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Recommendations to the
California Managed Health Care Improvement Task Force
for Meeting the Needs of People with Disabilities

Drafted and Submitted by:
Laura Remson Mitchell
Government Issues Coordinator
Multiple Sclerosis California Action Network (MS-CAN)
National Multiple Sclerosis Society
 

General Recommendations





check markChange the definition of "medically necessary and appropriate" to incorporate the concept of "maximizing functional capability," which includes maintaining function and preventing or delaying deterioration or loss of function. (See Suggested Definitions.)
 

check markRequire plans to develop more disability-sensitive benefit packages, with input from people with disabilities and their advocates.
 

check markAssure that people with disabilities and serious or complicated chronic health problems will have prompt access to health-care providers who are knowledgeable and experienced in dealing with the individual patient's particular health problems, including the option of having a specialist act as the patient's care coordinator/gatekeeper.
 

check markRequire all plans to comply with federal and state nondiscrimination and accessibility standards--including but not limited to those in the Americans with Disabilities Act--as a condition of retaining their license to operate.
 

check markLimit the financial risk to health-care providers who serve high-risk/high-cost populations.
 

check markRequire all health plans to include a mutual-risk point-of-service option. (This will give under-served people with disabilities a way of getting the care they need while encouraging plans to be more responsive to this population.) See Mutual-Risk Point-of-Service Option: A Conceptual Outline, by Laura Remson Mitchell, previously submitted to Task Force.
 

check markDevelop an effective mechanism for spreading the cost of caring for high-risk patients in order to minimize incentives to under-serve this population.
 

check markEstablish outcomes measures that are relevant to people with disabilities, and include people with disabilities in developing those outcomes measures!

Recommendations to the
California Managed Health Care Improvement Task Force
for Meeting the Needs of People with Disabilities(by Category)
 
 

Suggested Definitions





check mark"Medically necessary and appropriate" health services include any service (including but not limited to assistive devices, medication and treatment regimens) that is safe and effective and that can help to maximize the patient's functional capability, including any service(s) that would maintain current levels of function and prevent or delay deterioration or loss of function.
 

check mark"Functional capability" means the ability to perform the functions that a person normally could perform in the absence of illness, disability or other impairment.
 

check mark"Maximizing functional capability" includes both restoring biological function and providing assistive devices or supportive services to compensate for lost biological function.

Recommendations to the
California Managed Health Care Improvement Task Force
for Meeting the Needs of People with Disabilities (by Category)
 
 

Access Issues





check markRequire all plans to comply with federal and state nondiscrimination and accessibility standards--including but not limited to those in the Americans with Disabilities Act--as a condition of retaining their license to operate.
 

check markRequire plans to provide prompt access to specialty care (not just a one-time consultation) for enrollees with disabilities and serious or complicated chronic conditions. This includes referral for habilitative and rehabilitative care from providers who are knowledgeable and experienced in treating the enrollee's disability/condition.

check markRequire plans to permit enrollees who have disabilities or complicated chronic health problems to have a specialist in the enrollee's condition serve as that enrollee's primary care provider.
 

check markIf a plan or provider group within a plan doesn't include a specialty provider qualified to treat the enrollee's condition, require the plan (or group) to pay for appropriate care from a qualified out-of-network provider.
 

check markLevel the playing field among health plans to spread the risk of caring for high-cost patients, correct problems of adverse selection and eliminate incentives to ratchet down access and quality of care, especially for people with disabilities. With or without risk-adjustment mechanisms, this should include a requirement that all health plans include a point-of-service option. (See "Mutual-Risk Point-of-Service Option: A Conceptual Outline.")
 

check markProhibit medical underwriting, and move toward a system of community rating with guaranteed issue and renewal in order to assure that those with disabilities and chronic health problems--especially those who must purchase their own coverage--aren't excluded from coverage because of unaffordable premiums. This should apply not only to managed care but also to traditional indemnity health insurance products. (NOTE: For this to work properly, it also will be necessary to achieve universal coverage. Both of these goals should be actively pursued.)
 
 

Recommendations to the
California Managed Health Care Improvement Task Force
for Meeting the Needs of People with Disabilities (by Category)
 
 

Benefits Issues





check markRequire all plans to revise their benefits packages to reflect the needs of people with disabilities. This should be done with the active participation of people with disabilities and their advocates. Areas of concern include but are not limited to:

check markRequire all plans to modify their definition of "medically necessary and appropriate" to recognize that "maximizing functional capability" is a legitimate basis for authorizing care. (See suggested definitions.)
 

check markProhibit plans from setting arbitrary time limits on any therapy that still is medically necessary and appropriate (based on suggested revised definition) to maximize the enrollee's functional capability.
 
 


Recommendations to the
California Managed Health Care Improvement Task Force
for Meeting the Needs of People with Disabilities (by Category)
 
 

Consumer Protection/Control Issues





check markRequire all plans to make consumer information (including but not limited to information related to marketing, treatments, educational programs, the plan's grievance system and any material that plans must disclose to enrollees or to the general public) available in formats that can be used by people with physical, sensory, communicative and/or cognitive impairments.
 

check markProhibit health plans from discharging an enrollee to or placing an enrollee in any institutional setting without the informed consent of the enrollee or the enrollee's designated representative.
 

check markEstablish a disability/health plan liaison office to facilitate ongoing communication between health plans and disabled enrollees (and their advocates) and to help connect both plan providers and disabled enrollees with appropriate community resources.
 

check markEstablish outcomes measures that are relevant to people with disabilities--with the active participation of people with disabilities.
 

check markRequire health plans to modify their provider payment methods and/or other financial incentive arrangements in order to eliminate any penalties they impose on providers who treat high-risk enrollees and any inducement those arrangements may create to under-serve this population. Financial incentives that cannot be modified to eliminate the negative impact on care for high-risk enrollees should be prohibited outright.
 
 


 
 

Recommendations to the
California Managed Health Care Improvement Task Force
for Meeting the Needs of People with Disabilities (by Category)
 
 

Risk Adjustment Issues




check markA standardized benefit package is necessary in order for risk adjustment mechanisms to work. It is critically important that this benefit package be designed to meet the needs of people with disabilities and chronic illnesses. (See Recommendations on Benefits Issues.) The best way to do this is to involve people with disabilities and their advocates as active participants in designing such a package.

check markAdjusting capitation rates may not be enough to get health plans to deliver needed care to high-risk populations. check markIn order to properly evaluate results, appropriate outcomes measures must be developed. In view of the acute-care bias and general misunderstanding/lack of knowledge about disability issues that permeate the health-care system, it is essential that people with disabilities and their advocates play a significant role in developing these measures.
 


Submitted by Laura Remson Mitchell, Government Issues Coordinator
Multiple Sclerosis California Action Network (MS-CAN), National Multiple Sclerosis Society
e-mail: af752@lafn.org
1997
 
 
 
 

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