system of care for rhode island's children, youth and families

At the same time, Medicaid is a broad entitlement program with very stringent requirements
governing eligibility service definition, and reimbursement. Limits on utilization, provider
participation, or consumer choice are not permitted. This set of standards has clear
programmatic and budgetary implications, and may mean that Medicaid funding is not
universally attractive. However, it is also clear that Medicaid, particularly in light of the
mandate of EPSDT (Early Periodic Screening, Diagnosis, and Treatment), needs to be fully
leveraged.
This leverage can be accomplished by Care Networks being sufficiently knowledgeable to be
able to refer to and otherwise make use of services available to children throughout the rest
of the Medicaid system. In this way, Medicaid-financed services can “wrap” around services
provided by and through Care Networks. Care Networks do not need to control these
dollars, but do need to be able to access them.
Similarly, development of one or more case rates can be phased in over time, as data
becomes available to support and justify this structure. Case rates are simpler to administer
than encounter-based claiming, but need to be designed to provide the same level of data
feedback to inform ongoing decision-making.
For any financing strategy to be successful, it must be guided by constant review of
clear, accurate, actionable data that describes the operation of the system overall. This
data, at minimum, must include caseload (the number of active eligibles), expenditure (both
on an individual level, as well as projected for the System as a whole, based on current
eligibility and patterns), and outcomes (the result realized in consequence of the expenditure,
based on an understanding of the need at the onset of the expenditure).
Rate structure is an essential element of any financing strategy. Rates must be established in
a rational fashion that blends considerations of cost, capacity, and outcomes, and then
maintained in a disciplined fashion. If we value evidence-based services, they should be
reimbursed based on performance. The State should pay the same rates for like services
across all programs and departments, but should not pay higher rates than other payors unless
a sound rationale that supports the outcomes desired for the system can be articulated.
Coordination and cooperation among state departments is critical to address these issues.
Development of funding strategies must be concurrent with continuum of care design and
development, focused on maximizing resources that support the needs of the children.
Program and fiscal staff, across departments and agencies, must both be intimately involved
in planning and development.
The main financing challenges facing the Ideal System are:
• How to design a system of performance risk offset by financial reward;
• How to “transplant” monies invested in the current system to the allocation (sites,
practices, and modalities) required by the Ideal System;
31