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

2. 2 Todays 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?

3. 3 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

4. 4 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

5. 5 Option Two: Continue Grouping and Define Remedial Services Supportive, directive and teaching interventions provided in the individuals natural environment designed to improve the individuals 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.

6. 6 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 childs 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.

7. 7 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.

8. 8 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

9. 9 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

10. 10 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

11. 11 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

12. 12 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

13. 13 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

14. 14 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

15. 15 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 individuals 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

16. 16 Authorization for Remedial Services: Step Three – Approval of Provider Plan Option One: Continuation of todays 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.

17. 17 Option One: Remedial Services Provider Submits Proposed Service Plan to the Iowa Plan for Review and Approval Pros: –Mirrors todays 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

18. 18 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

19. 19 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 Plans current process Cons: –Only review of plan is retrospective –Difficult to monitor provider performance –Harder to stop interventions that dont meet the criteria for remedial services (e.g., big brother/sister)

20. 20 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

21. 21 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.

22. 22 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

23. 23 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

24. 24 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

25. 25 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

26. 26 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

27. 27 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

28. 28 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)

29. 29 Todays Agenda: Part 2 Payment Strategies Payment for services today Discussion of potential payment strategies for consideration

30. 30 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

31. 31 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?

32. 32 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

33. 33 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?