Presented and Facilitated by Beth Waldman, JD,. MPH Remedial Services Transition Committee: Meeting Two October 18, 2010.

Presented and Facilitated by Beth Waldman, JD,. MPH

Remedial Services Transition Committee: Meeting Two

October 18, 2010

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Today’s Agenda: Part 1 – Scoping the Service

How should Iowa define remedial services? Who should receive remedial services? How should authorization for remedial services

occur? Who should provide remedial services? What protections should be put in place to ensure

program integrity within remedial services?

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Definition of Remedial Services

Option One: As bring into Iowa Plan, do not define as grouping of services, but provide each individual service as a covered service within the Iowa Plan– Would allow for more clarity in what services are being provided

and may help in assuring that an individual is receiving all services that are medically necessary

Option Two: Continue to group services together as remedial services and specifically define– Continues the use of the term remedial services, reducing any

chance that individuals will think services are changed with move to the Iowa Plan.

Option Three: Define services separate for services provided in residential setting vs. in the home or community

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Option One: Bring Covered Services Individually into the Iowa Plan

Covered Services specifically expanded in Iowa Plan to include:– Behavioral and Health Intervention, including:

• conflict resolution,

• problem solving,

• interpersonal skills,

• communication skills, and

• social skills;

– Crisis intervention; and, – Community psychiatric supportive treatment

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Option Two: Continue Grouping and Define Remedial Services

Supportive, directive and teaching interventions provided in the individual’s natural environment designed to improve the individual’s level of functioning with a primary goal of assisting youth and their families in learning age appropriate ways to manage their behavior and regain or retain self-control, including crisis stabilization services.

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Option Three: Define separately as a residential or a community-based service

Amend Option Two to limit “remedial services” to home and community-based services.

Create new service known as “residential remedial services” and amend definition in Option Two to limit to those provided in a residential setting.– Supportive, directive and teaching interventions provided to

children in a state residential setting that go beyond services provided to all children in those setting and are designed to improve the child’s level of functioning with a primary goal of assisting youth in preparing to transition to the community and learning age appropriate ways to manage their behavior and regain or retain self-control, including crisis stabilization services.

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Admissions Criteria for Remedial Services

Require specific admission criteria that addresses:– Assessment through standardized tool– Specific need of individual for services to address needs for

behavioral support in the community; to assist children at risk for out of home placements; or transition from out of home placements

– Services required as part of overall treatment plan• Coupled with need for behavioral health outpatient services

• Needed to achieve treatment goals

Also require specific continued stay/reauthorization criteria and discharge criteria.

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Authorization for Remedial Services: Step One - Assessment

Option One: Allow comprehensive assessment by LPHAs and authorization of single services;

Option Two: Require comprehensive assessment by LPHA for a comprehensive set of behavioral health services (clinical services and remedial services)

Either option to include:– Use of fully credentialed LPHAs to provide assessments

– Standardized assessment tool

– Enhanced training to LPHAs

– Require face-to-face assessment

– Authorization for services to require, for children in the community, that a family member be present for some portion of the services

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Authorization: Standardized Assessment Tool

This would be a new requirement Assessment should:

– Review specific needs of client, including consideration of placement (home or residential setting)

– Provide reasonable and effective treatment plan • Provides least costly type of service that can reasonably meet the

needs of the member• Considers supplemental services when appropriate• Utilize family visits, as appropriate, consistent with best practices• Provide services consistent with the intensity of client need• Continued monitoring of progress• Reassessment of benefit of treatment at set interval based on client

outcomes

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Authorizations: Enhanced Training for LPHAs

Ensure LPHAs thoroughly trained on assessment for comprehensive services as a prerequisite to performing assessments– Specific admission criteria for distinct set of services

Ensure LPHAs understand availability of services in their geographic areas.

Provide continued training on evidence-based practices and technical assistance to implement

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Option One: Continue to Allow Single Service Authorizations

Pros:– Assessment may happen more quickly

Cons:– Not reviewing full service needs or considering other

services being provided– Continues “silo” for remedial services that trying to get away

from with move to Iowa Plan

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Option Two: Require Comprehensive Assessment for Set of BH Services

Pros:– LPHAs to perform comprehensive assessment of behavioral health

needs and recommend comprehensive set of services• Should include family in development of treatment plan where

appropriate

– Allows integration into single treatment plan and removes existing silos

– Can couple with ongoing oversight of implementation by LPHA to monitor compliance with treatment and to measure progress and service mix

– Ensure by requiring limited authorization periods (90, 120 days) Cons:

– Assessment process may take longer and cause delay in receiving services

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Authorization for Remedial Services:Step Two – Selecting a Provider

Option One: Upon assessment indicating remedial services, LPHAs to provide list of remedial services provider in area

Option Two: LPHA provides assessment to the Iowa Plan who shares list of remedial services providers in area with the individual/family

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Option One: LPHAs Refers to Providers

LPHAs provide list of potential remedial services providers to the individual/family– Should be required to include all remedial services providers in the

geographic area on list

– Prohibit LPHA from specifically recommending remedial services provider at same agency

• But if LPHA required to provide clinical oversight of plan, may be easier to coordinate if at same agency

Pros:– Giving list immediately to individual/family may allow for quickest

route to beginning services

Cons:– Continues perception of potential conflict of interest

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Option Two: Iowa Plan Refers to Providers

LPHAs provide results of assessments to Iowa Plan Iowa Plan forwards lists of remedial services

providers in the individual’s geographic area and encourages scheduling of appointment– Pros:

• eliminates possibility of conflict of interest in referring to remedial services provider at own agency

– Cons: • adds extra step/burden to the process

• family needs to start over with a new provider

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Authorization for Remedial Services:Step Three – Approval of Provider Plan

Option One: Continuation of today’s process (development of plan) and review and approval by the Iowa Plan

Option Two: Initially review and approve all remedial services plans; over time, based on provider performance, waive need for approval

Option Three: Develop random auditing process to review remedial services plans for all providers; include ability to take back payment based on review

Option Four: Require approval of plan only for high intensity cases; allow minimal hours without prior authorization and with retrospective review.

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Option One: Remedial Services Provider Submits Proposed Service Plan to the Iowa Plan for Review and Approval

Pros: – Mirrors today’s process so familiar to providers

– Initially would provide the Iowa Plan with direct way to monitor remedial services providers

– Allows review of specific types of interventions occurring within the framework of remedial services

Cons:– Significant undertaking to review all service plans

– Unclear that there has been improved quality using this process

– Requiring approval upfront delays individual receiving the needed services

– Too much paper

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Option Two: Initial Review of All Plans; Waive Providers from Review based on Performance

Pros:– Provides the Iowa Plan opportunity to review all plans

initially and monitor provider performance– Allows review of specific types of interventions occurring

within the framework of remedial services– Flexibility to reduce reviews based on provider performance

• Incentive to providers to develop strong plans

Cons:– Significant undertaking to review all service plans– Requiring approval upfront delays individual receiving the

needed services– Too much paper

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Option Three: Do Not Require Prior Approval of Services Plan, but Perform Random Audits and Required Paybacks

Pros:– Allows individuals to get services without delay due to approval

period– Reduces administrative burden on both providers and the Iowa

Plan– Retro reviews with potential for payback will incentivize

comprehensive treatment plans even if no prior review– Consistent with the Iowa Plan’s current process

Cons:– Only review of plan is retrospective – Difficult to monitor provider performance– Harder to stop interventions that don’t meet the criteria for remedial

services (e.g., “big brother/sister”)

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Option Four: Require Approval Only of Plans which include Remedial Services Above Threshold Set of Hours

Pros:– Targets review of treatment plans only for high-intensity

cases• Closer review to ensure fits within entire service plan

• Provider authorizations through discussions not through paper

– Reduces administrative burden on both providers and the Iowa Plan

Cons:– Requires designation of hourly threshold – Any plans without threshold only monitored during

retrospective audits

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Who should qualify to serve as a remedial services provider in Iowa?

Option One: Require the Iowa Plan to contract with current provider network while reviewing remedial services providers and determining who to contract with.

Option Two: Allow the Iowa Plan to contract only with remedial service providers currently in its network and others as necessary for access, while developing a process to procure/contract with qualified remedial services providers.

Option Three: Require the Iowa Plan to procure/contract with a new remedial services provider network prior to implementing remedial services as part of the Iowa Plan.

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Option One: Begin with Current Provider Network While Undergoing Review

Pros:– Allows for continuity of services

• Could phase out current providers that do not meet requirements as treatment plans end for consumers

– Allows the Iowa Plan sufficient time to review provider qualifications and credential a new provider type

Cons:– Brings entire group of providers despite some providers may

not meet requirements going forward

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Option Two: Begin by Utilizing Current Iowa Plan Providers that are Also Remedial Services Providers

Pros:– Allows for continuity of services for many members due to

overlap between providers– Allows the Iowa Plan sufficient time to review provider

qualifications and credential a new provider type

Cons:– May create access issues, requiring temporarily contracting

with some current providers– Need to transfer care to another remedial services for

consumers whose provider is not in Iowa Plan network

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Option Three: Contract for Remedial Services Provider Network Prior to Start Date

Pros:– Begin provision of services under Iowa Plan with full set of

providers that meet new contract and credentialing standards

– Clear delineation of transfer of services

Cons:– Time/resources needed to undertake re-contracting effort

may delay ability to move services under the Iowa Plan– Need to transfer care to another remedial services for

consumers whose provider is not in Iowa Plan network

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Credentialing Standards

Option One: Allow the Iowa Plan to utilize current Iowa Plan credentialing requirements and modify as appropriate for paraprofessionals for remedial services providers.

Option Two: Require remedial services providers to:– have demonstrated infrastructure to appropriately monitor

the services being provided by staff;– hire staff that meet minimum qualifications to provide

remedial services (including some level of experience)– provide comprehensive training to staff providing remedial

services– provide ongoing clinical support and supervision

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Option One: Allow Iowa Plan to Develop Credentialing Standards

Pros:– Allows the Iowa Plan to develop credentialing requirements

for remedial services providers consistent with other service providers

• Can leverage current Iowa Plan tools

– Hands off approach that provides flexibility to Iowa Plan to manage the services

Cons:– Give up ability to be directive on credentialing requirements

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Option Two: Dictate Details of Credentialing Requirements for Remedial Services Providers

Pros:– Clear delineation of requirements to be remedial services providers

and agreement on particulars from working group– Ensure provider agencies meet infrastructure needs including

quality management and cultural and linguistic competence– Provides minimal experience level with youth in order to serve as a

remedial services provider– Require specific and comprehensive trainings to be done by

providers– Requires ongoing supervision by a licensed clinician

Cons:– May note be consistent with other credentialing processes utilized

in the Iowa Plan

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Enhanced Program Integrity: A number of potential options

Require parent signature that approved service provided– Will prevent providers from billing without providing services

Ongoing monitoring reports on utilization of remedial services– Programmatic issues identified early and modifications to program

made quickly– Potential fraud and abuse cases reviewed early in process

Training for remedial services providers on program requirements– Basic training on Iowa Plan generally and remedial services

specifically– Use of educational bulletins on identified issues

Review reauthorization requests with eye toward progress and meeting overall treatment goals– Consider how to “step down” from remedial services (reduced

frequency; type of service)

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Today’s Agenda: Part 2Payment Strategies

Payment for services today Discussion of potential payment strategies for

consideration

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How are remedial services paid for today?

Providers receive fee-for-service payment on a cost basis– Payment cannot be above cap of 110% of the statewide average– A 15-minute interval constitutes one unit– Current system is difficult for providers– Remedial services providers may be getting higher rates in some

instances then outpatient visits provided by psychologists Because payment is cost-based; providers may have little

incentive to be efficient– Providers note spending more time than authorized (and

therefore have non-billable hours)– Providers at risk when continue to provide services as Medicaid

eligibility issues arise

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Discussion of Potential Payment Options

Payment in other states– FFS – typically paying in 15m increments

• Control utilization through authorization process– Per diem rates – where this has been tried, sense that may pay too much

for too little– Capitation – little capitation to providers underway; potential greatest where

a provider agency provides vast array of services (e.g., CMHCs) Should there be different rates of payment by setting of service?

– Group home– Individual home– Community-based setting

What financial incentives can be put in place to emphasis quality outcomes?

– Family units?– Enhanced FFS rate if meet quality goals?

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Proposed Topics for November & December

November: Quality & Payment– Ensuring quality

• Individual Service Plan development and monitoring

• Measuring quality

• Evaluation Plan– Needed to measure and confirm that goals are met in move to Iowa Plan

– Continued payment strategy discussion

December: Bringing it All Together– Review Remedial Services in Iowa Plan

• Proposed changes

• Transition strategy

– Discussion of Draft Report

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Next Steps

Incorporate feedback and finalize proposed scope of services

Discuss payment strategies Research quality improvement opportunities Draft outline of report and begin to collect

background materials Other?