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The Changing Landscape of Californias Service Delivery System for Older Adults and Persons with Disabilities

Prepared for the California Association of Area Agencies on Aging


March 21, 2012

Laurel Mildred, MSW Mildred Consulting and Advocacy

Hopes and prayers, the general desire to do good without knowing how, seem to us frail reeds on which to lean, though these are the bases on which many programs are begun.
-Pressman and Wildavsky, Implementation, 1984

Drivers of Systems Change


Economic Recession: Began December 2007, officially ended 18 months later, in June of 2009, but recovery very slow
Health Care Reform: Patient Protection and Affordable Care Act March 23, 2010

Recession
Twenty-eight states project that 2012 tax revenues will come in below pre-recession levels Since 2008/09, California has cut $15 Billion from health and human services programs, consequently losing another $15 Billion in matching federal funding

Cuts have included SSI/SSP, Medi-Cal and other health services, Adult Day Health Care, mental health and substance abuse funding, reductions in services for people with developmental disabilities, IHSS, senior services and nutrition programs. Completely de-funded Older Californians Act programs including Alzheimers Day Care Resource Center, Brown Bag, Linkages, Respite Purchase of Services and the Senior Companion program.

According to the California Budget Project, fiscal year 2010-11 General Fund spending in California was lower as a share of the States economy than in 33 of the prior 40 years.

Health Care Reform (ACA)


Reformed private and public health insurance systems. Increased coverage for people with pre-existing conditions. Creation of state health insurance exchanges to create more affordable coverage. Provided an expansion of health coverage to over 30 million Americans. Included expansion of Medicaid eligibility to 138% of federal poverty level, which Kaiser estimates will cover 1.4 million Californians by 2016. One-fifth of these are expected to have mental health and/or substance use disorders.

ACA Included LTSS Reform


$200 Billion spent on LTSS nationally each year; CA spends $13 Billion. Community First Choice Option for Personal Care Services. Extension of Money Follows the Person. Expansion of Aging and Disability Resource Centers. Creation of Medicaid Health Homes (90% match). Creation of Community Care Transition Program.

ACA LTSS Reform, Cont.


Expanded 1915(i) state plan option to increase HCBS. Workforce investments. Authority to Secretary HHS to emphasize HCBS. CLASS LTC Insurance Act (tabled; SB 1438 Alquist proposes CA CLASS Act). Established Center for Medicare/Medicaid Innovations. Established Medicare-Medicaid Coordination Office (Office of the Duals).

Risks in State ACA Implementation


Weak economy continues to drive Medicaid enrollment up. Medicaid expansion will cost states; FMAP begins at 100% and declines to 93% by 2019. Loss of ARRA federal stimulus funds in 2009. Per capita health care costs increasing faster than economy. Congressional budget actions. Lack of final regulations to guide implementation. Pending litigation in U.S. Supreme Court.

However, the incentives of the ACA combined with state budget distress are driving rapid change. Many states are undergoing or about to undergo a dizzying array of LTSS transformations. -On the Verge report

California is among them.

State Solutions
Managed Long-Term Services and Supports (MLTSS) A plan in which a contractor, a managed care organization, is responsible for providing beneficiaries with a defined set of services in exchange for a pre-paid capitation payment. Includes both skilled nursing and home and community-based services.

12 States already have Medicaid MLTSS programs 11 More States are implementing them in 2012-13 In addition, 28 States are undertaking dual eligible integration projects

Current CA Managed Care Models


Two Plan Model: State contracts with 2 plans: a local initiative (locally developed and operated), and a commercial plan. Available in 14 counties, serving 3 million beneficiaries County Organized Health System: One health plan administered by a public agency and governed by an independent board. 6 health plans available in 14 counties, serving 850,000 beneficiaries

Geographic Managed Care: State contracts with several commercial plans in a county
Available in 2 counties, serving 450,000 beneficiaries Steenhausen, 2012

Californias Bridge to Reform


SB 208 (Steinberg, Chapter 714, Statutes of 2010). Authorized 5-year 1115 waiver. Made $8 Billion federal Medicaid funding available in CA for uninsured adults and improvements to county safety-net. Mandatory enrollment of Medi-Cal seniors and persons w/disabilities into managed health care (91,000 were enrolled in first three months).

SB 208 also provided authority for


integrated Dual Demonstration projects in up to four counties. One county was required to be a County Organized Health System and one Two-Plan County. California was among 15 states to win a $1 million grant from CMS to plan the Demonstration.

Persons Who are Dual Eligible


Low-income individuals who qualify for Medicare & MedCal. 37% have both chronic conditions and functional limitations. Utilize more Medicare than non-duals. Also high utilizers of Medicaid services. California has 1.2 million people who are dual eligible. 71% are 65+ / 29% under 65. Within Medi-Cal 7% of beneficiaries, mostly in institutional care, account for 75% of program costs. Today, only 15% of persons who are dual eligible are enrolled in managed care.

Process for Developing the Dual Demonstration


Policy development, stakeholder outreach, 5 public stakeholder meetings, release of draft site selection criteria, and revision and release of final site selection criteria have taken place over the past 6 months.

Upcoming Processes:
March 2012 - Announcement of site selections Spring 2012 - Review and approval of CA proposal by CMS Summer 2012 - Development of 3-way financial contracts August/September - 2012 Readiness Review January 2013 - Launch

Key Issues With the Dual Demonstration Model


No Pass-Throughs (Blended Capitation Rate w/Full Risk) Transition Services No Enrollment Lock-in Do Not Score Up-front Savings Person-Centered, Independent Assessment Housing IHSS Consumer Direction Improvements to Behavioral Health Disability Access Quality Incentives Through Performance Measures

Counties that Have Applied for the Dual Eligible Demonstration


Alameda 2 Contra Costa 1 Orange 1 Los Angeles 3 Riverside 3 San Diego 5 Sacramento 1 Santa Clara 2 San Bernardino 3 San Mateo - 1

Designing a System in Mid-Air


Although the State has issued the Request for Solutions for the Dual Demonstrations and received 22 applications from 10 counties, the program is still being designed, with many program details to be determined in trailer bill language that has yet to be released.

Duals Coordinated Care Initiative Stakeholder Workgroups


Managed Care Organizations Beneficiary Notification, Appeals, Protections Provider Outreach and Engagement LTSS Integration, Network Adequacy Mental Health/Substance Use Disorder Services Integration Quality Outcome Measurements and Data Management Fiscal and Rate Setting www.calduals.org @calduals

But Wait, Theres More


Governors Coordinated Care Initiative within State Budget Adds Three Additional Expansions of Managed Care: 1) Initial Dual Demonstration expanded from 4 counties to ten in year one (2013), to other managed care counties in second year, and statewide in 2015. 2) Outside of the Dual Demonstration, also requires phased-in mandatory enrollment of all Medi-Cal beneficiaries into managed care for full continuum of services, including LTSS. 3) Beginning June 1, 2013, expands Medi-Cal managed care in rural counties that are currently fee-forservice.

Medi-Cal HCBS: In-Home Supportive Services (IHSS) Adult Day Health Care/Community-Based Adult Services Medi-Cal HCBS Waivers: Multipurpose Senior Services Program Assisted Living Waiver HCBS Waiver for the Developmentally Disabled Acute Hospital Waiver AIDS Waiver - Steenhausen, 2012

Options and Strategies to Impact the Developing System


1) Protect Caregiver Resource Centers from Being Cut in State Budget
Role of family caregivers not well understood, as evidenced by CRC elimination proposal. Raising Expectations ranked CA 30th on caregiver support. Potential for strategic campaign to educate policymakers and salvage CRC services.

2) Advocate to Re-invest Savings, Restore Older CA Act Programs

CA now one of only 7 states without state-only LTSS (AK, MS, MO, NH, NM, RI). In 2012, 12 states will increase these programs to help with rebalancing, and 17 will hold their funding steady. Authorization remains for these programs despite their being de-funded.

3) Develop Bridges & Business Models to Contract with Managed Care Plans
States using innovative strategies to maintain these services; one strategy is inclusion in duals integration projects. Another is marketing services to other state agencies. Finally, it is critical to develop business models to contract with private sector partners such as managed care plans.

4) Promote Aging and Disability Resource Centers and Person-Centered Assessment


ADRCs can perform independent assessment, information and referral, screening, financial assessment for benefits qualification, referral for clinical assessment and other valuable services. Some states, such as New Jersey, are strengthening front-end role of ADRCs, making them the single point of system entry. State can get FMAP for some ADRC functions.

5) Strengthen the Role of the Older Americans Act in Managed LTSS Through Federal Authorization
OAA due for federal reauthorization. Bernie Sanders (I-VT) introduced S. 2037 in January 2012 to reauthorize. National Council On Aging working on this; could collaborate to strengthen the formal role of OAA programs within emerging dual eligible and other integrated managed LTSS programs.

Discussion Points
Is California moving too fast? Is the State giving adequate time for stakeholder input, preserving current system strengths, and developing good public policy?

Do policy proposals demonstrate knowledge of and take into account the value and needs of family caregivers? Do policymakers need information and education about the role, contribution and health risks of family caregivers?

What are the linkages between the new managed service delivery system and Older Americans Act programs? Are policymakers and managed care plans familiar with Older Californians Act programs that are currently authorized but not funded?
What strategies are necessary to begin collaboration with managed care plans and to develop business models for the aging and disability network to create contracting relationships with plans?

What role do policymakers envision for Aging and Disability Resource Centers in the developing system, and what are the most effective ways to leverage that role so that the aging and disability network makes a strong contribution to the system of care?

Laurel Mildred, MSW Mildred Consulting and Advocacy Policymaking with People in Mind Laurel.Mildred@mildredconsulting.com www.mildredconsulting.com 916-862-4903 @LaurelMildred

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