as "teaching to the median" leaves students neglected at either end of the talent spectrum, managing health care to the median in traditional managed care leaves these populations at risk, lacking access to quality health care and health outcomes.

Health care is not easy to manage, and certainly the chronic care needs of at-risk populations are not. I know about these complicated challenges after a career of more than 30 years working in all levels of government mental-health and substance-abuse programs. I have seen firsthand how the specialized health care needs of just one of those groups, people with serious mental illness, have been largely unmet by traditional managed care.

Sadly, statistics from the National Research Institute tell this story best: People challenged with a serious mental illness die 25 years younger than their counterparts in the general population. This shorter life span is because their behavioral health issues usually are compounded by one or more chronic physical conditions, such as heart disease, respiratory problems, diabetes or stroke.

In my field, we recognize that there is a complex interplay between serious mental illness and physical health conditions. Imagine someone with bipolar disorder and diabetes whose disorganized thinking causes difficulty monitoring his blood sugar levels. Symptoms such as disorganized thinking (associated with complex behavioral health issues) often interfere with the effectiveness of primary care. Systems of care founded on primary care leave many of these populations with complex chronic needs powerless, without access to the real "primary" care they need.

Models of integrated health care for people with serious mental illnesses that bring together care for both mental and physical health needs in order to improve health outcomes, as an example, must be different to be effective. For such people, the first focus must be on their behavioral health needs to ensure successful impact of any physical health care therapies on their co-occurring medical conditions. There are models of specialty care that can transcend existing practices by giving Medicaid beneficiaries access to the right comprehensive care, all while stabilizing system costs.

The outcome of such models is undeniable. Pennsylvania's Behavioral Health Choices program averted $4 billion in projected expenditures through a specialty plan that integrates behavioral and physical health care. New York's Care Coordination Project also has been successful with a similar complex-care-management program that has reduced Medicaid spending by 41 percent compared to costs in other municipalities in the state. Specialty care plans have a proven track record from Arizona to Iowa, from Nebraska to Massachusetts. Aside from improvements in the quality of care, such plans have yielded an average savings of 20 percent during their second year of operation, with up to 15 percent projected in future years.

States have a window of opportunity to contemplate new models of care thoughtfully for their vulnerable populations. "One size" of managed care does not fit all. Governors should take this time to think about all of their residents and to demonstrate their great care.

Charles G. Curie was administrator of the U.S. Substance Abuse and Mental Health Services Administration in the George W. Bush administration.

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