Managed Care For People With Disabilities

1
Managed Care For People With Disabilities

• John G. Folkemer
• Maryland Department of
• Health and Mental Hygiene
• June 5, 2007

2
Maryland Managed Care Landscape

• Implemented HealthChoice in 1997
• Phase I of mandatory managed care initiative
• 7 participating MCOs
• Covers approximately 80 of Marylands Medicaid
  population
• Pregnant women, children, parents, and
  individuals with disabilities who are below age
  65 and not dually eligible
• Certain services are provided on a FFS basis
• Mental health, certain rehabilitation services
  (OT, PT, Audiology, and Speech Therapy), school
  health related services, medical day care,
  personal care, nursing home (after 30 day stay),
  and home and community-based waiver services

3
HealthChoice Continues to Improve Access
Percentage of SSI Enrollees Receiving an
Ambulatory Service (320 Days of Enrollment)
4
A Small of Enrollees Consume A Significant
Portion of Expenses (Most Still in FFS)
The elderly and disabled account for 23 percent
of enrollees, but 67 percent of Medicaid expenses
Excludes data for individuals with partial
benefits. Data as of January 2007
5
Current Long Term Care System

• Fundamental problems in Medicaid
• Little coordination between acute and long-term
  care services
• No coordination with Medicare
• No accountability for improving quality
• No systemic incentives for cost efficiency
• Not sufficient flexibility to provide services
  that best meet the needs of consumers
• People cant always get the right services in the
  right setting
• System is fragmented, not consumer-friendly

6
CommunityChoice Goals (Based on 2004 Legislation
-- SB 819)

• Develop alternatives to institutional care
• Coordinate acute and long term care services and
  financing with Medicare
• Control growth of long term care costs
• Flexibility to provide services specific to the
  needs of the client (e.g. assisted living, home
  modifications)
• Accountability for outcomes and quality of care
• Develop consumer-directed options

7
Why Risk-Based Managed Care for Persons with
Disabilities?

• More stable Medicaid enrollment
• High benefit from case management and disease
  management programs
• High prevalence of chronic conditions
• Multiple providers
• Create financial incentives to provide additional
  services, particularly community-based services

8
CommunityChoice Populations

• All adult dual eligibles (Medicare Medicaid)
• All adult Medicaid recipients who qualify for
  nursing home level of care
• All other Medicaid recipients age 65
• Includes
• All nursing facility residents
• Participants from two 1915(c) waivers
• Living at Home
• Older Adults Waiver
• About 74,000 individuals statewide

9
CommunityChoice Services

• All Medicaid benefits, including
• Primary and acute care
• Pharmacy
• Mental Health
• Long term care

10
Stakeholder Involvement

• Listening sessions (approximately 14)
• Regional public hearings (5)
• CommunityChoice Advisory Committee (held regular
  meetings)
• Six Subcommittee Workgroups (held regular
  meetings)
• Access
• Quality
• Finance
• Care coordination
• Role of state and local governments
• MCO qualifications
• Hired consultants to gather input on consumer
  direction and overall issues with managed care (4
  additional listening sessions)

11
SB 819 Limitations

• Service Carve-outs
• Specialty mental health
• Hospice
• Service Area
• Operate in two areas
• Payment Requirements
• Nursing homes and medical day care providers
  could not receive less than the Medicaid rate

12
New Secretary Reevaluates LTC

• CMS denied Marylands 1115 waiver application
• Consumers and providers continued to question
  design of CommunityChoice
• Opportune time to re-evaluate Marylands strategy
  to reforming long-term care services