For Profit Managed Care for Long Term Supports & Services Lessons Learned
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1 For Profit Managed Care for Long Term Supports & Services Lessons Learned Mike Chittenden, The Arc Nebraska Kevin Fish, The Arc of Sedgwick County Carrie Hobbs Guiden, The Arc Tennessee John Nash, The Arc North Carolina Dan Ohler, OPTUM 1
2 Learning Objectives 1. How managed care for Long Term Services & Supports (LTSS) is being implemented in other states 2. What is working and not working in managed care for LTSS 3. Best practices around implementation of a managed care system for LTSS 4. How stakeholder input can drive the process of developing and implementing managed care for LTSS 2
3 Kevin Fish The Arc of Sedgwick County (Wichita, Ks) 3
4 Medicaid Managed Care Innovations in the Public Sector Marketplace Dan Ohler, VP State Government Programs 4
5 Opening Thoughts The First Law of Improvement: Every system is perfectly designed to achieve exactly the results that it gets. Donald Berwick, former Administrator, CMS If you want to know what an organization values, analyze how they spend their money. Dr. John Camealy, Professor, Xavier University 5
6 IDD Market Overview Public Spend What are I/DD Services? Recent / Current Market Environment Market Drivers Annual Federal + State + Local I/DD (non-acute/medical) Spend of $61+ Billion Intermediate Care Facility (ICF/ID) Costs associated with providing care (acute and other) to individuals with I/DD in a segregated, institutionalized setting. Home & Community Based (HCBS) Waiver Costs associated with providing needed supports and services (non-acute) in an integrated, community setting. Other Primarily state and local, which may include administrative functions (e.g., case management) i. Fee For Service; cost-based; fragmented, no national model ii. Large un-served qualified population due to budget constraints (waiting list) iii. Inefficient / Inconsistent provision of services and supports i. DOJ activity to enforce ADA/Olmstead & reduce waiting lists (access) ii. New CMS Settings HCBS Final Rule (community driven) iii. Escalating costs driven by more individuals entering the I/DD system of care I/DD Annual Public Spending ($Billions per annum) $16.8 $13.1 $31.6 HCBS Waiver ICF/ID Other I/DD Population (thousands) HCBS Waiver Participants HCBS Waiver Waiting List State-operated ICF/ID Other ICF/ID $200,000 $175,000 $150,000 $125,000 $100,000 $75,000 $50,000 $25,000 $- Avg. Cost by Setting (PMPY) HCBS Waiver Institutional / ICF 6
7 The I/DD Marketplace There are approximately 7M individuals in the United States with an Intellectual and/or other Developmental Disability More than 60% rely on Medicaid for their health care coverage An estimated 80% are Medicaid eligible Nearly 75% live with family members Just over 1M receive formal services from an I/DD agency Total public spend for I/DD in the U.S. exceeds $61B There is a high level of health care utilization for people with I/DD Co-occurring mental illness: 33% Soars to 50% when including substance abuse Cardiovascular disease: 38% Central nervous system diseases: 28% Three or more chronic conditions: 45% Sources: Thomas Cheetham, MD; Kennedy Center, Vanderbilt University David Braddock, Coleman Institute, University of Colorado 7
8 HCBS Waiver Data There are over 250 waiver programs in operation in the United States Over 685K waiver participants with I/DD in FY2013 HCBS waiver enrollment has doubled since FY2000 In excess of $30 billion for HCBS waiver services in FY2013 The average expenditure per person is nearly $46,000 Medicaid represents 77.7% of all I/DD spending: 66% is Home & Community Based Services 27% is ICF/ID (i.e., Institutional) States are continuing to move toward greater expenditures on community versus institutional services: 53% of total I/DD spending is on HCBS vs. 24% for ICF/ID $18.3B of federal funds for HCBS vs. $8.3B on ICF Source: State of the States in Developmental Disabilities; Coleman Institute, University of Colorado (2015) 8
9 Yet for Many, They Wait Despite the growth in HCBS programs nationally More than 320K people are on Waiver Waiting Lists. Texas leads the nation with over 100K on a waiting list Many states report wait lists at more than ten years The real number is likely much higher as not every State maintains a waiting list; Not to mention many families have given up. State budget cuts have also curtailed growth in HCBS. 9
10 The Medicaid Marketplace Last year, Medicaid turned 50! 73M Americans are covered by Medicaid 22.9% of the population California the highest at 12.7M; Montana the lowest at 136K 6.3M additional people have enrolled in just the past year During expansion, 1 in 20 have joined the Medicaid rolls NY, TX, FL rank 2, 3, 4 after CA 48 States use Medicaid Managed Care for healthcare services 28 States also include managed long-terms services & supports 70% of Medicaid enrollees are covered by private Managed Care plans, which translates to 51.3M Medicaid beneficiaries Private Managed Care plans added 7.8M beneficiaries last year Source: The Still Expanding State of Medicaid in the United States; PriceWaterhouseCoopers, November
11 Medicaid Health Plans There are 194 private health plans now in the Market Medicaid continues to be local (i.e., to a State) Only 8 plans, or 4%, operate in more than 4 states 175 plans, or 90%, operate in a single state Private plans are primarily managing physical health benefits Behavioral Health carve-outs were once quite popular, but are now trending toward full integration with PH Integration in KS, IA, LA, TN Carve outs remain in MI, PA, WA I/DD largely remains the last frontier when it comes to MMC AZ, NJ, TN, TX for acute care only; NE in Jan 2017 IA, KS and TN the only states with full MC AZ, NE & TX all in process for full integration Source: PWC, Nov
12 So, why Managed Care? States are looking for full integration holistic services across the service spectrum Large number of people with I/DD also have a BH diagnosis BH & PH services already included in Medicaid Managed Care High number of beneficiaries are Medicaid eligible and/or enrolled in Medicaid programs Many States have identified their service systems as unsustainable Managed care provides opportunities to focus on access, cost containment initiatives and quality health outcomes MCOs building expertise in serving complex populations 12
13 I/DD Comprehensive System of Support Network Development Recruit/develop, train, support monitor and audit: Residential and Day providers Peers Vocational Resources Crisis Management Transportation Community Transition Person Centered Planning Community Based Residence Care Coordination Functional Assessment Specialized IT System with community record Quality Develops/manage overall quality plan including: Incident report monitoring Compliance with PCP Individual satisfaction measurement to assure personcentered services National Core Indicators Conducts regular provider audits to ensure all quality and safety requirements met I/DD Institution Medical Behavioral Pharmacy Dental Vision ID & Strat for complex case management * HCBS Home and Community Based Services + Person Centered Plan 13 Care Coordination I/DD Network Support Assures adequate network resources have I/DD Experience Clinical services IP/OP/IOP
14 Strategies for Approaching Managed Care Be proactive; do not let it just happen to you There are many models of Managed Care Perhaps your State will explore Managed Care Lite Engage the State Medicaid Agency in conversation Get a seat at the table; be prepared; do not be an obstructionist Gather other system stakeholders and work to develop a common ground on key components for your State Meet with Managed Care Organizations Find out what they value; what their key drivers are Ask them who their SMEs are; who their Advocates are The MCOs did not decide to bring Managed Care to your State Talk to colleagues in other states Find out what works and what needs improvement Be open-minded; assume positive intent 14
15 Managed Care Entities They can (and do) co-exist with current system stakeholders Develop Strategies for Collaboration Define Roles Commit to Working Together Develop Common Goals and Shared Outcomes Access; Quality of Care Remember: It s not about us, it s about enhancing the lives of individuals with I/DD 15
16 John Nash The Arc of North Carolina 16
17 Managed Care Principles: Assumptions System designs must start with the individual service recipient It must be a strong, sustainable, personcentered approach to health and long term services and supports The administrative structure must be designed to be highly efficient, cost effective and most of all accountable 17
18 Managed Care Principles: Assumptions Individuals with I/DD are valued members of their families and communities Less concerned with who manages the system than how the system is managed The system must be innovative and flexible 18
19 Managed Care Principles: Assumptions We will work with the administration, the legislature and other stakeholders to design the best system possible Systems are not evil they do what they were designed to do, even if that isn't what we intended there must be room to adjust! 19
20 Managed Care Principles: 1. Self-direction 2. Outcome- based reporting 3. Cost efficiencies cannot be achieved on the back of individuals with disabilities living in the community 4. Accountability 20
21 Managed Care Principles: 5. Integrated care must not be based on a medical model 6. Sub- capitation and payment reform 7. Health promotion incentives for individuals with disabilities must be a part of any benefit plan offered by the system 8. Managed care networks must not require provider exclusivity 21
22 Managed Care Principles: 9. Transition to a new system must be seamless 10. Statewide IT and payment systems must be a part of any system design 11. Reduce the waitlist 22
23 Carrie Hobbs Guiden The Arc of Tennessee 23
24 History of Managed Care in Tennessee Tennessee s entire Medicaid program (TennCare) is an 1115 waiver TennCare has used a managed care model for Health/medical care since 1994 Behavioral health since 2007 LTSS for people who are elderly or who have physical disabilities since 2010 (CHOICES Waiver) TennCare has had its share of struggles along the way for a full history of the program review the TennCare Timeline: 24
25 Tennessee s Employment and Community First (ECF)CHOICES Waiver ECF CHOICES opened for enrollment on July 1, 2016 ECF CHOICES will provide LTSS for both children and adults with intellectual disability (ID) and developmental disabilities (DD) other than intellectual disability (previously only people with ID were eligible for waiver services) ECF CHOICES is administered by TennCare and managed by three (3) Managed Care Organizations (MCOs): BCBS, Amerigroup, United Healthcare These three (3) MCOs also hold the contracts for medical care, behavioral health, and LTSS for people who are elderly or who have physical disabilities (CHOICES Waiver) 25
26 Tennessee ECF CHOICES Waiver continued: Eligibility requirements: Must have ID/DD Meet NF LOC or be at risk of institutional placement Meet financial requirements Three benefits packages (see handout) $15,000 (children and adults) $30,000 (adults) $45,000-$153,000 (adults) 26
27 On the Horizon: Managed Care and Outcomes Based Payments TennCare is moving towards outcomes based payments for medical services and LTSS TennCare has implemented its QuiLTSS project for nursing facilities Stakeholder group began meeting in 2014 Project implemented in 2015 bridge year Full project implementation 2016 QuiLTSS in process for HCBS much more challenging 27
28 Michael Chittenden The Arc of Nebraska 28
29 29
30 For Profit Managed Care for Long Term Supports & Services Lessons Learned Questions? Mike Chittenden, The Arc Nebraska Kevin Fish, The Arc of Sedgwick County Carrie Hobbs Guiden, The Arc Tennessee John Nash, The Arc North Carolina Dan Ohler, OPTUM 30
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