On September 22, 2014, the MLTSS Advisory Group met to discuss the state’s concept paper outlining their managed care program for state services provided to individuals with intellectual and developmental disabilities. The following is the text of my letter to Louisiana Department of Health and Hospitals with my comments on the concept paper and questions that arose after the presentations from that meeting.
September 30, 2014
Please accept this letter as commentary on the recently-released Concept Paper issued on September 22, 2014 for OCDD and other Medicaid services under MLTSS for individuals with intellectual and developmental disabilities (I/DDs).
My overarching comment for this paper and other materials around MLTSS is that all entities involved in the MLTSS process must bear in mind the complexity of the topic and significant stakes involved, along with individual and family need for simple, clear and concise information. Clear information prevents misinterpretation and miscommunication.
The following are my commentary on specifics of the Concept Paper draft and questions.
1. The current draft contains headings that do not describe the content in the section that immediately follows. It may be useful to use the topics we discussed in MLTSS Advisory Group as the headings and add others such as Medicaid/Medicare dually eligible individuals, Superwaivers, Comprehensive Flexible Supports, Program Oversight. Using these topics as categories will clarify specifics and provide continuity with other concept papers previously issued and discussed by the MLTSS Advisory Group.
2. Of the 8 or 9 pages of text, about 4 pages are devoted to behavioral health and early intervention programs, but there is little discussion about other items such as LTSS. While Behavioral Health and Early Intervention are important and do require their place in the paper, there is no clear picture of the concept the state has for other services.
3. The section entitled “Medicare/Medicaid Dual Eligibles” does not mention or address the needs of individuals who are dually-eligible. It does not discuss the population and unique challenges in serving them or how the state plans to address these hurdles.
4. Care coordination should more clearly be described. It is mentioned in various places and the current system is described, but there is no clear picture of the state’s concept of care coordination. The flexibility in care coordination should be described in more detail.
5. Under the section entitled “Demonstration as the Solution,” the 2-phase approach is introduced but the section only describes Phase 1. Phase 2 is not addressed until the section “Medicare/Medicaid Dual Eligibles.”
6. My understanding is that Early Steps will be handled in an administrative capacity (i.e., no risk/no capitation) in both Year 1 and Year 2. The paper does not indicate this, but needs to do so if my understanding is correct.
7. Hospital Sitters should definitely be required when the hospital facility needs/requires someone to assist with communication due to the person’s disability.
8. Under “MLTSS for I/DD: Goals of Redesign,” please clarify “enhance the effectiveness of family caregivers.”
9. Under “MLTSS for I/DD: Goals of Redesign,” please define “flexible authority” and “variety of support models.”
10. The Ombudsman Program should be presented and described in such a way as to communicate the state’s level of intent and commitment to this program beyond Year 1.
11. The paper does not indicate that a readiness assessment will be done. It is my understanding from the MTLSS Advisory Group meeting on 9-22-2014 that there will be a comprehensive readiness assessment that will include assessment of State, MCO and provider readiness before the system goes live. This needs to be included in the paper along with specifics about what will be assessed.
12. While CMS may consider an MCO sub-contracted provider a conflict-free entity to conduct needs assessments for individuals in the program, it is my concern that there will be behind-the-scenes influences by the MCO as the contractor of the assessing agency. Truly conflict-free assessment should be discussed and more deeply considered. Contracting separately with Human Service Authorities and Districts to do needs assessments should be considered before this is included in an MCO contract.
13. Page 5, Column 1, Item 6 states “address transition planning from acute medical and behavioral health settings from the point of admission.” Addressing transition from the point of admission is important for reduction in re-admissions and ensuring that individuals do not linger in mental health or hospital settings. That said, Transition should be discussed within the content of appropriate care based on the needs of the individual and the ability of the family/natural supports in the community to continue supporting them once they are released. Otherwise, the implication to families is that they would receive a “fast-food, drive through” approach to care. This is important and an issue now in behavioral health in Louisiana. Families currently have trouble accessing residential treatment and in-patient settings are not working on long-term underlying problems that need therapeutic resolution. Instead they focus on medication management stays of 3-5 days. The problem is, when individuals return to the community, there are long waits for therapeutic appointments and appropriate therapy services are not available or easy to find (i.e., specialized trauma therapy services for a child with violence and anger issues). The state’s concept of transition planning from date of admission needs further elaboration.
14. Consumer education is not really addressed in the paper, yet this is a population that will need extensive support and information. They need materials written for lower reading levels and detailed, meaningful information written for family caretakers of individuals with severe and complex medical issues. Bayou Health provided “marketing” materials only (Ex. Info on free gift cards for well-child visits, perks and other benefits). This population will need much more and will need it provided in different ways.
15. Under “Opportunities for Improvements in Efficiency, “ Column 2, the paper states that a potential area for savings through improved coordination and payment systems includes “improved diversion and transitions management as compliments to continued MFP rebalancing efforts.” It provides an example: “thirty seven percent (37%) of acute care costs of current I/DD waiver recipients are in pharmacy.” The phrasing is not easily understood and the example does not clarify the statement.
16. On Page 3 under “Administrative Complexity,” the last sentence in the first paragraph in that section: Are you saying that combining the system will be confusing or the current fragmentation of the systems is confusing? Also, it is a long sentence that is hard to follow and not tied to the care coordination discussion in the paragraph.
1. Will the MCOs use the same standard formulary that the Bayou Health plans are required to develop under their current contract? Will the MCOs develop their own common formulary?
2. Will the contract include provisions to override private insurance as a primary insurance when the private provider requires use of an out-of-state mail-order pharmacy, thus blocking a Medicaid recipient’s access to Medicaid for prescription coverage?
Behavioral Health-Related Questions
3. What are EPSDT Mental Health services?
4. How will “specialized behavioral health services” be available to the 1,100 or so individuals with I/DD in Louisiana Behavioral Health Partnership in Phase 1, when that is when the specialized MLTSS Behavioral Health service array and provider network, resource allocation, development, validation and operational capacity building will be developed? It appears this will not be ready for these or other individuals.
5. Following up on Question 4, how will the MCOs be able to provide behavioral health services to others in the system in Phase 1/Year 1 given the plan development in Phase 1 listed above and when the state acknowledges the lack of understanding by the MCOs of the needs of individuals with I/DDs?
6. Why would we place additional pressure the new behavioral health system in Year 1 by also making those services at-risk/capitation services. The paper itself cites difficulties of the Louisiana Behavioral Health Partnership to provide the necessary services. It is difficult to imagine how MCOs with no I/DD experience would be able to do anything different, especially in a capitated, at-risk environment.
7. The paper states that individuals with I/DD will be transitioned out of residential treatment facilities to “appropriate DD alternatives.”
a. Do you mean individuals with a Statement of Approval for OCDD Services?
b. What about those who are suspected to be eligible, but not yet confirmed to meet OCDD eligibility criteria?
c. What appropriate I/DD alternatives are you referring to?
d. Would people be forced to leave hospitals close to their home, family and supports to go to treatment in far reaches of the state for the sake of the plan, even if their current care is appropriate and working?
e. When would this transition take place? Phase 1? Phase 2?
f. If Phase 1, how will this be handled without endangering individual health given the lack of knowledge of MCOs and the fact that the behavioral health program will be in development at the same time.
Early Intervention-Related Questions
8. Please confirm that early intervention services will be handled in an administrative arrangement (non-risk/capitation) for Phase 1 and Phase 2. If this is correct, please include this in the paper as well.
9. Will there be a rate floor in Year 2/Phase 2 for early intervention providers? If so, please include this in the Paper.
10. How will the state ensure that Congressional intent of early intervention services as an educational program to mitigate costs for school systems is preserved using an educational model given the medical model that MCOs understand and use?
11. Will the MCOs have representation on the IFSP team? If so, how will the state ensure that federally-defined members of the IFSP team are the ones driving the services both directly and behind the scenes?
Questions regarding Concept Paper Wording
12. Under “Medicare/Medicaid Dual Eligibles” what does “implementation of a broader array of specialized LTSS options with joint coordination and care provision” mean
13. Under the same section, what does “implementation of conversion, diversification and repurposing supports” mean?
Transition and Readiness Assessment Questions
14. What will be assessed in the Readiness Assessment Process? Readiness of the MCOs, the providers, AND the state? Training completion only or training and competency? Staff capacity –numbers and training?
15. At what point during Year 1 will the state begin transition? Will it be after the readiness assessment? What if the readiness assessment indicates we are NOT ready? Or not ready in certain areas? Is the state prepared to delay Phase 2 in total or in part, if need be?
16. How will an administratively managed care program in Phase 1 inform through data what a risk-based program would be in Phase 2?
1115 Super Waiver Demonstration Questions
17. It was indicated that data collection would drive the development of the Super Waiver (1115) and services in Phase 2. If data has to be collected and analyzed, how much data from Phase 1/Year 1 does the state really think it will have in order to make decisions for Phase 2, given that transition will begin in Phase 1? 6 months? Less? More?
18. What new services are you contemplating within the 1115 waiver?
19. On Page 8, Column 1, the paper states “In addition to the above, the consolidated 1115 waiver service package will offer LTSS from implementation of Phase 1.” Munderstanding of the 1115 waiver was that it would be implemented in Phase 2? How will the 1115 waiver services package offer services in Phase 1? When during Phase 1? Is this referring to the transition?
20. Will the state include clearly stated criteria for MCOs changing and altering LTSS services and programs after the Super Waiver is implemented? Will MCOs be able to make changes to the program or services?
21. Under the Medicaid/Medicare Dual Eligibles Section, the paper indicates that a “level of need assessment will determine ability to request long-term institutional stay.” Do you mean it will determine whether a long-term institutional stay is appropriate for the person? Or will the assessment instrument itself determine whether a person can request a long-term institutional setting?
22. Will the need assessment take into consideration the length of time a person who is already in an institutional setting has been there, along with their desire to remain there as part of the consideration process of whether an individual may remain in the long-term setting? e., if they have lived in a setting like this for most of their lives, and do not want to leave will this be taken into consideration?
23. Will Medicaid/Medicare dully-eligible individuals be included?
24. How will the program reconcile issues with these 2 federal programs and consolidate care coordination for dually-eligible individuals? And, for those with private insurance in addition to Medicaid and Medicare?
Transparency, Reporting and Accountability Questions
25. Regarding transparency, Will the MCOs provide data that will not otherwise be validated? What will the MCOs be allowed to self-report? How will the state ensure numbers and information reported is correct and accurate?
26. What is the state’s plan for reporting to stakeholders? Will the state include stakeholders further in the process to determine what needs to be reported in order to have a transparent system? Stakeholders must be able to evaluate how MCOs are making decisions.
27. Will requirements exist for cost savings reporting deadlines for the MCOs?
28. Will the state include in the process for moving from Phase 1 to Phase 2, a provision for distribution and dissemination of final reporting data to the public before Phase 2 goes live? If so, will the state secure public comment before changes and beginning of Phase 2? It is of the utmost importance for the state to get feedback from the individuals affected by these changes, especially considering the state’s own acknowledgment thatthere is “relatively little experience nationally in I/DD commercial managed care.” This feedback could be a significant indicator of whether the state is truly ready to move to Phase 2.
29. Will the state require the MCOs to have Advisory Boards that include individuals and family members? Will the MCOs be required to submit the minutes of their Advisory Boards to the State as part of their reporting?
General Questions regarding the Program:
30. If we have truly managed out all the savings we can from HCBS why put those services in a risk-based capitated group in Phase 2? What, if any, are the advantages the state seeks in including them in a risk-based package of services?
31. Same question as #27 regarding Early Steps, if it will be handled in a capitated, risk-based program in Year 2.
32. Will there be a requirement for allowing out-of-network care if the network does not have a provider that can provide the appropriate services, particularly in the case of individuals with complex needs? (Ex. They may have three urologists on the network, but none have experience treating individuals with complex urologic issues due to Spina Bifida.)
33. Will OCDD’s MLTSS system include an electronic verification system for the program? In whole or in part?
In closing, please accept these comments for consideration in the final version of this document. If the questions cannot all be addressed within the context of the Concept Paper, please respond in another form regarding the answers. The answers and the final Concept Paper will ultimately influence the Request for Proposals and subsequent contract for OCDD’s MLTSS program and are vitally important for family understanding as the process moves forward.
With thanks in advance for your consideration and assistance, I am
Karen C. Scallan, CPSP