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Managed Care in LTSS and
Developmental Disability Services:
The Family Perspective Presented by:
Karen Scallan, CPSP
Special Needs & Parent Support Services of LA, LLC
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SNAPSS of LA, LLC
• Special Needs & Parent
Support Services of LA, LLC
• Certified in providing support
and advocacy services to
individuals and families of
individuals with disabilities.
• One of only 2 CPSPs in
Louisiana
• Assisting families in complex
health or benefit issues.
• System Change Advocacy.
• Statewide.
• Karen Scallan, CPSP
• Special Needs & Parent Support
Services of LA, LLC
• Certified Parent Support Provider
• Phone: 504-430-3604
• Email: [email protected]
• Twitter: @KarenScallan
• Facebook: Karen Scallan
• Blog:
http://parentperspectivesonmltss
.wordpress.com
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Objectives
• Provide an understanding of what managed
long-term supports and services (MLTSS)
means.
• Provide an understanding of the opportunities
for advocacy around MLTSS for individuals and
their families.
• Provide a better understanding of the parent
perspective around MLTSS.
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What is LTSS/MLTSS?
• LTSS is Long-Term Supports and Services. It includes nursing home services, home and community based services, institutional care.
• MLTSS is Managed Long-Term Supports and Services applying managed care techniques to LTSS.
• MLTSS umbrella could include other services though!
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Why Manage LTSS? • Cost savings (?)
• Cost predictability for states.
• Improved outcomes (?)
• Meeting increased demand (?)
In LA developmental disability waiver services are lean. Cost savings will come from institutional care (nursing facilities, ICF/DDs) and un-managed medical care.
ICF/DD= Intermediate Care Facility for Individuals with Developmental Disabilities
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• Louisiana issues Request for Information • La Department of Health & Hospitals
(DHH) invited potential MCOs to present.
• DHH started the MLTSS Advisory Group.
• MLTSS Advisory Group met several times and continues to meet.
• Office for Citizens with Developmental Disabilities (OCDD) is making changes to correct current problems in the system before MLTSS is implemented. (System Transformation Workgroup including families).
Louisiana’s Process
MCOs= Managed Care Organizations
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Louisiana’s Process
• Meetings of MLTSS Advisory Group tackled (via sub groups) – Choosing our Partners
– Focusing on Providers
– Rebalancing
– Implementation
– Benefit Design
– Care Coordination
– Enrollment
– Populations
– Accountability
– Consumer Protections
– Measuring Quality and Outcomes
– RFP Development and Procurement
– Stakeholder Engagement and Communication
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Concerns for Families: Managed Care for
Developmental Disability Services
• MCOs are predominantly experienced in
managing medical care;
• Most MCO experience in MLTSS is with
individuals who are elderly;
• MCOs have little to no experience with
individuals with intellectual or
developmental disabilities (I/DD).
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• Louisiana will address this by a
using a 2-Phase approach to build
capacity, knowledge, and abilities
of the MCO to work with
Individuals with intellectual and
developmental disabilities.
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Concerns for Families: Managed Care for
Developmental Disability Services
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• MCOs will have to address quality of life measures, not just quality of health care.
• MCOs must address Employment services for waiver recipients.
• MCOs must preserve of self-determination of individuals and self-direction programs.
Concerns for Families: Managed Care for
Developmental Disability Services
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• Louisiana will include performance
improvement projects in the MLTSS
contract one of which will be an
employment initiative
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Concerns for Families: Managed Care for
Developmental Disability Services
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• Reduction of providers available after “any willing provider” clause expires.
National Association of State Directors of Developmental
Disability Services & HSRI Guidebook on Managed care and
Developmental Disabilities regarding a 1996 program of
managed care for elderly individuals in Minnesota.
“…the task for long-term care providers will be to position themselves
to offer services which can substitute for acute care services and/or
provide the expertise and resources needed to meet the needs of
MCOs as they expand the services covered in their capitations in
response to purchasers such as state and federal governments or
retirement plans."
Concerns for Families: Managed Care for
Developmental Disability Services
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• Louisiana will
– Include an LTSS “Any willing provider”
clause for Yr 1;
– Set rates year 1;
– Set rate floors.
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Concerns for Families: Managed Care for
Developmental Disability Services
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• New managed care practice
of “Network Narrowing”
• Not all because they did not
met health outcomes
• Physicians on high end of the “usual and customary scale” were dropped, despite high outcomes for patients
• What does Network Narrowing mean to those with complex health care needs…
Just because there is a
urologist in the network does
not mean that urologist
understands complex urologic
problems associated with
individuals with Spina Bifida.
Concerns for Families: Managed Care for
Developmental Disability Services
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• Care coordination of significantly
medically involved individuals and
individuals with dual-diagnoses.
• Will care coordination = reduction of
services, denials of care?
Concerns for Families: Managed Care for
Developmental Disability Services
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• Louisiana will
– Include a flexible care coordination
team with an experienced I/DD care
coordinator for LTSS with a secondary
care coordination for acute care and
behavioral health.
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Concerns for Families: Managed Care for
Developmental Disability Services
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Concerns for Families: Managed Care for
Developmental Disability Services
INCLUDING EARLY INTERVENTION in MLTSS:
• Educational model, not medical
• Services provided in natural settings, not clinical
• Funding from US Department of Education
• Congressional intent: to reduce costs to school districts
• Required education components of pre-literacy, school readiness, language, and numeracy.
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• Louisiana will
– Include all early intervention services
in MLTSS
– But not in a capitation rate system
– Included administratively (i.e.,
handling paperwork, but not
managing care
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Concerns for Families: Managed Care for
Developmental Disability Services
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• Elimination of Waiver Waiting lists Discussion MUST include BOTH increase in
funding for HCBS AND RETENTION OF CURRENT
ELIGIBILITY REQUIREMENTS
• Independent Consumer Education
and Meaningful Information Medical limits and other details of plans
• TRUE Person-Centered planning
Concerns for Families: Managed Care for
Developmental Disability Services
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• Language Concerns
– Multiple Language Translation
of ALL materials
– Multiple Translations on web
sites
– Meaningful web sites
– Audio files reading info on
websites
Concerns for Families: Managed Care for
Developmental Disability Services
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• What assessment will be used to determine level of need? Who will conduct the assessment? – LA uses SIS/LA Plus--Probably
won’t be used for long.
– Costing more and more each year
– Push for state-required assessment
– No arbitrary or varying MCO assessments
Concerns for Families: Managed Care for
Developmental Disability Services
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• Louisiana will
– Develop a life-span assessment
– Which will be administered by a third
party, non-risk by the MCO
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Concerns for Families: Managed Care for
Developmental Disability Services
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• Expansion of provider network for current services with inadequate networks.
• Exemptions to requirements for in network providers when continuity of care is essential.
• Care in the least restrictive environment a top priority while preserving choice and self-determination.
Concerns for Families: Managed Care for
Developmental Disability Services
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LA’s MLTSS Advisory Group
Recommendations
• MCOs and State invest in quality
monitoring staff.
• Ombudsman Program in addition to an
External Quality Review contract (EQR)*
• Independent surveys of quality
• Individuals with disabilities and Family
Members as components of MCO advisory
panel and on care coordination teams
• All payments to MCOs tied to quality
measures.
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• Louisiana will
– Include an independent Ombudsman
contract in the MLTSS program
– Provide for independent surveys of
quality by OCDD or an independent
contractor
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LA’s MLTSS Advisory Group
Recommendations
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Ombudsman v. EQRO
Ombudsman
• Independent Contract
• vital to solving urgent issues
• In-the-moment
• Data collection
• Anecdotal stories supporting data
• Can drive system change and advocacy initiatives
EQRO
• External Quality Review
(EQR)
• Required by Medicaid
• Main purpose to conduct “analysis and evaluation of
aggregated info on quality
timelines, and access to
health care services that an
MCO or PHP or their
contractors furnish to
Medicaid recipients.”
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Recommendations by Louisiana’s
MLTSS Advisory Group
• Readiness Assessment – MCO network adequacy
– the state’s ability to support the MCO and providers,
– provider adequacy to meet technology and other requirements.
● Flexible Care Coordination allowing for different care coordination leader, (family, physician, psychologist) and innovation should be sought out for a self-directed care coordination model.
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• Louisiana will include a
comprehensive readiness
assessment of all systems in MLTSS
• Care coordination….not sure yet
what it will exactly look like.
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Recommendations by Louisiana’s
MLTSS Advisory Group
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A lot to take in…
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The Devil Will Be in the
Details.
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MLTSS and Louisiana
Parent Perspective on MLTSS:
http://parentperspectivesonmltss.wordpress.com
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Questions?
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