These are questions that were answered in a meeting with DHS and DDS Representatives regarding the organized care model that was recently presented by DHS. If you read and have further questions, please feel free to ask.
Please note: while many of these questions do apply to all DHS Medicaid recipients, we don’t have a lot of questions related to Behavioral Health or Aging because no one sent any. If you have them, please send them! We will be glad to try to get answers.
Location: Department of Human Services offices in Downtown Little Rock, Arkansas
Present: Melissa Stone (Director of DHS Developmental Services); Brian Bowen (DHS Chief of Staff); Lainey Morrow (MSL Founder); Katy Sursa (MSL Leadership Team)
Katy (K): We’ve heard about the tiers. How will the tiers be determined, and can you explain the tiers system and the eligibility criteria for each tier?
Melissa (M): So the tiers and eligibility is going to be different for DDS than it is for Behavioral Health because they’re different populations, and we’re treating a little bit differently. For DD, if you go through intake, and you fill out an application packet, and you say I think my child meets institutional level of care criteria, just like you would today, you’d call intake. You’d ask for an application, and on the application you can select whether or not you want to be on the Community Based Waiver, whether you want to go to a Human Development Center, whether you want to go to a state-run intermediate care facility or a group home. That process is not changing, so you’ll get through the front door the same way you always have – going through intake, filling out the application, sending in the appropriate testing for what the application asks for – and then the DDS psychology unit will make a determination, just as we always have, on whether you meet the institutional level of care criteria. If you meet that criteria, in order to determine functional need, those individuals are going to go through the Independent Assessment process. So if you meet institutional level of care, then you’ll be referred to an independent third-party assessor, who will implement an independent assessment and determine whether or not you fall into Tier 2 or Tier 3 for DD. And basically the difference is pretty simple. Tier 2 is you do not need 24 hour care, and then Tier 3 is you really need 24 hour care. So it’s a needs based risk assessment type tool. So really, if you think about it, it’s just affecting the people on our waiver, right now on the DDS wait list – because they’ve met that institutional level of care criteria to get on the wait list – and those that are living in private intermediate care facilities.
K: Okay, so if Level 2 is you don’t need 24 hour care, what’s the difference between Tier 1 and Tier 2?
M: So Tier 1 is individuals who do not meet institutional level of care. That’s a really large bucket for us. We provide a lot of services to children and adults who might have developmental disabilities and delays, but it doesn’t meet that definition of institutional level of care, which is basically you have to have one of the 5 categorically qualifying diagnoses: cerebral palsy, autism, spinal bifida, down syndrome, or a severe intellectual disability IQ-wise. And then you have to have two deficits in your ADLs that really impair you in daily living. So it’s a combination of those criteria that qualify you for institutional level of care. So there’s thousands of Arkansans that right now are just getting basically what I guess I would call a basic service level of therapy, and that’s kids and adults that are just getting outpatient Speech, OT, and physical therapy. And those that are getting more intensive therapy at a CHMS or a DDTCS. But if you cross that threshold, and you get qualified for institutional level of care, then you would fall into Tier 2 or Tier 3.
Lainey (L): Someone has mentioned that the TEFRA application has wording that would qualify you. Is that correct?
M: No, they’re getting that confused because here in Arkansas, being on TEFRA does not automatically qualify you for the DDS waiver, but in many states it does. So you have to meet that SSI definition of being disabled to be on TEFRA, but our [DHS] institutional level of care definition is different. I am [checking] the TEFRA form because I think there’s something on the form…
Brian (B): Something just from the national, yes…
M: One sentence that’s making this confusing and that’s making the TEFRA parents anxious and confused about it.
L: Then someone mentioned that if managed care, or this particular model, is being applied for cost savings, that’s one of the reasons, aren’t there a large amount of people in Tier 1 that aren’t going to generate cost savings?
M: We do have a large amount of people in Tier 1, but we made a determination at DHS to stick with Tier 2s and Tier 3s for DD and BA. You have to remember when you’re just thinking about DD it sounds like a really small amount of people, because it’s only like 8,000 people, but when you add in the 30,000 people for Behavioral Health that we’re going to mix together and kind of pool, we have enough on our plate. We think there’s enough cost savings there, because I think Dennis mentioned this on Friday, for those 30,000 people, we spend one billion dollars, so we think that there are ways to make that more efficient. And we think doing better care coordination and case management to give people the services they need is going to bring those efficiencies.
B: The other thing too that is different with this model, and I think that there is some misconception – this is not managed care. Full capitated managed care is different from this model. So in this model, it’s provider led, provider owned, and as Melissa was saying, really the focus that we see from an agency perspective is better care for the patients that we serve. We think that through this model and through the providers dictating the road that they take for their patients, they’re at a far better place to determine that than a managed care company coming in and saying, “OK. This is the way its going to be.” This model says, “OK. We as providers think that we need to offer X, Y, and Z services. We’re not tied by Medicaid essentially anymore” to offer innovative services or things that they can’t get reimbursement for currently through Medicaid because of the regulations that we have on us.
M: That’s why you’ll hear many of the DD providers promoting this model because as Brian was saying, we’re very restricted in terms of how we define how and when you’re paid and for what service, and this is going to allow, like he said for innovative, just things that you would want that currently right now Medicaid doesn’t reimburse for. The first thing that comes to my mind is equestrian therapy. We get asked for that a lot. That’s not one of the things that we cover. Or even a service dog. Things that go with a service dog, and service dogs can be very beneficial to a lot of clients… I mean it’s just a way of just saying, okay you’re an expert; here’s your money, and you figure out what they need. Rather than me saying, you only get X, Y, and Z. Because that’s how we’ve [DHS] been doing it all these years, and we think we can do better.
L: If Tier 1 is not affected, and the more “disabled” populations are in Tier 2 and 3, aren’t you going to hurt the more disabled people by only applying these changes to them?
M: No, I’d be surprised if that question came from one of our DD providers that I work with all of the time because they have a different mindset. I think people see [how their hands] are tied with how we currently pay, and I think this will allow flexibility and better care coordination. We’re kind of in this stage where we’re making a shift to a different model, and this is just a really good option for us. And we’ve been talking about care coordination and case management with the DD provider network for the past 2 years. And so I would say that for them, they’re excited about this. It might be scary to parents and guardians of people on the waiver because they think that we’re going to have to make some sort of shift in their services. There might be a shift, but I think it will be a better shift. We’re not going to do anything that puts clients’ health and safety at risk. That’s a standard that we will not lower.
K: One of the questions that was brought to us is clarifications on a benefits cap. Somehow it got out that there was a benefits cap, and beneficiaries would be capped at an amount and have to choose services which could result in families having to choose either day-hab or therapy. Can you expound on that?
M: So I think there’s 2 principles getting mixed up here. As you guys know, we passed through the legislature the 90 minute threshold to try to bring back some integrity and to try to push it back toward outcomes when we talk about therapy for children and adults. Those are Tier 1 recipients mostly, and some of the DDTCS and CHMS. I think they’re getting that confused when we talk about for Tier 2 and Tier 3, there will be an administrative payment inserted into the PASSE’s global payment, depending upon whether or not you fall into Tier 2 or Tier 3. But it’s not a benefit cap because there’s no way of doing that. Each client will receive the services that they need. Whereas the PASSE will get a global payment, there’s not necessarily a little cap on each person’s head that says this is all you can spend on A and B and C. They get a global payment, and then similar to an insurance pool, you know, I might not go to the doctor all this year, and they’re banking on that. We hope that, whereas someone else might be really sick and have to get their appendix out. That’s kind of the risk pool that they take on. So there’s no cap. But there will be the 90 minute threshold and that’s completely aside from this. But we said when we ran that through the legislature, we guarantee that we would put a really quick Prior Authorization process in place where we guarantee a 72-hour turn around for the PA process or the EOB process. And we guaranteed Pediatric clinicians in the field that they are evaluating.
B: And there’s an extension of benefits as well.
M: So if we can figure out, I mean if they need more therapy, they’re going to get more therapy.
K: There are certain service requirements on the waiver that you have to be enrolled in X amount of therapy in order to continue and continue to get your services if I understand that right?
M: [confusion] No…
K: So one of our parents came to me and said that in order to be on what she called the Autism waiver…
M: So that’s different.
K: That’s a different waiver? So she’s thinking that this waiver that we’re talking about incorporating in that. Because the Autism Waiver has 2o hours of therapy required.
M: Yeah, it does. Parent involvement. So the Autism Waiver is completely apart from this. Completely separate. You know, it’s a very limited kind of piloted waiver. We only serve 100 kids. There’s a huge parent involvement component. It’s working. It’s really working. That has nothing to do with any of this. She’s cool. If she needs to call me, she can.
K: If it is results based on therapy, there will be some kids who have physical therapy for 15 years and never end up walking. What results are we looking for?
M: So there’s no other way to do this but to look at outcomes. If we continue to set plans of care, which is a requirement for therapy, and we continue to set annual outcomes, which is also right now a requirement, we just have not been, we need to be doing a better job of it. If therapy is not working, we need to come up with a different route. I think that’s fair. Because for the kids and adults where therapy is working, then we need to be able to extend it and give them more.
K: I guess my question, if I could clarify, is who will be setting the outcomes? Will the therapist be setting those outcome goals or will it be, well if you’re getting physical therapy, then you must be doing A, B, and C, kind of prescribed outcomes that we’re looking for?
M: No, so the therapists will tell you, Speech, OT, and PT, they are required to put an outcomes measure in their evaluations. That’s something that we want to look for during the Prior Authorization or Extension of Benefits process. Is that outcomes measure in there? That will be something we review, and is it attainable? And then, is it working? So that will all be directed by the child or adult’s therapist. And then we’ll be looking to see that it’s in there, and that they are hitting outcomes. And I don’t want to scare people because my own son had therapy for a year and didn’t progress much. And then this year, he got it. You know? And so it’s not to say that if you don’t hit all your outcomes then it’s not working. It’s just that we need to regroup and be mindful and be looking at them.
L: So there’s no diagnosis where they really don’t ‘get it’ for so many years? I just wonder about individual diagnoses. So that’s not a possibility? Would you just deal with that on an individual basis?
M: Well, your therapist should be setting outcomes that are attainable to your diagnosis. Those outcomes are supposed to be set on an annual basis, and that’s under their requirements. So they need to be setting doable outcomes that can be met if therapy is working.
K: So what I hear you saying is that if a therapist sets an annual eval, and says that a child will be, say, at this point, and then they achieve that point, then that’s a desired outcome. But if they say they’ll be at this point, and they’re just below it, but show progress, is that still a desired outcome?
M: Yes. So nothing in the EOB process is going to say if you don’t hit every outcome at 100%, you don’t get it anymore. It’s just really making sure we get back to that quality metric of evaluations. Really getting back to the basics. And sitting down and setting up a feasible plan of care with outcomes inserted in it. Because we’re seeing evaluations that have neither. And you know, you get to the point where it’s like what’s the purpose? If you’re not going to be planning to hit a goal, what are we doing? So it will be better for the client. It should be something that we’re all trying to achieve, and everybody is on the same page. And I think it will inform parents more, and they’ll know what they need to be doing. Because I’ve found that sometimes it’s hard to understand what you’re trying to get to by the end of a therapy year. We need to get back to that so everybody knows what we’re doing.
K: According to the past information document, DDTCS and CHMS centers are Tier 1 services, but I also heard that Melissa Stone said that most of our DDTCS kids would fall into Tier 2 and Tier 3.
M: Lainey was at the meeting. I’d have to go back and look at our numbers. We probably have right now under 1000 children receiving waiver services and maybe 1000 children on the wait list. So it might be true that those couple thousand also go to a CHMS or DDTCS. But our recent numbers had showed that we have a lot more kids than that going into a CHMS or DDTCS that are not on our waiver or our wait list. Just because you’re a Tier 2 or Tier 3, you know, we still pay for people to go to a day-habilitation. We don’t want to stop that. It’s a good service for clients to get out in the community. We’re trying to broaden that so we can actually get out in the community more. But we don’t want to do anything that would stop people from interacting and being out in the community. But no, there’s very limited kids right now that this is going to affect.
K: One question in regards to the cost savings, the 3-5 year olds fall under Free and Appropriate Education, so if we cut their services, and they fall into this Tier system, and they end up getting cut… if it’s written into their IEP that they get X amount of therapy or X amount of services, then that would fall to the Department of Ed. So then are we necessarily cutting out of the budget, or are we just cost sharing?
M: So the Department of Ed Special Education unit and of course DDS work together as you can imagine work together very often, and they were fully in support of the 90 minute threshold. And when you go back and look, we had the therapy broken down by where the children were getting the therapy, and then we broke it down to in those buckets, how many kids were getting more than 90 minutes a week. For the children getting therapy at school, the thresholds are going to be very minimum for them because they’re already doing it. And the reason that the Department of Special Ed was in support of this is because they believe that while kids are in school they should be in the classroom receiving an education, and they’re promoting a model where therapists are coming into the classroom with them. And they’re seeing an increase in therapy, not to speak on their behalf, but I think they would tell you the same thing, where they see it almost as a detriment the amount of hours that kids are being pulled out of school to get therapy, and then being brought back and then trying to catch back up. So they were in support of this. Now as far as the IDEA, and we of course fully support the IDEA and feel like every child should get exactly what they need, and yes, if an IEP recommends it over 90 minutes, they will get the over 90 minutes. Yes, you’re right. So Medicaid will pay for certain therapy right now if it’s medically related. If it’s school-based related therapy, the school district is already supposed to be picking it up.
K: Right. But some of these kids are in centers like DDTCS centers and CHMS centers, and they’re 4. They’re not old enough. They’re not in the public school yet. Or some of them are 5 because you know, kindergarten waiver, they’re waiting until 6. Does that still fall to Medicaid, or does it fall on the center then, or does it fall to the Department of Ed?
M: So there’s a couple of different payment methodologies that go along with those kids. We run 2 programs over at DDS called the First Connections, which is a fully federally funded grant, and then we run a Part B grant. And both of them has a piece that complies with the IDEA. We have been putting a big push on working with the Department of Ed to go in and explain to parents when they sign kids up for those programs for CHMS or DDTCS, that they understand that they are essentially opting out of their rights under the IDEA because those programs are not mandated to have special ed teachers. But we want to ensure that parents when they sign them up are understanding that. Because many of these kids could be getting IDEA services from the school districts in their area. And so it’s a whole opt out form we’ve been creating and going around talking about it. It’s really complicated.
K: We would like clarification or details on the IA process that would be used for Tier determination. Who will administer this assessment? What will their qualifications be? How long will the independent assessment take?
M: Yeah, so I don’t know any of that right now. We wrote what we think is this really good RFP, and we are in the process of awarding it. It should be awarded probably the first couple weeks of March. We left a lot of flexibility in that RFP in terms of letting respondents tell us the best tool and the best way to administer it with the most qualified ‘administerers’. So we had some preliminary criteria – you can’t be below this, and we need you to have administered 50,000 DDS assessments in other states. So we had some benchmarks, but then we left it open to you tell us how you would do this. But I will tell you some of the fears is parents think that we’re going to make them drive to them. No, we put in there that we expect them to set up an appointment that’s convenient for the family. We already do some Independent Assessments in DDS, and we mandate that they go to the person. We know that transportation and time is a problem for many clients, and so we expect the vendor to go to them. And we got a lot of good respondents, and whoever is selected is going to be a good one just based on who responded. It was some good groups, so we are excited about it. And we should know more when we are actually are able to open that envelope the first of March. We’re anxious as you guys are because we want to implement July 1, and so we’re ready to get this thing going.
B: And that’s also part of the RFP process is education in the community, with parents…
M: So we put in there that they have to do so many state wide trainings, and phone trainings, and one-on-one trainings to our stakeholders, which parents are included in that, so people understand what’s happening.
K: This is from one of our therapists, she said, I would like more detailed information on how clients are placed into the Tier levels. Exactly what functional needs assessment are they going to utilize?
M: If you get on the DD sections, you’ll see what we mandated that be included in the assessment like natural supports, certain kinds of risk, and there’s like a laundry list of what we wanted the assessment instrument to be able look for. And we know whoever gets this bid has a tool that will do that, or they wouldn’t have met minimum qualifications, and they wouldn’t even be in the running.
L: A parent has asked – which they’re thinking of capitated other state examples – with this model, are they going to have to change doctors?
B: The intent is to have very minimal impact on the beneficiaries and recipients of services. We foresee it as all physicians, all providers, opting into the model. There may be some that don’t, but I think it’s going to be very few. And that’s something that’s outside of our control, that’s the reality of it.
L: But that’s a fear with capitated in other states that physicians have opted out. So that’s not something you anticipate?
B: [ Shaking head indicating No.]
L: Also, someone had asked would out of state physicians be somehow be cut out here, or is that still the same coverage as it has been?
B: It’s the same as insurance.
M: No, if you need to go to a hospital out of state, we send them lots of paperwork, and they fill it out and become Medicaid providers, and we certify them for whatever service. So that won’t change.
B: And we anticipate too, especially on the border towns, where you may have a physician in Texarkana, Texas, opting into this program because they see so many kids from Arkansas.
M: And they are a Medicaid provider.
L: We talked about for example, my daughter has a diagnosis, she would be assessed, which is supposed to happen once per year…
M: If she’s a Tier 2…
L: So assuming she were a Tier 2, and she had gotten her assessment. That is basically what you have described as a shell of the care she needs, the assessor kind of builds it. With my child’s diagnosis, there are possibilities that could pop up at any time. How do you anticipate those things? Like leukemia.
M: It’s the same concept we were talking about earlier when we were talking about an insurance pool. That’s why we have to get away from this rumor that each child has a set dollar amount hanging over his or her head. Because that’s not the way that this operates. I think when we talked about a set number it’s because we’re going to set an admin amount for whether or not you’re Tier 2 or Tier 3 that’s going to be a big part of the global payment. But it’s not going to be Joe’s got $500 and Frank’s got $200. It’s just not being set like that.
B: So the global payment set based off of claims data, historic claims data for these populations that we’re serving, and we will look at and take into account all of that. The likelihood of no one getting, using your example of leukemia, in a year is probably pretty low out of that population that’s going into this. So that will be factored into the global payment that goes to the PASSE organization in anticipation of a catastrophic illness like you’re talking about.
M: Yeah, because if you think about it, we have claims data that we can, historical claims data, that we can go back and look at. And we know exactly how much Medicaid rises every year. All of that is being taken into consideration when the global payment is being set.
L: So in short, a parent should never worry that their kid’s going to be covered?
M: I would say that for something like Leukemia, and something like that, I would not be worried that their child would not be covered.
L: So each parent will not have a budget they’re dealing with. So if the money runs out for a child with a lot of medical needs, then what happens?
M: Well, let me say this because I don’t want there to be any confusion. So if you’re on the DDS waiver, and you fall in, there is going to be a certain, your plan of care is individualized for you, and there is a dollar amount associated with you, just like it is right now. I’ve got 4200 people on the waiver, and I’ve got 4200 different amounts that we pay. That’s not changing. That will get rolled up into the global payment. So there’s still going to be caps on certain things, just like there is right now.
B: Realistically, the thought process is they will really see very minimal change. In fAact, there may be more things that they are now about to access that they couldn’t before because again this is the providers.
M: We’re kind of removing ourselves from it. We’re kind of saying, here you go. You guys are the experts. You guys do care coordination and case management. These are your people. You know how to take care of them.
L: Are they worried that if providers share in funds saved from the child’s budget, will it make them more likely to refer services less often?
M: So they’re thinking that the only way to save money is to cut services. And we’re saying that very likely happens under a full capitated managed care model. That is not what we envision under this model.
B: That’s a fair assessment.
L: Can you explain what you envision? In what way are you going to save money?
B: Better care coordination. It’s really a lot more preventative and continued care coordination and care management across the entire spectrum of services.
M: And that’s proven. It’s proven that if you do better dental care up front, you don’t have to pay for all of the root canals. It’s proven that if you do better prescription management for people with mental illness, and get them to take them, then you may not have to go to the Arkansas State Hospital as often. You have to remember that we’re mixing in [Behavioral Health], which do have some cost in terms of inpatient psych. That’s going to balance out some of the DD cost as well. So… I know there’s fear. I know change is scary. I know it is. It always is. But we really feel like this is a good model that’s going to bring good care to our clients. And we think that all of this preventative care is going to save money. We do. It’ll take a while, but we’re trying to change the trajectory of how the state looks in terms of health care and how healthy people are. And I think a good example of that is we’re trying to do that right here at DHS. We’re implementing all of these wellness programs because we know people here were healthier at DHS, our overall insurance would go down. We’re trying to do things at a DHS level that we hope to implement on a state-wide level. Just better quality healthcare to make people healthier across the state.
L: So something that happened in Texas. The percentage of kids in special needs care was about 12-13%. And after this was implemented, it went down to 8 with lots of kids not getting services they needed because districts were being rewarded for cost savings. Is that going to happen?
M: So they’re under a full capitated managed care model called Big Star.
L: In this model will people be rewarded for cost savings, which would mean they won’t…
M: So if there’s savings in the pool, then there will be a way to be paid with those savings.
B: To incentivize providers for…
M: We’re really focusing on outcomes. So we’re talking about incentive payments based on outcomes. And we’ve been talking about that for a really long time here, and we think this model is going to get us there. And I think an example of that in the DD world of my client who is 40 years old wants a job. We’ve been putting that in his plan of care for 5 years. Get him a job, and then we go back and say you got him a job. You did a really good outcome. So it’s just a different way of rewarding and paying people.
L: So for spending less, they’re not going to get rewarded necessarily, whereas people are afraid, they’re showing savings but it’s because they’re not treating people.
B: So what we’re looking at like Melissa said is outcome based results, which then will lead to savings, which then puts into the pool where we can incentivize providers.
L: Some therapists are unhappy that they perceive a lot of work has been done, and some of that work was wasted.
K: Like participating in the workgroup meetings and then their input not being really followed through on.
M: So they’re not in Tier 2 or 3, and they’re not in the model. They have developed a Prior Authorization / Extension of Benefit process that they brought to me on Friday that’s being reviewed for implementation, and to my knowledge that was one of the key things that the therapy workgroup has been working on. And they also brought another handful of recommendations that included annual evaluations for children going to CHMS and DDTCS, and there were other recommendations on the other paperwork that were given to me. But everything that they provided is being considered, and we are moving forward with the Extension of Benefit / Prior Authorization process. So I don’t know why they feel like that. I have heard comments, you know, we felt like we were doing this – being agreeing to the 90 minute caps, which I would argue they all weren’t in agreement since I got 9,000 comments – but we were doing this in lieu of managed care. I was very, very careful NEVER to say that.
L: You were.
M: NEVER to say that.
L: But there were other people who weren’t as careful.
M: Because that’s out of my control. Frankly, it’s out of a lot of our control. But I would say that we are grateful for the progress that the therapy workgroup and the therapists have made, and we are commending them for working together on some cost saving devices that we plan on implementing. And again, they are not included in the provider led model.
L: Wasn’t there a workgroup for provider-led? They might have been involved in that. But they feel like you all knew and have known for a while, that we were going to this.
B: So here’s the thing, and I think I can address this a little bit better than [Melissa] just because of my position on this. My perspective on this is that we are looking at an either/or model – politically, realistically. The majority of states have gone to managed care. We think, we feel that this…
B: Full capitated managed care if you look at it across the nation. I think there’s 31 states that have gone to managed care. So for us to think that we can not expect it to come here, potentially, is unrealistic. The benefit that we have is an experienced staff at the leadership level that can see pros, cons, and what happens when a managed care, full capitated MCO, comes into a state. And that’s how we started developing this model of we see where this is potentially going. And if we can offer a better plan to achieve savings and produces better outcomes for the beneficiaries of the state, of course we’re going to try that model. This model hasn’t made it through the legislative process yet. I’d like to think that it’s going to make it through because I think it’s a good plan, and I think it’s good for Arkansans. It provides more opportunities and really focuses on care of the beneficiaries more than an MCO historically does. I’m not trying to disparage MCO companies. They have their place in this world. They are what they are. But when you’re talking about the horror stories that you guys are hearing, and that’s a full capitated managed care model where the providers aren’t saying “no, we believe in this particular care for this patient.” So that’s why Dennis and I started working on this model. If this falls apart, I would be very willing to bet that you will see a full capitated managed care bill come from the legislative body.
K: How likely do you feel that that is to happen anyway?
B: We’re not trying to hide that. We’ve been telling that to the providers that we’ve been working with from day 1.
M: And I don’t think it’s been a secret that this managed care model was publicly talked about by the Governor during the special session. So it’s been out there for quite some time.
B: That managed care is a consideration, and I think the…
M: And when you’re looking at a balanced Medicaid budget, and when we need to save money right now. You have a handful of options.
B: We have to look at all options, and we as an agency felt that this was the best option to put forward and see if it, because the reality is if the providers decide that they don’t want this to work, this doesn’t work. Plain and simple. It is a provider led model.
L: And the people that you’ve met with do want it to work?
M: Yes, we think so.
B: A lot of the majority of DD providers have sent letters of support for it. All of the Behavior Health associations have said our members are in support. The Arkansas Waiver Association is the only one that is still trying to find out what position they want to take on it. And we’ve been very public about meeting with them and saying, “Tell us what you want because if you don’t want this, it’s not going to work.”
M: We really believe in this model. We think this model will be really good for our clients.
L: Have you approached legislators about this model?
M: It was sent out last week, and it was sent to legislators that are really involved with our health are policy here. And so yes, we have been in discussions.
L: So this draft, when do you expect that it would be…?
B: The filing deadline is March 6.
L: Which is pretty soon. Do you have sponsors for it?
M: I think that our Legislative Affairs office is working to firm up the sponsors at this point in time, but I don’t think they are ready to public say who’s sponsoring it.
L: It feels like when I’ve talked to legislators that they are very extreme. Either they are very capitated support or not at all. We have asked some if they’d be in support of provider led, and it’s almost like they didn’t know about it.
B: So that’s part of what we’re doing now. We were working closely with a group of core legislators. And we are now trying to expand out to educate more. And that’s what our Legislative Affairs office is working on right now to make sure that everyone understands.
M: You can imagine it’s a complicated concept.
K: And if it’s complicated for you, just imagine somebody who’s not doing it everyday. Regardless of their position or their education, they’re going to be confused.
M: And it’s right in the middle of the legislative session, so they’ve got a lot going on.
L: Can you explain the money that’s somehow going to fund the waiver wait list? Because that’s a benefit right, especially to people who are on the waiting list.
M: Yeah, that’s huge.
B: So we had other experts working with us on this, meaning we had the Arkansas Insurance department working with us on this to make sure that we were doing it properly. The way that this is set up is it will function as an insurance company essentially, which allows us to the collect a premium tax from monies flowing in, which will be put into the Medicaid trust fund and allocated for us to use on the wait list and other programs.
L: But that tax would not be applied to families?
M & B: No.
B: So standard insurance companies already have this in place, which is why we said if we make this like an insurance company, we can collect the taxes off of that. So your life, health, car already has a premium tax that the insurance companies are charging and paying into the Arkansas Insurance Department which goes for other benefits. That’s why we came up with this model. We saw it as a good way to address a very specific issue that we feel is important and that the Governor feels is very important.
M: So we anticipate with the premium tax money from this model, we’ll be able to serve an additional 1100 people. So if you pair that with the 700 people we hope to serve with the Tobacco money, we’ll be able to cut the wait list in half.
L: Can you comment on the waiver wait list bill that was voted down, and how this relates to it?
M: So I testified. I said this at the table, that I hated to get up there and oppose it because the spirit of the bill is something we are constantly trying to achieve, which is to eliminate the wait list. But the way that the bill was different from Act 50 that the Governor signed into law a couple weeks ago, the Tobacco settlement money, that was money that was not being utilized for any other programs at this time. So the bill that we publicly opposed was asking us to prioritize spending within the Medicaid budget on the DD wait list, so it was asking us to essentially use money that we’re using for something else right now and redirect it. And we were not comfortable doing that. I know that disabilities are the heart and soul for some people, but for others it’s child abuse and neglect, and for some others, it’s their aging parent who’s in a nursing home. And we just don’t want to get into the position of prioritizing what’s important because it’s all important. We knew that we were coming up with this model, which the money was going to be specifically directed to the wait list. So we feel like we’re making leaps and bounds in eliminating that wait list through innovative ways that we’ve come up with rather than taking money away from a program that might very much need it, take away from one to give to another. This is new money essentially, not already funding a current program.
L: So there are people who are not going to believe that this is good. What drawbacks would you say there are? Can you admit that there are drawbacks?
B: There’s a couple of things that make us realize the gravity of what we’re dealing with. One is we are one of the first states that has tackled this population together.
M: Usually you go in, and you target the non-specialty, so the non-DD, BH, Aging populations. You go in and put that model in, a lot of states go that route because this is a hard, typically across the nation, the biggest spend in the Medicaid budget. But we think we can do it. And I think our clients can get better care. It’s going to be hard to roll people into it.
B: It’s going to be hard, and that’s the thing.
M: It’s like turning a huge ship, and we have a plan for how we’re going to implement it every month. And it’s quite an undertaking. So if I would say there’s a drawback, it’s that you’ve got to bear with us because there’s going to be some tweaks along the way because it’s going to be difficult to move that many people into a different model and still maintain another model over here on the side. We’re going to be operating two different models essentially…
B: Until everybody is assessed…
M: Until everyone’s in there.
K: How long do you expect that to take?
M: We think it’ll be done by the end of December of ’18.
B: Yeah about a year.
L: How do you know which one you’re in? How’s that communication going to work?
M: Well, you’ll get an Independent Assessment.
L: So when you get one of those, you know you’re rolling into the other one.
M: And there are federal guidelines, and just to avoid basic litigation, there’s a lot of letters we will be sending these recipients that will fully advise them of their rights and their appeal rights and what’s happening because we don’t want anyone to be confused or to not understand how if they disagree what their next route is. We don’t want to be doing any of this in secret. So they’ll be getting a lot of notifications about what’s going on.
L: Any other possible drawbacks besides that?
B: So the other thing like you said, adjusting. We know that there are things that we are not anticipating that we will have to adjust for, and that is something that’s with any program. That’s going to be with an MCO coming in or us managing this model. The unknown and the adjustment period that’s going to be necessary for that I think is one of the, I won’t call it a fear because I’m not really afraid of implementing this model because of the level of involvement that we’ve had from providers across the spectrum – specialty providers, physicians, hospitals, so…
M: There’s a lot of moving parts. We have done a lot of transformation all at once, and it feels like it’s all happening July 1. We’re going to implement Independent Assessments, and we’re doing this model, and we’re doing therapy thresholds, and we’re doing EOBs. And it’s like we’re doing all of this stuff July 1 because we really want to hit that savings targets in terms of making we’re getting better outcomes and being more efficient and people are getting what they need. And it’s just a lot, but we think we can do it. There just might be some bumps.
L: Do you anticipate loss of jobs?
L: Mostly people in the industry who are worried.
K: Well, I think I can explain that.
L: Like small providers who could go under.
M: Only if they’ve been billing us 300 units a week without justification.
K: So for example, if you have X amount of therapists employed who have their own assigned caseloads. If the children who are there don’t requalify under these new standards for day-hab, then they may not be able to just receive outpatient therapy. Then if the caseload goes down, then we don’t need as many therapists, leading to job loss.
M: I’m not changing the criteria for how you get into day-hab. That’s not changing. That means that it’s a state plan service. There’s eligibility criteria for how you get into CHMS and DDTCS, and at this current time, we are not changing the eligibility criteria for how you get into the program. The Independent Assessment will have nothing to do with how you get into a DDTCS or a CHMS. They’re doing the developmental screener, but I’ve been very upfront in saying that’s just, that was based on feedback we were getting from PCPs, that they didn’t feel qualified to make referrals to these clinics. This developmental screener is going to be used as a tool for the PCP to utilize prior to making the referrals. But if you don’t fall into Tier 2 or Tier 3, meaning you don’t meet institutional level of care criteria, you’re not getting an Independent Assessment. We might refer you to this screener before you get referred, but it’s not going to say whether or not you get to go. So the provider group that you came with on Friday made up of DDTCS providers and CHMS providers, they brought to me that they want to do an annual evaluation on kids in DDTCS where right now it’s every 3 years. They want to bring the integrity of their program up, and they want me to raise it to yearly evals, which we are in support of. And the CHMS already does either a 6 month or a year, so it will make that more consistent.
L: So as for the Governor, he has asked for a certain amount of savings.
M: $835 million.
L: I thought we hit that with the previous stuff like the caps and the … Did we not hit it?
M: So we hit a big chunk of it. I think in the Behavioral Health, I’d have to go back and look at the Stephen Report. I think they had a model, a coordination care model, in their savings number. And I know for DD, we have had to change models. I have talked about conflict free case management. We have always intended to change the model, so for us it’s less about making the $835 million at this point, and more about getting better care coordination and case management that the clients weren’t getting before.
L: So what is the possibility that after a year the Governor says this wasn’t generating the amount of savings that I wanted.
M: We have made commitments to do some dashboards to give reports on how we’re hitting our projected goals. And that will be public.
L: Do you expect to see that progressively or immediately?
M: It was in the Stephen Group report kind of where we anticipated phasing in the savings numbers.
L: So he understands what you expect and is willing to wait for this to work?
B: He has been very supportive. I have faith that this is the best plan for Arkansas, and I’m relying on the advise of you all to say it’s working or it’s not working so. He has been very supportive of this model.
L: What sort of mechanism do you have for parents if it isn’t working? How do they communicate?
B: It’s very similar to what you do now. You appeal the process and go through the appeals process, which we handled at that level, as opposed to us with the new plan. Your providers are running this model. If you’re not liking it, then go to your provider and say, “I don’t like this. This isn’t working. How can we adjust?”
M: But that should give people some comfort that they can rather call the executive director at Access rather than having to call DHS.
L: Who are the providers?
M: We don’t know yet. We know who’s been talking about it, but they’re all forming behind the scenes right now. I think when the bill gets filed, I think we’ll have a better understanding.
B: There’s some guidelines and benchmarks in there too in the certification process. So it’s specialty providers.
L: So you don’t anticipate crickets as soon as the bill is released?
B: If that happens, then we pull the bill, and then it’s managed care most likely. But the specialty providers, the hospitals, the physicians have been very good about working on this. We see no reason that they will not continue to move toward this because they see benefits for their patients, and I hate to say for them, but it is for them when they look at full capitated managed care coming in. Alright, we get to be in the driver’s seat as opposed to the managed care. So it’s kind of a win, win for them. And I think they would tell you that.
K: So if what you’ve said today has helped a parent better understand it, and now they are on board, what can they do to help further this? Because honestly, we have 1700 people in our group all over the state.
M: So I would say this, just a basic thing that would help us. We put together a one-pager that you guys probably put up on your site and that we have on our Facebook page. If parents are in support of this, they can mail it out, they can call their legislators. They can talk about it.
B: Because one of the things – we always have an open door for everyone, specifically on this when it’s legislative, if a legislator wants to talk to us about this model, we will make it happen. There are some legislators that we haven’t had the chance to sit down and talk with because this is not…
M: In their arena usually.
B: It’s not their focus.
L: But they all have to vote on this.
M: And they all have constituents that this will affect. But you know, it’s not on radars until you put it on someone’s radar. So I would say that if people are in promotion of it, they need to contact their state representative or state senator with the one-pager and say we’re in support of this model. If they want to learn more, just direct them over here to us.
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