Transcript Preparing for Managed Care

Preparing for Managed Care
The Kansas Experience,
From providers, customers and
advocates
Audrey Schremmer, Executive Director
Three Rivers Inc., Center for Independent Living
Intro to Centers for Independent Living
• CILs’ mission, values, and services promote
community living for people with disabilities
• A majority of CIL staff and board must be persons
with disabilities
• CILs provide five core services including;
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information and referral
deinstitutionalization
independent living skills training
peer support
systems and individual advocacy.
KanCare
• KanCare, the Kansas Managed Care program
rolled out January 1, 2013
• KanCare was unique in its inclusion of all Medicaid
populations (with only a few small exceptions)
• It includes individuals in long-term care and supports
fee for service system. (HCBS Medicaid Waivers)
• It also includes an employment component
• The final Waiver, I/DD HCBS will come under KanCare
in 2014
Why Managed Care
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Long-term System Reform needed
Curb growth of Medicaid spending
Improve quality of Medicaid services
High rates of hospitalization and rehospitalization
• High utilization of nursing homes despite
growth in HCBS spending
• Poor Health outcomes
Managed Care from the Consumer’s
point of View
• The only reason the state is interested in
Managed Care is to save money…
• Managed Care means I’ll have more layers
between me and my healthcare provider
• It means I’ll have to fight for my rights; I’ve seen the
TV shows about people getting denied chemo and life saving
procedures…
• Managed Care equals less care
• And finally, confusion, what does it really mean?
From an Provider View
• Reimbursement for services will reduce
and/or I’ll have lengthy payment delays
• My paperwork just doubled
• Services will have to go thru lengthy approval
processes, slowing down care
• Someone else will be second guessing every
decision I make….
So where to begin as an
Advocate/Provider
• Develop diverse partnerships with other
Medicaid providers and health advocates and
Medicaid enrollees
• Develop effective means of communication
• Divide and conquer, or at least divide and get
really well educated
• Research other states who have moved to
managed care in the last 3 years – talk with
providers in these states, talk with participants
• Request meetings with State Medicaid
department early on to learn their goals and
expectations
• Again, utilize your network to assign as many
volunteers as possible to any and all State
workgroups –
• As you get a feel for the proposed structure of
the managed care system, review step by step
how your current system fits in this structure;
looks for changes, look for gaps
• Educate Medicaid enrollees and family members
and care providers thru mailings, community
forums, small meetings
• Encourage enrollees to attend every community
forum State hosts, they will be more effective
than providers
• Develop outcome measures/quality assurance
measures and forward to State staff, bring this up
at every community forum
• Utilize your best technical partners to analyze
RFP’s and to the extent possible, the contracts
once they are in force.
Key areas of influence
• Workgroup to develop mailings to Medicaid
enrollees
• Advocate to maintain similar processes within
each MCO; care plan development, grievance
processes etc.
• Advocate for strong Ombudsman program
• Insure any cost savings roll back into
strengthening/expanding current programs
Post Implementation Advocacy
• Insure widespread representation on State
oversight committees
• Develop methods to receive, analyze and
disburse data
• Press for continued education of MCO staff,
particularly care coordinators, if at all possible,
utilize former providers for this training
• Maintain effective communication with MCO’s
and State staff
Challenges from Administrative
Perspective post implementation
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Contract and Credentialing
System Interface
Getting accustomed to new processes
Employee Skill sets; managed care is very
different than previous systems
• Unanticipated service gaps
• Education of consumers and family members
Challenges for Providers Post
Implementation
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Education and support of staff
Training on new technology
Maintaining adequate fiscal reserves
Development/purchase of new fiscal
monitoring systems
• Consumers rely on providers to help resolve
issues with their MCO’s
Challenges for Consumers, Post
Implementation
• Lack of education about private health
insurance processes
• Unsure about processes – move from targeted
case management to MCO care coordination –
who handles what??
• Confusion about Client Obligation/Co-pay for
services,
• Eligibility Supports and advocacy
Advocacy Post Implementation
• And finally, it ain’t over till its over!
• Complacency and apathy can be deadly
• Medicaid enrollees rarely feel empowered,
advocacy training has to continue
• Track your data, when you help the State
reach mutually important goals, (reduced
hospitalization, increased access to health
care) you are better positioned to advocate for
system change