State and district perspectives ACCOUNTABILITY Using Medicaid School Program monitoring and data to drive accountability and program improvement: State and district perspectives

Section Chief, Health Related Resources June Cohen Section Chief, Health Related Resources Maryland State Department of Education Benjamin Feldman Director, Third Party Billing Baltimore City Public School System

The Medicaid School Program returns about $650,000,000 to schools per year. However, the program is not about money. Or at least, it should not be.

The goals of the program should be these: To support more and better services to children and families. To generate useful data to: Enforce accountability Drive program improvement.

Cost recovery is the corollary benefit.

This presentation will illuminate four questions: How can managers get to accountability data? What kinds of data can be captured? How can this data be used? How does this benefit Medicaid?

Getting to an Accountability Model There are two approaches to data collection: Targeted and universal

Targeted Data Collection Many states and districts understand and employ targeted data collection. Identify the known subset of children who fall under the purview of the Medicaid School Program.

Targeted Data Collection Collect service data for these children, only. Perhaps use preprinted encounter forms, identifying the provider and client child of interest.

Targeted Data Collection Targeted data collection makes some sense in small districts that serve a small and discrete Medical Assistance (MA) population. Or in very affluent districts where the Medicaid dollar is a minor contribution to the health and special education budget. This is basically a “clerical” model.

Targeted Data Collection Targeted data collection is a dead end that yields a single product: One-shot recovery.

Targeted Data Collection There is no chance for: Capturing services for children not recognized as eligible, Capturing services for children awarded retroactive eligibility,

Targeted Data Collection There is no chance for: Analysis of service delivery, Or any kind of accountability bonus.

Universal Data Collection Collecting documentation for every service, billable or not—rendered to every child yields an Ali Baba’s cave of information. Universal Medicaid School data MAPS Special Education service delivery.

What kinds of data can be captured? Examples of performance measures that can be captured and tested Behaviors that are often not managed are made visible, e.g., the performance of itinerant staff, health related service staff, service coordinators. Congruence with mandated timelines.

What kinds of data can be captured? More examples Congruence between the IEP and service delivery model. Support for document and complaint process. Interruptions in services. Direct services can be parsed cleanly by districts doing Administrative Claiming.

What kinds of data can be captured? More examples Comparability of services rendered to similar categories of students in similar or dissimilar situations. Children who should be served and are not. Children who should not be served and are. Children who are not receiving the full measure of IEP-mandated services. Children who are being over-served.

What kinds of data can be captured? More examples Compliance by service delivery staff and building administrators, to support recovery efforts. Support for recovery efforts can provide an objective and quantifiable performance measure to assess staff, building administration, area administration, and even district-wide administration.

What kinds of data can be captured? More examples Performance between staff and contractual providers can be compared. Service delivery can be analyzed across LEAs. Compliance data, modeled against IEP data, can ensure maximized recovery.

Where might problems lie? The accountability tools provided through data mining can be so powerful that Special Education may resist such exposure. Districts and States under judicial engagement are more vulnerable to scrutiny. Remember, in order to be accountable, one first has to count!

Where might problems lie? Providers may not see the benefits of documenting services rendered to all students. For these reasons, one documented promising practice is to locate cost recovery efforts within Budget & Finance, while not neglecting partnership with Special Education.

How can these data be used? Maximization of recovery Resource allocation Strategic budgeting Personnel evaluation Demonstration of compliance with federal and state mandates

How can these data be used? Identifying programs and districts with performance concerns Targeting technical assistance Supporting interest and advocacy groups Building exhibits for judicial disengagement

How can these data be used? Don’t forget the Office of the Inspector General’s Reviews! Maryland (and many other states) believed we were in complete compliance with federal regulations. Our experience has been substantially different. OIG is requesting significant penalties across the country. Maryland is in Phase II of monitoring all Medicaid providers for school-based services.

How can these data be used? Don’t forget the Office of the Inspector General’s Reviews! We have developed rigorous instruments and protocols. The state process mirrors the OIG process (documents provided). The state has required all districts to implement self-monitoring processes that mirror the state process.

How can these data be used? Don’t forget the Office of the Inspector General’s Reviews! The necessary commitment of time and human resources is tremendous…but the results justify the investment. The information amassed from monitoring provides critical information for the state and LEAs.

How can these data be used? Don’t forget the Office of the Inspector General’s Reviews! When Maryland negotiates with regional CMS, the state’s monitoring process and products will be the material demonstration of compliance with federal regulations. Monitoring is the mechanism for system improvement.

How can these data be used? Don’t forget the Office of the Inspector General’s Reviews! Monitoring will inform and direct technical assistance. Monitoring will direct and enforce self-improvement and procedural correction. If your state or district has not been monitoring, you should begin.

These all add up to PROGRAM IMPROVEMENT

How does this benefit Medicaid? The original intent of Congress can be clearly delineated and argued: that Medicaid dollars support the medical component of IDEA. All stakeholders—federal and state Medicaid agencies, families, advocacy groups, professional associations, administrators, school system staff—embrace accountability.

How does this benefit Medicaid? Keeping the Medicaid dollars on the table—not commingling them with other funds—enables state and district partners to articulate the goals and vision of the Medicaid School Program. Putting services to children and families first “de-sensationalizes” cost recovery efforts.

How does this benefit Medicaid? All local stakeholder groups’ interests can be served, including: State and district Boards State and district CFOs Special Education advocacy groups, e.g., Disability Law Centers Professional associations, e.g., ASHA Judicial oversight entities, e.g., Consent Decrees, special masters

How does this benefit Medicaid? More than to any other entity, CMS itself must recognize that their contribution to Education is medically necessary, purposeful, effective, efficient, and economical.