UPDATE ON LOUISIANA’S MANAGED CARE AND LONG-TERM SUPPORTS AND SERVICES INITIATIVE IN LOUISIANA February 28, 2014

This update summarizes what occurred at the Medicaid Managed Care and Long-Term Supports and Services (MLTSS) Advisory Group meeting held on February 6, 2014. This document was prepared by Karen Scallan, member of the MLTSS Advisory Group representing parents of children and youth with developmental disabilities and complex needs.  Questions regarding this information should be directed to Kcscallan@gmail.com.

 HOW TO COMMENT ON MLTSS IN LOUISIANA

YOUR VOICE IS IMPORTANT. THESE CHANGES WILL CHANGE HOW YOU OR YOUR LOVED ONE RECEIVES WAIVER SERVICES.  Learn more and send your comments by visiting the following links:

Find out More, Visit:  http://new.dhh.louisiana.gov/index.cfm/page/1684/n/379

Send Comments to:  dhh.louisiana.gov/index.cfm/page 1684/n/379.

 MEETING SET UP

The Louisiana MLTSS Advisory Group met on February 6, 2014 and the smaller work groups tackled several topics.  You can find the concept papers on each of these topics that were presented to the work groups by visiting:  http://new.dhh.louisiana.gov/index.cfm/page/1684/n/379

Implementation

Providers

Partners

Rebalancing

Here are my notes on the presentation of recommendations when we reconvened in the larger body:

 Implementation work Group

Questions for this group included:  Does the Advisory Group support DHH’s proposal to incorporate readiness assessment into the RFP? What areas of focus does the Group recommend?  What are recommended continuity provisions for implementation transition the group may have? How should transition be defined?  Should transition provisions be global or should there be specific provisions for certain services? Should the same continuity provisions apply across all service types? If not, what are the differences? Are there continuity concerns for individuals moving from Bayou Health or La Behavioral Health Partnership to MLTSS? 

 The group responded that:

The state should incorporate global readiness assessments for both DHH and providers.  The group felt this was very important.  DHH lost a lot of employees and is down from 12,000 to approximately 9,000 employees already.

The group questioned how ready the HCBS provider network is to meet technology demands a new MLTSS system.  Smaller providers are not on board for things like electronic visit verifications due to costs.  This is a huge initiative for them.

The group felt MCOs absolutely need a readiness assessment in the RFP process.  Billing preparedness readiness was also discussed. 

 The group also felt there needs to be:

●Continuity in provisions for implementation and transition

●Defined time frames for provider reimbursement

●Assurances of continuity for the Plans of Care (CPOC).

●One common application for access to all 3 MCOs on the provider side

●The same framework should remain the same

●Regional phase in just like Bayou Health was recommended

●Standardization of reporting was recommended

Group felt it would be easier to implement MLTSS for the elderly populations than individuals with developmental disabilities and they recommended a delayed implementation of 1 year for individuals with developmental disabilities, citing delays in Kansas’s implementation of MLTSS for the same population. The group discussed that the 1 year minimum transition must be in place to be sure there are enough specialists in the network

Everyone in the group agreed to a global transition period, i.e., they felt that all individuals needed a 90-180 day transition period as people sign up.  This may not even be sufficient for some.

The Group’s concerns regarding transition included:

●Consistency of data across all systems.

●IT system on the MCO side would be easy but we have to be sure all information and all plans are transitioned correctly so no work is lost that’s already been done to build the individual’s plan.

●Continuity of care for people with established relationships should be maintained

PROVIDERS WORK GROUP

Questions for this group included:  How might implementation of MLTSS be an opportunity to improve the provider network?  What improvements in provider quality and capacity would you like to see?  How can the state make3 sure providers are sufficiently prepared for transition to MLTSS?  What requirements should be placed on MCOs in this regard? How can the state facilitate smooth transition from FFS to MLTSS re: provider participation? What trainng activities should be provided?

The Group recommended that we need to:

●Ensure adequate timely communication

●Avoid drastic reductions to the managed care network

(citing higher cost specialists might be dropped, but vital)

●Avoiding losing good small providers

●Understand that accreditation may cost too much for smaller providers and cause

            push out

●Be sure that rates are adequate and have a floor

●Ensure there is timely reimbursement (set defined time frame in contract)

●Use existing provider during transition

●Include an any willing provider clause

●Maintain Quality standards

●Provide opportunities for smaller provider “co-ops” to share costs and/or other

            creative ideas

●Use shared savings as incentive

●Have at least the same market as existed in FFS network as a minimum

●To ensure IT system works before implementation

●Make sure IT systems are integrated with state systems

●Make sure there’s backup if system goes down

●Ensure reasonably responsive eligibility determinations

●Routine calls are made to insure there are no additional problems

 

Regarding training for the MCO, the group recommended:

●Care coordination – Should be ongoing & provided by the state and the MCO

●Standardized processes and consistency in reporting

●Training of all IT systems

 

Regarding training for recipients, the Group recommended: 

●All training should be clear

●Use variety of methods to provide recipient training

●Robust FAQ section frequently updated should be used

●Issues of decision makers/guardianship

●Readiness reviews

●Adequate understanding with detailed information (not just brochures, need details.

Each MCO may have different formularies for medications people MUST know

what is covered.)

 

Regarding other training, the Group recommended:       

●Training for MCO/providers on payment schedules

●Training for MCO/providers System training

●Training for MCO/providers and families on complaints and appeals

●Training for MCO/providers and families on Roles and responsibilities

●Training for MCO/providers and families on Robust orientation

●Training for MCO/providers and families on Care coordination

●Training for providers and MCO on Medicare billing

● Training for MCO/providers Laws and regulations applicable, ex. Act 378

 

The Group also recommended the state:

● Refer to AARP on AARP’s process

● Institute a desk review as part of readiness review

● Ensure standardization of forms, quality measures and reporting

● Set benchmarks to measure the network adequacy on an ongoing basis.

 

Partners Work Group

Questions included:  Should the MCOs be required to operate statewide?  What are the pros/cons of a statewide or regional approach?  With issuing 2 RFPs specific to disability populations, how many contracts should be awarded for each RFP?  Setting a range might be helpful.  What important questions should the RFP pose regarding: previous experience with LTSS populations and services; ability to build MLTSS networks; ability to provide proven clinical tools; ability to effectively engage stakeholders, advocates and consumers.  How should the RFP evaluation process address operational experience gaps for MCOs that may otherwise present as viable applicants? What are the considerations in the suggested approach?

The Group recommended:

●Contracts with the MCO should be statewide.  The Group believes there is a challenge around fragmentation. They also emphasized a recognition of entire state and broad cultural competence responsibility.

● There should be three contracts for both Aging and Adult Disabled Populations and Developmentally disabled populations.  They felt one did not provide choice; 5 was too unwieldy.

The Group recommended the RFP should ask about:

● Previous experience

● Medicaid experience

● Medicare experience

● MLTSS w/Medicaid experience

● Ability to build an adequate network

● How will they cover rural, underserved areas

● Need to add competent work force in application

● Experience with approach to self-direction

● Person-centered holistic approach (reality is, it is reimbursement centered)

● Case studies on how they met needs as a provider

● How will they work with the state to enhance network/work toward accreditation

● What tools will they use

● What experience do they have in cultural competence

● What are their recommendations/plans for standardization

● Describe their abilities to engage stakeholders

● Will they use best practice, evidence based practices with transparency and real

            partnership

● Will they use stakeholder information

● Will they share information on quality improvement

● How will they address gaps in service through values based approach

REBALANCING

Questions included:  Do you support the methods of rebalancing presented in the Rebalancing Concept Paper?  (Methods included: designing rate structures which incentivize rebalancing; Continuing to participate in CMS initiatives such as MFP and BIP; Providing financial incentives or assessing financial penalties for plans that fail to meet rebalancing goals. Are there other suggestions you have for encouraging rebalancing?  How should any savings from rebalancing be used?

The Group Recommended:

● 1115 Waiver without 1915© and state plan services

● Blended rate of service

● Rate floors

● Clinical guidelines (not really a DD issue, more elderly)

● HCBS can be more than small ICFDD, this complicates the blended rate

● Olmstead and HCBS guidelines from CMS

● Be sure to continue MFP and rebalancing incentive programs

● HCBS is at a disadvantage because they do not currently do cost reporting so it will be

            difficult for those providers.

● May have additional people become eligible  Where will that money come from?

● If savings are available that should go back into LTSS

● MCO should do everything it can do for HCBS even if there is a disincentive financially

● Sharing of client data

● Differences in MCO especially people going from Bayou Health to MLTSS

 

Subsequent Meeting Dates

Next meeting is June 2014

RFP Release anticipated in Summer 2014

For questions regarding this update contact:

Karen Scallan

kcscallan@gmail.com

What is Managed Care and Why is Everyone Talking About it?

Managed care is a broad term encompassing many strategies used by insurance companies, Medicare and state Medicaid agencies to curb the exploding costs of health care.  These strategies can be used individually or in various combinations with the goal of influencing patterns of use of services, prices charged, shifting costs away from the company or agency, making costs more predictable and putting incentives in place for providers to reduce their costs.

Before any attempts to manage care, all care was “fee-for-service” (FFS).  In other words, any invoice submitted for reimbursement was paid without question.  “Medical necessity” was whatever the doctor ordered.  This left the door open for abuses by some and significant waste in the system which contributed to rising health care costs.  Along came advances in medical technology, emergence of specialty care and other economic factors that all contributed to rising costs, making a bad situation even worse.  Today, states, insurers and consumers are finding themselves unable to meet rising demand and rising costs.

The private insurance marketplace first began responding to these rising costs early on.  They started developing ways to manage the care or really the costs to them for the care we receive.  For example, “pre-authorizations” for expensive procedures and elective surgeries and rating “usual and customary” cost of similar procedures in the community and denying claims over that cost are managed care techniques.  Employers also saw their costs of providing health insurance rise.  These private employers, who regularly negotiated for other goods and services needed for their businesses, began negotiating deals for lower costs of insuring their employees. 

State Medicaid agencies and Medicare began using managed care methods after seeing results in the private sector.  Some techniques initially used were setting lower rates for hospital reimbursement in addition to prior authorizations and conducting more and more reviews of how care was being used. 

Managed care was born out of the uncontrollably rising costs of healthcare.  But while these methods of cost containment still exist, alone they have not been enough to control the wildly increasing cost of care in the United States.  So, in the private sector, HMOs or “Health Management Organizations” were born.  When HMOs were introduced they ushered in new, additional methods of cost cutting such as “capitated” payments for care, “care management” and “service substitution.”

Capitated payments simply are a flat payment for a group of services or all services provided for a group of people.  In the case of Medicaid for example, the state may contract with a “Managed Care Organization” (MCO) to pay a capitated rate of $15/month per person to provide all the services enrollees may or may not need.  If the MCO can provide all the services for $12/month per person, then the $3 is profit.  If it costs $17, then the MCO assumes the loss of $2. If no services are needed, the MCO is still paid the $15 per month for that person, helping the MCO balance the risk.  The cost to the MCO is the “risk” the MCO assumes and “risk management” is key to the success of an MCO and driving down costs.

“Care management” came about to help screen and direct patients through the primary care physicians (PCP) who acted as care managers—a sort of gatekeeper.  Primary Care Physicians would approve a service before the patient moves to the next step of care through a specialist or receives a test.  The success of care management for the individual relies significantly on the knowledge base of the individual(s) providing the care management and their ability to determine the medical necessity of the requested service.  Today, care management can include individuals at the insurance company that have to approve services before they are provided, as well as help you navigate systems to get the services you need.

“Substitution practices” were instituted through care management when the care manager could determine a less costly method may be available to provide the same care.  For example, a patient may be directed to use outpatient services rather than inpatient hospitalization for a procedure.

Today, we also see additional “Utilization Management” methods such as “concurrent/recurrent review” where a treatment plan may be approved for 2 months but subject to review for progress before additional treatment is approved.  Concurrent/recurrent review is used a lot in the case of mental health care services.  “Benefit limits,” another utilization management method specifies limitations on a service, for example, limits to child birth hospital stays to 1 day unless there are complications.  “Peer/Practice Reviews” may be conducted by a hospital to internally review all costs for waste, or by insurers to identify practitioners who are not charging usual and customary charges.  Another way to cut costs is by studying health outcomes in various groups of individuals, looking for ineffective practices or practices that promote overuse of health care services. This is called “Retrospective Analysis.”

As these methods became more and more frequently used, insurance companies began offering “products” which packaged together several managed care practices to keep costs down.  From there, Managed Care Organizations began cropping up to help meet the demand for cost control and managed care continued to evolve.  Organizations began offering “Administrative Service” (“Administrative Service Organization or ASO) packages as a way for state Medicaid agencies to reduce costs.  The ASO has no risk but handles enrollment, claims processing and administrative functions and in some cases utilization management for a flat fee, reducing costs of hiring and maintaining staff to conduct program administration.

More recently, methods of managed care have included “Channeling” people to use only in-plan providers which can lead to vulnerability in-plan care is a lower quality of care (less choice).  “Supplier Network Control” is another method where MCOs have their own provider staff or buy out whole hospitals. “Bundling” is used to group all services under one payment.  For example, hospital admissions might be reimbursed at a flat rate per day to include all services while hospitalized, nursing, medications, the room, etc.  And even more recently “Health Promotion.”  Health promotion came about as a response to the complaints that so much of our health care costs go to responsive care and do not support the overall wellness of the individual or “preventative care” which saves money in the long run.  Paying for flu shots is less costly than paying for hospitalizations of large numbers of people with complications due to the flu.

Utilization Management and Managed Care can help stem the rising tide of health care costs. We need to reduce costs, but we must be careful because as we saw in the early days of HMOs, health of the individual could be sacrificed in the name of “savings” by arbitrary rule following without consideration of the needs of the individual or appropriateness of the care that is being denied.

Most experts agree that the economics of the health care services market are still rapidly fluctuating and very reactive to new technological innovations and newly implemented requirements.  The newest response may be a trend of “network narrowing.” (See my blog MLTSS and Network Narrowing:  A New and Concerning Trend? https://parentperspectivesonmltss.wordpress.com/)  Network narrowing simply means weeding out providers that don’t have the needed healthy outcomes in their patients as is now required, or who charge fees at the higher end of “usual and customary scale,” whether they have good outcomes or not.   In other words, narrowing the networks to the least costly and fewest number of providers they can have and still maintain that there is “access” to all needed services.  This is especially concerning to for those of us with family members with complex and multiple special health care needs who may need that higher priced specialist due to extreme and unusual circumstances.

There isn’t any one method that’s the managed care “ticket,” in other words, the one that’s going to reduce costs to the point where we can get the appropriate care we need, at a reasonable and manageable cost.  Probably some combinations would produce the most results.   But because costs are ever rising and the market (insurance companies, managed care organizations, self-insured employers, state Medicaid agencies, and Medicare) are continually looking for new ways to meet the demand, I think we will be seeing new trends for quite some time…a disturbing thought requiring the diligence and attention of any one with a family member with special health care needs.

HOW TO COMMENT ON MLTSS IN LOUISIANA

YOUR VOICE IS IMPORTANT. THESE CHANGES WILL CHANGE HOW YOU OR YOUR LOVED ONE RECEIVES WAIVER SERVICES.  Learn more and send your comments by visiting the following links:

Find out More, Visit:  http://new.dhh.louisiana.gov/index.cfm/page/1684/n/379

Send Comments to:  dhh.louisiana.gov/index.cfm/page 1684/n/379.

 For questions regarding this blog, contact:

Karen Scallan, kcscallan@gmail.com