In New York State, persons with intellectual and developmental disabilities are one of the last groups of Medicaid recipients to be included in the State’s coverage under Medicaid managed care. Close to 5.8 million of the 6.2 million Medicaid recipients are enrolled in Medicaid managed care. For the I/DD field, New York spends over $8.0 billion for approximately 125,000 persons. Over 90% of the spend level is for long-term services and supports mostly covered by a home and community-based waiver.
At the outset of this article, it is important to state that the field of I/DD is facing a severe fiscal crisis of its own. The field has not had a cost-of-living adjustment for nine years.
Since 2012, New York State has been developing an appropriate plan for Medicaid managed care (MMC) for the I/DD field. Delays have occurred because of concerns of advocates, providers, and families. State officials have concerns about the cost of starting-up MMC for the field of I/DD and the actuarial analysis that did not show any savings from MMC.
However, the State Office for Persons with Developmental Disabilities (OPWDD) has recently released a new draft of a revised plan. Over the past two years, OPWDD has been focused on two distinct areas: (1) improvement in care management processes using a home health model—as a first step towards manage care; and (2) creation of a policy framework for the implementation of provider-led managed care.
A new draft version of the New York State Medicaid Managed Care Organization I/DD System Transformation Requirements and Standards to Serve Individuals with Intellectual and/or Developmental Disabilities in Specialized I/DD Plans – Provider Led (SIPs-PL), which is referred to as the Qualification Document, was released for stakeholder review and comment.
In July 2018, DOH and OPWDD launched an enhanced care management program to support individuals with developmental disabilities and their families. This program consolidated more than 350 agencies providing Medicaid Service Coordination into seven regional provider-controlled Care Coordination Organizations (CCOs) providing Health Home Care Management under the federal program. At the same time, these CCOs expanded the role of new care managers, moving from OPWDD service-centric Individualized Support Plans (ISPs) to integrated and coordinated health and habilitative services through an expanded Life Plan. Approximately 100,000 individuals transitioned to this new model.
I want to address why Medicaid managed care is essential for persons with I/DD. MMC works for the field of I/DD because:
- It moves from a fee-for-service fragmented services world to a comprehensive plan and integrated funding model.
- It integrates the long-term services and supports (LTSS) with medical, behavioral and access to the full range of Medicaid benefits.
- It promotes the use of experienced providers of I/DD services to manage a comprehensive plan.
- It builds in service and resource flexibility through the use of a Life Plan that is not constrained by the current siloed service limitations.
- It brings the field of I/DD into the broader health reform agenda of the state and the marketplace.
- It puts pressure on the field to develop and measure the success in quality of care and general well-being of persons with I/DD through the use of value-based payment models.
I understand the reality of how hard it is to build Medicaid managed care for special populations having been directly involved in creating plans for special populations including for persons with HIV/AIDS and for the frail elderly. I also understand that there a few national models we can look to where plans in other states have successfully rolled out special plans. So, the evidence is limited to support the use of managed care for populations like those with I/DD.
What gives me some sense of confidence in taking on managed care for the I/DD population is the recent success of rolling out the comprehensive care management program under the federal health home requirements and funding. These Care Coordination Organizations are all provider collaborations covering close to 100,000 persons and were rolled out in record time in partnership with OPWDD. Both of these factors are core ingredients in implementing managed care. While the CCOs have only been operating for 20 months, and it is too early to declare a complete success, they show what can be done using a partnership between providers and the state.
I would also point to a start-up specialized managed care plan called Partners Health Plan (www.phpcares.org). Partners Health Plan is New York State’s only fully integrated duals advantage plan dedicated to serving individuals with intellectual and developmental disabilities and their families. By combining coverage and provider networks for Medicare, Medicaid, and IDD services, Partners is able to provide its members a cohesive, easy-to-navigate plan of care that is tailored to each individual’s needs. This is a small federal and state demonstration with 1700 enrollees (March 2020).
It gives me some pause in looking at the experience of how the behavioral health field has fared in being integrated into managed care. This experience has been very slow and fraught with implementation issues and is, perhaps, several years from fulfilling the promise of managed care for persons with behavioral health needs.
In the face of these initiatives, there are legitimate concerns raised by I/DD stakeholders and they are the following:
- Isn’t the timing of rolling our managed care out of line in the face of the state fiscal crisis?
- What is the source of funding for starting-up new plans?
- Will existing general Medicaid managed care organizations that already cover 5.8 million recipients be used if I/DD experienced providers can’t step up because they don’t have deep pockets?
- How can providers engage in developing managed care in the face of a fiscal crisis?
- Shouldn’t the state and the field complete the successful transformation of the CCOs, which is the first step for managed care, before putting the whole field at risk under managed care?
- What is the basis for VBP in the field of I/DD since there is no consensus on quality indicators and there is a complete lack of data to understand utilization, quality and cost of care?
Okay, I can hear stakeholders yelling out Yes to these concerns. However, in my optimistic approach to life, and with my experience of 18 years in state public service and 25 years as a provider and consultant, I would say that you have to start somewhere to build the future. And, if we want to control or shape the future we have to act. So, let’s start building the foundation for managed care because it is the most effective and efficient way to better use public funding to meet the needs of persons with Intellectual and Developmental Disabilities.
Arthur Y. Webb was the former commissioner of OMRDD (now OPWDD) from 1983 to 1990 and Executive Director of Division of Substance Abuse Services (now OASAS) from 1990 to 1992. Mr. Webb has held several senior executive positions in government and the nonprofit sectors. For the last ten years, he has been a consultant working with numerous nonprofits to translate public policy into innovative solutions. Presently is the Executive Director of the New York Integrated Network for Persons with Intellectual and Developmental Disabilities (a nonprofit collaboration of 12 providers). Contact: firstname.lastname@example.org or 917-716-8180.