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CONFLICT FREE CASE MANAGEMENT STRATEGIES FOR INTEGRATED AND MANAGED CARE LONG-TERM SERVICES AND SUPPORTS ENVIRONMENTS
September 5, 2013
Kimberly Donica Ohio Department of Medicaid Hope Roberts Ohio Department of Aging Mary Sowers and Brenda Jackson, Mercer Phoenix - 2325 East Camelback
MERCER 1 September 19, 2013
Conflict Free Case Management Introduction
• Conflict Free Case Management (CFCM) – History and Evolution
• Growth of Managed and Integrated Care
• CFCM in Integrated Care
• Building Accountability while Minimizing Conflicts
• Role of State in Ensuring CFCM
• How the Principles of CFCM Strengthen Long-Term Services and Supports (LTSS)
MERCER 2 September 19, 2013
Conflict Free Case Management – Context
• Excerpt from the 1915(i) Proposed Rule CMS 2249-P2 (page 47): – Conflicts can arise from incentives for either over- or under-utilization of
services; subtle problems such as interest in retaining the individual as a client rather than promoting independence; or issues that focus on the convenience of the agent or service provider rather than being person-centered. Many of these conflicts of interest may not be conscious decisions on the part of individuals or entities responsible for the provisions of service.
MERCER 3 September 19, 2013
Conflict Free Case Management History
Undo Influence Over Goals
Misaligned Financial Incentives
Compromised Individual Choice of Services
Provider Self Referral
The statutory provisions for CFCM were the product of many years of
experiences/issues in a number of states’ LTSS systems.
MERCER 4 September 19, 2013
Conflict Free Case Management History – Origins in Home and Community Based Services (HCBS)
1981 – OBRA Enables states to
offer HCBS as institutional alternative
1990 – 1999 Major growth
in HCBS – especially for
individuals with I/DD
1999 Olmstead Decision – Increased growth in
HCBS
2005 Deficit Reduction Act – 1915(i), MFP,
and other options for
HCBS 2010 ACA – BIP,
MFP expansion,
CFC, 1915(i) changes, and
others
Growth of HCBS often relied on existing infrastructure from state, county, and provider levels.
MERCER 5 September 19, 2013
Components of Optimal Conflict Free Case Management System
Eligibility decisions separate
from service provision
Robust oversight
and monitoring
State engaged in oversight
Clear paths and
tracking for grievances
and appeals
No relation by blood or marriage
Engage stakeholders
and track individual
experience
CMS has created common expectations across all HCBS, though there may be some authority-specific requirements in addition to
these basic elements.
MERCER 6 September 19, 2013
Conflict of Interest Safeguards
• Both Section 1915(i) [State Plan HCBS Option] and 1915(k) [Community First Choice Option] include requirements that states establish conflict of interest standards for the assessments of functional need, independent evaluation and assessment in 1915(i), and the person-centered service plan development process that apply to all individuals and entities, public or private.
• Minimally, this must require that individuals are not: – (1) Related by blood or marriage to the individual, or to any paid
caregiver of the individual. – (2) Financially responsible for the individual. – (3) Empowered to make financial or health-related decisions on behalf of
the individual. – (4) Individuals who would benefit financially from the provision of
assessed needs and services.
MERCER 7 September 19, 2013
Conflict of Interest Safeguards, (cont’d)
– (5) Providers of State Plan HCBS for the individual, or those who have an interest in or are employed by a provider of State Plan HCBS for the individual, except when the State demonstrates that the only willing and qualified entity/entities to perform assessments of functional need and develop person-centered service plans in a geographic area also provides HCBS, and the State devises conflict of interest protections including separation of assessment/planning and HCBS provider functions within provider entities, which are described in the State Plan, and individuals are provided with a clear and accessible alternative dispute resolution process.
MERCER 8 September 19, 2013
Conflict Free Case Management Integrated Care
• Three levels of integration: – Integrating PH/BH/LTSS – Integrating Medicare and Medicaid – Integrating individuals into the community
• Integration happening through variety of formal mechanisms: – Health Homes, MCOs, ACOs – Financial interests are aligned with coordination of care
• Integration includes development of comprehensive care plans
• How do you construct CFCM without undue interest for self-referral and having person-centered planning processes with integrity in integrated care?
MERCER 9 September 19, 2013
Integrated and Accountable Care and Conflict Free Case Management A Paradox?
• Not Necessarily! – Ever-increasing number of states are offering LTSS in managed and
integrated care environments, holding entities accountable for person-centered approaches to care and outcomes for individuals.
– In these arrangements, when one entity is responsible for, or in some cases “at risk” for, the services provided to the individual, tailored strategies to ensure objectivity, conflict mitigation, truly person-centered approaches to care delivery and positive outcomes must be constructed. - Nothing happens by chance.
MERCER 10 September 19, 2013
State Oversight and
Monitoring
Explicit RFP and Contract
and Operational Components
Stakeholder Engagement
Clear Role Identification
and Separation within an
Organization
Conflict Free Case Management Building Blocks for CFCM in Managed and Integrated Care
Deliberate Design
Decisions
MERCER 11 September 19, 2013
Conflict Free Case Management Strategy Examples
• State Retention of Certain Functions: – Example: State retains assessments and MCO develops plans of care.
• Administrative Firewalls Between Organizations for Certain Functions: – A separate entity retains assessment functions (e.g., ADRCs).
• Administrative Firewalls Within Organizations for Certain Functions: – Utilization Review units do not have responsibilities for assessment and
plan of care development.
No matter which structures are put in place – Each program should utilize stakeholder and consumer oversight and transparent lines of communication.
MERCER 12 September 19, 2013
Role of the State – Paramount
• In moving to accountable systems of care, either capitated or fee-for-service, the State must take deliberate steps to ensure that the program design and monitoring will contemplate the need for CFCM: – To keep individuals at the center of the service system; – To promote optimal outcomes and quality of life for individuals; and – To safeguard state resources.
• Some tools in use by states include: – EQRO reviews of medical records and validation of performance
measures; – Ombudsman Programs; – Independent Community Entities contracted to perform certain oversight
functions; and – Individual participants.
Ohio’s Experience and Conflict Free Case Management
MERCER 14 September 19, 2013
Conflict Free Case Management in Ohio
• Ohio is participating in several ACA opportunities that require CFCM including: – My Care Ohio (Ohio’s Duals Demo); – Conflict free requirements integrated into MCP’s contract requirements; – Firewalls developed for AAA’s due to the nature of their role within the
demonstration; and – Balancing Incentive Program.
• Ohio’s previous experience with CFCM positions us well to implement across the rest of the delivery system.
• Ohio has had established firewalls in the DD delivery system since 2009. – The structure of the system and the role of County Boards of DD lent
itself to conflicts of interest.
MERCER 15 September 19, 2013
Development of a Firewall Document
• Engage stakeholders early in the design process.
• Evaluate current infrastructure of your system.
• Identify existing policies and procedures that may be the building blocks of the firewall.
MERCER 16 September 19, 2013
Considerations
• What is the impact on consumers?
• What additional costs could be incurred when implementing the components of a firewall?
• To what other system outcomes will the firewall contribute?
• How are the firewall elements communicated?
• How will the firewall be monitored?
• What are the consequences of not maintaining the parameters of the firewall agreement?
Louisiana’s Experience and Conflict Free Case Management
MERCER 18 September 19, 2013
Louisiana Example
• Louisiana has a 1915(b)(c)(i) concurrent waiver program for adults and children with behavioral health needs, which is part of an approved BIP grant.
• Louisiana administers that program, Louisiana Behavioral Health Plan (LBHP) through a Prepaid Inpatient Health Plan managed care contract with Magellan.
• The contract is capitated for adults and non-risk for children.
• To ensure CFCM within the program, Louisiana outlined a series of firewalls in their approved authorities.
MERCER 19 September 19, 2013
Louisiana Conflict Free Case Management Firewalls
• The State agency (DHH) makes the final 1915(i) enrollment eligibility decisions. All eligibility determinations, including financial eligibility reviews for Medicaid, are performed by the current Medicaid eligibility staff.
• Targeting and clinical needs-based criteria assessments are performed by the plan pursuant to policies and procedures set up and approved in advance with DHH making the final enrollment determination.
• The individuals performing the assessments are not providers on the treatment plan. The plan conducts reviews of all individuals completing assessments and plans of care to ensure that they are not providers who have an interest in or are employed by a provider who is on the plan of care.
• Assessment units are administratively separate from utilization review units and functions. The clinical needs-based assessments are reviewed pursuant to the 1915(i) QIS requirements by DHH staff.
• Participant treatment plans are reviewed by the plan pursuant to policies and procedures set up and subject to the approval of OBH and Medicaid.
MERCER 20 September 19, 2013
Louisiana Additional Conflict Mitigation Strategies
• Individuals can advocate for themselves or have an advocate present in planning meetings.
• The Case Manager documents that the individual has been offered a choice among all qualified providers of direct services.
• The Plan has established administrative separation between those doing assessments and service planning and those delivering direct services.
• The plan established a consumer council within the plan to monitor issues of choice.
• The plan established clear, well-known, and easily accessible means for consumers to make grievances and/or appeals to the State for assistance regarding concerns about choice, quality, and outcomes and documented the number and types of appeals and the decisions regarding grievances and/or appeals.
• State quality management staff oversee the plan to assure consumer choice and control are not compromised.
• The State documents consumer experiences with measures that capture the quality of plan of care development.