Wisconsin Family Care

1. Wisconsin Family Care Shelley Hansen-Blake, President CAPOW Executive Director, REM Wisconsin

2. Wisconsin Family Care Goals • CHOICE – Give people better choices about the services and supports available to meet their needs. • ACCESS – Improve people's access to services. • QUALITY – Improve the overall quality of the long-term care system by focusing on achieving people's health and social outcomes. • COST-EFFECTIVENESS – Create a cost-effective long-term care system for the future.

4. Enrollment Data September 201138,034 Members • Three Programs: Family Care, PACE & Partnership • 10 Care Management Organizations • May provide single program or combination of one or more programs • Family Care (Long-Term Care): 33,292 (1935 TG unknown) • Developmental Disability: 12,072 • Frail Elder: 14,670 • Physical Disability: 4,615 • Acute & Primary Care through traditional MA Card Services • PACE & Partnership: 4,742 (80% Elder & Physical disability) • Combines acute/primary care with long-term care

5. IRIS: Include, Respect, I Self-Direct • Goals of IRIS: • INCLUDE – Wisconsin elders, adults with physical disabilities and adults with developmental disabilities who are Medicaid eligible are included in communities across Wisconsin just like everyone else. IRIS can help participants remain connected to others. • RESPECT – You choose where you live, what relationships you build, where you work, and how actively you participate in your community. • I SELF-DIRECT – IRIS is a self-directed option in which you creatively use your monthly budget allocation to help meet your individual long-term care needs. You decide what is important to you. • IRIS Enrollment: 4590 (8-31-11)

6. WI Family Care: The Good …. • Entitlement Program: • Eliminate Waiting Lists • 53 of 72 WI Counties participate • Consolidate Regional Resources • Levels availability of service through economies of scale • 10 MCOs vs. 72 Counties • Consumer Choice • ADRC Eligibility & Benefit Counseling • Maintain consumers at home longer (60% in home) • Cost Savings: • Pilot Counties achieved $452 PMPM Medicaid savings • Innovative Service Models blend consumer choice with savings

7. Family Care Case Mix Shift

8. WI Family Care: The Bad … • Pilots were not representative of expansion regions • Case Mix: PMPM $1800-$2800 FE & PD; $2900-$4600 DD • No standard provider rate setting methodology • Each MCO has it’s own, frequent changes in the formula • Long-Term Care Functional Screen not meant for rate setting • Provider rate reductions tied to MCO saving targets • DD providers sustained rate cuts from 7% - 35% • Cuts occur multiple times in one year; in consecutive years, and shortly after admission of new consumers • Lack of Uniform Processes • Billing Systems, Contract language, and program standards • Economic Recession derailed services across the board

9. WI Family Care: The Ugly … • Consumer Choice Restrictions • More housemates due to cost savings, moves to different homes or providers for less costly options, reduced community inclusion • Single MCO in most areas; IRIS resources insufficient for demand • Inadequate and confusing appeal process (consumer) • No appeal process for provider • If rate is inadequate to serve the individual, discharge is only recourse • Provider network shrinking due to inability to survive at reduced rates • Concern about quality, oversight, and continuity • Rapid Expansion without adequate resources for MCOs • Inexperienced Care Managers; lack of team process • Shift of case mix to high need individuals with developmental disabilities • Individuals with I/DD last target group to enter; acuity measures unproven

10. WI Family Care: The Ugly … • Expansion MCOs sustainability is at risk • Insufficient funds for high need clients • Enrollment cap in the midst of statewide roll out • Emergency enrollment process provides safety net • As attrition occurs, new individuals can be enrolled • Operating dual service systems for past decade • Several high population regions continue “legacy” waivers • Regions in midst of roll out unable to carry out full implementation • Re-Establishment of Waiting Lists • Matured MCOs (pilots) had eliminated waiting lists • Expansion areas partially cleared waiting lists • Anticipated Waiting List will grow to 16,000 by 2013

11. WI Family Care: The Pretty? … • Purpose of enrollment cap is to stabilize FC • Commitment by Stakeholders • Provider opportunities to develop innovative service models for high cost populations • DHS to reconvene rate setting initiative/project • Fresh outlook in new administration • “right amount, right time, right service, right place” • “Family Inclusiveness” model • Access ADRC sooner for “light touch” support • Avoid “Breaking Point” enrollment • More services in the “Shallow End” vs. “Deep End”

12. WI Family Care: The Pretty? … • Legislative and DHS pledge to maintain an open process and seek public input • Take the time to study problems and develop sound solutions • Develop & Implement additional practices to minimize waste, fraud and abuse of funds • Develop further outcome and quality measures • Provide technical assistance to MCOs and share best practices between organizations • We are in this together for the long haul … and have the mutual will to succeed!