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

o $3.5B Expenditures

o $1B + Wait List

o Autism?

3

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

4

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

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, 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

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 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?

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

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

17

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

18

All of these problems!

19

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.

21

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

• 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

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

o Trust issues

o A real voice in decisions

Policy and Program

Options made available to Consumers and

families

30

Specialty Populations

• Medically Fragile

o Increased use of Assisted/Assistive

Technology

o Lifespan issues

• Dual/ Treble Diagnoses

oCreate capacity

oUse of specialized teams

31

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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