Patti Cullen's Blog

Medicaid Reform Waivers Include HCBS Redesign — Got Any Ideas??

by Patti on Wednesday, October 12, 2011 1:15 PM

Section 53 of the omnibus health and human services bill that passed during the special legislative session includes a directive to the commissioner of human services to report to the Legislature by January 15, 2012 on a significant change to the medical assistance program in Minnesota — known as the medical assistance reform waiver. The legislative language describes in some detail the “projects” that are envisioned under this reform section — from “testing alternative payment and service delivery models” to “promoting personal responsibility and encourage and reward healthy outcomes” to “redesign home and community-based services.”

There are so many ways the current infrastructure for health care and long-term care delivery could be turned “on end” with this language — and that was the intention. The Legislature and administration, in negotiating this language, did so with a sense of urgency — the double-digit growth of the health and human services budget continues to be a major “budget-buster,” and something needs to be done.

There is no disputing that we need to look at what the government invests in, and how to get a better return on investment. I hope there are some unique ideas that evolve out of these discussions, although the timeframe is so short there is great concern about the “shotgun approach” where ideas get thrown out everywhere without time for the system or recipients to adjust to changes. One recent example is the new competitive bidding process for state-funded health plans — nearly 100,000 recipients will be changing their plans. There will definitely be implications that the state hasn’t yet seen, but we are on to the next reform initiative. When it comes to changes in the older adult service delivery arena, neither the numerous rate changes we have experienced in the waiver programs nor the significant changes in Medicare have been fully realized and we are on to the next reform.

Just last month Minnesota was highlighted in a national study as the #1 state for long-term services and supports for older adults, persons with disabilities, and family caregivers. We were the only state in the top quartile in the country for all four dimensions: affordability and access, choice of setting and provider, quality of life/quality of care, and support for family caregivers. So, we are doing great in the HCBS arena, but it isn’t enough given the budgetary pressures noted above.

The redesign for home- and community-based services (HCBS) includes a strong emphasis on less expensive alternatives, self-direction, targeting funds to those of greatest need, and performance measures. We are participating in the discussions right now, but I would sure like any new ideas that could be shared at these workgroup meetings — both reform-minded ideas that would work, and proposals that “would set us back.”

In particular, I would like to figure out how to bring forward ideas for redesign that address these areas:

1.      Transitions to acute care: when we continue to budget in silos, transitions that naturally occur as people age are not smooth, nor as cost-effective as they should be.

2.      Transitions to community supports: when fewer people become eligible for nursing homes and waivers due to a higher level of care threshold, what mechanism should be put in place to prevent crisis care?

3.      Prevention: much of what we do in the HCBS arena provides services that prevent and/or delay the more expensive acute care episodes — how can this be recognized?

4.      Palliative care: without getting into the political debate about “death panels,” we need to figure out how to provide and get paid for palliative care and programs like Honoring Choices.

5.      Separation of waivers: some of the difficulty we are seeing today with consumer-directed care and numbers who can be served in each setting.

6.      Quality measures: there needs to be a balance between the clinical/health needs of those we serve, the payment restrictions for the services they need, and the implications for the clients.

7.      Regulatory relief: a phrase often used but difficult to quantify and gain agreement on.

Feel free to call me with your ideas at 952-851-2487, or email me your thoughts at Our first workgroup meeting is this week — with an aggressive schedule where the state plans on having a draft completed in December, so put your thinking caps on and give me your input!

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