colorado power point on identifying and addressing a conflict of interest

8/14/2019 Colorado Power Point on Identifying and Addressing a Conflict of Interest

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When a Case Manager Wears More Than One Hat

Practical Tools for Identifying and Addressing a Conflict of Interest

Matthew Solano

Shari RepinskiDivision of Developmental Disabilities

Colorado Department of Human Services

Maureen Booth

Eileen GriffinMuskie School of Public Service

University of Southern Maine


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OverviewWhy addressing a Conflict of Interest is

an Important Quality Issue

Colorados Experience Background & Context

Tools for Identifying & Analyzing a Conflict ofInterest

Reviewing Safeguards & Discovery Methods forMitigating a Conflict of Interest

Identifying System Improvements for AddressingProblems


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Background & Context


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HCBS WaiversComprehensive Service Waivers (HCB-

DD)

Supported Living Services (SLS)

Childrens Extensive Services (CES)


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Colorados Delivery SystemDivision of Developmental Services

(DDD)

Health Care Policy and Finance (HCPF)

Community Centered Boards (CCBs)

Service Agencies

Regional Centers (RCs)


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Division of Developmental Services Serves approximately 12,400 adults &

children with DD through Medicaid and state-

funded programs Serves as the Operating Agency for the three

HCBS 1915 (c) waivers

Promulgates administrative rules

Designates TCM agencies (CCB) andcertifies direct waiver providers


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Health Care Policy and Finance Single State Medicaid Agency

Maintains administrative authority over allMedicaid programs, including the three HCBSwaivers operated by DDD

Provides oversight and direction for the threeHCBS waivers operated by DDD

Maintains final decision making authority overall Medicaid policies, rules, procedures andprocesses


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CCB Roles Information and Referral

Single Point of Entry

Case Management

Service Provider

Organized Health Care Delivery System

(OHCDS)Quality Assurance


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Historical PerspectiveColorados CCB System

Local communities of family members,

advocates and concerned citizens soughtand obtained legislative support for the

service system in the 1970s

Controversies over the dual roles of CCB

(service provider and case managementagency) since the systems inception


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Historical PerspectiveStrong tradition of local control

Local funding for services

Local focus of governance and humanrights monitoring

Recent System Changes

Move from bundled billing/bundled

payment methodology Implementation of Fee For Service

methodology


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Historical PerspectiveConflict of Interest as the focal point

due to multiple roles:

Only CCBs provide Targeted CaseManagement

Most CCBs provide Direct Waiver Services

All CCBs operate an Organized Health

Care Delivery System (OHCDS)


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Historical PerspectiveConflict of interest issues have been

reviewed by:

Special legislative committees The Colorado State Auditor

Local and statewide advocacy systems

DDD

CMS Regional Office Staff


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Meeting CMS RequirementsCMS Stated Concerns

Possible conflicts of interest due to CCBs

providing case management and directservices

CCBs role in ensuring specific qualityassurance and monitoring activities with itsown direct provider agency

CCBs role in ensuring quality assuranceand monitoring activities for agenciesparticipating in its OHCDS


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Meeting CMS RequirementsCMS Stated Concerns (cont.)

Conflicts of interest may hamper uniform

implementation of waiting list procedures CCBs have a disincentive for developingnew, independent service provideragencies in their area

CCB case managers may unduly influenceparticipants choice of a qualified provider


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Meeting CMS RequirementsStatewide Program

Waiver processes and procedures must be

consistent throughout the state and notvary due to local control issues;

Waiver assurances are to be metirrespective of the configuration of a localservice delivery system.


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Meeting CMS RequirementsAdministrative Authority

SMA must provide oversight of

performance of waiver functions SMA must maintain a written agreement

with any operating agency

SMA must specify in writing any function

delegated to a local agency and ensurethose functions meet waiver assurances


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Responding to Stated CMS ConcernsColorados Overall Strategy

Locate an independent, well qualified and

respected vendor to complete a study andmake recommendations

Develop a system of safeguards and

corresponding performance measures to

include in 1915 (c) waiver renewalapplications


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Scope of WorkDDD requested the Muskie School to

complete the following:

Review all pertinent statutes (state andfederal), regulations, policies, contracts

and reports;

Conduct a literature review regarding

safeguards and protections to addresspotential conflicts of interest.


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Scope of Work Review and research the practices of 6-8

states where TCM and waiver services

provided by the same agency are an

allowable/standard arrangement;

Conduct key informant interviews with

Colorado policy makers, providers, advocacy

agencies and others.


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Scope of WorkPrepare a final written report that:

Describes the methodology of the study,

findings and recommendations of thestudy;

Defines conflict of interest;

List appropriate safeguards;

Highlight areas of improvement in

Colorados safeguards and monitoring.


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Methodology & Approach


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Information Gathering Document review

Correspondence with CMS, reports, statutes,regulations, manuals, contracts, survey tools, etc.

Key informant interviews DDD, HCPF, CMS, etc.

Stakeholder input CCBs, advocates, parents, participants, case

managers, etc.

Looking at other states Ohio, South Dakota, Vermont, Wyoming


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Analytical FrameworkConflict of Interest

Public Duty

Private Interest

Identifying opportunities to act on

conflict of interest

Safeguards & discovery methods tomitigate opportunity to act


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Conflict of Interest A real or seeming incompatibility

between ones private interests and

ones public or fiduciary duties. Blacks Law Dictionary, Eight Ed., Thomson West, St. Paul, MN (2004)


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Public Duty Defined in contracts, statutes, regulations.

Our synthesis of the CCBs public duty:

The CCB has a duty to adhere to and promoteColorados programmatic goals for quality

Our synthesis of COs programmaticgoals: Every person meeting the States eligibility criteria

for developmental disability services has equitableaccess to services that meet individual needs andpreferences, are consistent with federal and statelaw, and are within existing resources.


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Private Interests Incentives natural to any business in a

competitive environment

Maximize revenue e.g., by increasing the number of people it

serves or the amount paid for services

Minimize costs e.g., by minimizing scope of services

provided to meet a clients needs Improving its competitive position

e.g., promoting awareness of services


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Conflict of Interest & Quality Distinguishing between a legally prohibited

conflict of interest (narrowly defined) and aconflict of interest having a potentially

negative impact on quality (broadly defined).

Key Question: From a quality standpoint,what are the system incentives and pressures(private interests) that tend toward a

breakdown in quality (public duty)?


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Key Strategy: Break the Problem Down Analyze conflict of interest in the context of

specific dual roles: e.g., provider and case

manager, or provider and single point of entry

Makes it easier to analyze the effectiveness

of safeguards, etc.

Makes it easier to develop a shared

understanding of the potential for problems


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Key Strategy: Analyze System, Not Accusations Not important to know whether any or all

CCBs actually act on a conflict of interest,only whether the conflict of interest and the

opportunity to act on it exists Question becomes: Does the system

adequately protect against acting on a conflictof interest?

The information we gathered flagged areasrequiring examination but was not the basisfor making judgments


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Findings & Analysis


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Applying the FrameworkFor each combination of dual roles:

Identify potential conflict between private

interest and public duty Identify opportunities created by dual role

to act upon conflict of interest


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Applying the Framework

For purposes of this analysis, most

issues connected to CCBs combined

role as a provider and: Single Point of Entry

Case Management


Quality Assurance


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A CCB OPPORTUNITIES TOCT ON RIVATE NTERESTS AS AIRECTSERVICEPR O V I DER Other CCB Role CCBs Public Duty asAgent of State CCBs Private Interest asP r o v i d e r Opportunities to Act on Private Interests

Single Entry Point!Information &Referral

!Eligibility Determination

!Managing Waiting List


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Safeguards

Safeguard: A policy, procedure or systemthat works to deter a CCB from actingcontrary to the goals of the program.

Evaluating the Adequacy of Safeguard: Does the safeguard adequately address the

potential conflict? Are there barriers to theeffectiveness of the safeguard?

Is there a method to assess the effectiveness ofthe safeguard in eliminating or reducing theconflict (e.g., oversight method)?


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Design Features

Design Features: Roles, responsibilitiesand organizational structures that eitherproduce or eliminate the potential for conflict.

Changes to design features may bewarranted if:

no effective safeguards exist,

substantial barriers to effectiveness ofsafeguards, or

weak or unavailable oversight methods areinadequate to confirm safeguard isworking.


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Provider & Single Entry Point

Single Point of Entry Functions

Information & Referral

Eligibility Determination

Administration of the Waiting List


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Information & Referral


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Eligibility Determination


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Managing a Wait List

POTENTIAL CONFLICT :Maximize revenue by m ov ing people up waiting list to fit with CCBs service openings ?Existing Safeguards Oversight Method

(Italics = proposed)

Barriers to Effectiveness

Persons are selected for

services from the waitinglist acc ording to criteria and

interpretive guidelinesestablished by the

Department.


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Service Provider & Case Manager

Case Management Functions

Service Planning

Provider Selection


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Service Planning POTENTIAL CONFLICT : Incentive to use service planning process to steer participants toward CCB services ?

Existing Safeguards Oversight Method(Italics = proposed)


The Department specifieselements that must be

addressed in the IP and theprocess and timelines for its

completion.


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Provider Selection


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Rate Negotiation POTENTIAL CONFLICT : Negotiate favorable rates for own providers and low rates with competition?



State rules govern purchaseservice rates and allowable

fees for se rvices provided tonetwork providers.


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Service Provider & Quality Assurance


Functions

Monitoring Services Complaints

Incident Reporting System


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Complaints POTENTIAL CONFLICT : Incentive to suppress complaints against CCB providers ?



Self advocacy or through guardiansor family members


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Incident Reporting POTENTIAL CONFLICT : Incentive to minimize incidents or otherwise limit follow -up investigations ?

Existing Safeguards Oversight Method



The CCB must establish policiesto ensure prompt notification ofspecific events determined by the

State (e.g., abuse, neglect, death,serious injuries) and othersidentified by the CCB.


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Structural Safeguards

Structural Safeguards Oversight Method



CCB Governing Boardmembership


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Three Categories of Recommendations

Incremental Strategies

Design Options

Out of Scope but RelatedDeciding How to Proceed is a Balancing

Test:

Implementation of a recommended remedy

should be weigh scope and severity ofproblem against cost and disruption to thesystem.


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Incremental Strategies

Comprehensive Operational Protocols forWaiver Programs

Clarify expectations & minimize CCB

discretion Incorporate safeguard enhancements

Document Oversight Methods & QualityIndicators

Enhance Authority and Visibility of Medicaid &DDD

Move Toward Greater Transparency


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Design Options

Recommended safeguards monitor, but donot prevent acting on a conflict;

Compounded effect of wearing multiplehats confusing to all, including CCB;

CCBs control over so much inhibits theability of the consumer, families andproviders to challenges the CCB, animportant check on the CCBs ability to acton a conflict of interest.


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Option 1: Separate Direct Service

CCB continues other functions but

contracts with providers for direct

service

Costs & Barriers

Potential Benefits


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CCB

Provider

Contracts

CMSPOE

DDD

Referral

Referral

Individual

Providers

Option 1: Separate Direct Service


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Option 2: Contract for OHCDS

DDD enters into contract with one or

more OHCDS. CCB can opt to serve as

OHCDS or as Single Point of Entry and

Case Manager but not both

Costs & Barriers

Potential Benefits


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Option 2: Contract for OHCDS

CCB

SPOE CM

ReferralOHCDS

DDD

Individual

Providers

Referral


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Option 3: Separate All Functions

Put all functions out to bid, no

guaranteed role of CCB

Costs & Barriers

Potential Benefits


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Option 3: Separate All Roles

DDD

CM OHCDS

Individual

Providers

SPOE Referral Referral

Referral


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Out of Scope Issues & Recommendations

Expand consumer choice and control as

quality safeguard

Enhance stakeholder voice in development of

local service options

Review quality of case management

Look at the impact of local funding on

inequity Examine quality of Adult Protective Services

investigations


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Colorados Response


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Colorados Response

Joint review of the final report by SMA(HCPF) and DDD

Public posting of the final report with ajoint response from both StateDepartments

Solicitation and review of stakeholder

and public commentPublic posting of stakeholder and

public comment


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Colorados Response

All except one (re: critical incidentreporting) of the incrementalrecommendations have been acceptedby both State Departments;

Re-design Options will require a multi-year strategy for implementation

Two design options determined to beviable, one option will not beconsidered.


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Colorados Response

Incremental Recommendations

Develop data measures of all existing

safeguards to ensure ongoingmonitoring and review;

Develop joint work plan forimplementation of recommendations

re: proposed enhancements andoversight methods, including datameasures.


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Colorados Response

Incremental Recommendations

Enhancements not requiring new staff

resources to be implemented by7/1/09 via joint work plan

Enhancements requiring new staff

resources will be considered by both

State Departments along with other

budget priorities


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Colorados Response

Implications for waiver renewal applications:

Incorporation into the overarching statewide

Quality Improvement Strategy (QIS) to be

implemented for all HCBS waivers in Colorado Enhancements and monitoring processes likely

will be specific to the three waivers operated by

DDD

Inclusion of several data measures asperformance measures in the 1915 (c) 3.5

application version


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Colorados Response

Options for Redesign

Most controversial

Most time consuming to analyze andto apply the recommended weighing

test identified in the report

Will require legislative action toimplement


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Colorados Response

Options for Redesign

1. Separation of service delivery from all

other roles appears to require the fewest

changes and disruption to the current

system

2. Separation of service delivery and

provider contracts from all other roles

would seem to require more changes

and risk of disruption of services


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Colorados Response

Options for Redesign (cont.)

Separation of all roles would be the mostsignificant change from the current

system and has the greatest risk for

disruption of services

Both Departments have committed to

analyzing and addressing recommendations

re: redesign subsequent to CMS approval of

the three renewal applications in July 2009

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