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DisAbility Rights Idaho’s Comments on Idaho Proposal to Contract with a Managed Care Organization (MCO) for Medicaid Services for People Who are Eligible for Both Medicaid and Medicare.
Introduction:
The Idaho Department of Health and Welfare (IDHW) has requested public comment on their proposal to contract with a Managed Care Organization (MCO) to provide Medicaid services to people who are eligible for both Medicaid and Medicare (Dual Eligible). This contract is intended to cover not only the types of medical services typically handled by health insurance companies, but also mental health services including psychiatric rehabilitation services, home and community based, long term care services and developmental disability related community supports. There are important differences between traditional medical treatment services and these community based support services which require careful and cautious planning and implementation. Although there are examples of MCO contracts covering some of these services in other states, we have not found any examples of states with a significant history of using a single MCO contract to provide all of these services statewide. This proposal appears to be without precedent.
The degree of uncertainty and the potential for large scale unpredictable changes in Idaho Medicaid in the next three years is enormous.
  1. Idaho is currently preparing a Request for Proposals (RFP) for an MCO contract for Medicaid mental health services.
  2. That contract is expected to be expanded to include substance abuse services after about a year of implementation.
  3. Sometime this summer, the U.S. Supreme Court is expected to rule on the constitutionality of the Affordable Care Act.
  4. In 2014, if the Act is upheld or partially upheld, a large number of people with severe and persistent mental illness (SPMI) will become eligible for Medicaid. Most of them will also be eligible for Medicare.
  5. Implementation of the Children’s Developmental Disability Redesign and changes in the Adult Developmental Disability including changing authority to §1915(i) are in process.
If the Mental Health MCO is different from the Dual Eligible MCO, there will be overlap or conflict between the populations served. Since the Mental Health MCO will already be in place by the time the Dual Eligible MCO is initiated we should expect to see large shifts of participants and costs into and between these two contracts as each of the events described above occurs. These shifts will cause confusion, and disruptions which are generally not beneficial to the participants or anyone else involved in the process. Even if the same MCO wins both contracts, the differences in terms and “per member per month” (PMPM) rates between the two contracts will cause problems. It may be unreasonable to expect any system to absorb all of these separate but interconnected changes in such a short period of time. Coordination of all of these change processes may simply overwhelm a newly created system which has no history or precedent.
Incentives to Provide Effective Preventive and Supportive Mental Health Services
It is imperative that the financial incentives built into the system reward high quality care and effective preventative practices. It has been demonstrated that it is possible to save money by employing effective preventive and support services for several chronic conditions such as asthma and diabetes. There is evidence that bundling traditional physical health with mental health treatment can reduce the cost of traditional medical care and reduce psychiatric hospitalization. However, these demonstrations placed the burden for the cost of psychiatric hospitalization on the MCO.
1.    If the cost of hospitalization is borne by the state, the MCO has an incentive to place people in state hospitals and to delay their return to the community as long as possible. Unless the full cost of hospitalization in state hospitals is somehow charged to the MCO, there is no incentive to prevent hospitalization or to have robust mental health supports to prevent recidivism.
2.    The system should also provide incentives for preventing people with SMI from entering the criminal justice system or jails, or committing suicide. All of these events can actually lead to cost shifting or cost savings for the MCO unless the payment system provides disincentives for these events.
DD Services and Supports
The PMPM method does not by itself provide incentives for effective DD supports services or treatment. The goal of these supports is to increase the capacity of the person for self determination, independence and community integration. The success of such services is not measured by their physical health status or need for more expensive medical treatment. Short of institutional placement, there is no consequence to the MCO for providing inadequate or ineffective services and supports. Placement in a state facility like SWITC would even be a net savings to the MCO and for certain individuals ICF/ID placement could be a savings over a robust and effective community supports plan. To be effective, there must be a strong incentive to provide effective developmental services and supports. This can only be accomplished with a robust and accurate quality assurance system and well designed incentives to meet the expectations of that system. We are not aware of any examples of such a system. Traditional health insurance plans do not have expertise or experience with these services.
1.    The MCO should be required to contract with a highly qualified, independent entity to evaluate the quality and effectiveness of DD supports and services.
2.    IDHW should consider carving out DD supports and services from the plan or preserving them as a fee for service system. With a robust system of quality assurance and care management practices.
Enrollment:
1.    Require that consumers have at least 90 days to make a choice among plan providers.
2.    Require plans to contract with community-based organizations such as Independent Living Centers, and others.
3.    Include programs for people with mental illness, to educate potential enrollees about their options and to assist them in selecting delivery systems that best serve their individual needs.
4.      Allow enrollees to change plans at any time, without imposing a lock-in period.
Provider Networks:
Many dual eligibles have longstanding, beneficial relationships with providers that might not be in the existing network of a health plan or delivery system that participates in the program. To maintain continuity of care and respect these relationships, participating plans should:
1.    Maintain an open network provider system in order to contract with providers that are not currently in the network.
2.    Offer single case agreements that allow participants to continue seeing their current provider without arbitrary limits on the duration of the relationship.
3.      Require that all providers are trained on independent living and mental health recovery approaches.
Long Term Services and Supports (LTSS):
The goal of LTSS for dual eligibles should be to promote their independence, choice,
dignity, autonomy and privacy. LTSS must emphasize community and home-based services over institutional care in compliance with the Olmstead v. L.C. and E. W.  decision.
1.    LTSS services and should be based on conflict of interest free comprehensive evaluations which include an evaluation of functional status, social and vocational needs, socioeconomic factors, personal preferences, and the ability to obtain accessible services.
2.    Require plans to maintain current levels of LTSS until a comprehensive assessment is conducted.
3.    Contract with LTSS providers who have the capacity and expertise to meet member needs.
4.    Have the beneficiary play the central role in the LTSS assessment and in the development of an LTSS plan.
5.    Support family care giving through designation of family members as paid aides when consumers request this, as well as through respite services.
6.    Provide personal care assistant services, including an option for self-directed services.
7.    Ensure that people with developmental disabilities (DD) have the opportunity to participate in the My Voice, My Choice HCBS Waiver option.
8.    Ensure that people with both a developmental disability and a mental illness have coordinated LTSS from providers with expertise in supporting both conditions.
Care Coordination:
Most health insurance companies have no experience with community based services for people with SMI or DD.  Typical health plan care coordination generally consists of having a nurse call the member occasionally on the phone. Case Management and Service Coordination services for people with SMI or DD must be much more “hands on”. It must include regular face to face meetings and intervention or advocacy on behalf of the member with other providers and community contacts such as landlords or the courts. Traditional health plan care coordination must not replace these vital support services. Plans must be required to contract with qualified and experienced DD service coordinators and SMI case managers, and whenever possible to continue with the member’s current services.
The care coordination team must include a LTSS provider or coordinator (could be the case manager or the TSC) who is responsible for maintaining the LTSS. Few PCPs are able or willing to perform this function.
LTSS care coordinators will often be needed for people receiving home care LTSS as well.
Crisis Services:
People who require LTSS for physical disability, DD, or SMI are at risk for crises in their lives and in their care needs. Plans will need to be able to quickly approve and provide additional services to deal with a crisis caused by a change in the person’s physical or mental health status, the imminent loss of living arrangements, unpaid supports, or other catastrophic events.  The ability of the system to respond to unexpected crises in the community without resorting to institutional placement should be a key requirement of the plan.  The plan should also be well coordinated with non-Medicaid crisis services and be able to access them when needed.
Compliance with Olmstead v. L.C. and E.W. and Best Practices for community based services.
The MCO must be in full compliance with the community integration mandate of the Americans with Disabilities Act (ADA) and the Supreme Court decision in Olmstead v. L.C. and E.W. Although the ADA has lesser implications for private health insurers, the Medicaid program must comply with Title II of the Act and the community integration mandate. This will require the contractor to make community services available in cases where institutional placement would be less expensive. It also requires services to help prevent hospitalization for people with mental illness.
1.    There must be incentives and requirements in the plan to provide for recovery oriented, person centered plans of service.
2.    The plan must allow for self directed services in all areas of long term services and supports including mental health.
3.    DD services should emphasize self determination, community integration, employment opportunities and training for eligible individuals.
The proposal for a single MCO contract for all Medicaid services for all people with dual eligibility is unprecedented and moves Idaho into uncharted territory in LTSS models. IDHW should be extremely cautious and move slowly and deliberately toward this project. Planning to implement it in the current time frame with such an array of both known and unknown variables (e.g. the Mental Health MCO contract, the implementation of the ACA, the pending decision in the Supreme Court on the constitutionality of the ACA, the efforts to redesign DD services, several pending federal lawsuits) may be too ambitious and ill advised.
If Idaho does proceed at the proposed pace, there are serious issues to be addressed in the areas of DD services, mental health services and other LTSS.
Submitted by
James R. Baugh
Executive Director, DisAbility Rights Idaho.

3 thoughts on “Idaho Medicaid Managed Care Proposal

  1. IdaGirl

    As an agency in the Treasure Valley that provides comprehensive, in-depth care management to adults and children with mental health (and developmental) diagnoses, we are also apprehensive about Idaho's plan for managed care. Our team of 17 coordinators (all with BA's in social sciences, and a combination of MSW's, licensed counselors and Master's level degrees) meet face to face, at least monthly, with our SPMI clients. We love that we can be objective (we don't provide any other services) and can help to identify needs and/or duplications of services. I believe that what we do is both helpful and cost-effective. Often, when our clients are experiencing crises, we are able to step in and link them to unique resources, thereby preventing hospitalization, psychiatric relapse, loss of housing or other major stabilizers. We collaborate with psychiatric hospitals to assist with "discharge plans." Some of our clients have legal concerns and are "repeat offenders." Recently, I met with an SPMI woman recently released from prison. She had been out for two months. I was dismayed to discover that, despite her probation officer's involvement in her life, there had been no mental health provisions. She was severely mentally ill and diagnosed in prison as having Autism. She had no idea how to apply for Medicaid - and was not on any medications since leaving the prison because she couldn't afford them. The probation officer's primary concern was that she find a job. We also work closely with our children who have special needs in the schools. We help to ensure that all services are met, according to the 504 plan or IEP. We provide valuable documentation that may be the tipping point of whether a student qualifies for an IEP. We make referrals, if needed and/or requested by the school team. At times, we assist Idaho's Department of Health & Welfare. I have attended DHW family meetings where we were the primary source of information and hope for the struggling family. Several prominent physicians refer clients to us, when they are concerned about the family and don't know what the next step is. Because care management is ALL that we do, we unturn every stone to find that unique resource (as the State's resources are dwindling). I am not against managed care, per se, but it is hard to believe that a system based on budgets and financial bottom lines would work diligently, in the best efforts of their clients, to ensure quality and needed services. Heidi Knittel, M.A., unBefuddled, LLC

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  2. Jim Baugh

    In order for any system to produce the desired outcomes, the system must be designed with the proper incentives. Incentives for effective services can be developed if we have some consensus on: what the desired outcomes are, how can we detect and record the outcomes, and how will we reward the systems and providers who contribute to these outcomes. I fear that no one has done any of these things very thoroughly for either mental health or developmental disability services. Unfortunately, Managed care contracts are rushing ahead as if these services were just like medical management of diabetes or asthma. They are not.

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