On November 18, 2015 representatives with the AWA (Arkansas Waiver Association) met with John Stephen, managing partner with TSG (The Stephen Group, Inc.) to share AWA’s recommendations regarding Medicaid and HCBS (home and community-based services) reform for individuals with intellectual and developmental disabilities in Arkansas. According to the most recent TSG report, the average amount of adult participants in the following programs per month in 2014 were: DDTCS (Developmental Day Treatment Clinic Services)-10,122, ACS Waiver (Alternative Community Services)-3,886, ICF (Human Development Centers and Private Intermediate Care Facilities)-1,238. While there are a myriad of concerning issues impacting Arkansas Medicaid beneficiaries, the AWA attempted to cogently present to Mr. Stephen the most pertinent issues impacting the delivery of supports to Arkansans with disabilities at a systemic level.
· Ensure Assessments and Plans of Care are Based Upon Objective Criteria that Truly Meet Individualized Needs
o If Arkansas Medicaid is going to shift to a system that is driven by a standardized assessment that determines each individual’s needed level of services and supports, and the amount of money to be allocated to provide those services and supports, then the state must ensure that the validity and confidence level of the assessment tool and budgeting algorithm used are statistically significant.
o Plans of Care that are generated from the standardized assessment must be based on objective criteria and true individualized needs.
· Reimburse Community Providers Based Upon Actual Cost or Adjust Rates to Reflect True Operational Needs
o ICFs in Arkansas are currently reimbursed based upon the actual costs to operate. Community providers however are reimbursed based upon rates that are pre-set and non-negotiable. As operating costs continue to rise through inflation and unfunded mandates, community-providers are struggling to generate enough revenue to meet operational and programmatic demands.
· Rebalance the Long-Term Services and Supports Model and Permanently Dissolve the ACS Waiver Waiting List
o According to a report prepared by TSG and provided to the Arkansas Health Reform Legislative Task Force, the average cost to provide care to a person in the community within the ACS Waiver program is $69,000 per year as opposed to $135,000 per year in an ICF. Many studies have also demonstrated that quality of care increases and maltreatment decreases when persons are supported in the community.
o While numerous recommendations were made in the TSG report regarding methods to fund the waiting list, the AWA recommends the following:
§ Option 1: Immediately cease all new admissions to ICFs and redirect all new beneficiaries requiring long-term supports to the community.
§ Option 2: Only fund ICF plans of care based upon the level of services and supports generated from the standardized assessment. If the ICF cost to care for the individual exceeds the level of care amount, the ICF either assumes the additional cost or shifts the cost to the individual to pay out of pocket.
o The State of Arkansas should immediately create a review group for the transition of all individuals in state custody who currently reside in an ICF. For individuals in State custody, the State must utilize less restrictive and less costly alternatives as the first option. If the individual’s less restrictive placement proves unsuccessful after having utilized all community services, then a more restrictive placement may be allowed.
· Shift to a Value-Based Purchasing Model that Incentivizes and Requires Quality Outcomes
o Quality outcomes must be defined and adhered to that are based on both health and quality of life metrics. Quality of life metrics must include multiple domains such as socialization, employment and meaningful life. The AWA recommends the Personal Outcome Measures utilized by the Council on Quality and Leadership.
· The State Must Encourage and Not Unnecessarily Interfere with Provider Competition
o The state must lift the unnecessary ban within Act 645 that inhibits new providers from serving DDTCS beneficiaries in a county that is not considered underserved. More competition, not less has demonstrated higher value (outcomes to cost) in most industries including health care.
o As the system progresses, the state must work to ensure the system does not evolve into one that consists of only a few providers, but one that has many. More providers, not less will offer a greater number of consumer options and create a market-driven environment that will naturally yield value.
· Remove the Annual Prescription for Services Requirement
o Individuals currently receiving ACS Waiver services are required to obtain a new prescription for services annually in order to maintain eligibility. Except for a few exceptions, Arkansas Medicaid contains an annual payment cap limiting an individual’s ability to receive physician services. In an effort to save costs, the AWA recommends the removal of the annual prescription requirement except during instances in which there is a change in the individual’s condition or plan of care.
· Fund and Support Internships and Job Development
o Many employers have identified their desire to employ individuals with disabilities but cannot devote the time and resources necessary to train them to be successful. Unlike many applicants without disabilities, people with disabilities often lack the basic skills necessary to be a successful applicant such as problem solving, social interaction and workplace conduct. Internship programs that pay individuals minimum wage or higher while teaching these skills would fill this void and result in more people gaining and maintaining employment in an integrated and competitive setting.
o Many individuals with disabilities may oftentimes be more successful working in a particular job that has been customized or modified for their abilities. Furthermore, many employers are unaware of the benefits that people with disabilities often bring to the general workforce such as higher retention. Funding job development would fill this gap as more employers would be educated on and assisted with employing individuals with disabilities.
With the Arkansas Medicaid system in flux and the concern for cost containment greater than ever, many of Arkansas’s most vulnerable citizens continue to be an afterthought in the midst of a system redesign that will impact every facet of their lives. Through careful and deliberate implementation of the suggestions made above, the Arkansas Legislature and Governor will be better equipped to create a system that rewards quality, encourages competition and meets the needs of all Medicaid beneficiaries. The AWA is grateful to John Stephen for listening and taking into consideration its concerns and suggestions regarding Arkansas Medicaid reform and looks forward to working closely with all stakeholders to develop a system that truly embodies quality and value.
Keith Vire, President
Arkansas Waiver Association