SAFEGUARDING PERSONS WITH SPECIAL NEEDS AS

NEW YORK STATE TRANSFORMS THE MEDICAID PROGRAM

By: Arthur Y. Webb
December 2011
I believe that we are at the precipice of another major transformation of Medicaid in the New York.
While the struggles between limiting government spending and protecting its most vulnerable citi-
zens are ongoing struggles that many of face every day, the policies of Governor Andrew Cuomo are
fundamentally shifting Medicaid to a very different and hopefully better place. The Governor achieved
something in 2011 that no governor has achieved in the Medicaid program since Medicaid was en-
acted.
A little footnote on history: Much has been made of Governor Hugh Careys administration and its role
in saving New York City from bankruptcy. We have to look back to 1976-77 fscal years when Chap-
ter 76 of the Laws of 1976 was passed, which caused Medicaid spending to be reduced from one year
to the next. This was the frst and only time that Medicaid spending was lower than the previous fscal
year. I was Governor Careys lead person in negotiating Chapter 76 of the Laws of 1976, one of the
major highlights of my career in public service. State legislative leaders at the time, such as Bingham-
tons Jim Tallon and Syracuses Tarky Lombardi, understood the balance between capping spending
and ensuring coverage of the most vulnerable and were instrumental in passing effective reforms.
Its noteworthy, however, that those reforms, as broad as they were, pale in comparison to what is
transpiring here in New York today.
New York, through policies put forth this year by Governor Andrew Cuomo, has undertaken the most
signifcant redesign of Medicaid since the program began some 45 years ago. Governor Cuomo is
fundamentally changing how the states Medicaid program works, impacting both how care is de-
livered and the reimbursement available to providers. This shift shines a spotlight on the struggles
between government spending and the protection of our most vulnerable citizens.
In the 2011 legislative session, Governor Andrew Cuomo was able to gain the authority to cap the
Medicaid program for two fscal years, impose a new cost of living index and set in motion one of the
most sweeping and seminal sets of Medicaid reforms in the U.S. And the biggest change of all is the
mandate to move all Medicaid recipients into managed care, or into what the state is calling care
management models. There will be no exemptions. This is monumental for New York. The move
away from fee-for-service especially for the most vulnerable enrollees is extraordinary. Indeed, for
me, I have yet to fnd the words to adequately capture these sweeping changes. When you are in the
middle of this tidal wave, it is hard to get your breath.
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The Medicaid Redesign Team (MRT) process the state is using, which is being jointly managed by Jim In-
trone, Deputy Secretary to the Governor for Health and Director of Healthcare Redesign, and Jason Helg-
erson, deputy commissioner for Medicaid at the Department of Health, is taking a broad approach Medicaid
cost and care issues. The Medicaid Redesign Team (MRT) process is impressive for its breadth, its transpar-
ency and openness, and its intelligence and its inclusiveness. The MRT (See http://www.health.ny.gov/
health_care/medicaid/redesign/ for more information) has an outside body of advisors, which includes
virtually all the major players in health care in New York. Its work is soon to be complete.
The ImporTance of SafeguardS
The concentration of my work is on analyzing the impact of the Medicaid redesign on the needs of spe-
cial populations including frail seniors, persons with developmental disabilities, behavioral health substance
abuse disorders, and crafting new approaches for providers to better serve these populations. However,
while I am all in favor of pursing managed care and have been for many years, there are recommendations
that state offcials might heed to ensure that enough safeguards are in place to protect these individuals as
we redesign Medicaid.
A recent commentary by John Iglehart in Health Affairs, triggered me to think more broadly about my own
experience and to offer recommendations for safeguards. Contextually, New York has over fve million re-
cipients in Medicaid and spends over $50 billion making it one of the most expensive programs in the U.S.
When I tell people that one in four New York residents are enrolled in Medicaid and close to one out of fve
families, they are taken aback and astounded and this audience often includes professionals who are work-
ing in the health services. We know and understand that Medicaid has tremendous impact on New Yorks
health care sector. And all of these enrollees will be in some form of care management. How this happens
is a big deal. In New York, there already are over 3.5 million Medicaid recipients enrolled in managed care
but the high cost, high need persons are not or are only partially covered for medical care in managed care.
The special populations remain in fragmented, uncoordinated fee-for-service programs for their special
needs. On the other hand, and just to be clear, many of the most vulnerable are getting great care and treat-
ment by committed and capable community organizations and providers many of them are my clients. I see
in my work that services are frustratingly fragmented and the connections between medical services and
behavioral and developmental disabilities services are in many cases non-existent and at worse, danger-
ously contraindicated.
The most fundamental of changes in the Cuomo Administrations Medicaid redesign is the ultimate disap-
pearance of the traditional fee-for-service model, replacing it with a managed care model. Ultimately, the
State says it intends to move all Medicaid recipients into managed care. Mandatory enrollment of Medicaid
recipients living with HIV/AIDS began in 2010. Starting in 2012, enrollment in Managed Long-Term Care
MLTC) will also be mandatory for those requiring 120 days or more of care. Beyond that, the State plans to
move Medicaid recipients into care management, into what the Health Department calls Care Coordina-
tion Models (CCM).
New York is shifting risk for the most expensive and the neediest recipients to care management and man-
aged care plans. This is driven by the recognition of the need to save money while assuming that care will be
delivered in more cost-effective ways. Iglehart references the Lewin Group report that was prepared for the
Americas Health Insurance Plans (AHIP), which concludes that studies strongly suggest that the Medicaid
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managed care model typically yields cost savings. The savings are largely gained by reducing unneces-
sary hospital admissions. Thats the good news.
However, to quote Iglehart, there are surprisingly few data available to indicate what the overall quality
managed Medicaid will produce. He also quotes Diane Rowland of the Medicaid and CHIP Payment and
Access Commission (MACPAC) who says we need to learn more about how these plans handle long-term
care and chronic illness.
In a recent letter to the editor of Health Affairs in response to Igleharts article, Marguerite Burns and Sharon
Long urge caution in the anticipation of cost savings for states that move complex Medicaid populations
from fee-for-service to managed care. They cite an article by Burns, in which she concludes based on her
study that Medicaid MCO programs as implemented are not associated with lower Medicaid spending.
Thus, state Medicaid programs should consider additional policy tools to contain health care expenditures
in this population. I would add that safeguards need to be built into public policy and regulations.

SuggeSTIonS for SafeguardS
Given that we dont have the comprehensive evidence on effectiveness on managed care or care man-
agement models to assert best practice models for managed care and care management for those with
long-term needs and chronic illness, then, what should the state do? So far, the Medicaid offce is using
an open process and taking the time to ensure the regulations and state plans are well developed and
practical. The move towards implementing the newly authorized health homes is a case in point where the
state is using a deliberate process to initially assign those with serious mental illness to well-established
providers who are committed to developing health homes. While this is partially based on evidence of cur-
rent practices, they are using common sense and seeking wise outside counsel. Likewise in the Offce of
Persons with Developmental Disabilities (OPWDD), the proposed new People First waiver sets out some
broad principles that will transform the DD feld. These are exciting opportunities but we also need some
carefully planned safeguards.
But nevertheless, there need to be clear safeguards installed in all new programs. Taking a cue from Igle-
hart and Burns, and from my experience especially using the experience as one of the founders of a full
risk, full capitation special needs plan with six community-based organizations for people living with HIV/
AIDS plus extensive work in the feld of long-term care, here are some suggestions:
Transitioning:
X Provide suffcient time to transition consumers, providers, families and regulators to live under man-
aged care.
X Consumer education and awareness efforts have to be extensive using non-traditional approaches to
reach the thousands of enrollees.
X Many Medicaid recipients have beneftted from being enrolled in federal waiver programs and these
should not be disbanded without careful transitions.
X Provider education is needed because so many providers have built successful business models based
on traditional FFS funding. Understanding the new risk models requires education. Lets learn from the
current California waiver and the safeguards they have imposed.
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Quality Measures and Evidence-based protocols:
X Build the evidence base for quality and best practices so that over time the policies and regula-
tions of the state evolve to refect what we learn.
X Quality of care metrics have to be developed and installed that refect the reality of how diffcult it
is to serve people with special needs
X With IT platforms for producing electronic health information being woefully behind in the felds of
behavioral, long-term care and, as well as, generally in care for those with chronic illness, the state
and managed care companies will have to be patient and invest in the platforms that will provide
this health information.
Care Management Models and Innovation
X Offer a wide range of risk-based Medicaid care management models that include provider-based
opportunities. This will help in getting to best practices.
X Services that have been created over many years need to be assessed for their practical value and
preservation.
X Recognize that many of the social supports and housing services are keys to stabilizing a persons
life and well-being.
X There needs to be appropriate care coordination models that build in an understanding of the
needs of special populations. Ensure that networks of care are broad and specialized enough to
care for comprehensive needs.
X We need new user connectivity through robust care coordination models and by using existing
relationships with community providers.
X Ensure the effective coordination and integration of medical care with behavioral needs.
Payment Methods
X Rates for managed care have to be suffcient and adjusted for acuity to ensure access to services
and quality of care and refect actuarial soundness.
X If there is risk-sharing with providers, risks should be shared on a fair and equitable basis and not
simply dumped onto providers.
X Be mindful of the Commonwealth Fund report that indicates the low performance of publicly trad-
ed plans in use of premium dollars and achieving quality of care.
Oversight
X Possibly establish independent advocates like Ombudsman to oversee the practices of managed
care companies.
X Create reporting tools that are transparent to all stakeholders.
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I think that going to managed care or care management is absolutely the right thing to do but there
needs to be safeguards for all concerned parties.
Arthur Webb
December, 2011
References:
For further information please see the papers on this website: www.arthurwebbgroup.com
See:
Kodner, D., New York States People First Waiver: Concept Paper on Strategic Issues and Options
Related to the Development of Innovative Medicaid Managed Care Models for Developmentally Dis-
abled Adults, Arthur Webb Group, Ltd. July 2011.
Kodner, D., Dual Eligibles: Understanding this Special Needs Population and Options to Improve
Quality and Cost-Effectiveness of Care Through Integrated Solutions, Arthur Webb Group, Ltd.
September 2011.
Kodner, D., The Medical Home: Improving Its Fit with the Frail Elderly and Other Special Needs
Populations, Arthur Webb Group, Ltd. October 2011.
*Arthur Webb has been involved in health and human services since 1971, with over 20 years of experience as a provider of a wide range of health and
human services and almost 18 years as public offcial in New York State government. His government experience includes responsibility for Medicaid
budgets in the budget division; commissioner or director of four government agencies including Department of Social Services (the welfare, Medicaid
and social services agency); Offce of Mental Retardation and Developmental Disabilities; Offce of Substance Abuse Services; and Health Planning
Commission. As a provider, Mr. Webb was president & chief executive offcer of Village Care of New York and, most recently, chief operating offcer of
St. Vincents Catholic Medical Centers in New York.
The Arthur Webb Group provides advice and consultation to health care providers, health plans, disease and utilization management companies and
government offcials. The group specializes in offering innovative solutions in the post-acute world.