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Network description:
Commonwealth Care Alliance is a statewide nonprofit
consumer-governed care system whose mission is to expand clinical
programs such as those offered by CMA to a statewide scale.
Pharmacy benefit and management:
TPA/Information systems:
History of the organization:
Despite the
movement of more than half of all Medicaid beneficiaries into
managed care over the past decade, with demonstrable benefit for
Temporary Aid to Needy Families (TANF) and expansion populations
standard mainstream Medicaid managed care approaches have not been
successful in addressing the cost and care challenges encountered by
the 12 percent of Medicaid (and dually) eligibles who account for 75
percent of expenditures: the populations that are the focus of CCA.
With rare exception nationwide, Medicaid managed care has not
developed the specialized networks, benefit design and care
management approaches, and the behavioral health and long-term-care
service integration, that is critical to serving the health care
needs of these populations.
Conversely, a variety of small
programs with clinical and consumer roots have consistently
demonstrated common strategies that have effectively been able to
improve care and manage costs for the populations that are the
central focus of state Medicaid programs. These strategies include:
a clear central mission to serve special populations; meaningful
consumer involvement at all policy and operational levels,
specialized primary care networks, new approaches to care
coordination and care management and integration (rather than
fragmentation) of behavioral health and long-term-care services.
Such strategies have been demonstrated in “boutique” programs such
as Community Medical Alliance (CMA), Minnesota’s MSHO and MDHO
funded models such as Axis Health Care, Wisconsin’s Community Health
Partnership and approximately 50 PACE replication sites across the
country.
In this regard, the experience of
the Community Medical Alliance (CMA) has been particularly
instructive. Over the past 11 years, CMA, functioning as a pilot
prepaid health plan in Massachusetts, has been able to develop team
models of care that shift clinical decision making to the home,
substitute home and community services for hospital and
institutional services, and consistently cost less than Medicaid
adjusted premiums for adults with AIDS and severe physical
disability and children with technology dependence.
It is the experience both of CMA
and similar pilot programs that leads us to the conclusion that the
challenge now is no longer the “invention” of effective care
approaches for these populations, but rather “bringing to scale”
what we know works. It is to meet this challenge that CC, HCFA and
BCIL have come together to create CCA.
CCA - Progress to Date
1
CCA was incorporated in March 2003; leadership management and
staff team has been assembled.
2
A primary care network of excellence to serve elders has been
assembled and a contract award has been granted by the Division of
Medical Assistance (DMA) and Center for Medicare and Medicaid
Services (CMS) for the Senior Care Options (SCO) program. Program
operations began on June 1, 2004 with members enrolled from the
Springfield area. Enrollment activities are now also underway in
other areas of the state.
3
A contract from DMA for the care of individuals with a
complex mix of chronic illness and behavioral health issues at the
Brightwood Health Center in Springfield began September 3rd, 2003 as
a Pilot Program of the PCCP program.
4
Planning is underway to develop a variety of “care
management” programs for a variety of populations who are not well
served and whose costs are unmanaged. The scope of these pilot
programs and the specific populations to be served will become
clearer over the next several months.
Three major challenges the organization faces during 2004:
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