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 o $3.5B Expenditures o $1B + Wait List o Autism? 3

IDD Costs and Cost Drivers • Pennsylvania ranked 10 th in Spending on IDD • Residential Services o PA Ranked 27 th in (1-6) Out of Home Placement  FY 2013 rate $101,281/person o PA Ranked 5 th in 16+ Out of Home Placement o PA Ranked 34 th 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 1 in 5 Americans over 65 20.2% 20% 19.3% 16.1 % 13% 6

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. 75,000,000 60,000,000 45,000,000 30,000,000 15,000,000 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 8

Pennsylvanians with DD 190,330 estimated Pennsylvanians with Developmental Disabilities* 53,237 137,093 28% 72% Receiving Services Not Receiving Services *Based on 1.49% prevalence of Pa citizens, US Census 9

People in PA with IDD Total 190,333 Receiving ODP Residential Services Out-of-Home 16,010 8% Receiving ODP Services In- 37,228 Home 20% Not Enrolled in ODP 131,619 69% Not Receiving Unserved Services Emergency Living with 2,436 1% Families? Unserved Critical 3,038 2% *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 o Fee Schedules o 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

Investment Decisions Living Arrangement/Program and Average Cost per Person April 2015 30,000 $26,591 25,000 Persons 20,000 15,000 Ave Cost/Mo. 11,949 11,689 $11,581 $11,213 10,000 $5,021 5,000 2,085 $1,666 1,287 956 P/FDS $20,000 Family Living $60,252 0 Group Homes $138,972 Group Family Private State Center P/FDS Private ICF/ID $134,556 State Center $319,092 Homes Living ICF/ID Waiver 16

Long Term Implications Type of Annual 5 years 10 years 20 years Service P/FDS $30,000 $150,000 $300,000 $600,000 Family Living $60,252 $301,260 $602,520 $1,205,040 Group $138,972 $694,860 $1,389,720 $2,779,440 Homes 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 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. 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. 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 Traditional MCO • Knowledgeable of • Little experience in Population MLTSS or IDD population • Established relationship • Little experience with with stakeholders Advocacy • Saving or Incentives • Profit driven driven back into services 25

Provider-Based Considerations • Operationally o Do we have the right model? o Will it improve services and access while managing cost? • Financially o Do we have the operational capitalization? o Do we have the risk capitalization in place? • Politically o Will it sell? o 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 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