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By Monica E. Oss

I walked away from the keynote by Nancy Thaler, Deputy Secretary for the Office of Developmental Programs at the Pennsylvania Department of Human Services—The Future Of Long-Term Services & Supports: A New Business Model For A Medicaid Managed Care Market—at the 2017 OPEN MINDS Executive Leadership Retreat with a different perspective than I had anticipated. Ms. Thaler’s presentation did focus on the move of Medicaid long-term services and supports to managed care (MLTSS), and she provided some great background on that transition. But my big takeaway wasn’t that managed care was a cost and quality issue facing the I/DD field—the question is how to develop systems that offer appropriate alternatives to residential care.

Nancy Thaler

The managed care trajectory in the I/DD system is an interesting one. Long-term services and supports, including I/DD, have been incorporated in Medicaid managed care since the advent of Medicaid in Arizona. And that program gets relatively high marks from consumers and their advocates. The number of states that have included I/DD support services in MLTSS is smaller than the number of states with MLTSS for other consumer groups—at current count only 10 (see Strategy In The I/DD Market). Some experiences have been good and some not. Just as each state’s Medicaid program is varied, so is the method in which they deliver MLTSS to the broader population—and the I/DD population specifically. Each state uses different types of MCOs—private, public, the state Medicaid agency—and different waiver authorities that effect how many individuals they serve and how. These models each have their advantages and disadvantages and have resulted in both positive and negative experiences for stakeholders.

But my big “aha” moment in Ms. Thaler’s presentation was her comment that for the I/DD population, managed care models don’t necessarily offer cost savings from reduced use of institutions because there is relatively low utilization of facility-based interventions and there is a (legal) waiting list of consumers looking for service. Her point was that the budget management issue, whether in managed care or not, is really about providing a system that allows consumers with I/DD to live with families and friends rather than 24-hour staffed group homes. She used statistics from Pennsylvania as an example—there are 2,885 consumers requesting care in a residential treatment setting. And, for the highest-need consumers, that 24-hour staffed residential facility would cost $233,000 a year versus $90,000 per year for an alternate living arrangement and community support services.

Her advice to advocates? Whether your state is looking at managed care or not, the more important issues are the same. Ensure that the system is focused on self-determination, community participation, development of life sharing and supported living options, and adequate access to behavioral health services. With the rising incidence of autism and intellectual disabilities (see Finding The Opportunities In Serving The 1 In 68 and Prevalence Of Autism Among U.S. Children Now 1 In 68), a focus on these system design issues is going to be more important than ever.

For more on managing your population of consumers, join OPEN MINDS Senior Associate Ken Carr, on November 7 for his session, “Technology & Reporting Requirements For Population Health Management: Preparing For Value-Based Reimbursement”, at The 2017 OPEN MINDS Technology & Informatics Institute.


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