TransitionofAged,BlindandDisabledPopulationstoaManagedLong-termCareSystemExamples,Concerns,RecommendationsThoughmanagedcareprogramshaveonlypenetrated2.3%ofthelong-termcaremarket,thereareindicationsthattheirprevalenceisexpanding,albeitslowly.By2003,managedlong-termcare(MLTC)ofsomeformhadtakenrootin7states,whileMLTCspecificallyfortheelderlyexistedorwasindevelopmentin17states.Asignificantmotivatingfactorforthisrestructuringhasbeentoimprovethequalityandefficiencyofserviceprovisionoverthetraditionalfee-for-servicesystem.Anumberoffactorshavecontributedtotheslowgrowth:“complexprogramdesignchoices(includingpaymentmethodology),relativelylongplanningandstart-upperiods,resistanceoflong-termcareprovidersandadvocates,
difficultstate-federalpolicyissues,theneedforasubstantialpopulationbase,limitedinterestamongpotentialsuppliers,
andinadequatestateinfrastructure”
(Saucier,Burwell,&Gerst,2005,p.1).
TheNationalLeadershipConsortiumonDevelopmentalDisabilitiesanalyzedandcomparedtransitiontomanagedcareinfourstates:Arizona,Michigan,VermontandWisconsin.
Salientpointsofthisanalysisarepresentedtoprovideanoverviewoftransitionstrategies,obstacles,implicationsandrecommendations.Itisimportanttonoteattheoutsetthatnoneofthefourstatesfeaturedadoptedamanagedcareapproachwiththeprimarypurposeofreducingstatespendingonlong-termcareservices.Thegoal,rather,wastoachieveenhancedstatewideequityinaccessandtoimprovethecost-effectivenessandqualityofservices.Thereportalsonotesthatthefederalstatutorywaiversuponwhichtheprogramsintheexamplesarebasedwereinitiallyapprovedyearsago.ItisnotclearwhethertheCentersforMedicareandMedicaidServices(CMS)wouldnegotiatesimilaragreementswithotherstatestoday,althoughtherecentrecessionandthesignificantnumbersofindividualsonlongwaitinglistsforservicesinmoststatesputspressureonpolicymakersforsolutionstomeettheneed.
AreasofConcernAnumberofconcernshavearisenasaresultofthisshiftfromafee-for-servicetoamanagedcaresystem.
RiskSharingThefeaturedstatestookseveraldifferentapproachestowardsharingriskintheimplementationoflong-termmanagedcare.InVermontandArizona,thestategovernmentassumes100%ofthefinancialrisk.InMichiganandWisconsin,thestategovernmentsharesthefinancialrisksofcostoverrunswithcountyormulti-countymanagedcareentities.Inthesetwostates,thestatespecifiestheminimumfinancialreservesthataManagedCareOrganization(MCO)mustretainandoffersincentivestobuildtheircashreserves.MichiganlimitsthePre-paidIn-patientHealthPlans’(PIHP)riskexposureto7.5%
overthetotalamountoftheplan’sannualcontractwiththestate.NeitherMichigannorWisconsinhasaclearcontingencyplanforthepossibilityofanMCOorPIHPinsolvency,though.Inthecaseofsuchanoutcome,itispresumedthatthestatewouldbetheultimateguarantoroftheplans.
TransitionofAged,BlindandDisabledPopulationstoaManagedLong-termCareSystemExamples,Concerns,RecommendationsThoughmanagedcareprogramshaveonlypenetrated2.3%ofthelong-termcaremarket,thereareindicationsthattheirprevalenceisexpanding,albeitslowly.By2003,managedlong-termcare(MLTC)ofsomeformhadtakenrootin7states,whileMLTCspecificallyfortheelderlyexistedorwasindevelopmentin17states.Asignificantmotivatingfactorforthisrestructuringhasbeentoimprovethequalityandefficiencyofserviceprovisionoverthetraditionalfee-for-servicesystem.Anumberoffactorshavecontributedtotheslowgrowth:“complexprogramdesignchoices(includingpaymentmethodology),relativelylongplanningandstart-upperiods,resistanceoflong-termcareprovidersandadvocates,
difficultstate-federalpolicyissues,theneedforasubstantialpopulationbase,limitedinterestamongpotentialsuppliers,
andinadequatestateinfrastructure”
(Saucier,Burwell,&Gerst,2005,p.1).
TheNationalLeadershipConsortiumonDevelopmentalDisabilitiesanalyzedandcomparedtransitiontomanagedcareinfourstates:Arizona,Michigan,VermontandWisconsin.
Salientpointsofthisanalysisarepresentedtoprovideanoverviewoftransitionstrategies,obstacles,implicationsandrecommendations.Itisimportanttonoteattheoutsetthatnoneofthefourstatesfeaturedadoptedamanagedcareapproachwiththeprimarypurposeofreducingstatespendingonlong-termcareservices.Thegoal,rather,wastoachieveenhancedstatewideequityinaccessandtoimprovethecost-effectivenessandqualityofservices.Thereportalsonotesthatthefederalstatutorywaiversuponwhichtheprogramsintheexamplesarebasedwereinitiallyapprovedyearsago.ItisnotclearwhethertheCentersforMedicareandMedicaidServices(CMS)wouldnegotiatesimilaragreementswithotherstatestoday,althoughtherecentrecessionandthesignificantnumbersofindividualsonlongwaitinglistsforservicesinmoststatesputspressureonpolicymakersforsolutionstomeettheneed.
AreasofConcernAnumberofconcernshavearisenasaresultofthisshiftfromafee-for-servicetoamanagedcaresystem.
RiskSharingThefeaturedstatestookseveraldifferentapproachestowardsharingriskintheimplementationoflong-termmanagedcare.InVermontandArizona,thestategovernmentassumes100%ofthefinancialrisk.InMichiganandWisconsin,thestategovernmentsharesthefinancialrisksofcostoverrunswithcountyormulti-countymanagedcareentities.Inthesetwostates,thestatespecifiestheminimumfinancialreservesthataManagedCareOrganization(MCO)mustretainandoffersincentivestobuildtheircashreserves.MichiganlimitsthePre-paidIn-patientHealthPlans’(PIHP)riskexposureto7.5%
overthetotalamountoftheplan’sannualcontractwiththestate.NeitherMichigannorWisconsinhasaclearcontingencyplanforthepossibilityofanMCOorPIHPinsolvency,though.Inthecaseofsuchanoutcome,itispresumedthatthestatewouldbetheultimateguarantoroftheplans.

ManagementandAdministrationThemanagementandadministrationofthemanagedlong-termcaresystemspresentanotherareainwhichavarietyofframeworkshavebeendemonstrated,bothatthestateandlocallevel.
Atthestatelevel,ArizonaandVermonthaveestablishedsharedresponsibilitybetweenthestateDevelopmentalDisabilities(DD)programagencyandthesinglestateMedicaidagency.Inthisarrangement,theDDprogramagencyisresponsibleforoverseeingtheserviceprocurementandthedeliveryprocess.TheMedicaidagencyisresponsiblefortheoversightofthestate’ssection1115waiver/demonstrationprogram.ForMichiganandWisconsin,allactivityisconductedbythesingleMedicaidagencywhichservesastheDDprogramagencyaswell.
Allofthestatespresentedhereforcomparisonadopteddifferentstructuresforlocallevelmanagementandadministration.InArizona,sevendistrictofficesmanageallaspectsofdeliveryservicesandstate-fundedDDservicesincludingthedirectprovisionofsupportcoordination.InMichigan,thestatementalhealth(MH)andsubstanceabuse(SA)divisionscontractwithanetworkof18PIHPstoobtainallMedicaid-fundedspecialtyservicesforindividualswithMH,SAandDDneeds.ThefunctionsofthePIHParesupplementedby46CommunityMentalHealthServicesPrograms(CMHSPs),whicharethesingle-point-of-entryforallpublicMH,SAandDDservices.ForVermont,anetworkoftennon-profitdesignatedagenciesacrossthestateoperatesasthesingle-point-of-entry.ParticipatingcountiesinWisconsinappointanMCOtoberesponsibleforplanningandprocuringalllong-termservices.AseparatenetworkofAgingandDisabilityResourceCenters(ADRCs)isresponsibleforassistingindividualsandfamilieswithfindingresourcesanddeterminingeligibility.
EligibilityInallfourstates,eligibilityisatwo-tieredprocess.Individualsmustfirstmeetthestate’sstatutorydefinitionofhavinga“developmentaldisability”or“mentalretardation.”Individualsmustthenprovesufficientseverityinordertoqualifyforthelong-termservicesprogram.MichiganandWisconsinhaveadoptedthefederaldefinitionofDD,whichcontainsonlyfunctionaldescriptors.ArizonaandVermontlinkeligibilitytothedefinitionof“mentalretardation,”otheretiologicalconditionsandthefederaldefinition’sfunctionaldescriptors.
FundingAllstatesconsolidateavarietyoffundingstreamstoformasingle,flexiblesourceoffundingandcitethisfeatureasoneofthemainmotivatingfactorsinswitchingfromfee-for-servicetolong-termmanagedcare.ArizonacombinesMedicaidfundingforhomeandcommunity-basedservices(HCBS)andIntermediateCareFacilitiesfortheMentallyRetarded(IMF/MR),
healthplancoverage,andbehavioralhealthcoverage.MichiganandWisconsinbothcombinetheHCBSwaiverandICF/MRdollars,certainstateplancoverage,andthestateandcountymatch.VermontcombinestheHCBSwaiverandICF/MRdollarswiththeflexiblefamilygrants.
ImplementationTheprimaryconcernwithimplementationismitigatingtheimpactofanoverhaulofthestatesystem.
InWisconsin,fivepilotcountiesimplementedaFamilyCareprogramforalleligibletargetpopulations,
whileonecountylimitedservicesduringthepilotperiodtoeligibleseniors.Fiveyearslater,after“Allstatesconsolidateavarietyoffundingstreamstoformasingle, flexiblesourceoffundingandcitethisfeatureasoneofthemainmotivatingfactorsinswitchingfromfee-for-servicetolong-termcare.”
ManagementandAdministrationThemanagementandadministrationofthemanagedlong-termcaresystemspresentanotherareainwhichavarietyofframeworkshavebeendemonstrated,bothatthestateandlocallevel.
Atthestatelevel,ArizonaandVermonthaveestablishedsharedresponsibilitybetweenthestateDevelopmentalDisabilities(DD)programagencyandthesinglestateMedicaidagency.Inthisarrangement,theDDprogramagencyisresponsibleforoverseeingtheserviceprocurementandthedeliveryprocess.TheMedicaidagencyisresponsiblefortheoversightofthestate’ssection1115waiver/demonstrationprogram.ForMichiganandWisconsin,allactivityisconductedbythesingleMedicaidagencywhichservesastheDDprogramagencyaswell.
Allofthestatespresentedhereforcomparisonadopteddifferentstructuresforlocallevelmanagementandadministration.InArizona,sevendistrictofficesmanageallaspectsofdeliveryservicesandstate-fundedDDservicesincludingthedirectprovisionofsupportcoordination.InMichigan,thestatementalhealth(MH)andsubstanceabuse(SA)divisionscontractwithanetworkof18PIHPstoobtainallMedicaid-fundedspecialtyservicesforindividualswithMH,SAandDDneeds.ThefunctionsofthePIHParesupplementedby46CommunityMentalHealthServicesPrograms(CMHSPs),whicharethesingle-point-of-entryforallpublicMH,SAandDDservices.ForVermont,anetworkoftennon-profitdesignatedagenciesacrossthestateoperatesasthesingle-point-of-entry.ParticipatingcountiesinWisconsinappointanMCOtoberesponsibleforplanningandprocuringalllong-termservices.AseparatenetworkofAgingandDisabilityResourceCenters(ADRCs)isresponsibleforassistingindividualsandfamilieswithfindingresourcesanddeterminingeligibility.
EligibilityInallfourstates,eligibilityisatwo-tieredprocess.Individualsmustfirstmeetthestate’sstatutorydefinitionofhavinga“developmentaldisability”or“mentalretardation.”Individualsmustthenprovesufficientseverityinordertoqualifyforthelong-termservicesprogram.MichiganandWisconsinhaveadoptedthefederaldefinitionofDD,whichcontainsonlyfunctionaldescriptors.ArizonaandVermontlinkeligibilitytothedefinitionof“mentalretardation,”otheretiologicalconditionsandthefederaldefinition’sfunctionaldescriptors.
FundingAllstatesconsolidateavarietyoffundingstreamstoformasingle,flexiblesourceoffundingandcitethisfeatureasoneofthemainmotivatingfactorsinswitchingfromfee-for-servicetolong-termmanagedcare.ArizonacombinesMedicaidfundingforhomeandcommunity-basedservices(HCBS)andIntermediateCareFacilitiesfortheMentallyRetarded(IMF/MR),
healthplancoverage,andbehavioralhealthcoverage.MichiganandWisconsinbothcombinetheHCBSwaiverandICF/MRdollars,certainstateplancoverage,andthestateandcountymatch.VermontcombinestheHCBSwaiverandICF/MRdollarswiththeflexiblefamilygrants.
ImplementationTheprimaryconcernwithimplementationismitigatingtheimpactofanoverhaulofthestatesystem.
InWisconsin,fivepilotcountiesimplementedaFamilyCareprogramforalleligibletargetpopulations,
whileonecountylimitedservicesduringthepilotperiodtoeligibleseniors.Fiveyearslater,after“Allstatesconsolidateavarietyoffundingstreamstoformasingle, flexiblesourceoffundingandcitethisfeatureasoneofthemainmotivatingfactorsinswitchingfromfee-for-servicetolong-termcare.”

assessments,planswereannouncedtoexpandstatewidebytheendoffiveyears.Planninggrantswereawardedtogroupsinvariouscatchmentareasacrossthestate.TherewasanexpectationthatalloftheparticipatingorganizationswouldbandtogethertoformaManagedCareOrganizationtocontractwithDHS.TheMCOswouldservemulti-countycatchmentareaswiththepilotcountiesservingasthebase.
Ofthefourstatesprofiled,onlyArizona’sprogramcoverstheentirestate.Themajorityarelimitedtoacountyormultiplecountieswithurbancenters.Moststateandplanofficialsconsultedbelievethatmanagedlong-termcareneedsanurbanbasetobeviable.Thereneedstobeanadequatevolumeofparticipantsandsupplyofproviders.
StatesthatproposedmodelsoffullyintegratingacuteandlongtermcarebycombiningMedicaidandMedicarefinancingstreamsexperiencedprotractedplanningperiodsofmorethanfiveyears.OtherstatesreducedplanningperiodsbytakingMedicareoffthetableandworkingwithCMStodevelopunprecedentedapproachestoHCBSwaivers.TokeepthedooropentoMedicare,TexasincludedincentivesforduallyeligibleconsumerstojoinMedicare+Choiceplans(nowMedicareAdvantage).
Acrosstheboard,therehasbeenstrongresistancetofullyintegratingacuteandlongtermcare.
ChallengeofmaintaininganadequateprovidernetworkTheAZDivisionofDevelopmentalDisabilities(DDD)maintainsanetworkofover3,000“qualifiedvendors”(underformalcontractwithDDD)and“individualindependentproviders”(IIP)(whomustmeetDDDqualificationsandenterintoanIndividualServiceAgreement).Individualsandfamiliesmay:a)identifytheirownIIPorindividualwillingtobecomeanIIPorselectfromalist,b)chooseaqualifiedvendor,orselectfromalist,orc)beautomaticallyassignedaqualifiedvendor.
TheConsortiumreportmakestheclaimthat“theavailablesupportoptionsoftenarebroaderunderamanagedcareapproach,especiallyinsparselypopulatedareasofthestate.”Enrolleesareassuredofhavingaccesstoatleasttwoprovidersofanycoveredservice,unlikeinthefee-for-servicesystem.However,theydonotexplainhowthestatesaddressprovidercapacity.
OneexecutivedirectoratastatewideprovideragencyinWIexpressedaneedforsupportsforcommunityprovideragenciesandrecommendedofferingstart-upfundstohelpprovideragencies,
especiallysmallindependentproviders,makethetransition.TheCEOofalargeresidentialprovideragencyinanotherstatevoicedconcernthatwithouttheabilitytoofferprovidersfaircompensation,
reasonablebenefits,apositiveworkenvironment,andrecognitionfortheirservices,serviceswouldbeseriouslycompromised.
Texasaddressedprotectionforthelongtermcareprovidersbygivingthreeyearsoftransitionprotection.
MassachusettsrequiresSeniorCareOrganizationstosubcontractwithatleastoneAgingServicesAccessPoint(ASAP),thestate’straditionalportalforcommunitylongtermcareservices.
OneapproachtoprotectingexistingLTCinfrastructureistoensurethattraditionalproviderscanthemselvesbecomerisk-bearingmanagedcareorganizations.InFL,certainlongtermcareproviders“Onebeneficialoutcomeofthesystemtransitionisthatitobligatesstatestomakeservicesandsupportsavailabletoalleligibleindividualsaccordingtowhen, whereandhowtheyneedthem.”
assessments,planswereannouncedtoexpandstatewidebytheendoffiveyears.Planninggrantswereawardedtogroupsinvariouscatchmentareasacrossthestate.TherewasanexpectationthatalloftheparticipatingorganizationswouldbandtogethertoformaManagedCareOrganizationtocontractwithDHS.TheMCOswouldservemulti-countycatchmentareaswiththepilotcountiesservingasthebase.
Ofthefourstatesprofiled,onlyArizona’sprogramcoverstheentirestate.Themajorityarelimitedtoacountyormultiplecountieswithurbancenters.Moststateandplanofficialsconsultedbelievethatmanagedlong-termcareneedsanurbanbasetobeviable.Thereneedstobeanadequatevolumeofparticipantsandsupplyofproviders.
StatesthatproposedmodelsoffullyintegratingacuteandlongtermcarebycombiningMedicaidandMedicarefinancingstreamsexperiencedprotractedplanningperiodsofmorethanfiveyears.OtherstatesreducedplanningperiodsbytakingMedicareoffthetableandworkingwithCMStodevelopunprecedentedapproachestoHCBSwaivers.TokeepthedooropentoMedicare,TexasincludedincentivesforduallyeligibleconsumerstojoinMedicare+Choiceplans(nowMedicareAdvantage).
Acrosstheboard,therehasbeenstrongresistancetofullyintegratingacuteandlongtermcare.
ChallengeofmaintaininganadequateprovidernetworkTheAZDivisionofDevelopmentalDisabilities(DDD)maintainsanetworkofover3,000“qualifiedvendors”(underformalcontractwithDDD)and“individualindependentproviders”(IIP)(whomustmeetDDDqualificationsandenterintoanIndividualServiceAgreement).Individualsandfamiliesmay:a)identifytheirownIIPorindividualwillingtobecomeanIIPorselectfromalist,b)chooseaqualifiedvendor,orselectfromalist,orc)beautomaticallyassignedaqualifiedvendor.
TheConsortiumreportmakestheclaimthat“theavailablesupportoptionsoftenarebroaderunderamanagedcareapproach,especiallyinsparselypopulatedareasofthestate.”Enrolleesareassuredofhavingaccesstoatleasttwoprovidersofanycoveredservice,unlikeinthefee-for-servicesystem.However,theydonotexplainhowthestatesaddressprovidercapacity.
OneexecutivedirectoratastatewideprovideragencyinWIexpressedaneedforsupportsforcommunityprovideragenciesandrecommendedofferingstart-upfundstohelpprovideragencies,
especiallysmallindependentproviders,makethetransition.TheCEOofalargeresidentialprovideragencyinanotherstatevoicedconcernthatwithouttheabilitytoofferprovidersfaircompensation,
reasonablebenefits,apositiveworkenvironment,andrecognitionfortheirservices,serviceswouldbeseriouslycompromised.
Texasaddressedprotectionforthelongtermcareprovidersbygivingthreeyearsoftransitionprotection.
MassachusettsrequiresSeniorCareOrganizationstosubcontractwithatleastoneAgingServicesAccessPoint(ASAP),thestate’straditionalportalforcommunitylongtermcareservices.
OneapproachtoprotectingexistingLTCinfrastructureistoensurethattraditionalproviderscanthemselvesbecomerisk-bearingmanagedcareorganizations.InFL,certainlongtermcareproviders“Onebeneficialoutcomeofthesystemtransitionisthatitobligatesstatestomakeservicesandsupportsavailabletoalleligibleindividualsaccordingtowhen, whereandhowtheyneedthem.”

areauthorizedtobecomediversionprogramcontractorsbyvirtueoftheirstateproviderlicensurestatus.
Mostorganizationsthathaveenteredthemanagedlong-termcarebusinessareprovider-basedorganizationsthathavedevelopedamanagedcarecapacity.
StrengthsandWeaknessesTheconsortiumreportsoughtfeedbackfromkeystakeholdersinthefourstatesfeatured.Keystakeholdersincluded:stateandcountyprogramadministrators,directorsofadvocacyorganizations,
stateofficials,andprovideragencyexecutives.Someoftheirinputispresentedbelowintheformoftransitionstrengths,weaknessesandrecommendations.
StrengthsOnebeneficialoutcomeofthesystemtransitionisthatitobligatesstatestomakeservicesandsupportsavailabletoalleligibleindividualsaccordingtowhen,whereandhowtheyneedthem.Thiseliminatedtheneedforwaitinglists.Oneobservercommented,“It’shardtoseehowafiscallyconservativestatelikeArizonacouldhaveexpandedservicessobroadlyinafee-for-serviceenvironment.”
ManyexplainedthatcombiningrelevantMedicaidandnon-Medicaidfundingstreamsallowedgreaterflexibilitytodesignsupportsaroundtheneedsandpreferencesofeachindividual.
Twoadministrativeofficialsrespondedtoeffectsofanemphasisoncost-effectivenessandtherelatedtoolstocraftsupportplansthatmakemoresenseandcostless.Onestated,“[we]canfocusonservicesandsupportsappropriatetothepersonratherthanstrugglingtoobtainwhateverscantresourcesareavailable.”Anotherobservedthat,“[the]waitinglistsinfee-for-servicesystemsgaveconsumerseither‘aCadillac[program]’ornothingatall.”
•Manyrespondentscitedthebenefitofhavingafixedpointofaccountability.
•Intervieweesexpressedthattheglobalmanagementofdollarspromotesanincentivetointervenebeforeamajorcrisisoccurs.
•Stakeholdersemphasizedtheimportanceoftherighttochoosebetweenqualifiedproviders.
•ItwasobservedthattheadditionalfederaldollarsresultingfromthemanagedcareagreementwithCMShelpedtostabilizethefinancialstatusofthestate’sMedicaidprogram.
•Anumberofrespondentspraisedthecommitmenttoachievinggeographicequitythatresultedfromthechangefromfee-for-servicestomanagedlong-termcare.
WeaknessesStakeholdersexpressedthatgeographicequityinaccesstoserviceshadnotyetbeenfullyachieved.Whilethestatutoryandregulatorygoalswereseentobehighlyprogressive,itwasnotedthatopportunitiestoreceivesupportsinnewandcreativewayswasnotreadilyavailable.
“combiningrelevantMedicaidandnon-Medicaidfundingstreamsallowedgreaterflexibilitytodesignsupportsaroundtheneedsandpreferencesofeachindividual”
“Manyrespondentswereadamantintheirviewthatwhenstateselecttoconstructamanagedcaredeliverysystemupontheframeworkofitscurrentsystemrisksitcreatesconfusionandoverlap.Itwasadvisedthatanewframeworkbeadoptedtoensurethattheuniquerequirementsofalong-termmanagedcaresystembeadequatelyaddressed.”
areauthorizedtobecomediversionprogramcontractorsbyvirtueoftheirstateproviderlicensurestatus.
Mostorganizationsthathaveenteredthemanagedlong-termcarebusinessareprovider-basedorganizationsthathavedevelopedamanagedcarecapacity.
StrengthsandWeaknessesTheconsortiumreportsoughtfeedbackfromkeystakeholdersinthefourstatesfeatured.Keystakeholdersincluded:stateandcountyprogramadministrators,directorsofadvocacyorganizations,
stateofficials,andprovideragencyexecutives.Someoftheirinputispresentedbelowintheformoftransitionstrengths,weaknessesandrecommendations.
StrengthsOnebeneficialoutcomeofthesystemtransitionisthatitobligatesstatestomakeservicesandsupportsavailabletoalleligibleindividualsaccordingtowhen,whereandhowtheyneedthem.Thiseliminatedtheneedforwaitinglists.Oneobservercommented,“It’shardtoseehowafiscallyconservativestatelikeArizonacouldhaveexpandedservicessobroadlyinafee-for-serviceenvironment.”
ManyexplainedthatcombiningrelevantMedicaidandnon-Medicaidfundingstreamsallowedgreaterflexibilitytodesignsupportsaroundtheneedsandpreferencesofeachindividual.
Twoadministrativeofficialsrespondedtoeffectsofanemphasisoncost-effectivenessandtherelatedtoolstocraftsupportplansthatmakemoresenseandcostless.Onestated,“[we]canfocusonservicesandsupportsappropriatetothepersonratherthanstrugglingtoobtainwhateverscantresourcesareavailable.”Anotherobservedthat,“[the]waitinglistsinfee-for-servicesystemsgaveconsumerseither‘aCadillac[program]’ornothingatall.”
•Manyrespondentscitedthebenefitofhavingafixedpointofaccountability.
•Intervieweesexpressedthattheglobalmanagementofdollarspromotesanincentivetointervenebeforeamajorcrisisoccurs.
•Stakeholdersemphasizedtheimportanceoftherighttochoosebetweenqualifiedproviders.
•ItwasobservedthattheadditionalfederaldollarsresultingfromthemanagedcareagreementwithCMShelpedtostabilizethefinancialstatusofthestate’sMedicaidprogram.
•Anumberofrespondentspraisedthecommitmenttoachievinggeographicequitythatresultedfromthechangefromfee-for-servicestomanagedlong-termcare.
WeaknessesStakeholdersexpressedthatgeographicequityinaccesstoserviceshadnotyetbeenfullyachieved.Whilethestatutoryandregulatorygoalswereseentobehighlyprogressive,itwasnotedthatopportunitiestoreceivesupportsinnewandcreativewayswasnotreadilyavailable.
“combiningrelevantMedicaidandnon-Medicaidfundingstreamsallowedgreaterflexibilitytodesignsupportsaroundtheneedsandpreferencesofeachindividual”
“Manyrespondentswereadamantintheirviewthatwhenstateselecttoconstructamanagedcaredeliverysystemupontheframeworkofitscurrentsystemrisksitcreatesconfusionandoverlap.Itwasadvisedthatanewframeworkbeadoptedtoensurethattheuniquerequirementsofalong-termmanagedcaresystembeadequatelyaddressed.”

Anumberofchallengeswereexpressedbyrespondents:
•Therewasunevenaccesstoindividualizedservicesbetweencounties.
•Problemsacquiringandmaintainingadequatenumberofqualifiedpersonnelwerecited.
•Stakeholderscommentedthattransitioninvolvesasteeplearningcurvebecauseitisanentirelynewmannerofadministeringservices.
Thisshiftofteninvolvesre-training.
•Ahighturnoverrateinadministrativestaffwasobserved,evenafterre-training.
•Concernwasexpressedbyadvocatesthat“naturalsupports”and“familystabilization”wereoftenusedascodewordsforreasonstodenyadultsaccesstoout-of-homelivingarrangementstheyneedanddesire.
Manyrespondentswereadamantintheirviewthatwhenstateselecttoconstructamanagedcaredeliverysystemupontheframeworkofitscurrentsystemrisksitcreatesconfusionandoverlap.Itwasadvisedthatanewframeworkbeadoptedtoensurethattheuniquerequirementsofalong-termmanagedcaresystembeadequatelyaddressed.
PerspectivesofManagedCareCompaniestowardABDDesignWithproposalsforwrappingABDpopulationsintomanagedcareserviceprovisionsonthetableinmanystates,nationally-basedmanagedcarecompanieshaveexpendedresourcessolicitingfeedbackfromdisabilityadvocates,andafewhavesubmittedpolicypapers,statementsofintent,orphilosophytoguideon-goingdiscussions.
America’sHealthInsurancePlans(AHIP)andADAPT,anationaldisabilityrightsorganization,
supportthefollowingguidingprinciplesforservingindividualswithdisabilitiesthroughMedicaidhealthplanstopromoteavailabilityofservicesthatareresponsivetotheseindividuals’interestsandconcerns.
1.Regionaltraining:National,regional,state-based,andlocaltrainingshouldbedesignedandconductedthroughcollaborationofindividualswithdisabilities,healthplans,States,andotherstakeholders.Theseinitiativesshouldfocusonhowtheintegrationanddeliveryofacuteandcommunitylongtermservicesadvancecommunityintegrationprinciplessuchas:
1)consumerdirectedservices;
2)personcenteredplanning;
3)accessible,affordable,integratedhousing;
4)voluntaryservicecoordination;
5)deliveryofservicesinthemostintegratedsetting;
6)accesstoindependentcommunity-basedservicecoordinators;
7)serviceplanresponsivetotheuniqueneedsofindividualenrollees,includingaccesstonetworkandoutofnetworkspecialists,whohaveexperienceinservingindividualswithdisabilities;
“America’sHealthInsurancePlans(AHIP)andADAPT, anationaldisabilityrightsorganization, supportthefollowingguidingprinciplesforservingindividualswithdisabilitiesthroughMedicaidhealthplans”
•RegionalTraining•Ongoingdialoguewithstakeholders, includingindividualswithdisabilities•Communityintegration•Outreachandeducation•Communityintegrationandconsumerdirectedservices•Controlofindividualhealthmaintenanceactivities•AccesstomedicalequipmentandassistivetechnologyAnumberofchallengeswereexpressedbyrespondents:
•Therewasunevenaccesstoindividualizedservicesbetweencounties.
•Problemsacquiringandmaintainingadequatenumberofqualifiedpersonnelwerecited.
•Stakeholderscommentedthattransitioninvolvesasteeplearningcurvebecauseitisanentirelynewmannerofadministeringservices.
Thisshiftofteninvolvesre-training.
•Ahighturnoverrateinadministrativestaffwasobserved,evenafterre-training.
•Concernwasexpressedbyadvocatesthat“naturalsupports”and“familystabilization”wereoftenusedascodewordsforreasonstodenyadultsaccesstoout-of-homelivingarrangementstheyneedanddesire.
Manyrespondentswereadamantintheirviewthatwhenstateselecttoconstructamanagedcaredeliverysystemupontheframeworkofitscurrentsystemrisksitcreatesconfusionandoverlap.Itwasadvisedthatanewframeworkbeadoptedtoensurethattheuniquerequirementsofalong-termmanagedcaresystembeadequatelyaddressed.
PerspectivesofManagedCareCompaniestowardABDDesignWithproposalsforwrappingABDpopulationsintomanagedcareserviceprovisionsonthetableinmanystates,nationally-basedmanagedcarecompanieshaveexpendedresourcessolicitingfeedbackfromdisabilityadvocates,andafewhavesubmittedpolicypapers,statementsofintent,orphilosophytoguideon-goingdiscussions.
America’sHealthInsurancePlans(AHIP)andADAPT,anationaldisabilityrightsorganization,
supportthefollowingguidingprinciplesforservingindividualswithdisabilitiesthroughMedicaidhealthplanstopromoteavailabilityofservicesthatareresponsivetotheseindividuals’interestsandconcerns.
1.Regionaltraining:National,regional,state-based,andlocaltrainingshouldbedesignedandconductedthroughcollaborationofindividualswithdisabilities,healthplans,States,andotherstakeholders.Theseinitiativesshouldfocusonhowtheintegrationanddeliveryofacuteandcommunitylongtermservicesadvancecommunityintegrationprinciplessuchas:
1)consumerdirectedservices;
2)personcenteredplanning;
3)accessible,affordable,integratedhousing;
4)voluntaryservicecoordination;
5)deliveryofservicesinthemostintegratedsetting;
6)accesstoindependentcommunity-basedservicecoordinators;
7)serviceplanresponsivetotheuniqueneedsofindividualenrollees,includingaccesstonetworkandoutofnetworkspecialists,whohaveexperienceinservingindividualswithdisabilities;
“America’sHealthInsurancePlans(AHIP)andADAPT, anationaldisabilityrightsorganization, supportthefollowingguidingprinciplesforservingindividualswithdisabilitiesthroughMedicaidhealthplans”
•RegionalTraining•Ongoingdialoguewithstakeholders, includingindividualswithdisabilities•Communityintegration•Outreachandeducation•Communityintegrationandconsumerdirectedservices•Controlofindividualhealthmaintenanceactivities•Accesstomedicalequipmentandassistivetechnology

8)deliveryofservicesbasedonindividualneedasdeterminedbyfunctionalassessment;
9)livablewage/benefitsforattendants;and10)comprehensive,continuousqualityimprovementprograms.
2.Ongoingdialoguewithstakeholders,includingindividualswithdisabilities:InestablishingandoperatingprogramstoprovideservicestoindividualswithdisabilitiesthroughMedicaidhealthplans,statesshouldensuresignificantstatewideandlocalongoingpublicinputinthedevelopmentofMedicaidhealthplancontractrequirementsandprogramdesignincludingeligibility,rates,
communityintegrationprinciples,andprogramrequirements.Aspartofthisprocess,healthplansshouldfacilitateongoing,activeparticipationbyindividualswithdisabilities.
3.Communityintegration:StateprogramsshouldincludeandadequatelyfundarequirementthatMedicaidhealthplansprovidecoveredindividuals,regardlessofageorextentofdisabilityorplaceofresidence,withtheoptionforservicestobedeliveredinthemostintegratedsetting,andthatservicesbebasedonafunctionalassessmentoutlinedinaperson-centeredplan.Toallowcoveredindividualstotakeadvantageofthisoption,statesshouldfacilitateaccesstohousingthatmeetstheindividual’sneeds.Accesstocommunityintegrationservicesshouldnotbelinkedtospecifictypesofhousing.
4.Outreachandeducation:Anaggressivestrategyofoutreachandeducationforpopulationswithalldisabilitiesregardlessofageshouldbeimplementedtoensurethattheseindividualshavetheinformationtheyneedtobeknowledgeableabouttheprogramsandservicesavailabletothem.
Theseeffortsshouldincludeuseofcommunitybasedorganizations,wheneveravailable,inthedevelopmentandimplementationoftheseoutreachandeducationinitiatives.
5.Communityintegrationandconsumerdirectedservices:Medicaidmanagedcareprogramsthatserveindividualswithdisabilitiesshouldofferhomeandcommunity-basedservicesasanoptionforcoveredindividualsregardlessofageorextentofdisability.ThereshouldbenoinstitutionalbiasinthefinancialorfunctionaleligibilitycriteriaforthecoverageoflongtermservicesandsupportsprovidedunderstateMedicaidmanagedcareprograms.Consumer-directedservicesshouldbeofferedasafirstdeliveryoptionforallcoveredindividuals.Toallowcoveredindividualstotakeadvantageofthisoption,statesshouldfacilitateaccesstoassistancewithlocatingaccessible,affordable,andintegratedhousingnotlinkedtotheirothercommunitysupportservices.
6.Controlofindividualhealthmaintenanceactivities:Coveredindividualsshouldhavetheoptionofdeveloping,negotiating,andimplementingplanstoacceptriskforandtakecontroloftheiractivitiesofdailyliving,instrumentalactivitiesofdailyliving,andhealthmaintenanceactivities.
Healthmaintenanceactivitiesshouldincludebutnotbelimitedto:1)medicineadministration;
2)catheterization;3)ventilatorcareincludingsuctioning;4)IVinjections;5)woundcare;
6)tubefeeding;7)bowelcare.Toexpandavailabilityofsuchoptions,statesshouldworkwithhealthplansandadvocates,includingthoserepresentingindividualswithdisabilitiesandnurses,toenactlawsthatamendnursepracticeacts.
[Note:GeorgiapassedHB1040in2010,givingindividualswithdisabilitiesthisoption,underhealthprofessionalorders,andaftertrainingbyaregisterednurse.]
7.Accesstomedicalequipmentandassistivetechnology:FundingshouldbeprovidedunderstateMedicaidmanagedcareprogramsforcoveragethatallowsindividualsaccesstoappropriatemedicallyorfunctionallynecessarydurablemedicalequipment(DME)andassistivetechnologythatwouldenhanceindependentfunctioningandpromoteindependentlivingforcoveredindividuals,includingprofessionalassessmentofneedandtypeofequipment,andset-upandtrainingforusers.
8)deliveryofservicesbasedonindividualneedasdeterminedbyfunctionalassessment;
9)livablewage/benefitsforattendants;and10)comprehensive,continuousqualityimprovementprograms.
2.Ongoingdialoguewithstakeholders,includingindividualswithdisabilities:InestablishingandoperatingprogramstoprovideservicestoindividualswithdisabilitiesthroughMedicaidhealthplans,statesshouldensuresignificantstatewideandlocalongoingpublicinputinthedevelopmentofMedicaidhealthplancontractrequirementsandprogramdesignincludingeligibility,rates,
communityintegrationprinciples,andprogramrequirements.Aspartofthisprocess,healthplansshouldfacilitateongoing,activeparticipationbyindividualswithdisabilities.
3.Communityintegration:StateprogramsshouldincludeandadequatelyfundarequirementthatMedicaidhealthplansprovidecoveredindividuals,regardlessofageorextentofdisabilityorplaceofresidence,withtheoptionforservicestobedeliveredinthemostintegratedsetting,andthatservicesbebasedonafunctionalassessmentoutlinedinaperson-centeredplan.Toallowcoveredindividualstotakeadvantageofthisoption,statesshouldfacilitateaccesstohousingthatmeetstheindividual’sneeds.Accesstocommunityintegrationservicesshouldnotbelinkedtospecifictypesofhousing.
4.Outreachandeducation:Anaggressivestrategyofoutreachandeducationforpopulationswithalldisabilitiesregardlessofageshouldbeimplementedtoensurethattheseindividualshavetheinformationtheyneedtobeknowledgeableabouttheprogramsandservicesavailabletothem.
Theseeffortsshouldincludeuseofcommunitybasedorganizations,wheneveravailable,inthedevelopmentandimplementationoftheseoutreachandeducationinitiatives.
5.Communityintegrationandconsumerdirectedservices:Medicaidmanagedcareprogramsthatserveindividualswithdisabilitiesshouldofferhomeandcommunity-basedservicesasanoptionforcoveredindividualsregardlessofageorextentofdisability.ThereshouldbenoinstitutionalbiasinthefinancialorfunctionaleligibilitycriteriaforthecoverageoflongtermservicesandsupportsprovidedunderstateMedicaidmanagedcareprograms.Consumer-directedservicesshouldbeofferedasafirstdeliveryoptionforallcoveredindividuals.Toallowcoveredindividualstotakeadvantageofthisoption,statesshouldfacilitateaccesstoassistancewithlocatingaccessible,affordable,andintegratedhousingnotlinkedtotheirothercommunitysupportservices.
6.Controlofindividualhealthmaintenanceactivities:Coveredindividualsshouldhavetheoptionofdeveloping,negotiating,andimplementingplanstoacceptriskforandtakecontroloftheiractivitiesofdailyliving,instrumentalactivitiesofdailyliving,andhealthmaintenanceactivities.
Healthmaintenanceactivitiesshouldincludebutnotbelimitedto:1)medicineadministration;
2)catheterization;3)ventilatorcareincludingsuctioning;4)IVinjections;5)woundcare;
6)tubefeeding;7)bowelcare.Toexpandavailabilityofsuchoptions,statesshouldworkwithhealthplansandadvocates,includingthoserepresentingindividualswithdisabilitiesandnurses,toenactlawsthatamendnursepracticeacts.
[Note:GeorgiapassedHB1040in2010,givingindividualswithdisabilitiesthisoption,underhealthprofessionalorders,andaftertrainingbyaregisterednurse.]
7.Accesstomedicalequipmentandassistivetechnology:FundingshouldbeprovidedunderstateMedicaidmanagedcareprogramsforcoveragethatallowsindividualsaccesstoappropriatemedicallyorfunctionallynecessarydurablemedicalequipment(DME)andassistivetechnologythatwouldenhanceindependentfunctioningandpromoteindependentlivingforcoveredindividuals,includingprofessionalassessmentofneedandtypeofequipment,andset-upandtrainingforusers.

TheNationalAdvisoryBoardonImprovingHealthCareServicesforSeniorsandPeoplewithDisabilitiesproposes“Sixprinciplesnecessarytomodernizeourhealthcareinfrastructure.”ThesesupportAHIP’sandADAPT’sprinciples.
•Enhanceself-carethroughimprovedcoordination•Encouragecommunityintegrationandinvolvement•ExpandAccessibilityofServicesandSupports•Upholdpersonalpreference•Empowerpeopletoparticipateintheeconomicmainstream•InvestinimprovedtechnologyWhilethisconsensusdocumentdoesnotspecificallyaddressmanagedcaresystemschange,itreiteratesprinciplesforintegratinglongtermcareandhealthcarethroughflexiblefunding,betteruseoftechnology,incorporationofcommunitysupportsandindividual,person-centeredplanningtoenhanceservicedelivery.Manyofthesesameconceptshavebeenadvancedinthecontextofmanagedcare.
AdvicetodisabilitystakeholdersinotherstatesTheexperienceofthesefourstatesdescribeshowamanagedcareplancanbeavehiclethatprovideseligibleindividualswithreasonablypromptaccesstothelongtermsupportstheyneed.Mostoftheindividualsservedwouldsaythattheyarebetteroffthanindividualsinstateswithlongwaitinglists,
despitethefactthatnoneofthestateshavesolvedalltheservicedesignchallenges.However,allwouldagreethathastilyconceivedplansthatareaimedprimarilyatslashingstateoutlayscanhavedisastrousconsequences.TheNationalConsortiumconcursonthefollowingrecommendationsforstatesconsideringtransitiontomanagedcare:
Design•Assessindividualstates’situationscarefullybeforerestructuringpublicly-financedlong-termservices.
•Makesuretheplanclearlyreflectscorevaluesintendedtobeinstilledintheprogram.
•Involverepresentativesofkeystakeholdergroupsinallaspectsofdevelopmentandimplementation.
•Taketimetoresolvepotentialissuesduringdesignandinitialimplementationphases.
•Understandthestate’sprimarymotivationsforadoptingamanagedcareplanandfocusontheactionsnecessarytosecuretheinterestsofpeoplewithDD.
•Designtheplantopromoteefficientuseofavailableresources.
Implementation•Makesurethatthestateagencyresponsibleforimplementingtheprogramhasthenecessaryresourcestoactivelyoverseeandenforceperformanceexpectations.
•Includespecialinitiativestoensurethatthegoalsofcommunityinclusion,
participation,independenceandproductivityarereflectedinthelivesofprogramparticipants.
“hastilyconceivedplansthatareaimedprimarilyatslashingstateoutlayscanhavedisastrousconsequences”
TheNationalAdvisoryBoardonImprovingHealthCareServicesforSeniorsandPeoplewithDisabilitiesproposes“Sixprinciplesnecessarytomodernizeourhealthcareinfrastructure.”ThesesupportAHIP’sandADAPT’sprinciples.
•Enhanceself-carethroughimprovedcoordination•Encouragecommunityintegrationandinvolvement•ExpandAccessibilityofServicesandSupports•Upholdpersonalpreference•Empowerpeopletoparticipateintheeconomicmainstream•InvestinimprovedtechnologyWhilethisconsensusdocumentdoesnotspecificallyaddressmanagedcaresystemschange,itreiteratesprinciplesforintegratinglongtermcareandhealthcarethroughflexiblefunding,betteruseoftechnology,incorporationofcommunitysupportsandindividual,person-centeredplanningtoenhanceservicedelivery.Manyofthesesameconceptshavebeenadvancedinthecontextofmanagedcare.
AdvicetodisabilitystakeholdersinotherstatesTheexperienceofthesefourstatesdescribeshowamanagedcareplancanbeavehiclethatprovideseligibleindividualswithreasonablypromptaccesstothelongtermsupportstheyneed.Mostoftheindividualsservedwouldsaythattheyarebetteroffthanindividualsinstateswithlongwaitinglists,
despitethefactthatnoneofthestateshavesolvedalltheservicedesignchallenges.However,allwouldagreethathastilyconceivedplansthatareaimedprimarilyatslashingstateoutlayscanhavedisastrousconsequences.TheNationalConsortiumconcursonthefollowingrecommendationsforstatesconsideringtransitiontomanagedcare:
Design•Assessindividualstates’situationscarefullybeforerestructuringpublicly-financedlong-termservices.
•Makesuretheplanclearlyreflectscorevaluesintendedtobeinstilledintheprogram.
•Involverepresentativesofkeystakeholdergroupsinallaspectsofdevelopmentandimplementation.
•Taketimetoresolvepotentialissuesduringdesignandinitialimplementationphases.
•Understandthestate’sprimarymotivationsforadoptingamanagedcareplanandfocusontheactionsnecessarytosecuretheinterestsofpeoplewithDD.
•Designtheplantopromoteefficientuseofavailableresources.
Implementation•Makesurethatthestateagencyresponsibleforimplementingtheprogramhasthenecessaryresourcestoactivelyoverseeandenforceperformanceexpectations.
•Includespecialinitiativestoensurethatthegoalsofcommunityinclusion,
participation,independenceandproductivityarereflectedinthelivesofprogramparticipants.
“hastilyconceivedplansthatareaimedprimarilyatslashingstateoutlayscanhavedisastrousconsequences”

•Makesurethatcommunityprovideragencieshavethetoolsandthequalificationsnecessarytoprovidehighqualitysupports.
•Developprovidercapacityinallareasofthestatetoprovidemeaningfulchoice.
ThreeConcludingThoughtsFirst,havingastateagencyserveasthehubofamanagedcaresystemratherthanplacingitinanon-governmentalmanagedcareorganizationmakesmoresenseiftheprimarygoalistoprotecttheinterestsofthetax-payingpublicandassurepublicaccountabilityforservices.
Second,integratinghealth,behavioralhealthandlongtermcareservicesmayprovideclearbenefitsifonestateagencycanco-managethedifferentstreams.
Finally,theimportanceofavalue-basedpolicyfoundationcannotbeoverestimatediftheriskofover-medicalizinglongtermcareservicesistobeavoided.
References“DeclarationforIndependence:ACalltoTransformHealthandLongTermServicesforSeniorsandPeoplewithDisabilities.”TheNationalAdvisoryBoardonImprovingHealthCareServicesforSen-
iorsandPeoplewithDisabilities,April,2009.
NationalLeadershipConsortiumonDevelopmentalDisabilities,(2009).Reassessingtheimpactofmanagedcareinthedevelopmentaldisabilitiessector.PolicyInsightsBulletin, 1.
Saucier,P.,Burwell,B.,&Gerst,K.(2005).ThePast, PresentandFutureofManagedLongTermCare.Cambridge,MA:Medstat.
ForMoreInformationPleaseContact:
PatriciaD.Nobbie,Ph.D.
GeorgiaCouncilonDevelopmentalDisabilitiesTwoPeachtreeSt,Suite26-230,Atlanta,GA30303Phone:404-657-7409Fax:404-657-2132TollFree:888-275-4233
Email:pnobbie@dhr.state.ga.us•Makesurethatcommunityprovideragencieshavethetoolsandthequalificationsnecessarytoprovidehighqualitysupports.
•Developprovidercapacityinallareasofthestatetoprovidemeaningfulchoice.
ThreeConcludingThoughtsFirst,havingastateagencyserveasthehubofamanagedcaresystemratherthanplacingitinanon-governmentalmanagedcareorganizationmakesmoresenseiftheprimarygoalistoprotecttheinterestsofthetax-payingpublicandassurepublicaccountabilityforservices.
Second,integratinghealth,behavioralhealthandlongtermcareservicesmayprovideclearbenefitsifonestateagencycanco-managethedifferentstreams.
Finally,theimportanceofavalue-basedpolicyfoundationcannotbeoverestimatediftheriskofover-medicalizinglongtermcareservicesistobeavoided.
References“DeclarationforIndependence:ACalltoTransformHealthandLongTermServicesforSeniorsandPeoplewithDisabilities.”TheNationalAdvisoryBoardonImprovingHealthCareServicesforSen-
iorsandPeoplewithDisabilities,April,2009.
NationalLeadershipConsortiumonDevelopmentalDisabilities,(2009).Reassessingtheimpactofmanagedcareinthedevelopmentaldisabilitiessector.PolicyInsightsBulletin, 1.
Saucier,P.,Burwell,B.,&Gerst,K.(2005).ThePast, PresentandFutureofManagedLongTermCare.Cambridge,MA:Medstat.
ForMoreInformationPleaseContact:
PatriciaD.Nobbie,Ph.D.
GeorgiaCouncilonDevelopmentalDisabilitiesTwoPeachtreeSt,Suite26-230,Atlanta,GA30303Phone:404-657-7409Fax:404-657-2132TollFree:888-275-4233
Email:pnobbie@dhr.state.ga.us