1. Better Care, Equity in Services, Fairness for Providers David Ivers DDPA Annual Spring Conference May 22, 2012

2.  Data  Research  Meetings and more meetings  Committees and Subcommittees  Negotiations  All under auspices of DDPA Board & Exec Committee

3. ▪Prospective payment instead of retrospective reconciliation ▪Get rid of 15-minute units and go to daily or monthly rate ▪No risk sharing across providers ▪No subcontracting requirement ▪Preserve licensed nonprofit community providers per 20-48-101 et seq. ▪Allow for DD Health Homes to coordinate care instead of medical home ▪Create a broader, more flexible DDTCS service package ▪Retain entitlement status for enhanced DDTCS ▪Integrate all DD care plans and licensure requirements ▪Minimize administrative burdens (focus on outcomes not process) ▪Use assessment to ensure resource allocations are based on actual need

4. ▪Use assessment that is tailored to DD ▪Do not require full assessment every year ▪Pilot first & phase-in implementation ▪Revise income eligibility requirements ▪Obtain meaningful data ▪Behavioral health services ▪Adequate Rates ▪Consider “Community First Choice” option under ACA ▪Big Picture: Reduce inequality in amount of services and reduce waiting list

5.  Prospectively Bundled Payment Vs.  Retrospective Reconciliation with risk

6.  DD Lead Provider vs.  Principle Accountable Provider (PAP)

7.  Total Medicaid Budget (2012): $4.7 Billion  DD Services (2012):~ $600 Million

8.  Waiver Slots (2012): 4,100  Waiver Waiting List (2012): 2,127

10. Service# of AdultsDD Expenditures Number% to Total Dollars (in millions)% to Total Avg Cost Per Ben. HDC106415.16%10435.25%97,744 ICF4266.07%258.47%58,685 Waiver Only122917.51%5518.64%44,752 Waiver & DDTCS203829.03%8829.83%43,180 DDTCS Only226332.24%237.80%10,163 Total 7020100%295100%42,023

11. ServiceHalo ExpendituresTotal Expenditures Dollars (in millions)% to Total Avg Cost Per Ben. Dollars (in millions)% to Total Avg Cost Per Ben. HDC38.57%2,82010732.42%100,564 ICF25.71%4,695278.18%63,380 Waiver Only1028.57%8,1376519.70%52,889 Waiver & DDTCS1131.43%5,3979930.00%48,577 DDTCS Only925.71%3,977329.70%14,141 Total35100%4,986330100%47,009

12. DD service episodeExpenditures impacted by health home Initial phase: Adult DD clients 1 7,020 1 Includes DD clients ages 18+ receiving HDC, ICF, Waiver and/or DDTCS services. Excludes 180 clients ages 18-20 receiving outpatient therapy only and excludes 13 clients receiving DDTCS transportation but not receiving DDTCS services 2 Includes medical and behavioral spend, personal care, in-patient, out-patient, pharmacy, dental, hospice and non-emergency transportation. Does not include third party liability or state hospital expenditures SOURCE: Medicaid claims data for claims incurred in SFY 2010 $ 295 M DD expenditures for adults 1Ensure DD care provision is efficient and based on client needs –Align resources provided with level of need –Expand plan customization options for clients 2Minimize resources / time not focused on delivering client care $ 45 M Medicaid halo expenditures for adults (e.g., medical, behavioral) 3Increased care coordination –Integrate care across DD, medical & behavioral health –Reduce unnecessary medical and behavioral health spend –Promote wellness activities

13.  Separate payment from episode  In form of PMPM (Per Member Per Month)  Likely require use of co-ops or some other sharing of resources  Separate quality measures  Full benefit dependent upon HIT

14. (ACA § 2401 – Adds § 1915(k) to SSA) Under consideration by DHS “Home-and-community-based attendant services and supports” Increased Federal match of 6%. No expiration. Statewide, no cap or waiting list. Cannot discriminate based on age or type of disability or form of services/supports required. Must meet institutional LOC

15. DDPA web site at http://www.arkansasddpa.org/ http://www.arkansasddpa.org/ medicaidreform.htm “Arkansas Healthcare Improvement Initiative” at http://humanservices.arkansas.gov/ http://humanservices.arkansas.gov/ director/Pages/APII.aspx