Managed Care: We Cannot Stop the Winds of Change, but We can Direct the Sails

Transcription

1 1 Information for Managed Care: We Cannot Stop the Winds of Change, but We can Direct the Sails Oklahoma Developmental Disabilities Services October 1, 2015 Barbara Brent, Director of State Policy on behalf of the SELN

2 2 MEDICAID A REFRESHER & MORE

3 State Plan Benefits Structure of Medicaid Present Mandatory Services must be provided to everyone eligible Optional Services if provided by the state, must be provided to everyone eligible Congress adopted additional waivers Section 1915 (c) Home and Community-Based Services Waivers Section 1915 (b) Managed Care Waivers Concurrent Section 1015 (b) and 1915 (c)waivers Section 1115 Research & Demonstration Projects 3

4 Waivers 4 Waivers are vehicles states can use to test new or existing ways to deliver and pay for health care services in Medicaid and the Children s Health Insurance Program (CHIP). There are four primary types of waivers and demonstration projects: Section 1915 (c) Home and Community-Based Services Waivers: States can apply for waivers to provide long-term care services in home and community settings rather than institutional settings. Serve people who would otherwise be in an nursing home or ICF/DD Services furnished in accordance with a plan of care Safeguards for the health and welfare of participants Afford participant choice of between institution and community-based services Required that the average costs not exceed the average institutional costs Allowed states to target a population Allowed states to waiver the state-wideness requirement of Medicaid

5 HCBS 1915 (c) Waiver Services Case management Homemaker and home health aide services Personal care services Adult day health services Habilitation services Residential habilitation Day habilitation Expanded Habilitation Services as provided in 42 CFR (c): Prevocational Supported Employment Education Respite care services Day Treatment Partial Hospitalization Psychosocial Rehabilitation Clinical Services Live-in Caregiver Other service requested by the State * Sometimes the services will have different names but this is the basic structure 5

6 Medicaid Expanding Disability Services in 2007 to (i) State plan - Home and Community Based Services 1915 (j) State plan - Self-Directed Personal Assistance Services 1915 (k) State plan - Community First Choice Option

7 Waivers and Authorities 7 Section 1915 (c) Home and Community-Based Services Waivers: States can apply for waivers to provide long-term care services in home and community settings rather than institutional settings. Section 1915 (b) Managed Care Waivers: States can apply for waivers to provide services through managed care delivery systems or otherwise limit people s choice of providers through mandatory enrollment. Concurrent Section 1915 (b) and 1915 (c) Waivers: States can apply to simultaneously implement two types of waivers to provide a continuum of services to the elderly and people with disabilities, as long as all Federal requirements for both programs are met. Section 1115 Research & Demonstration Authority: States can apply for program flexibility to test new and innovative approaches to financing and delivering Medicaid and CHIP. Section 1915 (a) Authority: States can enter into contracts with organizations to provide services in the state plan; Must be voluntary; only existing services and cannot limit contractors Section 1932 (a) Authority: States may mandate enrollment in managed care. Certain groups are exempt. Rural areas must have a least 2 options

8 Basic Medicaid Structure 8 Mandatory Benefits Physical Health Acute Care EPSDT Optional Benefits ICF/DD ICF/SNF Personal Care Home Health Nursing Rehab 1915 (i) 1915 (j) 1915 (k) Home and Community Based Waiver 1915 (c) Section 1115 Demonstration Waivers Managed Care and Other Innovations Section 1915 (b) Waiver Managed Care

9 9 MANAGED CARE THE BASICS

10 Why States Do Managed Care 10 Can allow states to achieve budget stability over time and assist in predicting costs Assists in limiting states financial risk, passing part or all of it on to contractors by paying a single, fixed fee per enrollee Allows one (or more depending on design) entity to be held accountable for controlling service use and providing quality care and support Creates the potential to provide services to more people and create flexibility in service provision - if done very carefully and all components are in place

11 Generally, Managed Care Includes 11 A defined network of providers, as opposed to the freedom to choose any qualified provider under Section 1902 (Social Security Act, that then describes CMS authority) Selective contracting on the part of the Medicaid program, as opposed to giving an agreement to any qualified vendor Capitated payments, in which the managed care contractor accepts a set monthly amount to provide a package of services, as opposed to being reimbursed for each service provided. This is often referred to as per member per month

12 Managed Care Authorities Demonstration Waivers 1915 (b) (c) Concurrent Waivers 1915 a alone or in combination 1915 b- several types The applications don t look like the 1915 (c), except for the c portion of the 1915(c). Important to get familiar with the authorities and applications. But first---determine what does the state want to accomplish through managed care? What problem does the state believe managed care might solve?

13 Section 1915 (b) Managed Care Waivers (b) Waivers are one of several options available to states that allow the use of Managed Care in the Medicaid Program. When using 1915(b), states have four different options: 1915(b)(1) - Implement a managed care delivery system that restricts the types of providers that people can use to get Medicaid benefits 1915(b)(2) - Allow a county or local government to act as a choice counselor or enrollment broker) in order to help people pick a managed care plan 1915(b)(3) - Use the savings that the state gets from a managed care delivery system to provide additional services 1915(b)(4) - Restrict the number or type of providers who can provide specific Medicaid services (such as disease management or transportation) In long term services and supports, it is more typical to see 1915(b)(3) used concurrently with 1915 (c)

14 Concurrent Section 1915 (b) and 1915 (c) Waivers 14 States can provide traditional long-term care benefits (home health, personal care, and institutional services), as well as HCBS services (e.g. homemaker services, adult day health services, community navigator, and respite care) using a managed care delivery system. By combining a 1915 (c) with a 1915 (b), or other authorities outlined in the Managed Care Delivery System section, the managed care delivery system authority is used to either Mandate enrollment into a managed care arrangement which provides HCBS services or Limit the number or types of providers which deliver HCBS services.

15 Section 1115 Demonstrations 15 Section 1115 of the Social Security Act gives the Secretary of HHS authority to approve experimental, pilot, or demonstration projects that promote the objectives of the Medicaid and CHIP programs including managed care. Purpose: to give States additional flexibility to design and improve their programs, is to demonstrate and evaluate policy approaches such as: Expanding eligibility to individuals who are not otherwise Medicaid or CHIP eligible Providing services not typically covered by Medicaid Using innovative service delivery systems that improve care, increase efficiency, and reduce costs. Section 1115 demonstrations are approved for a five-year period and can be renewed, typically for an additional three years. Demonstrations must be budget neutral to the Federal government, which means that during the course of the project Federal Medicaid expenditures will not be more than Federal spending without the waiver.

16 What and Whose Care is Managed Acute Care Behavioral Health Long Term Supports and Services and any combination 16 And there are carve outs and carve ins Carve out children Carve out SSI recipients Carve out child welfare Target elderly only Target elderly and disabled Target I/DD

17 Managed LTSS Care in I/DD 17 In Managed Care Arizona (1115) Michigan (b/c) Wisconsin (b/c) North Carolina (b/c) Kansas (1115) Texas piloting IDD, sending out RFI New Hampshire * (1115), recent notification of I/DD roll out-no specific date In Planning or Pre Implementation Stage New Jersey (1115) - delayed Illinois (1115) Florida legislative exploration Tennessee adding IDD soon Iowa- fast track Louisiana* (1115) New York* (b/c) * pre-implementation

18 Who is Managing? Public vs. Private and Why it Matters Public Sector as MCO I/DD AZ (for I/DD) Michigan (I/DD & BH) NC (I/DD & BH) Wisconsin (A & D; I/DD) public is an option Texas (I/DD) State government: Arizona Counties WI; Local Managing Entities/NC 18 Private Sector MCO- profit or non-profit * implemented Kansas (All populations)* Wisconsin (A&D; I/DD) with public option* New Hampshire (A&D; I/DD) New York (A&D) (I/DD) Louisiana (All populations) Illinois (All populations) Texas (A&D)* Most Behavioral Health and Senior Managed Care When public, direct ability to anchor long established policy, rule, statute, service specifications, admin directives. When private- need to ensure all are purposefully tied through binding mechanism (e.g.. references and binding through contract)

19 Managed Care IN ACUTE HEALTH CARE Approximately 80% of Medicaid participants are in managed care in America for some or all of their services All states except and Alaska and Wyoming have some kind of managed care program of some sortwhether it is for a portion of medical/acute care (most common),behavioral health, and much less often, long term services and supports. 19

20 Establishing Expectations for Managed Care Long Term Services and Supports 20 Two important learning documents 1. CMS Guidance for Managed Care Long Term Services and Supports - 10 Key Elements 2. National Council on Disability- 20 Principles for Managed Care

21 National Council on Disability 20 Principles for Managed Care The goal must be to assist individuals with disabilities to live full, healthy, participatory lives in the community. 2. Managed care systems must be designed to support and implement person-centered practices, consumer choice, and consumer-direction. 3. Employment is a critical pathway toward independence and community integration. Enrollees must receive the supports to secure and retain competitive employment. 4. Families should receive the assistance they need to effectively support and advocate on behalf of people with disabilities. 5. Key disability stakeholders are fully engaged in designing, implementing and monitoring the outcomes and effectiveness. 6. The service delivery system must be capable of addressing the diverse needs of all plan enrollees on an individualized basis. 7. States should complete a readiness assessment before deciding when and how various sub-groups of people with disabilities should be enrolled. 8. Each network should have sufficient numbers of qualified providers in each specialty area to allow participants to choose among alternatives. 9. CMS should require states to include providers of institutional programs as well as providers of home and community-based supports within the plan s scope. 10. The existing reservoir of disability-specific expertise should be fully engaged in designing service delivery and financing strategies and in performing key roles within the restructured system.

22 National Council on Disability 20 Principles for Managed Care Long Term Services and Supports (cont.) 11. Responsibility for oversight must be assigned to highly qualified state governmental personnel The federal government and the states should actively promote innovation in long-term services and supports for people with disabilities. 13. Savings achieved through reduced reliance on high-cost institutional care, reductions in unnecessary hospital admissions and improved coordination and delivery of services should be used to extend services and supports to unserved and underserved individuals with disabilities. 14. Primary and specialty health services must be effectively coordinated with any long-term services and supports. 15. Participants in managed care plans must have access to the durable medical equipment and assistive technology. 16. The state must have in place a comprehensive quality management system that not only ensures the health and safety of vulnerable beneficiaries but also measures the effectiveness of services in assisting individuals to achieve personal goals. 17. All health care services and supports must be furnished in ADA-compliant settings. 18. Enrollees should be permitted to retain existing physicians and other health practitioners who are willing to adhere to plan rules and payment schedules. 19. Enrollees should be fully informed of their rights and obligations under the plan as well as the steps necessary to access needed services. 20. Grievance and appeal procedures should be established that take into account physical, intellectual, behavioral and sensory barriers to safeguarding individual rights under the provisions of the managed care plan as well as all applicable federal and state statutes.

23 CMS Guidance for Managed Care 10 Key Elements Adequate Planning and Transition Strategies 2. Stakeholder Engagement 3. Enhanced Provision of HCBS (ADA/Olmstead) 4. Alignment of Payment Structures with MLTSS Programmatic Goals 5. Support for Beneficiaries 6. Person-centered Processes 7. Comprehensive and Integrated Service Package 8. Qualified Providers 9. Participant Protections/States Oversight 10. Quality CMS Guidance to States Using 1115 Demonstrations or 1915 (b) Waivers for Managed Long Term Services and Supports Programs

24 And Keeping Focused Families play a central role in planning & overseeing the delivery of IDD services Families are here for a lifetime- MCOs need to learn about supporting people AND families Historic managed care techniques can conflict with fundamental IDD support principles Achieving efficiency through service inputs vs. building personalized support networks Emphasis on employment and community Use of natural supports 24

25 And Now: 25 WHAT IS POSSIBLE IN MANAGED CARE LONG TERM SERVICES AND SUPPORTS(MLTSS) HOW TO MAKE IT WORK FOR PEOPLE WITH I/DD A ND CAUTIONARY NOTES B U I L D I N G O N T H E B A C K G R O U N D, O V E R V I E W A N D P R I N C I P L E S T H E S A I L I N G T E A M D I R E C T S T H E S A I L S, N A V I G A T E S T H E S T O R M S A N D S H A R E S T A L E S W I T H O T H E R S A I L O R S

26 It can be good- it can be difficult 26 Managed care long term services and supports (MLTSS) can expand in-home supports, assist in addressing the waiting list, further innovations in the HCBS rule implementation, increase supports to people But, including I/DD is newer (only AZ, WI, MI and NC are truly experienced) It takes time to plan slow down to make it work; it takes longer than first anticipated

27 Readiness Assessment, Planning & Phase-In 27 Must be clear about what problem is managed care meant to solve? Why is it being done? Assumptions about savings should be tested Why? For seniors, services are medical & personal assistance and, unfortunately, provided for much shorter time due to people s age. Savings come from keeping people out and getting people out of nursing homes and supporting them in community. But, long service array is shorter and provide for few average years. Those assumptions aren t the same for people with I/D. Services are not primarily medical for most people and are instead on going community services to increasing learning over a lifetime. Services can be provided from early childhood for up to 60 or more years, with the kinds of services changing as the person learns as grows (employment, attendant care, respite, supported living, in home supports) Planning is different for I/DD LTSS than for acute care or other populations. Why? It isn t just about enough physicians, psychiatric hospitals or home health agencies it s about employment services and supports to families. There is already a network of service providers known by families, consumers and the DD agency. Keeping continuity and availability of these providers within the new MCO networks will take support and intentional planning Small providers are the most creative and the most at risk - no cash flow or I.T. system Stakeholders in I/DD are accustomed to have to having a meaningful seat at the table and strong voice. People with I/DD and families are the heart of the system and need to be involved first- - way before plans are completed. Involve people early and often. So do support coordinators/case managers. So do providers. Families need to be involved first.

28 IDD and Seniors & Disabled are not the same-planning and implementation are different Care Issues 28 Seniors-Health care and ADLS needs primary IDD - involvement in the community primary; services having little to do with health condition for most people Primary Services Seniors - medical and personal assistance IDD - habilitation, training, employment, family supports Family Care Giving Seniors In the later years of life IDD - Begins at birth and is there through a life time Focus Seniors Comfort, quality, and connections in remaining years of life IDD - Getting a Life Length of Service Seniors- Averages 3 years but happily can be more IDD - up to 60 years Natural Supports Seniors- Many people have a lifetime of natural supports to rely on IDD - need to build and maintain them throughout life

29 Stakeholder Engagement What is Possible 29 A seat at the table in policy development not just testimony at a forum. Start early, start with people with disabilities and their families. Don t forget providers and others, but a lesson learned is not getting people with I/DD and families together early. Providers and health plans are vital stakeholders but cannot be the primary messengers to families. On going participation reviewing policies and deliberating together Statewide groups are good; local groups with state involvement keep people involved and participating Make materials understandable. Have families and self advocates review them before they go out? Make transportation and respite available so people can participate Involved stakeholders in implementation Consider contracting with family and/or self advocacy groups to mentor, collect data on what is and is not working, provide information (AZ contracts with the Parent to Parent information Center) Involve stakeholders in quality oversight A big lesson learned in a state was not including the I/DD stakeholder community early on, including the planning stages with lack of knowledge of how robust this community is. Became political. Not only was this difficult for the state, support coordinators/case managers and providers, If was frightening for families and people with I/DD as the communication came from people other than the state and without their primary input.

30 Managed Care LTSS Prepare for Some Resistance-Why? 30 Families Built DD Systems over 50 years- They are integral to the system 1950s & 60s - State programs and State Statues 1970s Right to Education 1980s Deinstitutionalization litigation 1990s Medicaid HCBS Service System HCBS Waiver

31 Families Skeptical When Hearing Reason for MLTSS is Controlling Costs 31 No current runaway budgets Community services are not an entitlement in all but a few states States manage within a limited appropriation Enrollment is capped for 1915 c waivers People with DD are not high users of hospitals or nursing homes Thousands are on the waiting list across the country The system has already rebalanced except in a few states When families here saving money, it generally translates to cutting services for people living with families because that is what has happened in the past

32 Families Are Skeptical About Replacing the Current System- What Families Say 32 State DD Director -is a high level executive branch officer that families and people with disabilities know and have access to- MCO directors do not have the familiarity at the personal level Families have long been considered valued stakeholders Service coordinator to assess needs, create a person-centered plan and monitory service delivery- someone who stands by us Services geared toward supports across the lifespan as people learn and grow in the communities Provider network almost exclusively non profits, started by families and faith based organizations; families sit on the boards and fund raise Oversight through licensing, certification and monitoring of providers, often by DD agency

33 What s Important to Families 33 Access to Service Eliminating Waiting Lists Transitioning from school to adult life a real job with needed supports Support for families that is flexible, meets their needs and is consumer/family directed Their sons and daughters having a good and happy life with friends, family, a valued role in the community What happens to their sons and daughters when they die? Who will be there for them? Early stakeholder engagement with families and people with disabilities to address the concerns and what is important-and to include them in planning is essential. Providers and advocates, too- - but hearing from and engaging with primary customer matters.

34 What Families Need to Hear re: MLTSS Vision and Values there is a purpose beyond coordinating care and reducing costs The words Support families School to work transition Competitive employment Self-direction control over services & budget Small, innovative providers in their community will continue Support coordination Eliminate waiting lists Collaboration with consumer and family groups & associations.they will have a say the way they do now 34

35 Tools to Encourage Integrated Settings- Values AND Compliance with HCBS Settings Rule- requirement in all Medicaid Authorities with HCBS 35 Make integrated services more cost effective - build incentives for community based services in the capitation rate Keep institutions in the capitation rat, like nursing homes-where are biggest cost savings otherwise? Make expectations about self determination, community integration, work clear in the MCO contracts School to work transition Service approvals based on desired outcomes, not just an assessment Use manuals to communicate policies about roles and responsibilities i.e. case management/support coordination Build expectations into provider qualifications Measure the delivery of services for integration value In family homes with support In their own homes In shared living Age appropriate for children and adults Employment outcomes Integration regardless of medical or behavioral labels People with trachs, g-tubes, suctioning, ventilators, medical frailty People with behavioral reputations; criminal offenders

36 What Can Be Accomplished - Aligning Payment Structures with Goals 36 Capitation should include ICFs/nursing homes: If these services carved out, largest part of state spending is off table for rebalancing system Invest savings in desired HCBS options (supporting families, employment, smaller settings) and serving the waiting list And remember to help others understand capitation. It can be confusing. People might misunderstand, thinking that per member per month means each person gets that specific amount for their own services vs. this is total amount the MCO receives for everyone to be served and have their needs met-some people need more, some less.

37 What Can Be Accomplished - Aligning Payment Structures with Goals- cont. Spend sufficient time on capitation methodology. Capitation in (MLTSS) is unique for people with I/DD. In past, or in less experienced states, capitation often relied/relies primarily on what was spent in past year(s), plus regulatory changes & basic demographics. To drive innovation, realistically predict costs, attain desired outcomes & achieve rebalancing over time, capitation should not look solely at factors listed above. Also factor in: Desired policy changes, valued outcomes-examples: more in home supports, crisis support to prevent out of home placement, employment, early intervention, aging caregivers, smaller homes, youth coming out of school needing employment and community support, best/promising practices in alignment with HCBS rule 37 MLTSS capitation in I/DD is new, except in a few states. Extensive data is needed to develop actuarially sound capitation rates, especially those predicated with all factors. If state does not have robust data system and analytics readily available, more time needed to pull data for first capitation (and ongoing) The draft CMS Managed Care rules recently released heighten expectations for actuarially sound rates and capitation requirements.

38 Aligning Payment Structures with Goals cont. Rate setting- decide which components will be retained by state vs. what authorities MCOs will have: When state sets rates, may be more guarantees for core service expectations, but will MCO sign contract if not some flexibility? Can there be balance-state sets rate for some services especially when MLTSS for I/DD begins? Does state provide rate guidelines for desired outcomes such as HCBS employment & in home support, or does MCO have full ability to design rates as long as enough providers in network? Defining network strong adequacy standards and monitoring regarding LTSS outcomes may assist when MCOs set rates. States should approve rate methodologies, and bar is growing higher (takes time and data) Network oversight to ensure rate structure supports desired outcomes, such as increase in home based support, supportive living, supports to families, employment Network development and oversight can/should reach beyond basic adequacy. More than about sufficient doctors, hospitals, therapists (while important!), day programs and group homes. Should be specific about desired & needed services to achieve program's purpose (e.g. x # of families need respite in x area, x providers needed to meet need, x # of providers need to transform day or prevoc programs for x # people to comply with HCBS rule, and more. Should be reviewed, approved and monitored by the the state staff with I/DD expertise. And then, there is rate methodology for services. More discussion needed 38

39 Keeping Strong Support Coordination 39 People with I/DD and families (and others -advocates, providers, state I/DD staff) fear losing true essence of support coordinators, when receiving MCO care management as long embedded I/DD elements are unknown unless specifically trained, outlined in contract, and specifically listed in policy manuals, clinical practice guidelines and/or service specifications. What is often currently seen in MCO MLTSS care coordination if no I/DD support coordination requirements: Identify service needs Help decide course of actin Meets person by phone/in person to identify medical, functional, social and behavioral health needs - Develop a plan of care Give providers information needed about any changes in health to help in delivering service Reviews information from health provider, specialists, non-medical in order to determine needs-help with timely access to benefits, good services Misses many core elements of I/DD support coordination

40 Keeping Strong Support Coordination 40 More than the coordination of benefits, goods and services A person who: Does not work for a provider (conflict free) Develops an on- relationship with the person and family Develops the individual plan with them Is well versed in person centered planning, understanding the person s gifts, strengths, vision for a good life and not just support needs Conducts on-going oversight (checks in) to make sure services are delivered and are achieving outcomes Is available for ad hoc problem solving- available as a touchstone for the person and/or their family- a relationship In a few states, intentional and comprehensive support coordination is embedded in the system; in others, this remains a concern.

41 Qualified Providers 41 Basics are certification, licensing, background checks, credentialing (for clinical services), credentialing agencies MCOs and providers need training in disability specific areas, history and values base, person centered processes, I/DD vs. behavioral health, seniors, and acute care. Have people with I/DD and family members provide training, as well as state I/DD employees. Assure the training of non-certified direct support professionals; establish a core curriculum. Direct support professionals that haven t worked with people with I/DD may be inclined to think in terms of care and protection instead of learning and community support. Keep small providers/agencies and the rich network of HCBS agencies known in the community Providers/agencies need training in billing, encounters, coding & other insurance based knowledge. Arizona had billing whisperers to assist providers with insurance-based billing changes.

42 Participant Protections, Rights and Responsibilities 42 MCO are well-versed in consumer rights, responsibilities and protections, but may be unfamiliar with the basic expectations in I/DD protections and rights that will have to be embedded in contractor (or more likely binding in contract and referenced in statute, rule, policy, administrative and policy manuals, or other administrative vehicles) Some examples of rights less familiar to MCOs not currently involved or newly involved in MLTSS for people with I/DD: Right to most integrated settings Fair compensation for labor Right to have privacy and right to have visitors at any time Right to own property Right to date Right to presumptive competency Right to be free from excessive medications Right to positive behavior support practices and non restrictive interventions to increase desired behavior and decrease problematic behavior Right to contact Human Rights Committees * MCO will need to be educated and understand the expectations and their role in assurances

43 Quality Comprehensive Incident management Reporting; monitoring; trending individuals, providers and MCOs Evaluate Support Coordination Participant Feedback Utilization who is receiving supports and where, underserved, targeted areas? Desired outcomes reached? Review and trend grievances, complaints, appeals, claims, provider monitoring, incidents, quality of care concerns, outcomes, performance improve plans/projects, and compliance data The oversight of MCO quality by the State is as important as the MCO s system. It cannot be delegated to the MCO and I/DD state expertise is needed. 43

44 What to Expect of the State 44 A strategic plan for design and implementation Involvement of stakeholders in a meaningful and every step of the way A contract that has requirements specific to I/DD State oversight of MCO performance contract management- and with I/DD state expertise Adequate staff to conduct oversight states have found they cannot reduce infrastructure and need state I/DD expertise to do the job right Information system that provides transparent data- lots of data A complaint/problem resolution system at the state level Performance outcomes in the contract that are meaningful to I/DD A touchstone- the state must be there for people with I/DD, families, providers, advocates and MCOs

45 Some of the State s Tools Contract requirements and performance standards Policies, manuals, clinical practice guidelines, service specificationsdoesn t all fit in the contract and can t all be left to the MC Provider network plan approval and oversight- have stakeholder input on valued and needed I/DD services Performance measurement 45 Performance Improvement Projects (PIP)-an opportunity to improve a specific in HCBS that has not often measured in managed care Payment Incentives and Penalties, particularly after MCOs are well established in I/DD MLTSS. Not easy to start with these and there is a lot to do to plan, design, partner and implement MLTSS without adding many HCBS incentives potential for values based purchasing in employment, etc.

46 Measuring Progress 46 Managed care is more than a financing mechanism. Defining quality outcomes for people with I/DD, building on what works, and supporting more people and their families in the community= Progress.

47 Thank You! 47 Barbara Brent