Shaping policy, sharing solutions, strengthening communities
Managed Long Term Services and Supports or Mangled LTSS? Virginia Network of Private Providers Fall Conference 2014
ANCOR is… A national nonprofit trade association advocating and supporting • Over 1200 private providers of services and supports to • Over 1,00,000 people with disabilities and their families • And employing a workforce of over 800,000 direct support professionals and other staff
The American Network of Community Options and Resources Vision: Advancing excellence in supports and services ~ Leading the way to communities of choice. Mission: To inform, educate and network service providers to safeguard, develop, grow and extend their capacity to support the choices of people with disabilities.
• State Budget Instabilities Future Uncertainties • Congress is struggling with multiple life-changing reforms such as health reform, immigration, environmental disasters, and wars • Uncertain political climate – move to social extremes • Health Reform - Medicaid Reform - Managed Care, Exchanges, Expansion, Duals • Changes to Federal Rules - Companion Care, Employment, new HCBS Rule • Less Money: Federal, state, and local deficits • Workforce Issues - DSPs • DOJ Olmstead Enforcement
$56.65 Billion Public Funds Braddock, et.al., Coleman Institute and Dept. of Psychiatry, University of Colorado, 2013. http://stateofthestates.org
Federal Spending on Medicaid and Medicare is Unsustainable
States Can’t Make Up the Difference
Prevalence of Cognitive Disability in US Braddock, et.al., Coleman Institute and Dept. of Psychiatry, University of Colorado, 2013. http://stateofthestates.org
People with disabilities account for the largest share of Medicaid spending Elderly 10% Elderly 25% PWDs 15% Adults 25% PWDs 43% Adults 13% Children 49% Children 20% Enrollees Expenditures on benefits FY 2008 Total = $318 billion Total = 59.5 million SOURCE: KCMU and Urban Institute estimates based on data from FY 2008 MSIS and CMS-64, 2011.
HCBS Waiver Waitlists
Workforce is Shrinking 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, 2006
DSP Wages are Below Federal Poverty Level
Most People Are Supported in <6 Person Settings Braddock, et.al., Coleman Institute and Dept. of Psychiatry, University of Colorado, 2013. http://stateofthestates.org
More People with I/DD Live with Family Caregivers than in our Publicly Funded System
Why Would States Look at Managed Care? • Allows State officials achieve budget stability over time through capitation • Limits states’ financial risk, passing part or all of it on to contractors by paying a single, fixed fee per enrollee • Allows one entity to be held accountable for controlling service use and providing quality care
MLTSS DEFINITION • Managed Long Term Services and Supports (MLTSS) refers to an arrangement between State Medicaid programs and contractors through which the contractors receive capitated payments for LTSS and are accountable for quality, cost and other standards set in the contracts • Capitation can be for all services or selected services • Contractors can be local, regional or national • LTSS populations include persons with age-related, physical or intellectual/developmental disabilities. Many of these also have serious mental illness.
October 2010 VT WA ME MT ND NH MN MA OR NY WI SD ID MI RI CT WY PA NJ IA NE OH DE IN IL NV MD UT WV VA DC CO KS MO KY CA NC TN OK SC AR AZ NM GA AL MS AK LA TX FL HI MCO only (16 states and DC) Almost all states operate comprehensive PCCM only (12 states) Medicaid managed care programs MCO and PCCM (19 states) No MMC (3 states) SOURCE: KCMU/HMA Survey of Medicaid Managed Care, September 2011.
STATES WITH MLTSS GREW FROM 8 TO 16 Between 2004 TO 2012 Burwell, Brian, and Jessica Kasten. Transitioning Long Term Services and Supports Providers Into Managed Care Programs . May 2013; Truven Health Analytics, Print. Prepared for the Centers for Medicare & Medicaid Services (CMS), Disabled and Elderly Health Programs Group.
19 STATES HAVE MLTSS PROGRAMS in 2014 10 States are Projected to Move to MLTSS in the Next Year Burwell, Brian, and Jessica Kasten. Transitioning Long Term Services and Supports Providers Into Managed Care Programs . May 2013; Truven Health Analytics, Print. Prepared for the Centers for Medicare & Medicaid Services (CMS), Disabled and Elderly Health Programs Group.
States Including IDD Populations in 2012 Burwell, Brian, and Jessica Kasten. Transitioning Long Term Services and Supports Providers Into Managed Care Programs . May 2013; Truven Health Analytics, Print. Prepared for the Centers for Medicare & Medicaid Services (CMS), Disabled and Elderly Health Programs Group.
Early States with Strong MLTSS for Individuals with IDD • Arizona since late 1980s ALTCS 1115 • Michigan since 1998 – 1915 b & c with network of pre-paid capitated MCOs with strong values and person centered planning in regulations • Wisconsin since 1999 – 1915 b & c Family Care for LTSS only with self directed option
Eight States Include People with IDD • Arizona Seven in all HCBS and ICF settings Delaware does not enroll people • Hawaii already in IDD HCBS Settings • Indiana Hawaii and Washington don’t • Michigan include HCBS/ICF but provide all • North Carolina other services in MLTSS Settings • Pennsylvania Pennsylvania is for now • Washington only adults with autism • Wisconsin • Delaware Burwell, Brian, and Jessica Kasten. Transitioning Long Term Services and Supports Providers Into Managed Care Programs . May 2013; Truven Health Analytics, Print. Prepared for the Centers for Medicare & Medicaid Services (CMS), Disabled and Elderly Health Programs Group.
New States Emerging Since 2012 • Florida • Illinois has submitted an MTLSS 1115 that • Illinois will include all populations • Kansas • New Hampshire includes IDD in 2014 • Louisiana • KanCare Implemented in 2013. Includes • New Hampshire IDD in 2014. CMS approved a waiver that • New Jersey ultimately continues an IDD waiting list • New Jersey implements MLTSS 1115 • New York waiver • Ohio • New York DISCOs • Tennessee • Tennessee promotes IDD in 2014 • Texas • Texas passed legislation 2014 • Virginia Burwell, Brian, and Jessica Kasten. Transitioning Long Term Services and Supports Providers Into Managed Care Programs . May 2013; Truven Health Analytics, Print. Prepared for the Centers for Medicare & Medicaid Services (CMS), Disabled and Elderly Health Programs Group.
States with Self-Direction in MLTSS Burwell, Brian, and Jessica Kasten. Transitioning Long Term Services and Supports Providers Into Managed Care Programs . May 2013; Truven Health Analytics, Print. Prepared for the Centers for Medicare & Medicaid Services (CMS), Disabled and Elderly Health Programs Group.
MLTSS examples include a diverse range of program models LTSS without Acute: Acute Care Arizona Long Term Care Pennsylvania Adult Community OR Services System Autism Program Behavioral LTSS without Behavioral Health: LTSS with Behavioral Health: Health New Mexico Coordinated Long Term OR TennCare CHOICES Services Services Medicaid- and Medicare- Medicare Medicaid-funded Services Only: funded Services: OR Services New York Managed Long Term Care Minnesota Senior Health Options Older Adults with Institutional Adults of All Ages and Levels of Level of Care Needs Only: Populations Care: OR Florida Nursing Home Hawaii QUEST Expanded Access Diversio n Local Contractors: National Contractors: Contractors OR Wisconsin Family Care Texas Star+Plu s Partnership Payment Full-Risk Capitation: Partial-Risk Capitation: OR Methods Massachusetts Senior Care Options Wisconsin Family Care
Non-Clinical Outcomes of LTSS • Just now emerging • Different from medical managed care programs • No current consensus • No actuarial data
States Must Identify Non-Clinical Outcomes in Contracts • Advocate for state to hold managed LTSS entities accountable to achieve certain outcomes. • Insist on state incentivizing achievement of outcomes by managed LTSS entities/providers. • Ensure that outcomes are meaningful to people with disabilities and measureable.
Possible Outcomes To Consider • Percentage of Participants with jobs • Number of hours Participants are engaged in volunteer work • Participants’ independence and social skills • Satisfaction and quality of life indicators • Stable housing • Transportation available when desired • Free from abuse and neglect
A Word about Employment Butterworth, John, Frank A. Smith, Allison Cohen Hall, Alberto Migliore, Jean Winsor, Daria Domin, and Jamie Cuilla Timmons. "StateData: The National Report on Employment Services and Outcomes." Www.statedata.info . Institute for Community Inclusion, Winter 2012.
Two State Scenarios • Kansas • New Jersey
Kansas Experience • January 2012 – All Medicaid Services to be put under Managed Care • February 2014 – IDD included
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