IDD Managed Care Seven Springs Annual Conference October 07, 2015 - - PowerPoint PPT Presentation

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

2

Why Managed Care and IDD

• Improve Quality
• Increase Access (Decrease/Eliminate Waiting

List)

• Stabilize Cost
• $3.5B Expenditures
• $1B + Wait List
• Autism?

3

IDD Costs and Cost Drivers

• Pennsylvania ranked 10th in Spending on IDD
• Residential Services
• PA Ranked 27th in (1-6) Out of Home Placement
• FY 2013 rate $101,281/person
• PA Ranked 5th

in 16+ Out of Home Placement

• 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

4

Projected Increased Demand

• Factors Influencing growing demand
• Aging Caregivers
• Litigation promoting access
• Increased longevity of persons with IDD
• Downsizing and closure of public and private IDD

Institutions

• Braddock, et al 2015

5

The Impact of Aging Baby Boomers

6

13% 16.1% 19.3% 20% 20.2%

1 in 5 Americans over 65

Pennsylvania’s Aging Population

7

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.

8

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, Population Division, Interim State Population Projections, 2005

Females aged 25-44 Individuals 65 and older

Larson, Edelstein

Pennsylvanians with DD

53,237 28%

137,093 72%

*Based on 1.49% prevalence of Pa citizens, US Census

190,330 estimated Pennsylvanians with Developmental Disabilities*

Receiving Services Not Receiving Services

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16,010 8% 37,228 20% Unserved Emergency 2,436 1% Unserved Critical 3,038 2% 131,619 69% Not Receiving Services Living with Families?

People in PA with IDD Total 190,333

Receiving ODP Residential Services 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

11

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

12

Traditional Managed Care Principles

• Pre-Authorization
• Utilization Management
• Reimbursement Structures
• Fee Schedules
• Negotiated Rates; Per diems
• Standardized Admission Criteria
• Avoidance of Readmissions
• Length of Stay
• Gaining Efficiencies
• Outcomes/Performance Based Contracting

13

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?

14

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

15

5,000 10,000 15,000 20,000 25,000 30,000 Group Homes Family Living Private ICF/ID State Center P/FDS Waiver 11,689 1,287 2,085 956 11,949 $11,581 $5,021 $11,213 $26,591 $1,666

Investment Decisions Living Arrangement/Program and Average Cost per Person April 2015

Persons Ave Cost/Mo.

P/FDS $20,000 Family Living $60,252 Group Homes $138,972 Private ICF/ID $134,556 State Center $319,092 16

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.

20

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.

22

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

23

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

24

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

25

Provider-Based Considerations

• Operationally
• Do we have the right model?
• Will it improve services and access while

managing cost?

• Financially
• Do we have the operational capitalization?
• Do we have the risk capitalization in place?
• Politically
• Will it sell?
• Does it best position providers and those they

serve?

26

What We Have Learned

• CHOICE – Personalized services are essential to real choice –

support people in their choice of restaurants not just a selection from

• ne 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

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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

28

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

29

Consumer and Family Advocacy

• New system needs to support both Families &

Consumers

• Organized advocacy & individual advocacy
• Trust issues
• A real voice in decisions
• Policy and Program
• Options made available to Consumers and

families

30

Specialty Populations

• Medically Fragile
• Increased use of Assisted/Assistive

Technology

• Lifespan issues
• Dual/ Treble Diagnoses
• Create capacity
• Use of specialized teams

31

Status and Future

• Two provider based MCOs
• RCP-SO
• WPHS
• DHS has been meeting with Commercial

MCOs

• State is embarking on MLTSS
• IDD delayed until 2018?
• ???

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