IDD Managed Care - RCPA Annual Conference
Transcript of IDD Managed Care - RCPA Annual Conference
IDD Managed Care
Seven Springs Annual Conference
October 07, 2015
Richard S. Edley, PhD, RCPA
Terrence McNelis, MPA, NHS
Presentation Overview
• Why the discussion about IDD Managed Care
in PA?
• IDD costs and cost drivers in PA
• Problem areas in the system
• Applicability of Managed Care principles
• Transforming the system
• Provider-based solutions v. traditional Managed Care models
• The role of consumer and family advocacy
• Specialty Populations
• Status and Future
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Why Managed Care and IDD
• Improve Quality
• Increase Access (Decrease/Eliminate Waiting
List)
• Stabilize Cost
o $3.5B Expenditures
o $1B + Wait List
o Autism?
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IDD Costs and Cost Drivers
• Pennsylvania ranked 10th in Spending on IDD
• Residential Serviceso PA Ranked 27th in (1-6) Out of Home Placement
FY 2013 rate $101,281/person
o PA Ranked 5th in 16+ Out of Home Placement
o PA Ranked 34th in State Operated Facilities FY 2013 – 1,069 persons rate $378,016
• Persons with IDD living with Aging Caregivers (FY 2013 – 41,085)
• Waiting List – 17,000 – 20,000• Braddock, et al 2015
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Projected Increased Demand
• Factors Influencing growing demand
o Aging Caregivers
o Litigation promoting access
o Increased longevity of persons with IDD
o Downsizing and closure of public and private IDD Institutions
o Braddock, et al 2015
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The Impact of Aging Baby Boomers
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13%
16.1%
19.3%
20%
20.2%
1 in 5 Americans over 65
Pennsylvania’s Aging Population
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The Challenges
More people will need Medicaid funded long term
supports & services.
The work force is not growing as fast as the need
for support staff.
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15,000,000
30,000,000
45,000,000
60,000,000
75,000,000
2000 2005 2010 2015 2020 2025 2030
Source: U.S. Census Bureau, Populat ion Division, Interim State Populat ion Project ions, 2005
Females aged 25-44 Individuals 65 and older
Larson, Edelstein
Pennsylvanians with DD
53,23728%
137,09372%
*Based on 1.49% prevalence of Pa citizens, US Census
190,330 estimated Pennsylvanians with
Developmental Disabilities*
Receiving Services
Not Receiving Services
9
16,0108%
37,22820%
Unserved Emergency 2,436 1%
UnservedCritical
3,038 2%
131,61969%
Not Receiving Services
Living with Families?
People in PA with IDDTotal 190,333
Receiving ODP ResidentialServices Out-of-Home
Receiving ODP Services In-Home
Not Enrolled in ODP
*Based on 1.49% prevalence of PA citizens, US Census 10
System generated problems
• Fee for Service model fragments LTC
• Projected Payment Structure eroding
private organizations
• No cost of Living since 2007
• Underpaid workforce
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Why Managed Care
• Current system is unsustainable
• Real transformation needs to occur
• Tweaking current regulations and payment mechanisms not enough
• Positive experience with managed care: physical health and behavioral health HealthChoices
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Traditional Managed Care
Principles• Pre-Authorization
• Utilization Management
• Reimbursement Structureso Fee Schedules
o Negotiated Rates; Per diems
• Standardized Admission Criteria
• Avoidance of Readmissions
• Length of Stay
• Gaining Efficiencies
• Outcomes/Performance Based Contracting13
IDD Managed Care: Questions
• What of the Traditional Managed Care Model is
Applicable?
• Where are the Savings and Efficiencies in ID
System?
• Where are the Quality Issues?
• What will be the “Model”?
• What are the other State Models?
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Model Questions and Issues (Examples)
• What can be pulled from traditional managed care?
• What can be learned from other States?
• Inclusion of key stakeholders
• Role of the SCOs
• Assessment and measures
• Where is the cost savings?
• Where are the quality issues?
• How are vocational providers part of the model?
• How will residential services be impacted?
• Inclusion of Autism and Developmental Disabilities
• Physical health/disabilities
• Information Technology
• MCO Financing
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0
5,000
10,000
15,000
20,000
25,000
30,000
GroupHomes
FamilyLiving
PrivateICF/ID
State Center P/FDSWaiver
11,689
1,2872,085
956
11,949$11,581
$5,021
$11,213
$26,591
$1,666
Investment DecisionsLiving Arrangement/Program and Average Cost per Person
April 2015
Persons
Ave Cost/Mo.
P/FDS $20,000Family Living $60,252Group Homes $138,972Private ICF/ID $134,556State Center $319,092
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Type of Service
Annual 5 years 10 years 20 years
P/FDS$30,000 $150,000 $300,000 $600,000
Family Living $60,252 $301,260 $602,520 $1,205,040
Group Homes
$138,972 $694,860 $1,389,720 $2,779,440
Private ICF/ID $134,556 $672,780 $1,345,560 $2,691,120
Public ICF/ID $319,092 $1,595,460 $3,190,920 $6,381,840
Long Term Implications
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Transforming the System
• Involvement of stakeholders
• Assure Flexibility across the lifespan
• Move toward less restrictive settings
• Create community capacity
• Reward quality services
• Full healthcare integration
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All of these problems!
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Perspective
Eeyore, the old grey donkey, stood by the side of
the stream, and looked at himself in the water.
"Pathetic," he said. "That's what it is. Pathetic."
He turned and walked slowly down the stream for
twenty yards, splashed across it, and walked
slowly back on the other side. Then he looked at
himself in the water again.
"As I thought," he said. "No better from this side.
But nobody minds. Nobody cares. Pathetic, that's
what it is.”-- A.A. Milne, Winnie the Pooh, 1926.
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Do we prefer extinction or growth
• Focusing on products rather than customers.
• What business are you really in?– Railroads
– Movies
– Slide Rules
– Watches
– Video Stores
Theodore Levitt, Marketing Myopia,
Harvard Business Review, 1960.
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Product vs Customers Focus
• The railroads did not stop growing because the need for passenger
and freight transportation declined.
• They let others take customers away from them because they
assumed themselves to be in the railroad business rather than
in the transportation business.
• Hollywood barely escaped being totally ravished by television.
Actually, all the established film companies went through drastic
reorganizations.
• It thought it was in the movie business when it was actually in
the entertainment business. “Movies” implied a specific, limited
product. This produced a fatuous contentment that from the
beginning led producers to view TV as a threat. Hollywood scorned
and rejected TV when it should have welcomed it as an opportunity.
• Levitt, ibid.
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The Provider Perspective
• We need to fundamentally change how services are designed and delivered
• We need to focus on quality in time of diminishing resources
• Systems based on person-centered planning and managed care principles
• Reinvestment of efficiency dividends
– Direct care wages, benefits, training and supervision
– Waiting list
– State/county fiscal relief
– Davis, OPRA, 2014
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Implications for Our System
• Fundamental system changes through financing reforms that drive policy changes– Risk shared with provider
– Funder predictability and accountability
– Taxpayer and societal value
– Improved health outcomes at lower cost
• Eligibility and service planning– Simplified and customer focused
• Quality– Improved quality
– Data transparency
– Shift focus from inputs to outcomes• Davis, OPRA, 2014
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Provider-Based vs Traditional MCO
Provider Based
• Knowledgeable of
Population
• Established relationship
with stakeholders
• Saving or Incentives
driven back into services
Traditional MCO
• Little experience in
MLTSS or IDD population
• Little experience with
Advocacy
• Profit driven
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Provider-Based Considerations
• Operationallyo Do we have the right model?
o Will it improve services and access while managing cost?
• Financiallyo Do we have the operational capitalization?
o Do we have the risk capitalization in place?
• Politicallyo Will it sell?
o Does it best position providers and those they serve?
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What We Have Learned
• CHOICE – Personalized services are essential to real choice –
support people in their choice of restaurants not just a selection from
one menu
• COMPLEXITY – Support doing the right thing for the right
reason, less rules more training and values
• NATURAL CAPACITY – Look to the family, friends and
community, supported by a robust structure
• AUTONOMY – Avoid a vision of entitlement and a cultivation of
dependence
• FLEXIBILITY – Recognize that our work is a human endeavor
with services needing to be personal and very individualized
• STEWARDSHIP – Avoid costly solutions and structures that do
not add value to peoples lives
• Dennis Felty, 2015 27
Present Model and Future Model
• Focus on activities (documentation, verification,
audit, compliance to standards)
– Fee for service
– Units of service
• Focus on outcomes (how our services impact a
person’s life in a real and meaningful way, in the
ways that are important to them)
– Personal Outcomes/System Outcomes
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System Outcomes
• Customer defined outcomes and improved quality
• Improved financial predictability for funders and providers
• Reinvest efficiency dividends– Direct care wages, benefits, training and supervision– Waiting list– State/county fiscal relief
• Importance of focusing on quality in time of diminishing resources
• Must ensure health and safety - true, but want to improve health
• Changing the face of how services are designed and delivered
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Consumer and Family Advocacy
• New system needs to support both Families &
Consumers
• Organized advocacy & individual advocacy
o Trust issues
o A real voice in decisions
Policy and Program
Options made available to Consumers and
families
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Specialty Populations
• Medically Fragile
o Increased use of Assisted/Assistive
Technology
o Lifespan issues
• Dual/ Treble Diagnoses
oCreate capacity
oUse of specialized teams
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Status and Future
• Two provider based MCOs
oRCP-SO
oWPHS
• DHS has been meeting with Commercial
MCOs
• State is embarking on MLTSS
• IDD delayed until 2018?
• ???
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