“Let’s develop reimbursement that is respectful of the diverse lifestyles of people with MR and their families and that is tied to outcomes they value, [but] be careful…that we don’t develop policies that will cover more people, with more flexibility, without ensuring the basic level of care that we know our people need.”
High rates of poverty among adults and children with MR mean that a large proportion of them rely on publicly financed health care insurance, which is not always well-adapted to serving their needs. People with MR find that many providers avoid the program, citing low reimbursement rates, administrative burden, and fear of being inundated with underfinanced patients. Providers who are committed to treating individuals with MR report that restrictive Medicaid rules on which services are covered, in which settings, can limit use of innovative service models.
Families with private-sector coverage encounter gaps in coverage, unaffordable premium payments, and little flexibility in designing packages of services to meet their children’s needs. Cost-avoidance and cost-shifting by both public and private payers force families to try to mediate between special education programs and third-party payers and between long-term and acute care systems. Research and understanding of financing structures, to better accommodate service needs of individuals with MR, are hindered by lack of critical utilization and reimbursement data.
Potential strategies: Test effects on health outcomes, for people with MR, of diverse models for providing health care services, service packages, and financing mechanisms. Identify factors in varying combinations that affect outcomes. Determine effects of adjunct services, including respite care, transportation, child care, and case management, in combination with medical, dental, and other health services, on outcomes. Support longitudinal studies of portability of health services packages as educational, employment, and residential circumstances change. Develop methods of ensuring accountability for sufficiency and quality of health care services, including accountability for outcomes, in models for flexible health service financing.
Definitions: Use appropriate definitions of “effective,” “cost-effective,” and “health outcomes” in research, organization, and financing of health care for individuals with MR.
Potential strategies: Assess the relationship between different rates of Medicaid and Medicare provider reimbursement and any impact on access to health care for individuals with MR. Identify sources and amounts of costs to providers that are associated with meeting specialized needs of individuals with MR. Assess the effect of offsetting such costs on provider acceptance of individuals with MR. Assess combined and separate effects of cost-offsets and nonfinancial provider supports, described elsewhere in the Blueprint, on provider acceptance.