1. 2 3 pennsylvania’s mltss proposal: key considerations for advocates june 30, 2015 eric carlson...
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Pennsylvania's MLTSS Proposal: Key Considerations for Advocates
Featuring
Eric Carlson from Justice in Aging
June 30, 2015
Welcome to CARIE’s first ReadyTalk webinar. We will begin shortly. All phones will be on mute. We will be using the chat feature for questions. This webinar is being recorded and will be archived. We will share a link to the archived presentation and slides later this week. Please direct any questions to Kathy Cubit at [email protected].
www.carie.org
Please visit our website to sign-up for our monthly public policy newsletter, CARIE Connection, and for a copy of CARIE’s recent oral
testimony about Pennsylvania’s MLTSS proposal.
Two Penn Center 1500 JFK Blvd., Suite 1500
Philadelphia, PA 19102-1718 T: 215-545-5728
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Pennsylvania’s MLTSS Proposal:Key Considerations for Advocates
June 30, 2015
Eric Carlson
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A Rush Towards MLTSS
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• PA’s Discussion Document cites 22 states (including PA) that already have MLTSS.
• Number may be higher – NASUAD Integration Tracker lists 26 states.
Is the Move to MLTSS Evidence-Based?
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• Q. Where is the empirical evidence supporting MLTSS? Many of the arguments still are relatively theoretical, but CMS still seems to be strongly in favor of Medicaid managed care.• Resisting the move to managed care is not necessarily impossible, but it
likely would be difficult.• One issue is the growing political influence of health plans.
• Systems frequently carve-out DD/ID populations, due to separate service system and/or political pressure.
Questioning the Rationalefor Moving to MLTSS
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• Shouldn’t there be some real evidence at this point?
• The fact that states are moving to MLTSS, is not equivalent to a finding that MLTSS is working as promised.
• State should be expected to produce some data to support its proposal.
• Recent data has shown relatively poor performance by dual-integration programs.
In General, More SpecificityIs Needed
• There’s obviously nothing wrong with rebalancing, person-centered
services, etc.– But how can we be sure that the MLTSS system actually will produce the
desired results?
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Person-Centered Planning
• “Continuity of service protections that remain in place until the new
service plan is developed and implemented.”– A relatively low bar to just require continuity until a service plan is in place.
– Need continuity of care when service provider not in network, or when
beneficiary is new to managed care. (This is addressed in the “Access to
Qualified Providers” section.)
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Person-Centered Planning (cont.)
• “The application of a person-centered service planning process.”– To really be person-centered, the consumer must be in charge, and this is
where most MLTSS system fall short.
• “[S]tandardized and validated assessment tool that reviews …
physical, psychosocial, and functional needs and preferences.”– What will this be used for? System should be transparent in how it allocates
personal care hours.
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Person-Centered Planning (cont.)
• “The maximization of self-direction in service including education on
how to use these self-directed options.”– How much discretion will the consumer have? What does this mean in
relation to provider networks? How can the consumer be sure that the
budget is adequate?
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Services and Supports Coordination• “MLTSS vendors will be required to operate companion Medicare and
Medicaid LTSS plans so that the full range of Medicaid and Medicare
benefits are provided by the same health plan.”– Medicare managed care is optional – many dual-eligible plans have had high-
opt-out rates.
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Services and Supports Coordination (cont.)• Financial incentives to discourage cost-shifting.– Such as?
• “Additional supportive services appropriate to the target population.”– These services need to be specified, and reasonably available.
• Use of service coordinators who will monitor consumer’s care and
qualify of services that he or she is receiving.– But will this person be independent?
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Access to Qualified Providers• Access to providers, and network adequacy.– Difficult to measure and enforce this in a meaningful way. Inadequate
networks are recognizable after the fact.
• “Qualifications and credentialing”– Some questions as to how this is applied to MLTSS services.
• Good to reference support for providers in transition to MLTSS.
• Good also to reference continuity of care during transition to MLTSS,
and for possibility for staying with out-of-network provider when
provider supply within network is insufficient.8
Emphasis onHome and Community-Based Services
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• Very little detail provided. There’s one three-sentence paragraph, and the last two sentences make little sense.
• Should make sure that, at a minimum, services and slots from current waivers are retained.
• What would make HCBS meaningful?• e.g., broad service package; ability to choose HCBS even if
relatively more expensive; effective rebalancing provisions.
Performance-Based Payment Incentives
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• Payment structures should improve HCBS opportunities, incorporate person-centered service design, promote health, ensure efficiency, etc.
• These are admirable goals, but it’s unclear how to structure payment this way. As always, financial incentives are subject to gaming and unintended consequences.
Participant Education and Enrollment Supports
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• Conflict-free choice counseling, and “[e]nrollment and disenrollment independent of the vendors.” -- these are good.
• Advocacy and ombudsman services.• Need funding and freedom – proposed federal regulations
would prohibit ombudsman programs from representing in appeals.
Participant Educationand Enrollment Supports (cont.)
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• Choice of plan,and “sufficient” advance notice of enrollment.• Better consumer protections would be voluntary enrollment
(very unlikely) or at least:• Reasonable standards to excuse a consumer from managed
care, and• Increased ability to change plans for cause.
Preventive Services
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• Given that most enrollees will be dual-eligible, this seems to be mostly a matter of Medicare policy.
• “The existing Medicare preventive services will be intergrated or expanded into the Medicaid program and LTSS.”• What does this mean?
Participant Protections
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• Almost no detail here – vague references to coordination with APS, and “a comprehensive grievance and appeals process.”
• One issue is the ability to appeal service plans.
Quality and Outcomes-Based Focus
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• Supposed to address five areas:• Quality of life.• Consumer experience and satisfaction (references person-level
encounter data).• Health/service outcome.• Community integration.• Rebalancing.
• Danger is that the data has no real-world impact.
Request for Stakeholder Input
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• Program Design• Planning Phases• Implementation• Oversight• Quality
Justice in Aging Would Be Happy to Help
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• On-going project to work with state advocates.
• Justice in Aging on-line resources:
• On-Line Library to MLTSS Contracts.
• MLTSS Toolkit.
Suggestions
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• Be as specific as possible – do the state’s work for it, as possible.• Refer to existing models from proposed federal regulations
and/or other states’ programs.• Don’t be bought off by vague promises or flowery, unenforceable
language.• Also don’t rely too heavily on performance measures; question as
to how they might have a real-world impact.
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Questions?
Please ask questions using the chat feature.