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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Adequate Insurance.

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Strategy. Managed Care

Approach. Create for implement specifications within specialty managed care plans to capitate rates for CYSHCN

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Overview. Some states have implemented specifications within their managed care contracts for created specialty managed care plans for children and youth with special health care needs. (CYSHCN). In most of these plans, special. (risk adjusted) capitation rates are set, reflecting the higher costs associated with meeting the health care needs of CYSHCN.[1]

Evidence. Expert Opinion. Strategies with this rating are recommended by credible, impartial experts, guidelines, or committee statements; these strategies are consistent with accepted theoretical frameworks and have good potential to work. Often there is literature-based evidence supporting these strategies in related topic areas that indicate this approach would prove effective for this issue. Further research is needed to confirm effects in this topic area.

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source. (Read more about understanding evidence ratings).

Source. Boston University's Catalyst Center Financing Strategies Database

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Cost. This strategy helps to decrease the financial expenditure incurred by individuals, healthcare systems, and society in general for healthcare services.
  • Social Determinants of Health. This strategy advances economic, social, and environmental factors that affect health outcomes. SDOH include the conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.
  • Health Outcomes. This strategy helps contribute to reducing avoidable differences among socioeconomic and demographic groups or geographical areas in health status and health outcomes such as disease, disability, or mortality.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Policy Development and Enforcement (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Population/Systems-Focused

Examples from the Field. Access descriptions of ESMs that use this strategy directly or intervention components that align with this strategy. You can use these ESMs to see how other Title V agencies are addressing the NPM.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies).

Quadrant 1:
Measuring Quantity of Effort ("What/how much did we do?")

PROCESS MEASURES:

  • Number of specialty managed care plans created for modified to include specifications for CYSHCN. (Measures progress in developing tailored plans)
  • Number of community partners, including families and providers, engaged in designing and refining specialty managed care plans for CYSHCN. (Indicates plan development)

Quadrant 2:
Measuring Quality of Effort ("How well did we do it?")

PROCESS MEASURES:

  • Percent of specialty managed care plans that include quality metrics and incentives specific to CYSHCN. (Measures focus on quality improvement)
  • Percent of specialty managed care plans that require network providers to have demonstrated expertise in serving CYSHCN. (Shows commitment to specialized care)

Quadrant 3:
Measuring Quantity of Effect ("Is anyone better off?")

PROCESS MEASURES:

  • Number of training sessions provided to managed care organizations on the unique needs and best practices for serving CYSHCN. (Measures capacity building for quality care)
  • Number of partnerships between specialty managed care plans and community-based organizations to address social needs for CYSHCN. (Indicates holistic approach)

OUTCOME MEASURES:

  • Number of emergency department visits and hospitalizations among CYSHCN in specialty managed care plans. (Measures impact on appropriate utilization)
  • Number of policies changed to support the sustainability and spread of specialty managed care plans for CYSHCN. (Shows systems change for long-term impact)

Quadrant 4:
Measuring Quality of Effect ("How are they better off?")

PROCESS MEASURES:

  • Percent of capitation rate spending on CYSHCN that goes towards preventive and community-based services versus acute care. (Measures upstream investment)
  • Percent of CYSHCN in specialty managed care plans. (Indicates reach of enrollment)

OUTCOME MEASURES:

  • Percent reduction in health gaps for CYSHCN in specialty managed care plans compared to CYSHCN in traditional plans. (Evaluates impact on access)
  • Percent of CYSHCN in specialty managed care plans who transition successfully to adult care with continuity of services. (Assesses long-term outcomes and care transitions)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

References

1 Catalyst Center/National Center for Health Insurance and Financing for Children and Youth with Special Health Care Needs. Managed Care Financing Strategy.
https://ciswh.org/project/the-catalyst-center/financing-strategy/managed-care/

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.