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  1. 1. Department of Health Services Managed Long-Term Care in Wisconsin Presented by: Kathleen Luedtke Planning & Analysis Administrator Division of Long-Term Care
  2. 3. Population Snapshot <ul><li>Estimated population in 2010 5,772,370 </li></ul><ul><li>Population increase between 2025 and 2035 25.2% </li></ul><ul><li>Change for people over 65 130% </li></ul><ul><li>Change for people over 85 185% </li></ul><ul><li>2000 Census 16% self-identified </li></ul><ul><li>as having a disability </li></ul>
  3. 5. Philosophy of Family Care <ul><li>Access, Choice, Quality and Cost-Effectiveness and the right service, in the right amount, at the right time </li></ul><ul><li>Person-centered </li></ul><ul><li>Outcomes-driven </li></ul>
  4. 6. Highest Level Program Elements <ul><li>Aging and Disability Resource Centers (ADRCs) </li></ul><ul><li>Family Care (partially integrated with health care) </li></ul><ul><li>Family Care Partnership (fully integrated with health care) </li></ul>
  5. 7. Family Care benefit includes all Medicaid long-term care services
  6. 8. Family Care Partnership benefit includes all Medicaid primary and acute and LTC services and Medicare primary, acute, prescription and LTC benefits
  7. 9. Aging and Disability Resource Centers <ul><li>Outreach and Marketing (Where are we?) </li></ul><ul><li>Prevention Activities (Staying as healthy as you can) </li></ul><ul><li>Information and Assistance (Help that is available) </li></ul><ul><li>LTC Options Counseling (Making the best choices) </li></ul><ul><li>Elderly and Disability Benefit Counseling (Applying for or keeping your public benefits) </li></ul><ul><li>Short-Term Care Management (Help now ) </li></ul><ul><li>Emergency Referral (Medical or other emergencies) </li></ul><ul><li>Functional Eligibility (What do I need?) </li></ul><ul><li>Financial Eligibility (Finding out of you can get Medicaid) </li></ul><ul><li>APS/Elder Abuse Prevention (Immediate help if you or others are in danger or are vulnerable) </li></ul>
  8. 10. Program Services <ul><li>Adaptive aids, communication aids, medical supplies, home modifications </li></ul><ul><li>Home health, therapies, nursing, personal care, supportive home care </li></ul><ul><li>Residential services, nursing home care </li></ul><ul><li>Transportation, daily living skills training, supportive employment </li></ul><ul><li>Nutrition Services, including home delivered meals </li></ul><ul><li>Emergency response system services </li></ul><ul><li>Respite care, adult day care, day services </li></ul><ul><li>Case management </li></ul>
  9. 11. Self Direction in Wisconsin <ul><ul><li>Self-direction of services within Family Care or Family Care Partnership care plan </li></ul></ul><ul><ul><ul><ul><li>Select which services you wish to direct, but continue to have support of care team </li></ul></ul></ul></ul><ul><ul><li>July 1, 2008, IRIS waiver became available in counties with Family Care </li></ul></ul>
  10. 12. Managed Care Organizations <ul><li>To support elders and people with disabilities to get the care and results they want in a way that manages money wisely </li></ul><ul><li>Risk-based, managed care business model with reimbursement based on actuarially sound rates </li></ul><ul><li>Public agencies or districts, private organizations, profit or not </li></ul><ul><li>Directly provide service or contract for service </li></ul>
  11. 13. Interdisciplinary Care Teams <ul><li>Help consumers determine the outcomes they want </li></ul><ul><li>Include consumers in decision-making and creating a plan for services that is focused around the member, not the bureaucracy </li></ul><ul><li>Provide services to the consumer, either with staff from the MCO or staff the MCO hires to help the consumer </li></ul><ul><li>Coordinate with other services the consumer needs, like medical care or hospitalization </li></ul><ul><li>Assure that quality services are provided </li></ul>
  12. 14. Interdisciplinary Care Teams <ul><li>Member and member’s family </li></ul><ul><li>Social worker 1-40 ratio </li></ul><ul><li>RN 1-60 ratio </li></ul><ul><li>NP 1-60 ratio in Family Care Partnership </li></ul><ul><li>Disability or health-related specialists as needed </li></ul>
  13. 15. Managed Care Tools <ul><li>Long Term Care Functional Screen (LTCFS) </li></ul><ul><ul><li>Automated tool for assessing level of care </li></ul></ul><ul><ul><li>Screeners, certified by DHS, verify and input: </li></ul></ul><ul><ul><ul><li>Diagnoses / health conditions </li></ul></ul></ul><ul><ul><ul><li>ADL/IADL deficits </li></ul></ul></ul><ul><ul><ul><li>Behavioral challenges </li></ul></ul></ul><ul><ul><ul><li>Other risk factors </li></ul></ul></ul><ul><ul><ul><li>Current level of informal supports </li></ul></ul></ul><ul><ul><li>The screen determines: </li></ul></ul><ul><ul><ul><li>Nursing home/ICF-MR level of care </li></ul></ul></ul><ul><ul><ul><li>Family Care eligibility </li></ul></ul></ul><ul><ul><ul><li>SDS waiver eligibility </li></ul></ul></ul><ul><li>Resource Allocation Decision-Making (RAD) tool </li></ul><ul><ul><li> </li></ul></ul>
  14. 16. Quality Management <ul><li>MCO activities required under contract, including ongoing monitoring of quality measures and PIPs </li></ul><ul><li>QRO (Metastar) annually reviews internal quality programs at both MCOs and resource centers </li></ul><ul><ul><li>Performs quality site visits </li></ul></ul><ul><ul><li>Monitors implementation of contract standards </li></ul></ul><ul><ul><li>Performs member-centered plan reviews and member outcome interviews </li></ul></ul><ul><ul><li>Reports findings to DHS and CMS </li></ul></ul><ul><li>DHS performs member satisfaction </li></ul><ul><li>survey </li></ul>
  15. 17. Financing <ul><li>Capitation payments to MCOs are a combination of federal Medicaid and state match </li></ul><ul><li>Payments to MCOs for Partnership members are also capitated, but come from both DHS and federal Medicare (for nursing home and health services covered by Medicare) </li></ul><ul><li>Counties contribute based on their 2006 contribution of local funds toward waiver participants. County contribution will be reduced over the first 5 years each county participates, based on statutory provisions created by 2007 Wisconsin Act 20. </li></ul>
  16. 18. Capitation <ul><li>2009 Rates 5.8% increase (average) </li></ul><ul><ul><li>High Family Care $2,983 </li></ul></ul><ul><ul><li>Low Family Care $2,314 </li></ul></ul><ul><ul><li>High Family Care Partnership $3,447 </li></ul></ul><ul><ul><li>Low Family Care Partnership $2,385 </li></ul></ul><ul><li>Administration is approximately 5.5% </li></ul><ul><ul><li>of rate in 2009 </li></ul></ul>
  17. 19. Rate Setting <ul><li>Actuarially sound projection of costs of benefit </li></ul><ul><li>Based on past expenditures trended forward </li></ul><ul><li>Costs are associated with functioning – LTC functional screen </li></ul><ul><li>Individual MCO rates are built from these projected costs of actual enrollees (actual case mix) </li></ul><ul><li>Adjusted at year end for: </li></ul><ul><ul><li>Cost share (PETI) </li></ul></ul><ul><ul><li>Case mix at year end </li></ul></ul><ul><ul><li>High cost ICF-MR relocations </li></ul></ul><ul><ul><li>High cost ventilator-dependent enrollees </li></ul></ul>
  18. 20. Grievance and Appeals <ul><li>MCO internal process </li></ul><ul><li>DHS/EQRO process </li></ul><ul><li>State-level hearing </li></ul><ul><li>Ombudsman services </li></ul>
  19. 21. Federal Authority <ul><li>Family Care 5 year (2009) </li></ul><ul><ul><ul><li>1915 (b) and (c) waivers </li></ul></ul></ul><ul><ul><ul><li>Medicaid card services </li></ul></ul></ul><ul><li>Family Care Partnership 2 year (2009) </li></ul><ul><ul><ul><li>State plan amendment - 1932(a) </li></ul></ul></ul><ul><ul><ul><li>1915 (c) waiver </li></ul></ul></ul><ul><ul><ul><li>All Medicaid services in state plan </li></ul></ul></ul><ul><li>CMS reviews/approves all rates and contracts </li></ul>
  20. 23. History of LTC in Wisconsin <ul><li>Nursing home entitlement </li></ul><ul><li>Community Options Program (1980-) </li></ul><ul><li>HCBWs (1983-) </li></ul><ul><li>PACE (1985-) </li></ul><ul><li>Partnership (1996-) </li></ul><ul><li>Family Care (2000-) </li></ul><ul><li>IRIS (2008-) </li></ul>
  21. 24. Mandate for Change <ul><li>Independent Evaluation </li></ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul><ul><li>Governor Doyle’s 2005 Directive </li></ul><ul><li>CSC Grant Award </li></ul><ul><li>Systemic Problems </li></ul><ul><ul><ul><ul><li>72 programs </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Waiting lists </li></ul></ul></ul></ul><ul><ul><ul><ul><li>20+ funding streams, each with requirements </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Budget and legislative challenges </li></ul></ul></ul></ul>
  22. 25. Why Managed Care? <ul><li>Family Care saves money directly by purchasing or providing services more economically </li></ul><ul><li>Family Care reduces costs indirectly by helping members have better health and abilities to function, so they have less need for services </li></ul><ul><li>Replacing high-cost services with lower cost services (e.g., more CBRF and less nursing home; more supportive home care and less home health care) </li></ul><ul><li>Emphasis on preventive care and interventions </li></ul><ul><li>Savings on the acute care side – reduced hospital costs </li></ul><ul><li>Better service coordination </li></ul>
  23. 26. Why Managed Care? <ul><li>More aggressive negotiation of rates with contracted service providers </li></ul><ul><li>Purchasing disposable medical supplies in bulk </li></ul><ul><li>Employing claim specialists to maximize reimbursement fro other payers such as Medicare and private insurance </li></ul><ul><li>In general, much closer attention to cost effectiveness </li></ul>
  24. 27. Why Managed Care?
  25. 28. Planning and Implementation for Statewide Expansion <ul><li>10 Planning and implementation grants – $100,000+ </li></ul><ul><li>Planning groups include public agencies (counties) and private agencies </li></ul><ul><li>Planning started in February 2006 and continues </li></ul><ul><li>Each group must plan for ADRC and CMO </li></ul><ul><li>at its own pace </li></ul><ul><li>Some groups have planned for more than one program </li></ul>
  26. 29. November 2008 - ADRCs <ul><li>ADRCs cover 2/3 of Wisconsin’s population 18+ </li></ul><ul><li>28 ADRCs cover 38 of Wisconsin’s 72 counties </li></ul><ul><li>Budget for SFY 2009 (July 2008 – June 2009) is $34.5M* </li></ul><ul><ul><ul><ul><ul><li>* Includes small amount of federal dollars </li></ul></ul></ul></ul></ul>
  27. 30. November 2008 - MCOs <ul><li>Contracts with 9 managed care organizations for long-term care </li></ul><ul><li>20,000 enrollees </li></ul><ul><li>50% of state population 18+ has access </li></ul><ul><li>MCO budget SFY 2009 (July 2008-June2009), estimated*, all funds </li></ul><ul><ul><ul><li>Family Care $580M, not including card services </li></ul></ul></ul><ul><ul><ul><li>Family Care Partnership $156M </li></ul></ul></ul>
  28. 33. Expansion Challenges <ul><li>Fidelity to the model </li></ul><ul><li>Lack of MC business expertise among new MCOs </li></ul><ul><li>Getting care under management </li></ul><ul><li>Lack of healthy redundancy </li></ul><ul><li>Scaling components of internal and external infrastructure - franchising </li></ul><ul><li>Budget constraints </li></ul><ul><li>Burgeoning workforce shortages </li></ul>
  29. 35. <ul><li>Children’s Long-Term Supports </li></ul>
  30. 36. The Vision <ul><li>Children with disabilities and their families will pursue their unique hopes and dreams with assistance that: </li></ul><ul><li>Is family-designed and controlled, </li></ul><ul><li>Is individualized and seamless, </li></ul><ul><li>Lasts as long as needed, and </li></ul><ul><li>Involves a variety of community partners. </li></ul>
  31. 37. Current Trends <ul><li>Maximize federal financial participation (FFP) by using state and local dollars to match federal dollars. </li></ul><ul><li>Administer long-term support funding through “managed care models”. </li></ul><ul><li>Control of resources from fee-for-service programs to a system charged with understanding child and family needs </li></ul>
  32. 38. Current Trends <ul><li>The implementation of Family Care for adults who are elderly or have disabilities, has increased regionalization of services and decreased county involvement and capacity to manage human services for these populations. </li></ul><ul><li>We are beginning to see the impact on children’s long-term supports. </li></ul>
  33. 39. Investment <ul><li>Now is the time to invest in developing a managed care model for children’s long-term support. </li></ul><ul><li>What structure for managed long-term care offers the families of eligible children the greatest degree of control, individualization and effective support? </li></ul>
  34. 40. Limitations <ul><li>The State currently lacks knowledge and experience in applying managed care to the more complex situation of families of minor children. </li></ul><ul><li>Children with long-term support needs are cared for almost entirely by their parents, with help from public schools and private health insurance. </li></ul><ul><li>The cost of long-term support services is generally modest. </li></ul><ul><li>There is little excess money, given limited use of institutional settings, to serve the thousands of families currently on waiting lists. </li></ul>
  35. 41. What Can We Do? <ul><li>Merge most existing funding. </li></ul><ul><li>Move money, or initially, funding equal to the value of specific MA card services to the more flexible CLTS waiver benefit. </li></ul><ul><li>Merging the funding would allow the system to make more rational allocation decisions, would provide more flexibility and choice to families, and would reduce complexity and high transaction costs. </li></ul>
  36. 42. How Will We Assess Progress? <ul><ul><li>What kind of processes for allocating limited funding resources seem to be the most fair and efficient and produces the most satisfaction? </li></ul></ul><ul><ul><li>How many different local approaches, resources, and organizations are developed by and for families, especially alternatives to highly professionalized services? </li></ul></ul><ul><ul><li>How much local ownership develops? </li></ul></ul><ul><ul><li>Is there a spirit of cooperative problem-solving between the state, counties and families? </li></ul></ul>
  37. 43. Opportunities <ul><li>This initiative offers Wisconsin an opportunity to learn more about and to advance the agenda of the Children’s Long Term Support Committee and its 1998 Foundations paper. </li></ul><ul><li>We need to move the concepts of the Foundations forward. </li></ul><ul><li>This is consistent with CLTS Council resolutions. </li></ul>
  38. 44. Further Information <ul><li>Children’s Long-Term Support Webpage and Foundations Paper </li></ul><ul><ul><li> </li></ul></ul><ul><li>Beth Wroblewski </li></ul><ul><ul><li>608-267-5139 </li></ul></ul><ul><ul><li>[email_address] </li></ul></ul>
  39. 45. More Information [email_address] 608-267-4896 <ul><li>Family Care Website </li></ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul><ul><li>Family Care Partnership Website </li></ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul><ul><li>ADRC Website </li></ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul><ul><li>Family Care Expansion Website </li></ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul>