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 Services
o 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
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*
137,093
72%
53,237
28%
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 InHome
37,228
20%
Not Enrolled in ODP
131,619
69%
Not Receiving
Services
Living with
Families?
Unserved
Emergency
2,436 1%
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
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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)
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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
11,689
$11,581
Ave Cost/Mo.
11,949
$11,213
10,000
$5,021
5,000
1,287
2,085
$1,666
956
0
Group
Homes
Family
Living
Private
ICF/ID
State Center
P/FDS
Waiver
P/FDS
Family Living
Group Homes
Private ICF/ID
State Center
$20,000
$60,252
$138,972
$134,556
$319,092
16
Long Term Implications
Type of
Service
P/FDS
Annual
5 years
10 years
20 years
$30,000
$150,000
$300,000
$600,000
$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
Family Living
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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!
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?
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–
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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
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–
–
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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
Population
• Little experience in
MLTSS or IDD population
• Established relationship
with stakeholders
• Little experience with
Advocacy
• Saving or Incentives
driven back into services
• Profit driven
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?
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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
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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
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
o Create capacity
o Use of specialized teams
31
Status and Future
• Two provider based MCOs
o RCP-SO
o WPHS
• DHS has been meeting with Commercial
MCOs
• State is embarking on MLTSS
• IDD delayed until 2018?
• ???
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