California providers and HMOs are gearing up to develop capitated pilot programs for treating seriously ill children under Medicaid.
The department of health services is expected to issue requests for proposals for three-year tests of the program by mid-year.
California is moving its population in Medi-Cal, its Medicaid program, into managed care under several models. But unlike most states, a California law mandates that managed-care pilots must test how best to treat these children.
Until pilot results are in, chronically ill children will continue to be seen by the special providers that have been caring for them under the California Children's Services program. For example, a child in Medi-Cal diagnosed with leukemia will receive treatment under fee-for-service from a CCS provider and will get primary care from the managed-care plan, said Susan Maddox, president and chief executive officer of the California Children's Hospital Association.
The challenge for Medi-Cal managed-care plans and providers is to identify children with these special needs and refer them to CCS, she said.
The state has already turned down one pilot that would have cared for most of the 140,000 seriously ill Medi-Cal children through a consortium of children's hospitals, university hospitals and key providers, she said.
The state will approve a handful of pilots, said Marydee Gregory, M.D., a pediatrician and chief of children's medical services at the state health department.
Gregory believes the major benefit of the program emerging from the pilots will be coordination of care and making the special-needs program more accessible to parents and smoother for providers, she said.
But during the transition, "each of the different (Medi-Cal) managed-care models has a different problem" properly referring these children, Gregory said.
There has already been confusion among providers over who will serve L.A. Care, Los Angeles County's public-private Medi-Cal plan, when it starts March l. But Edwin Benjamins, director of utilization and case management at the plan, said providers are being trained in proper referrals.
Benjamins predicts managed care will improve access to care for more children with serious illnesses.
"The process of educating the providers and the HMOs is going to help identify more of those children," he said.