U.S. Department of Health and Human Services

Evaluation of the District of Columbia's Demonstration Program, "Managed Care System for Disabled and Special Needs Children": Final Report

Executive Summary

Abt Associates Inc.

June 2000

This report was prepared under contract #500-96-0003 between the U.S. Department of Health and Human Services (HHS), Health Care Financing Administration (HCFA) and Abt Associates Inc. In addition to HCFA, other support for the study, Evaluation of the District of Columbia's 1115 Waiver for Children with Special Health Care Needs, has been provided by HHS's Office of the Assistant Secretary for Planning and Evaluation, Office of Disability, Aging and Long-Term Care Policy. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the ASPE Project Officer, Gavin Kennedy, at HHS/ASPE/DALTCP, Room 424E, H.H Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. His e-mail address is: Gavin.Kennedy@osaspe.dhhs.gov.

Demonstration Implementation and Management

• This Demonstration tests the viability of a program to coordinate and integrate care for SSI-eligible children with special health care needs, financed through capitation payments. Health Services for Children with Special Needs (HSCSN) manages the Demonstration, under a waiver administered by the District of Columbia (DC) Medicaid.

• During the Demonstration, HSCSN (1) has undergone a fundamental restructuring, (2) has experienced serious problems coordinating with other DC agencies serving special needs children, and (3) has experienced repeated financial losses.

• HSCSN concludes that the capitated model tested in the Demonstration is not viable, in part because the population of special needs children in the District is too small to protect a plan against severe financial losses. Despite a proposal by DC Medicaid to add stop-loss protection, HSCSN has announced that it will not enter the waiver re-competition.

Demonstration Enrollment

• HSCSN has enrolled nearly one-half of all eligible children in the District.

• Participation in the Demonstration is voluntary. This has meant that families and children who participate are different in several ways from those who did not enroll. In particular, participants tend to be heavier users of services than non-participants.

Care Management

• Care manager teams, made up of a team leader, care managers and care manager associates, coordinate with each participating child's primary care provider (PCP).

• Problems in communication among major stakeholders (care managers, providers, outside agencies, families) have impeded effective care coordination throughout the Demonstration.

• In response to care manager and provider concerns, HSCSN has moved to reduce caseloads for the care manager teams.

• Families generally agree that care managers have eased the burden on informal caregivers by assuming many of the logistical functions of coordinating care. Stakeholders share the perception that care management is the most valuable feature of the Demonstration.

Impacts of the Demonstration

• The Demonstration may have positive impacts over a range of outcomes, but design and data problems place limits on the evaluator's ability to detect these impacts.

• According to most measures, Demonstration participants enjoy equal or better access to services, compared to non-participants. Participants' caregivers are generally more satisfied with their access to services than non-participants.

• Despite positive perceptions of the Demonstration expressed by caregivers, there is little evidence that these caregivers benefit from reduced burden, relative to non-participants.

• Participant caregivers report somewhat heavier use of many medical services than do non-participant caregivers. However, the most salient differences between groups are in preventive services: participants are more timely in their use of preventive services than non-participants.

• There is some evidence that Demonstration participants are more physically impaired than non-participants. However, measures of mental and developmental function show no consistent patterns.

• Despite higher reported satisfaction with access to services among participants, participants' caregivers are not more positive about their children's current or future health status.

• In general, participants use more of most ambulatory and institutional services than non-participants, and their rates of utilization increase, once in the Demonstration.

Policy Implications

• Although the particular model tested in this Demonstration may not be viable, coordination and integration of care, provided by professionals who understand special needs children, is a valuable service.

• Policy makers might consider alternative models of financing care management for special needs children -- for example, primary care case management (PCCM) programs that pay a child's principal physician directly to provide coordination and integration.