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I don’t believe I am going out on a limb in order to say that waiver services for people with disabilities will end up moving to a bundled payment, outcome based system for reimbursement.  If you look at what CMS has stated, and looked at what it’s doing, the idea that any level of health care or social service will remain a pure fee for service payment model, would be the more outrageous comment to make.I realize that the time for all of this is not tomorrow, which is good news for providers in the field of developmental disabilities.  But let’s look at the tea leaves together and you tell me what you think it means.

At the beginning of the year, CMS put out a statement that by 2018, significant portions of the Medicare system will be paid using alternative payment methods.  Today, CMS has rolled out changes that joint replacement procedures will now be part of a bundled payment system.  Starting January 1st close to 800 hospitals in 75 different markets may be obligated to accept this alternative payment method.  I realize that this is a matter involving Medicare, and for that matter a very specific medical procedure.  How do we continue the progression over to Ohio, and into Ohio Medicaid for that matter?

In my opinion, the recently passed finance bill created the avenue for this kind of thinking to come into Ohio’s Medicaid system.  Specifically, managed care organizations became a larger player in the Ohio health care system.  Managed Care, which today represents 76% of all Medicaid recipients in Ohio, will see that close in on 100% over the next three years.  For instance, all children in a Foster Care program will now be mandated to be in a managed care program.  The behavioral health “carve out” that prevented managed care organizations from contracting for most of the services from community mental health centers has been removed completely, with implementation some time in 2017 – 2018.  In addition to youth in foster care, and a “carve in” of the “carve out” for behavioral health, people with a developmental disability are now allowed to enroll onto a Medicaid managed care plan by choice.  Taken altogether, and we will have a pretty complete Managed Medicaid system in Ohio.

Still, why would we believe that fee for service will be gone from our beloved Medicaid system?  Where’s the direct leap from these ideas in Medicare and happenings at the Federal level to what goes on in a state run Medicaid system?

We only need to read through the Ohio Department of Health’s web site to find this quote.

The Centers for Medicare and Medicaid Innovation announced on Feb. 21, 2013 that Ohio was one of only 16 states to receive Model Design funding for the State Innovation Models (SIM) initiative. The State of Ohio received up to $3,000,000 to develop a State Health Care Innovation Plan. Ohio was one of only two states to receive the maximum award amount. Ohio used the SIM grant to develop a plan to expand the use of patient-centered medical homes and episode-based payments for acute medical events to most Ohioans who receive coverage under Medicaid, Medicare and commercial health plans

If you caught the date, you will notice that was over two years ago.  What do you think the state has been doing since the announcement in February 2013?  Well, quite a lot actually.  And it’s not too difficult to find out the details, up to this point, because the state is pretty good at sharing all of this information for all to see and read. (I wanted to make sure that I wasn’t sounding too much like a conspiracy theorist)  I particularly like the presentation documents from the Office of Health Transformation that were used in April of 2015.  The documents do a nice job of identifying various stake holders as well as describing the use of bundled payment options that will be used and rolled out consistently over the next 3-4 years.  Twenty specific episodic payments will be defined, inclusive of behavioral health, by 2016.  The documents go on to express over 50 episodic payments will defined by 2018.  The state of course needs partnerships on the payer side to make this happen and they have done a tremendous job in lining up Aetna, Medical Mutual, Anthem, and…..all of the manage care plans for Ohio’s Medicaid system.

As I stated earlier, I am not trying to come across as a conspiracy theorist.  These are not secrets being kept in any secure way that a Google search can’t uncover.  It’s a matter of choosing to look, choosing to listen, and determining what to do and when to act.  As far as what a provider who specialized in serving people with a developmental disability can do, I think there are some some clear and specific actions and resources to start with.

First of all, make sure you have a data system that can interact with, robust electronic medical record software like Epic, and Cerner.  Electronic exchange is going to be important, as will be reporting on outcomes and quality.  Make sure you are looking at software and a provider that can be up to the task.  You are going to become part of the health care system in some form and fashion, and you certainly will be a part of the ongoing dialogue regarding the cost of Medicaid to the tax payer.  Be able to share information, and prove value to that very system.   Second, get your team working together and across their programs, vs being territorial or “siloed” in their approach and resource sharing.  Finally, after you are confident you have solid team work happening, point your communication outward vs inward. You are about to become part of a very complex field of medical, behavioral, and social service providers that you should get to know (and vice versa) and start figuring out how everyone fits and works together.

I think we all have the time to figure some things out and to stay in front of this.  I have already seen other parts of our care system in Ohio be caught off guard with the changes that are happening to them now.  Agencies that specialize in supporting people with developmental disabilities do not need to have the same fate.    Generate a good strategic plan for the next 2-3 years, with accountable goals and objectives that touch all people and all actions within your organization.  This will provide the best approach to assure that your agency will be in the proper condition when opportunities arrive.

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