Managed Long Term Care is Coming; What Can WE Do?

June 19th, 2013National Participant Network

www.wearenpn.org

Guest Speakers

• Dohn Hoyle, ARC of Michigan• Suzanne Crisp, NRCPDS• Rebecca Shuman, Advocate

Values Based Systems Change

VOW - to effect systems change causing the system(s) to fund and do what we already know is right & what people want.

Principles of Michigan’s Waiver Renewal and Tenets for Managed Care

• The honoring of each person’s preferences and choices including the presumption of competence and interpreting behavior as communication

• Doctors and other professionals would serve in consultative roles and their involvement would be only as desired or needed.

• Regular individual feedback and a focus on the outcomes the individual wants would form the basis for quality assurance.

Principles of Michigan’s Waiver Renewal and Tenets for Managed Care continued

• Self-determination would govern peoples’ lives and they would have choice and control over their own budgets according to their desires.

• The person who coordinates supports would play a personal agent role to help an individual achieve the outcomes they wished.

• Informal and generic supports would be considered prior to the implementation of supports through the Waiver

• External people and anyone unwanted would not intrude in the lives of the individuals served by the waiver

Desirable Elements of Managed Care are:

• A single funding stream

• Capitation with growth

• Local discretion

• Shared risk or stop loss

• People on waiting lists must be served

• We welcome change• We want what the waiver promised• Since prospects for new money are low, the re-

direction of public dollars offer the most efficient possible use of public dollars

• Control the growth rate of expenses• Carve out presents an opportunity

Goals

• Fulfill the promise of the Code revisions

• Individualize Supports

• Eliminate barriers

• Contain the rise of costs for services that do

add value

• Provide needed and desired services for

those on waiting lists

VALUES Michigan’s public mental health system for persons with developmental

disabilities should promote individuals to be:

• Empowered to exercise choice and control over all aspects of their lives

• Involved in meaningful relationships with family and friends supported to live with family while children and independently as adults

• Engaged in daily activities that are meaningful, such as school, work, social, recreational, and volunteering

• Fully included in community life and activities

SUPPORTS AND SERVICES

The reason for defining the “alternative” supports and services is to:

• Identify an acceptable array of service/support options

• Which can be provided on an individualized and very flexible basis

• Depending on the desires and needs of the person

• To establish mechanisms to track what services/supports are delivered

MEDICAL NECESSITY CRITERIA

• Mental health and developmental disabilities services are supports and services: designed to assist the beneficiary to attain or maintain a sufficient level of functioning in order to achieve his goals of community inclusion and participation, independence,

• “The funder shall offer and support easily accessed methods for consumers to control and direct an individual budget including providing them with methods to authorize and direct the delivery of services and supports from qualified providers selected by the consumer.”

Policy Guideline

Integrated Care Coordinator

• Managed Care – It is the Answer but What is the Question?

• Suzanne Crisp

• Currently, 16 states use managed care• Currently, 12 of those states offer participant

direction• By 2014, another 14 states will offer managed

care• All of those states will offer participant

direction

How Prevalent is Managed Care?

Learning about the Environment

• Reviewed Following Request for Proposals & Contracts– AZ, FL, HI, MA, MI, MN, NM,NC, TN, TX,WA, WI, NH, KS,

IL, PA, NY– Obtained copies of Request for Proposals, Invitations

to Bid, and Contracts executed between the State Authority and Health Plans

– Arizona’s Policy and Procedures• Site Visits– AZ, TX, TN, & MA

What did we Learn?• Wide variety of Federal Authorities support managed care– 1915(a), 1915(b), 1915(b)/(c), 1915(i), 1915(j), 1915(k), and

1115 Demonstrations• Vast majority of states enroll elders and adults• Managed Care Organizations do what states tell them to

do• If participant direction is offered in the traditional fee-for-

service program – it is required in managed care program• States require advisory committees

More Findings

• Participant direction is voluntary• Services to be self-directed include:– Personal Care, Attendant Care, and Respite– Trend to offer skilled care and therapies

• Training is available but typically not required• Back-up plans are required• Financial Management Services typically are

contracted with Managed Care Organization

More Findings

• Provision of information and assistance (self-directed counseling) is usually conducted by managed care staff

• Over ½ programs reviewed allow budget authority

• Many are using electronic visit verification systems

Recommendations: States Should

• Include the community in the development of the basic design, RFP, Contract, Management, and Quality Strategies

• Require the role of the participant as paramount• Provide specific language on advocacy, engagement,

participant-direction, and necessary supports• Ensure roles and responsibilities are identified• Require flexible individual budgets

States Should Require:

• Specify benchmarks for participant direction• Require participant to be part of the Quality

Evaluation System• An Ombudsman Office – without conflict• Informal concern/issue resolution and a

formal appeals process

Thank You!

suzanne.crisp@bc.edu281-360-2027