NEW YORK STATES PEOPLE FIRST WAIVER

Concept Paper on Strategic Issues & Options Related to the Development of Innovative Medicaid Managed Care Models for Developmentally Disabled Adults
By: Dennis Kodner* (This paper was prepared under the direction and guidance of Arthur Webb) July 2011
INTRODUCTION According to New York States Medicaid Design Team, of the 865,000 Medicaid patients with multiple chronic conditions, some 100,000 recipients in the Medicaid program are people with developmental disabilities (DD); 80% have been assessed as needing an institutional level of care through either an ICF/MR or nursing home.1 The DD group is the states costliest ($6.4 billion/$10,500 per member per month). Even with the enormous investment made by New York State over the past 20-years to reduce the systems expensive and inappropriate institutional bias through Medicaid waivered home and community-based services (HCBS) operating under the auspices of both the Office of People with Developmental Disabilities (OPWDD) and the Department of Health, it has become abundantly clear that demand and concomitant costs for this special need group will continue to climb into the future. There are several explanations for this anticipated trend: 1) the widespread availability and popularity of Medicaid waivered DD services 2; 2) the graying of the DD population and their family caregivers, thus increasing needs for more extensive formal support; and, 3) the rise in the proportion of individuals with multi-system health needs requiring more complex and expensive care.3 Finally, despite extensive DD service and support networks found in many parts of New York State and elsewhere, Medicaid recipients still lack the kind of comprehensive, coordinated, effective, high-quality, and person-centered care that their complex conditions demand. New York State recognizes that it is at a turning point. While strongly committed to fulfilling the United States Supreme Courts Olmstead mandate, it also recognizes that the current DD system is inadequate from the quality of care and quality of life perspectives and is also becoming increasingly unaffordable. The State is seeking an 1115 waiver from the Centers for Medicare and Medicaid Services (People First Waiver) to transform its approach to addressing the complex and costly needs of the DD population through a multi-year research and demonstration project. Designing, developing and testing new and creative managed care-like service delivery and payment models forms the core of this initiative. 4

1 See New York Medicaid Redesign Team, 2011. 2 There are approximately 4.5 million individuals with DD; about 60% live with family caregivers. (Larson & Lakin, 1995). Spending for DD services reached $34 billion in 2002; almost 80% of this amount was used to fund HCBS (Braddock at al, n.d.). Nationally, two-thirds of HCBS waiver spending was on behalf of Medicaid recipients with DD (Doty et al, 2006). Generally speaking, the HCBS waivers for DD recipients have facilitated deinstitutionalization, enhanced community living options, and achieved cost-effectiveness as compared to care expenditures in ICF/MR facilities (Lewin Group, 2005). 3 This cohort includes dually diagnosed patients with a combination of physical and mental health needs, as well as patients diagnosed with Autism. In line with national trends, Medicaid recipients with Autism increased by 500 percent in New York State between 1989 and 2010. 4 For a summary see NYS Office for People with Developmental Disabilities and NYS Department of Health, Concept Paper: New York States 1115 Waiver Research and Demonstration Project (People for Waiver).

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This concept paper will examine strategic factors related to the development of innovative managed care models for adults with DD. However, to provide context, we will first describe the complex epidemiologic, clinical and service profile of the DD population and the challenges involved in serving them. Next, we will sketch recent efforts in four states (Arizona, Michigan, Vermont and Wisconsin) to operate specialized managed care plans for DD recipients under Medicaid. Then, we will look at several successful managed care programs around the country targeted to people with DD. Drawing on this background and the lessons learned, we will conclude with the identification of several critical issues and options that should be taken into account by New York State as it moves ahead with the People First Waiver. DEVELOPMENT DISABILITIES: DIVERSE, COMPLEX AND CHALLENGING DD is a diverse set of severe chronic conditions that are due to mental and/or physical impairments which generally begin early, but usually last a lifetime; it affects approximately 1.6 percent of the U.S. population (Larson & Lakin, op cit).5 Included are people with mental retardation (MR), cerebral palsy (CP), autism spectrum disorders, Downs syndrome, Spina Bifida and other complex genetic, chromosomal and fetal disorders. First and foremost, people with DD experience problems with major life activities such as language, mobility, learning, self-care, independent living, and economic selfsufficiency. However, depending on the specific syndromes and diagnoses involved, there can be a host of associated physical health problems. In addition, psychiatric illnesses are more likely to co-occur in DD patients; some patients may also exhibit challenging and abnormal behaviors. Overall, adults with DD have lower life expectancies than those in the general population, but they are increasingly living to older ages with advances in medical knowledge and adaptive technologies. While a heterogeneous group, adults with DD have limited social networks, rarely marry, are often poor, and frequently experience negative health outcomes. The latter largely stems from the negative attitudes and major knowledge gaps of medical and other health professionals, as well as the fact that DD patients are frequently unnoticed, uncomplaining and unheard (Lennox, 2006). The literature also indicates that adults with DD have an average of 5.4 conditions, half of which go unrecognized and/or are poorly managed (Beange et al., 1995). Many of these medical conditions (for example, epilepsy, mental disorders, sensory impairments, swallowing problems, chronic constipation, reflux esophagitis, and dental disease) are more common in patients with DD than in the general population. These patients also tend to be passive recipients of too many, and sometimes inappropriate, medications. And, finally, their health status is further compromised by a host of lifestyle problems such as inadequate physical activity, poor diet and obesity. In order to remain at home and in the community, adults with DD not only require excellent primary and specialty medical care, but also access to appropriate mental health services and an array of non-medical community-based supports, including residential services, personal care, habilitation, assistive technology, and other kinds of non-institutional long term care. Given this challenging clinical, psycho-social and service delivery profile, Medicaid managed care plans for adults with DDwhatever their designshould be organized around the following five (5) core characteristics: X Comprehensive primary and acute care services sensitive to the special needs of DD patents; X Broad and flexible array of habilitation services and home, community and residential long term care services to develop and support maximum independence; X Mental health services capable of addressing the psychiatric and behavioral management needs of the DD population; X Specialized systems of care coordination and management to effectively link providers and integrate the complex services and clinical care of individuals with DD on an ongoing basis; and, X Emphasis on autonomy and self-determination, individual responsibility, and person-centered care. Systems of care organized along the above lines should improve care quality and personal health outcomes, increase efficiency and cost-effectiveness, and enhance patient and family satisfaction and quality of life.

5 Other studies suggest that upwards of 3 percent of the total population could be affected by DD. In any case, people with DD are relatively numerous.

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MEDICAID MANAGED CARE IN THE DD SECTOR: A BRIEF LOOK AT FOUR STATES6 Advocates for disabled citizensincluding those with DDhave traditionally been strongly opposed to Medicaid managed care. While capitated managed care plans are theoretically better equipped to address the disabled populations need for comprehensive, flexible, and coordinated care arrangements when compared to the fragmented, fee-for-service system, the limited evidence from mainstream Medicaid managed care plans suggests that they can end up medicalizing care, reducing access to needed services, and producing great dissatisfaction for disabled enrollees (Vladeck, 2003). DD advocates were especially concerned that the shift to managed care would ultimately lead to the dismantling of community service networks funded by Medicaid HCBS waivers. The push to enroll people with disabilities in Medicaid managed care on a voluntary basis finally fizzled in the late 1990s in the face of mounting opposition from the disability community and cost-shifting concerns. Despite these circumstances, the policymakers of four statesArizona, Michigan, Vermont and Wisconsinconcluded that the only way to maintain the economic viability of Medicaid-covered DD services was to adopt a managed care approach designed to improve the accessibility, quality and cost-effectiveness of long term care services. Each state approached its managed care solution differently: Arizona Arizona, the last state to join the Medicaid program, entered into an agreement with the federal government in 1982 through a Section 1115 demonstration waiver, to establish the Arizona Health Care Cost Containment System (AHCCCS). AHCCCS is a statewide, state-operated managed care plan. From the start, this enabled the state to share a wide range of program costs with the federal government. In the late 1980s, Arizona added a long term care component referred to as the Arizona Long Term Care System (ALTCS). From its inception, ALTCS focused on two populations: 1) older persons and adults with physical disabilities; and, 2) individuals with DD (both children and adults). The program targets children and adults with MR and other DD-related conditions. It is jointly managed by AHCCCS (primary, acute, mental health, and long term care services) and the States Division on Developmental Disabilities (DDD)through its regional officesfor specific DD services. DDD contracts with qualified vendors and independent providers that have been traditionally part of the DD network across the state. To fund the DD program, AHCCCS combines dollars from Medicaid HCBS and ICF/MR, health plan services, behavioral health services, and limited state-only services. Capitation operates at the state-level only, with AHCCCS subcontracting on a capitation basis with DDD. Michigan Between the mid-1980s and early 1990s, Michigan provided the existing network of county mental health boardslater referred to as Community Mental Health Services Programs (CMHSPs)with greater flexibility to administer state and federal funds and deploy resources locally in exchange for assuming stronger managerial responsibility and accountability for program performance, client outcomes and costs. Each CMHSP received a global budget composed of the various federal and state funding streams covering mental health, DD and substance abuse services. By the late-1990s, however, this system began to suffer from unstable funding, as well as increasing service demand. To address this problem, Michigan transformed the county-based CMHSPs into a network of prepaid, capitated managed organizations. This restructuring of the system was undertaken with both Medicaid 1915 (b) and (c) waivers. As a result, the Michigan pro6 This section is based, in part, on a report issued by The National Leadership Consortium on Developmental Disabilities, Reassessing the Impact of Managed Care in the Developmental Disabilities Sector.

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gram enables all Medicaid recipients (both children and adults) to receive mental health, DD, and substance abuse services, whether they are qualified to receive waivered HCBS or not (i.e., even if they are not eligible for institutional care.) These managed care organizationsformally known as Pre-paid Inpatient Health Plans (PIHPs)were first operated by their respective county-run CMHSP. However, in 2001, the State mandated that each PIHP must serve at least 20,000 enrollees. As a result, counties were encouraged to partner with nearby counties to run a PIHP. Today; there are 49 counties, but 18 PIHPs. Operating within the above framework, CMHSPs serve as the single point-of-entry to public mental health, DD and substance abuse services. They also manage all non-Medicaid dollars and services, although the trend has been to contract with CMHSPs to provide and/or arrange these services on their behalf. Vermont When faced with a $600 million shortfall in its overall Medicaid budget in 2004-2005, Vermont sought a Section 1115 demonstration waiver known as the Global Commitment (GC) to Health. A major goal of GC was to gain control over, and the flexible use of, Medicaid-funded health and health-related services, while enabling future investments in care needed by the Medicaid population. In exchange for federal waiver approval, Vermont agreed to operate its Medicaid program under a global federal spending cap; the cap was set at $4.7 billion spread over a 5-year period. While the state assumed some financial risk for federal funding under this formula, it also received important flexibilities, e.g., including state health and health-related expenditures under this initiative, as well as the use of unspent funds to seed upstream investments. DD services were ultimately included in the GC program.7 The existing DD system continues within the above GC framework. A network of ten (10) areawide non-profit Designated Agencies (DA)under contract with the state Department of Disabilities, Aging and Independent Living (DAIL)determine client eligibility for both children and adults, and provide and/or purchase needed services from local contractors. DAs have used managed care-like approaches, like case management, since their inception. Wisconsin After several years of study on the state-level, a 1999 law directed the establishment of a new programFamily Care (FC)and the piloting of new managed care models encompassing long term care services only under the program.8 The law, which covered the adult DD population, also provided options for FC recipients to self-direct their own services and supports. The FC program was not authorized to operate statewide until pilot programs in a limited number of countries received a positive evaluation. Indeed, an external evaluation found that FC eliminated waiting lists, substantially improved patient choice, enhanced access to information about long term care options among the target populations, achieved high consumer satisfaction, and reduced costs vis--vis traditional fee-for-service arrangements. The decision was finally made by Wisconsin in 2006 to gradually extend FC statewide by 2011. FC operates under Section 1915 (b) and (c) combo waivers. The program pools HCBS waiver and ICF/MR dollars, certain state plan coverages, and state and county matching funds. Covered services are delivered and/or arranged by a network of managed care organizations contracting with the State Department of Health Services (DHS). In some cases, these homegrown managed care plans were formed by elements of the existing DD service system. Lastly, Wisconsins network of Aging and Disability Resource Centers (ADRCs) are linked to the FC system. ADRCs make elderly and disabled citizens aware of long term care services and supports throughout the state, as well as eligibility requirements for various programs including FC. SUMMARY AND KEY POINTS Overall, the review of this four state experience by the National Leadership Consortium on Developmental Disabilities suggests anecdotally that these managed care initiatives have largely enhanced timely, streamlined, consumer-friendly eligibility and access for patients/clients to needed DD services and supports. They also appear more cost-effective than 7 Long term care services for the frail elderly and adults with physical disabilities, however, are operated under a separate Section 1115 Medicaid waiver. 8 A separate program, the Wisconsin Partnership Program, was also established. This program involves the comanagement of health and long term care services under a single managed care plan. The Wisconsin Partnership Program should not, therefore, be confused with FC.

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traditional fragmented, fee-for-service care arrangements. Finally, they contribute to a more stable funding situation and assure greater program accountability. Nonetheless, there are concerns about the ability of managed care programs to promote individualization, support community integration, and enhance self-direction and independence, as well as their tendency to medicalize care. These are core quality of care and quality of life issues. The focus of these states has been on applying the financial, organizational, service delivery, and clinical tools used by managed care to improve the access, coordination, quality and cost-effectiveness of DD services. It is interesting to note that none of the initiatives sketched above attempt to fully integrate primary care and other medical services with the plethora of other services and supports needed by individuals with DD. This complex profile of need was discussed in the previous section. As noted in the sketches above, there are similarities and differences in terms of how each of the states placed DD services within a managed care framework: Target population(s): -Children and adults (AZ, MI, VT) -Adults-only (VT) Federal waivers: -Section 1115 (AZ, WI) -Section 1915 (b) and (c) combo waivers (MI, WI) Combined funding streams: -HCBS and ICF/MR dollars (AZ, MI, VT, WI) -Health plan coverage; behavioral health coverage (AZ) -Certain state plan coverages; state/county match (MI, WI) -Flexible family grants (VT) Managed care structure: -State agency assumes role of managed care organization (AZ,VT) -Managed care organizations (MI, WI)9 Local service providers: -Official county/regional provider entities (MI, VT) -Contract agencies and providers (AZ, MI, VT, WI)Capitation: -State-level only (AZ, VT) -Risk-based managed care contracting (MI, WI) Risk-sharing: -State with county (WI) -State with managed care organization (MI)10 -State through federal waivers (AZ, VT) State administration: -Single agency (MI, WI) -Joint Agencies (AZ, VT)

9 10

No commercial HMOs are involved. Michigan limits the total risk of each PIHP to 7.5% over the amount of its annual contract.

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TWO MEDICAID MANAGED CARE MODELS FOR INDIVIDUALS WITH DD: THE MEDICAL SIDE11 We identified several creative managed care models for people with disabilities in general. The following two Medicaid models have been especially successful in accommodating the special needs of individuals with DD: Community Medical Alliance (Massachusetts) Community Medical Alliance (CMA) was the first fully-capitated managed care plan for patients with disabilities in U.S. Its origins are in the Urban Medical Group, a non-profit group of family physicians and nurse practitioners that specialized in caring for the frail elderly and adults with severe disabilities which began in the 1970s. While formerly a separate managed care organization only serving people with disabilities, CMA is now part of a larger Medicaid HMO (Neighborhood Health Plan or NHP). As a specialized clinical program, CMA largely focuses on individuals age 18-64 with HIV/AIDS, severe physical disability, and DD. It receives a sub-capitation from the Medicaid managed care plan of which it is part. The capitation rate is risk-adjusted for AIDS and severe physical disability; a standard SSI rate applies to other persons with disabilities, including individuals with DD (if not considered severely disabled). The SSI rate presents a major challenge to CMA/NHP in addressing the medical needs of DD patients who are not severely disabled. There are a number of special features of the CMA model: Nurse practitioner care management, home-based primary care, 24-hour on-call services, disability-specific crisis intervention services, flexible use of capitation, carve-in of mental health services, and integrated physical health and mental health care. Services for enrollees with DD are based on a model developed in 1996 in collaboration with the Massachusetts Department of Mental Retardation. In addition to the above features, CMA has developed a specialized provider network for people with DD. This includes a program to manage mental health and substance abuse emergencies. Developmental Disabilities Health Alliance (New Jersey) Established in 1997 and beginning operations in 2000, Developmental Disabilities Health Alliance (DDHA) is a private, statewide health care company with six sites that provide comprehensive primary care, mental health services, and care coordination to people with DD. Sites are located in each of the states Division of Developmental Disabilities (DDD) regions. Primary care is provided by physicians specialized in DD; they are especially attuned to the unmet physical health and mental health needs of the DD population. They are supported by a team of nurse practitioners, social workers, psychologists, and care coordinators. NDDHA works closely with DDD and the DD service community. New Jersey mandates managed care enrollment for the states SSI recipients with disabilities; recipients can select one of several HMOs with a state contract. If a person with DD is in one of these plans and it contracts with DDHA, they will receive all of their primary care and care management services through DDHA. SUMMARY AND KEY POINTS Having a medical/health home is an essential component of high-quality, efficient, cost-effective care for adults with DD. A review of the innovative CMA and DDHA models briefly sketched above suggests that the following elements should be incorporated into a Medicaid managed care model in New York State for adults with DD: X Access to primary care physicians specialized in the needs of adults with DD; X Back-up by a clinical team including nurse practitioners, social workers and other professionals; X Focus on case management/care coordination X Availability of in-office and at-home primary care services;

11

Based, in part, on Bedford VA Research Corporation, 2006.

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X Around-the-clock coverage and DD-specific crisis intervention capabilities; X Strong links with providers of mental health, substance abuse, long term care services and supports, and other specialized DD services; X Integration of physical health and mental health care; and, X Clinically-based, risk-adjusted capitation rate. STRATEGIC ISSUES AND OPTIONS In this final section of the paper, we will highlight some of the key strategic issues and options that states and providers face in organizing and operating managed care systems for adults with DD. Coverage of services People with serious disabling conditions need a comprehensive array of services to sustain and participate in community living. Adults with DD, in particular, require access to acute care, long term care services and supports, mental health and substance abuse services, and specialized DD habilitation and community integration services for the remainder of their lives. Yet, state Medicaid-waivered managed care efforts have to date ignored the medical side of the equation. Medicaid recipients with DD presumably continue to receive health services of various kinds through mainstream fee-for-service and managed care arrangements with little or no attention given to the often specialized nature of the medical care required. Some of the unique health problems experienced by DD patients were sketched earlier in this paper, as were two specialized medical care models to address them; these factors need to be carefully taken into account. In reforming and modernizing the Medicaid system for adults with DD, New York State should carefully consider this wide range of services as a total package, and therefore design the best way to organize, operate and finance their delivery in a managed care framework. This is integral to the next key strategic issue. Integration of health, long term care, and mental health services and supports To emphasize a previous point, people with DD demand coordinated and flexible access to a very wide range of appropriate services on an ongoing basis. The degree of integrationthat is, how closely systems, provider organizations, clinicians, care, and financing are linkedis a key variable. The greater the level of integration, the better the opportunity is to achieve efficient, high-quality, cost-effective service delivery, and optimum personal health outcomes and quality of life.12 Managed care modelswhether vertically integrated, capitation-financed entities that consolidate all services within a single service system or network arrangements where providers coordinate care on behalf of individuals across a wide range of services and settingscan be especially effective in ensuring access to appropriate services, coordinating care, and achieving quality, cost-effective results. Nonetheless, such programs are difficult to develop and operate; they can also be risky, particularly in the absence of solid experience. The following managed care designspresented in order of preference and complexityrepresent a range of reasonable options that could be developed and tested under New York States People First Waiver: X DD Special Needs Plan (SNP). Patterned on New Yorks successful HIV Special Needs Plans (HIV SNPS) for people living with HIV/AIDS, DD SNPS would deliver, arrange and coordinate acute, long term care, mental health, substance abuse and other specialized support services for adults with DD.13 All DD SNP primary care providers would be DD specialists, and each plan would provide care through its own provider network. 14 X DD Managed Long Term Care Plan (MLTCP). Patterned on New Yorks successful Managed Long Term Care (MLTC) Program, adults with DD would receive coordinated long term care services and supports through a specialized MLTCP. (This is similar to approaches taken in the Medicaid waivered states described in this paper.) In addition, 12 13 14 For an overview of the concepts and key facets of integration and integrated care, see Kodner, 2009. For details on the favorable cost and usage impacts of the HIV SSP, see Lewin Group, 2009. DD SNPS would be encouraged to contract with providers in the DD network.

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the Medicaid DD recipient would receive her/his health related services through a Medicaid Managed Care Plan (see below); the DD MLTCP and MMCP would be required to work closely together to coordinate all of the individuals care irrespective of the setting. X Medicaid Managed Care Plan (MMCP) with Enhanced DD Capabilities. Adults with DD who are not in DD SNPS would be given options, ultimately required, to enroll in mainstream Medicaid Managed Care Plans (MMCPS). To ensure that the MMCP is DD-friendly and capable, the plan would have to develop a modicum of specialized capabilities identified by the State. Two other options are possible: 1) health plan subcontracting with a primary care group specialized in the care of DD patients (similar to Massachusetts-based CMA); and, 2) State contracting on behalf of MMCP enrollees with a primary group specialized in the care of DD patients to serve as their patient-centered medical home (similar to New Jersey-based DDHA). Encouraging involvement of agencies in DD Network Agencies that are part of DD networks around the state are very important community resources; they should play an essential role in the reformed DD system under Medicaid. 15 In addition to mandating active State encouragement and support of contracting with the managed care organizations above, local/regional DD network providers could be encouraged to organize Provider Service Networks (PSNS) that would ultimately become full-fledged DD SNPS or DD MLTCPS. The State could provide seed funds to regional groups to support development and implementation of promising PSN initiatives. As in Florida, PSNS would operate for the first 3-years, first on a modified fee-for-service basis and then gradually assuming risk. At the end of this initial period, the PSN would have to meet full working capital and reserve requirements and operate on a capitated basis.16 Risk-adjusted capitation financing Risk adjustment is a critical component of prepaid, capitated managed care. This is important since health care costs differ greatly across patients and patient groups based on their health status. If capitation rates do not properly reflect patient characteristics and costs, managed care financing can work against the provision of accessible, high-quality care for people with DDwhether in the acute, mental health or long term care settings. To be successful in managed care for the DD population, New York State must calculate capitation rates on the basis of the best methods and diagnostic data available. Risk adjustment methods based on medical diagnostic data from Medicaid claims records are the most useful to start; this includes Adjusted Clinical Groups, Diagnostic Cost Groups, and Chronic Illness and Disability Payment System.17 Age, gender and functional status drive the overall need for, and cost of, long term care services and supports in general; level of care (as used by the MLTC Program) might be a more accessible risk adjustment method. How other specialized DD services would be risk-adjusted, if at all, remains a question. Perhaps the use of global budgets could entice providers and organize the flow of funds from the state. (See Webb and Hajj paper on Global Budgets, 2011) Other issues There are many other strategic issues and options relevant to designing effective Medicaid managed care options for adults with DD. At the very least, the following essential requirements and components should receive serious attention: X Providers with experience and expertise in serving people with DD should be represented in each specialty in the managed care network. X DD-related disability training should be required for all providers in managed care organizations. X Managed care organizations should be required to engage the services of an outside patient advocate ensuring that the needs and concerns of enrollees are being appropriately addressed. 15 For example, DD network providers in Wisconsin were involved in some parts of the state in organizing local Family Care (FC) programs. 16 See Moulton, 2008. 17 For a brief summary of how these methods compare and contrast, see Bedford VA Research Corporation, 2006.

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X Managed care organizations should allow enrollees with DD the flexibility in their choice of primary care physician (PCP), including the designation of specialists as the PCP if this makes sense from the clinical perspective; also access to out-of-plan providers when required in-plan services are inadequate to meet a documented special need. X Each managed care enrollee with DD should receive a full baseline assessment and physical examination within 30days of enrollment, and be periodically re-assessed, say 120-days thereafter. X Strong links should be fostered between the PCP and Case Manager/Care Coordinator to ensure integration between the DD enrollees physical health, mental health, and long term care needs, as well as ongoing continuity of care. X A consumer-directed personal assistance option emphasizing consumer choice and control should be offered to the enrollee with DD in lieu of the professional/ bureaucratic model of home- and community-based services traditionally found in health plans and provider agencies. Within budgeted spending limits, individuals would be allowed to freely choose types and amounts of paid services they judged are best able to meet their personal care needs.18 X A quality assurance mechanism with DD-specific measures is necessary to identify and address the quality issues and concerns of this special needs populationespecially in a managed care setting. X An Advisory Committee should be established within each managed care organization consisting of people with DD and their caregivers to actively solicit feedback and help guide program operation.

18 For a detailed discussion of this innovative approach, as well as how it would fit in a managed care framework, see Doty et al., 2007 and Kodner, 2003.

*This paper was prepared at the direction of Arthur Y. Webb on behalf of the ArthurWebbGroup, Ltd. The AWG provided financial support for this paper. Dennis Kodner, PhD, FGSA is a global thought leader on health systems/services integration. He is an expert on coordinated care and managed care systems for the people with chronic, disabling, medically complex, and high-risk conditions, including the frail elderly and those whose needs cut across the health, mental health, long term care and social service systems. *Arthur Webb has extensive experience in the policy and practice areas of managed care. When he was the President & CEO of VillageCare, he was one of the founders along with five other community-based providers and funders of a successful Special Needs Plan for AIDS, a full risk, full capitation plan. He also was the commissioner of the Office of Persons with Development Disabilities from 1983-1990. See www.arthurwebbgroup.com

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REFERENCES Beange, H. et al. (1995). Medical Disorders of Adults with Mental Retardation: A Population Study, American Journal of Mental Retardation, 99 (6): 595-604. Bedford VA Research Corporation (2006). Medicaid Reform in Florida: Recommendations for Promoting Access and Quality in Medicaid Managed Care for Persons with Developmental Disabilities. Center for Health Quality, Outcomes & Economic Research, April 26th. Braddock, D. et al. (n.d.). The State of the States in Developmental Disabilities. 2004 Edition. Washington, DC: American Association on Mental Retardation (AAMR). Doty, P. er al. (2007). Designing the Cash and Counseling Demonstration and Evaluation, Health Services Research, 42:1. Kodner, D. (2003). Consumer-Directed Care: Lessons and Implications for Integrated Systems of Care, International Journal of Integrated Care, 3 (June). Available from: http://www.ijic.org. Kodner, D. (2009). All Together Now: A Conceptual Exploration of Integrated Care, Healthcare Quarterly, 13 (October): 6-15. Larson, S. and Lakin, K. (1995). MR/DD Data Brief, Prevalence of Mental Retardation and/or Developmental Disabilities: Analysis of the 1994/1995 NHIS-D. Lennox, N. (2006). Following Treatment Guidelines for Developmentally Disabled Adults, Canadian Family Physician, 52 (November): 1373-1374. Lewin Group (2005). An Independent Assessment of the West Virginia MR/DD Waiver, March 30th. Lewin Group (2009). Evaluation of New Yorks HIV Special Needs Plan Program: Cost and Usage Impacts, November 6th. Moulton, N. (2008). Medicaid Managed Care and Persons with MR/DD. A Presentation to the Missouri Association of County Developmental Disabilities Services, Health Management Associates, July. New York Medicaid Redesign Team (2011). Redesigning the Medicaid Program. Albany, NY: State of New York Department of Health, January 13th. New York State Office for People with Developmental Disabilities and New York State Department of Health. (n.d.). Concept Paper: New York States 1115 Waiver Research and Demonstration Project (People First Waiver). The National Leadership Consortium on Developmental Disabilities. (n.d.). Reassessing the Impact of Managed Care in the Developmental Disabilities Sector, University of Delaware Center of Disability Studies, Policy Insights, 1:1. Vladeck, B. (2003). Where the Action Really is: Medicaid and the Disabled, Health Affairs, 22:1: 90-100.