The Arc of Illinois

December 8, 2009

Leaders in The Arc:

I have been talking to many legislators, in both parties, about managed care. What they have been telling me is that they do not want to see managed care imposed upon the developmental disability or mental health systems. So you need to be talking to your State Senators and Representatives about carving out our services/supports from any managed care proposal being discussed.

I have also been doing a lot of reading on managed care lately and I want to share some of the information with you.

First of all, "The Illinois Blueprint for System Redesign" does talk about managed care as an available alternative to the waiver. However, the "Blueprint" clearly cautions us:

"At present, the best option for Illinois is to expand its Home & Community Based Services waiver capacity and improve its operations. Illinois should ensure that the design of the waiver aligns with the goals and objectives it has set for the service system. Additionally, the financial gains achieved through expansion of the waiver and/or refinancing current services should be reinvested in the community system. Later, once Illinois has addressed some of the underlying problems in its developmental disabilities services system, other options may be considered."

In my opinion, imposing a managed care system on an already underfunded community system is extremely problematic. Remember, Illinois is ranked 47^th when compared with other states in funding home and community based services by The State of the States in Developmental Disabilities, David Braddock, Ph.D.

Four states operate managed care systems. They include:

      Arizona

      Michigan

      Vermont

      Wisconsin

Last year Bob Gettings did an analysis of the key issues that impact people with developmental disabilities in these four states, Reassessing the Impact of Managed Care in the Developmental Disabilities Sector. I have copied his conclusion at the end of my report and attached his entire study to this email. In my many conversations with Bob, it is quite evident that he is a proponent of managed care over the years.

If you are interested, here are some resources on managed care and individuals with developmental disabilities:

1. Reassessing the Impact of Managed Care in the Developmental Disabilities Sector, Robert M. Gettings, 2009.
   
2. The Blueprint for System Redesign in Illinois, Gary Smith and John M. Agosta, Ph.D., 2008, pages 13-14.
   
3. Managed Care and People with Developmental Disabilities: A Guidebook, Gary Smith and John Ashbaugh, 1995.

Tony Paulauski

The Arc of Illinois

815-464-1830

Conclusion

The main aim of this bulletin has been to examine the experiences of four states that have applied managed care principles to the delivery of Medicaid-funded long-term services to persons with developmental disabilities. In deciding to adopt a managed care framework, each state was attempting to address a somewhat different set of issues and achieve a distinctive set of policy goals; but, the common motivating thread was the recognition on the part of policymakers that the state's existing methods of financing long-term services were unsustainable over the long haul. Each state set out to make services readily accessible to all eligible beneficiaries and, to the enormous credit of all involved parties, thus far this goal has been largely achieved in all four states. On the other hand, far less progress has been made in affording individuals with disabilities similar opportunities to live, work and recreate with their non-disabled peers in all geographic areas of the state. By most reports, access to person-centered support was unevenly distributed across these states prior to the advent of the managed care program and remains so today. Nor is the track record of the four states in promoting self-directed services demonstrably better than that of many other states.

It is impossible to predict how existing service delivery practices in these four states might be impacted were Medicaid funding to be seriously curtailed, either as a result of federal statutory spending constraints or the lack of adequate state matching dollars. Certainly, in each state we could expect a major reassessment of program goals and the system's capability of achieving those goals. But, given the progressive social agendas which all four states have pursued over the years, it seems reasonable to assume that individuals with disabilities would be as well, or better, off than their counterparts in most other states that operate within a fee-for-services framework. Indeed, given the tools available to emphasize cost-effective support strategies, the four states that were the focus of this review might be better positioned to survive a major realignment in Medicaid funding than would a lot of other states.

In a widely read, well received 1995 analysis of potential applications of managed care within the developmental disabilities services sector, Smith and Ashbaugh wrote:

[W]hatever mistrust there might be about managed care has to be balanced against its trinity of promises: lower costs, better access, and higher quality. Curbing Medicaid payments to the states means developmental disabilities systems will face a far different fiscal landscape in the foreseeable future than has been true over the past decade. . This altered [low growth] fiscal landscape has enormous implications for the health and vitality of these systems and even more profound implications for the people and families who depend on these systems for supports. In this vein, dismissing managed care makes no sense. DD service systems will need to take advantage of every tool available in order to survive and be responsive to the people they support.xii

These words were written at a time when Congress was on the brink of imposing an across-the-board cap on federal Medicaid spending. Today , the nation appears to be approaching another crisis in financing not only Medicaid services but other major social entitlement programs as well (e.g., Medicare; Social Security, SSI, Food Stamps, etc.). Given the circumstances, Smith and Ashbaugh's admonition to consider all of the "arrows in our quiver" seems as relevant today as it was thirteen years ago. And, as unsettling as it may seem, managed care is one of those arrows.