Conflict Free Case Management - ADvancing States Free Case Management History Undo Influence Over Goals Misaligned Financial Incentives Compromised Individual Choice of Services Provider

CONFLICT FREE CASE MANAGEMENT STRATEGIES FOR INTEGRATED AND MANAGED CARE LONG-TERM SERVICES AND SUPPORTS ENVIRONMENTS

September 5, 2013

Kimberly Donica Ohio Department of Medicaid Hope Roberts Ohio Department of Aging Mary Sowers and Brenda Jackson, Mercer Phoenix - 2325 East Camelback

MERCER 1 September 19, 2013

Conflict Free Case Management Introduction

• Conflict Free Case Management (CFCM) – History and Evolution

• Growth of Managed and Integrated Care

• CFCM in Integrated Care

• Building Accountability while Minimizing Conflicts

• Role of State in Ensuring CFCM

• How the Principles of CFCM Strengthen Long-Term Services and Supports (LTSS)


Conflict Free Case Management – Context

• Excerpt from the 1915(i) Proposed Rule CMS 2249-P2 (page 47): – Conflicts can arise from incentives for either over- or under-utilization of

services; subtle problems such as interest in retaining the individual as a client rather than promoting independence; or issues that focus on the convenience of the agent or service provider rather than being person-centered. Many of these conflicts of interest may not be conscious decisions on the part of individuals or entities responsible for the provisions of service.


Conflict Free Case Management History

Undo Influence Over Goals

Misaligned Financial Incentives

Compromised Individual Choice of Services

Provider Self Referral

The statutory provisions for CFCM were the product of many years of

experiences/issues in a number of states’ LTSS systems.


Conflict Free Case Management History – Origins in Home and Community Based Services (HCBS)

1981 – OBRA Enables states to

offer HCBS as institutional alternative

1990 – 1999 Major growth

in HCBS – especially for

individuals with I/DD

1999 Olmstead Decision – Increased growth in

HCBS

2005 Deficit Reduction Act – 1915(i), MFP,

and other options for

HCBS 2010 ACA – BIP,

MFP expansion,

CFC, 1915(i) changes, and

others

Growth of HCBS often relied on existing infrastructure from state, county, and provider levels.


Components of Optimal Conflict Free Case Management System

Eligibility decisions separate

from service provision

Robust oversight

and monitoring

State engaged in oversight

Clear paths and

tracking for grievances

and appeals

No relation by blood or marriage

Engage stakeholders

and track individual

experience

CMS has created common expectations across all HCBS, though there may be some authority-specific requirements in addition to

these basic elements.


Conflict of Interest Safeguards

• Both Section 1915(i) [State Plan HCBS Option] and 1915(k) [Community First Choice Option] include requirements that states establish conflict of interest standards for the assessments of functional need, independent evaluation and assessment in 1915(i), and the person-centered service plan development process that apply to all individuals and entities, public or private.

• Minimally, this must require that individuals are not: – (1) Related by blood or marriage to the individual, or to any paid

caregiver of the individual. – (2) Financially responsible for the individual. – (3) Empowered to make financial or health-related decisions on behalf of

the individual. – (4) Individuals who would benefit financially from the provision of

assessed needs and services.


Conflict of Interest Safeguards, (cont’d)

– (5) Providers of State Plan HCBS for the individual, or those who have an interest in or are employed by a provider of State Plan HCBS for the individual, except when the State demonstrates that the only willing and qualified entity/entities to perform assessments of functional need and develop person-centered service plans in a geographic area also provides HCBS, and the State devises conflict of interest protections including separation of assessment/planning and HCBS provider functions within provider entities, which are described in the State Plan, and individuals are provided with a clear and accessible alternative dispute resolution process.


Conflict Free Case Management Integrated Care

• Three levels of integration: – Integrating PH/BH/LTSS – Integrating Medicare and Medicaid – Integrating individuals into the community

• Integration happening through variety of formal mechanisms: – Health Homes, MCOs, ACOs – Financial interests are aligned with coordination of care

• Integration includes development of comprehensive care plans

• How do you construct CFCM without undue interest for self-referral and having person-centered planning processes with integrity in integrated care?


Integrated and Accountable Care and Conflict Free Case Management A Paradox?

• Not Necessarily! – Ever-increasing number of states are offering LTSS in managed and

integrated care environments, holding entities accountable for person-centered approaches to care and outcomes for individuals.

– In these arrangements, when one entity is responsible for, or in some cases “at risk” for, the services provided to the individual, tailored strategies to ensure objectivity, conflict mitigation, truly person-centered approaches to care delivery and positive outcomes must be constructed. - Nothing happens by chance.


State Oversight and

Monitoring

Explicit RFP and Contract

and Operational Components

Stakeholder Engagement

Clear Role Identification

and Separation within an

Organization

Conflict Free Case Management Building Blocks for CFCM in Managed and Integrated Care

Deliberate Design

Decisions


Conflict Free Case Management Strategy Examples

• State Retention of Certain Functions: – Example: State retains assessments and MCO develops plans of care.

• Administrative Firewalls Between Organizations for Certain Functions: – A separate entity retains assessment functions (e.g., ADRCs).

• Administrative Firewalls Within Organizations for Certain Functions: – Utilization Review units do not have responsibilities for assessment and

plan of care development.

No matter which structures are put in place – Each program should utilize stakeholder and consumer oversight and transparent lines of communication.


Role of the State – Paramount

• In moving to accountable systems of care, either capitated or fee-for-service, the State must take deliberate steps to ensure that the program design and monitoring will contemplate the need for CFCM: – To keep individuals at the center of the service system; – To promote optimal outcomes and quality of life for individuals; and – To safeguard state resources.

• Some tools in use by states include: – EQRO reviews of medical records and validation of performance

measures; – Ombudsman Programs; – Independent Community Entities contracted to perform certain oversight

functions; and – Individual participants.

Ohio’s Experience and Conflict Free Case Management


Conflict Free Case Management in Ohio

• Ohio is participating in several ACA opportunities that require CFCM including: – My Care Ohio (Ohio’s Duals Demo); – Conflict free requirements integrated into MCP’s contract requirements; – Firewalls developed for AAA’s due to the nature of their role within the

demonstration; and – Balancing Incentive Program.

• Ohio’s previous experience with CFCM positions us well to implement across the rest of the delivery system.

• Ohio has had established firewalls in the DD delivery system since 2009. – The structure of the system and the role of County Boards of DD lent

itself to conflicts of interest.


Development of a Firewall Document

• Engage stakeholders early in the design process.

• Evaluate current infrastructure of your system.

• Identify existing policies and procedures that may be the building blocks of the firewall.


Considerations

• What is the impact on consumers?

• What additional costs could be incurred when implementing the components of a firewall?

• To what other system outcomes will the firewall contribute?

• How are the firewall elements communicated?

• How will the firewall be monitored?

• What are the consequences of not maintaining the parameters of the firewall agreement?

Louisiana’s Experience and Conflict Free Case Management


Louisiana Example

• Louisiana has a 1915(b)(c)(i) concurrent waiver program for adults and children with behavioral health needs, which is part of an approved BIP grant.

• Louisiana administers that program, Louisiana Behavioral Health Plan (LBHP) through a Prepaid Inpatient Health Plan managed care contract with Magellan.

• The contract is capitated for adults and non-risk for children.

• To ensure CFCM within the program, Louisiana outlined a series of firewalls in their approved authorities.


Louisiana Conflict Free Case Management Firewalls

• The State agency (DHH) makes the final 1915(i) enrollment eligibility decisions. All eligibility determinations, including financial eligibility reviews for Medicaid, are performed by the current Medicaid eligibility staff.

• Targeting and clinical needs-based criteria assessments are performed by the plan pursuant to policies and procedures set up and approved in advance with DHH making the final enrollment determination.

• The individuals performing the assessments are not providers on the treatment plan. The plan conducts reviews of all individuals completing assessments and plans of care to ensure that they are not providers who have an interest in or are employed by a provider who is on the plan of care.

• Assessment units are administratively separate from utilization review units and functions. The clinical needs-based assessments are reviewed pursuant to the 1915(i) QIS requirements by DHH staff.

• Participant treatment plans are reviewed by the plan pursuant to policies and procedures set up and subject to the approval of OBH and Medicaid.


Louisiana Additional Conflict Mitigation Strategies

• Individuals can advocate for themselves or have an advocate present in planning meetings.

• The Case Manager documents that the individual has been offered a choice among all qualified providers of direct services.

• The Plan has established administrative separation between those doing assessments and service planning and those delivering direct services.

• The plan established a consumer council within the plan to monitor issues of choice.

• The plan established clear, well-known, and easily accessible means for consumers to make grievances and/or appeals to the State for assistance regarding concerns about choice, quality, and outcomes and documented the number and types of appeals and the decisions regarding grievances and/or appeals.

• State quality management staff oversee the plan to assure consumer choice and control are not compromised.

• The State documents consumer experiences with measures that capture the quality of plan of care development.

Documents

Conflict Free Case Management - ADvancing States Free Case Management History Undo Influence Over Goals Misaligned Financial Incentives Compromised Individual Choice of Services Provider