To control Medicaid budgets but also increase low-income families' access to quality primary health care, sufficient momentum has gathered in many states over the last several decades

…to move the focus of medical care from the emergency rooms and clinics of neighborhood hospitals to alternative delivery sites, specifically to conveniently located community clinics (linked to backup hospitals) and expanded health maintenance organizations...¹

...have bolstered their efforts to successfully and effectively enroll a substantial proportion of the Medicaid-eligible population in HMOs as a means of controlling the steeply rising expenditures and improving the equality of care they receive.²

These HMOs (through their associated primary care providers) function as the "gatekeepers" for Medicaid consumers-assisting, guiding and overseeing the utilization of health services. As many states prudently have recognized, however, an HMO's gatekeeping function is undermined if the consumer is not well-educated about managed care, the role of HMOs and PCPs, and helped to wisely choose the "best fit" HMO/PCP. Enrollment brokers educate the potential and current managed care enrollees with respect to these issues. Only if the Project staff delivers an accurate, understandable and culturally sensitive presentation can the benefits of managed care be realized. Fortuitously, this is what happens when Automated Health Systems, Inc. (AHS) is the enrollment broker, as we are in West Virginia, Wisconsin and Ohio.

Our winning strategies are to:

• involve key stakeholders in planning, implementation, and monitoring;
• educate Medicaid consumers about managed care through the use of comprehensively-trained Enrollment Specialists;
• link Medicaid consumers with primary, preventive and behavioral health care providers who assure the availability of needed services while avoiding inappropriate care;
• diversify the consumer outreach effort to ensure that as many people as possible enroll;
• work with existing community agencies to educate consumers about managed care; and
• reduce the socio-cultural reasons Medicaid consumers do not make the best use of health care services by promoting cultural competency among providers.

Our efforts have resulted in:

• increased comprehension of the philosophy of managed care among all stakeholders;
• greater consumer satisfaction with health care providers and the move to managed care (documented through surveys), more consumers making informed and timely decisions about the choice of an HMO, and increased appropriate health care utilization and health status (improved health) among Medicaid families;
• reduction and greater budget predictability of Medicaid expenditures; and
• enhancement of a health delivery system compatible with, and supportive of, broader health care and social service reform (e.g., welfare to work), the introduction of SCHIP families to managed care, the planned expansion of other smaller and innovative efforts in special managed care programs, such as inclusion of the SSI population.

1	Eli Ginzberg, Improving Health Care for the Poor: Lessons for the 1980's, JAMA, February 9, 1994, pp. 466.
2	Ibid., p. 467.