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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

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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

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Kevin Fish The Arc of Sedgwick County

(Wichita, Ks)

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Medicaid Managed Care

Innovations in the Public Sector Marketplace

Dan Ohler, VP

State Government Programs

dohler@optum.com

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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

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IDD Market Overview

$31.6

$13.1

$16.8

I/DD Annual Public Spending ($Billions per annum)

HCBSWaiver

ICF/ID

Other 686

325

I/DD Population (thousands)

HCBS WaiverParticipants

HCBS WaiverWaiting List

State-operatedICF/ID

Other ICF/ID

Public Spend Annual Federal + State + Local I/DD (non-acute/medical) Spend of $61+ Billion

What are I/DD

Services?

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)

Recent / Current

Market Environment

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

Market Drivers 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

$-

$25,000

$50,000

$75,000

$100,000

$125,000

$150,000

$175,000

$200,000

HCBS Waiver Institutional / ICF

Avg. Cost by Setting (PMPY)

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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

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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)

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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.

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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 2015

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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 2015

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• 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

So, why Managed Care?

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Person Centered Planning

Functional Assessment

Care Coordination

Community Transition

I/DD Network Support Assures adequate network resources have I/DD Experience

ID & Strat for complex case management

I/DD Institution

Community Based Residence

Network Development

Recruit/develop, train, support monitor and audit: •Residential and

Day providers •Peers •Vocational

Resources •Crisis

Management •Transportation

Quality

Develops/manage overall quality plan including: Incident report

monitoring Compliance with PCP Individual satisfaction

measurement to assure person-centered services

National Core Indicators

Conducts regular provider audits to ensure all quality and safety requirements met

Specialized IT System with community record

Clinical services IP/OP/IOP

Care Coordination

I/DD Comprehensive System of Support

♦ Medical ♦ Behavioral ♦ Pharmacy ♦ Dental ♦ Vision

* HCBS – Home and Community Based Services + Person Centered Plan

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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

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• 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

Managed Care Entities

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John Nash The Arc of North Carolina

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Managed Care Principles:

Assumptions

• System designs must start with the individual service recipient

• It must be a strong, sustainable, person-centered 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

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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

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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!

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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

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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

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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

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Carrie Hobbs Guiden The Arc of Tennessee

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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: https://www.tn.gov/tenncare/article/tenncare-timeline

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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)

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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)

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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

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Michael Chittenden The Arc of Nebraska

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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

Questions?