TIM Fuchs: Thank You, and Good Afternoon Everyone.I'm with the NCIL Here in Washington

A Two-Part Webinar/Teleconference Series on Managed Care and the Independent Living Movement - Part 1: Managed Care 101presented by Merrill Friedman, Bill Henning and Suzanne Crisp on August 28, 2012

TIM FUCHs: Thank you, and good afternoon everyone.I'm with the NCIL here in Washington DC.I want to welcome you to the webinar on managed car.It's presented by the new opportunity community center,a national training assistance program of the independentliving research utilization, ILRU in Houston.This webinar was organized and facilitated by thenational council on independent living and support for thepresentation provided by the U.S. department of educationand RSA.

Today's call is being recorded so we can archive on ourwebsite. We will break several times during thepresentation to answer your questions.

For those on the webinar, you can ask your questions inthe public chat. That is the text box under the emote conon the webinar platform, or use the chat feature in thecart screen. I'm there in case you have questions.

And then for those on the phone, of course you can justpress 7 during our Q&A breaks.

The materials for today's call including the PowerPointpresentation and an evaluation form, are on the trainingweb page that was sent to you in the confirmation e-mail.If you can't find that link or you don't have thosematerials for any reason, just e-mail me at Tim at NCIL.ORGI have my e-mail open right now. If you don't have thePowerPoint or the eval link, let me know and I'll get it toyou.

Please do take a minute after the call today to fill outthe evaluation.

It's very easy to complete. It's very brief but reallyimportant to us. We take them seriously as we look toimprove all our presentations

I have been thrilled because this has been a verypopular call. I have seen registrations flooding in rightup until just a few minutes ago

I know you didn't join to hear me talk about evaluationsor emoticons, so to introduce our presenters for the callsthis week.

Each presenter brings a unique perspective to thediscussion and I'm really thrilled to have them with us.Bill Henning is with us from Boston, the executivedirector of the Boston center for independent living.Merrill Freedman is vice-president for advocacy. Iwonder if any clls are going to adopt that, thevice-president for advocacy.

Merrill is also chair of the Michigan sclk, excuse me,vice-president for advocacy at Amerigroup, a managed careorganization, and also with us today, this week, I shouldsay, to moderate our discussion is Suzanne Crisp. Inaddition to being fantastic presenter and expert onMedicaid, Suzanne is the program design for Boston college.We have all had a lot of fun developing the presentationalong with the folks at ILRU.

And I want to thank each of you for being with us thisweek and helping put this together.Let's get started.

I'm going to turn it over to Suzanne to begin.

> SUZANNE CRISP: Thank you, Tim.It's always a pleasure for me to meet with my friends atthe disability community.

Thanks for inviting me.

One of the hottest topics in long-term care services andsupport is managed care.

I guess a close second right now are Medicare andMedicaid eligible, they call them dual eligible.Today and Thursday we're going to be talking aboutmanaged care.

Managed care in its broadest sense is a service deliverysystem that coordinates and channels the use of the ofservices to achieve desired access, service and healthoutcomes while controlling costs.

We might ask ourselves why is this service delivery soattractive to Medicaid agencies.

Certainly our speakers will discuss this in more detail.But a few reasons why would be to reduce state budgetdeficits by controlling spending.

And to improve access to needed services by creating acoordinated network to eliminate gaps and reduceduplications.

Basically managed care organizations, or NCOs, can belarge for profit organizations, like Amerigroup, or smallernot for profit groups like local providers, and they can bea combination of both for profit and nonprofit entities.

The state Medicaid agency selects the managed careorganization, or managed care organizations , through acompetitive bid process. They are paid on per member permonth set fee, typically called a kapTaited rate, andtypically are held at full risk or partial risk forproviding services.

In other words, they are paid the per member per monthrate, and they are expected to serve that individual invarious settings then.

If they don't serve that individual within the varioussettings, then the managed care entity is at risk foradditional financing of services.

The state typically defines what services are includedin a healthcare plan, and there's quite a bit of diversitywith this.

For example, some plans manage only the home andcommunity based services.

Some manage home and community based services plusinstitutional services. For example, nursing facilityservices.

And some plans also include all of long-term careservices and supports plus acute care services.Even some other plans serve the dual eligibles, Medicareand Medicaid enroll es then.

An our next slide we see that a recent report by truevine, formally Thompson Reuters, this report is veryhelpful to understand the growth of managed care.The link is attached here.

Don't link on that now, but after the session pleaselook this report over.

It highlights all 16 states servicing Medicaidparticipants with a managed care delivery system.Particularly is note worthy that by 2014, a projected 26states will be operating with managed care as opposed tofee for service traditional service delivery system.Knowing that half of our states will be managed careoriented,nl and ILRU developed this webinar to beginpreparing the disability community with both the knowledgelevel and begin a dialogue about the role of centers forindependent living in a managed care environment.

Today's session will focus on establishing a solidframework to understanding managed care. Thursday'ssession will focus on the role of centers for independentliving.

There was a glossary that was sent out in the e-mailthat Tim referenced. I believe it's dated Monday the 27th.This glossary was developed for you in order to keeptrack of all the new language and definitions that we areseeing that come from the world of managed care.

We're going to be, our format is going to beinterviewing Merrill and Bill with a number of questions.Our format will be very informal.

There will be discussion back and forth between Bill andMerrill.So let's get started now.

On slide 3 is our first question.Merrill, I'd like to ask you, what is managed care andwhy are states adopting it?

> MERRILL FRIEDMAN: Sure, thanks Suzanne. And goodafternoon everyone. We're absolutely thrilled to be hereand having this discussion on a larger scale. Fortunatelyfor me and thanks to Tim, my cool and groovy title, I haveactually had the opportunity to meet with a lot of thecenters individually. But clearly there are manyconversations to come.

Managed care, you did a great sort of textbook answer,which is always good for me to hear because I sometimeslike forget what the bigger picture of managed care may be.It's really an approach to delivering and financinghealthcare services. In the PowerPoint you will see someof this.

But it really is to generate some improvement aroundquality and access to the care and services, and ultimatelyeither saving costs or rebalancingI know we have all heard a lot about rebalancing latelyas well.

It really looks at that kind of financial risk andcoverage that a managed care entity can provide to cover arange of defined healthcare services, which is the benefitdesign and inclusion of services that Suzanne wasmentioning earlier.

Then that would be defined for a defined population.As we have seen in many of the states lately and theones going forward, people, states really design their own.So it just is so different. And we always say if you areseen wen one Medicaid program you have seen one.That's because states are so basic and that would beback to the definition around getting an approach thathelps to deliver and finance healthcare services for peoplewith disabilities.

So when we really look at it now, we look at improvingaccess to services and the coordination of those care andservices.

There is a significant reliance on preventive andprimary care, and that has really been the genesis andhistory of managed care.

Now its actually really has a different focus, with Iwe're really happy to be part of, which is bringing up theimportance of what those services and support look like,how they are delivered, how people access them, how peoplechoose them, how people direct them.

So really trying to change the face of what the relianceis.

And yeah, you know, definitely looking to eliminate allof that sort of duplicative services, the unnecessaryservices. A lot of people get multiple calls, let's say,from providers, or I have to go back for testing that theyhave already had, which, one, can be a nuisance, and two,can actually alter the results.

Not in their favor.

Then looking again at that collaboration between managedcare and provider.

Then that kind of tees up a little bit of Thursday'sconversation because we're really going to look at who arethe providers now and talking about the role of the centersat that point as well.

> BILL HENNING: We probably will integrate thatinto today's discussion a little bit.

> MERRILL FRIEDMAN: I'm sure we will.Bill, do you want to add to that before I keep rambling?

> BILL HENNING: I think one of the things that isreally important to get out there is to reemphasize thecontext.

As Suzanne said, you know, projection is up to 26 stateswill have active managed care plans.Many already do in the private insurance market.Many already do for Medicaid populations exclusive ofpeople with disabilities.

This is in some sense a tidal wave that e are not goingto be able to get out of the way fromI think that is really important. We're in a climate,as the trailer introducing this set, I think, on the alert,anyway.

You know, it may not be adequate just to say no to theseplans. A lot of them got really tagged with a badreputation in the '90s when they emerged, HMOs and whatnot.

But states are grasping, as is the federal government,at ways to control costs, to save money.

We have got, you know, ACA, the affordable care actupheld by the Supreme Court, that is with us.If the Republicans win the elect, though vowed to getrid of it. Even if that happens you still have a budgetthat will change Medicaid, that will change Medicarefunding.

Health reform, health change is with us. Managed careis a very active response by governments to all of thistotally dynamic situation.

So it doesn't mean we accept everything that is put outby the government or CMS or a provider, but it means tojust say no may be to be saddled with a radically worsealternative too.

I don't want to link this in a totally negative context,but in the past advocates have said no nono, whetherhealthcare advocates, disability, elder advocates. I'm notsure that is a sufficient response. Or at best a holdingaction probably.

> MERRILL FRIEDMAN: Right. I think, you're exactlyright, and I think being able to leverage that dialogue anduse managed care, so to speak, to ensure self direction,you know, eliminating institutional bias

I think there are ways to kind of open up avenues tosome of the very important policy influences that thedisability community is trying to have within healthcare,and use managed care as a vehicle to get there.

> BILL HENNING: I would agree totallyI think it's a period where active engagement andadvocacy is essential

I think one of the things that a lot of activists aresaying, if you want to be a disability rights activist in2012, you better be a healthcare activist.

That doesn't mean there aren't other issues out there,ADA compliance, other formats, housing, but healthcare isso prominent.

And with the duals initiative and other areas wherelong-term services and supportsor home and community basedservices as it's similarly known, get merged into theseplans, what we think of as vital elements of independentliving funded by Medicaid in the states may be part of theprimary care system in certain ways.

And if we are not active, we can lose control andconsumer direction will not exist.Conversely, as Merrill says, this can become a vehicleif we are strenuous in our advocacy, to advance thatconcept.

> MERRILL FRIEDMAN: Right. You know, and I think,you know, somebody I was talking to recently said this isreally now, you know, no longer a matter of, you know, aprovider and accessing.

This is really about system and systems change.You know, we know that NCIL and the centers forindependent living have been very involved in that, so itis now about systems change in healthcare.

So when you look at some of these private contracts, andwe have seen both. We have seen a lot of work by thecommunity that has been able to influence these contractsin a very positive way, and we have seen a lot of work bythe community that has influenced in a positive way and thestate has still gone and done something else.

So I think it's really hard because we don't always knowwhat the outcome is going to be

I do believe as we get better at working together onthis, we will continue to strengthen the overall influence.Because we talked about it in our planning sessions,that we all want community first. You know. Then beingable to get the services that you need in the community.That really does make sense for managed care too and forthe states from a financial perspective.

If we continue to forge forward with that being a largepremise, again the state has to be receptive to it. Sothere's a lot of work around that. But going to some ofthese private managed care contracts, and I know, IBM, youreferenced it, and I have always said it, that managed carehas had a very crappy reputation over the years.

But it has changed. And I think that all managed careorganizations are trying to sort of get to a level playingfield and do more of the right thing, and to do that itdoes take a lot of influence from the disability community.

> BILL HENNING: Yeah. I mean it's almost a secret,but in the independent living community, we know the valueof home and community based services.It's almost second nature. I don't think a lot of usstop and think how much they are intrinsic to thephilosophy we believe in, the advocacy we do.

But they are actually somewhat foreign to the primarymedical, the an I cute care medical -- acute care medicalworld, the healthcare providers and managed care entities.If we can sell these things, you can promote communitybased services.

You know, if you look at personal assistance services,economically, they keep people out of an institutionalsetting, but they keep people active. They are consumercontrolled, and they improve wellness, they improve health.Somebody with a significant physical disability, perhapssomebody with quadriplegia, needs active PAS to stayhealthy.

We know that has to be upright, has to be out of bed.You don't, you have many complications with breathing,you get skin breakdown, far more expensive for the managedcare entity if you have a skin breakdown.

Same thing if you can integrate active purchase and useof durable medical equipment. You will prevent manysecondary conditions that are the bane of people withsignificant physical disabilities.

Same with, you know, community peer mental healthservices. If you can get somebody who has been isolatedbecause of some form of significant and persistent mentalillness as the industry labels it, get them some care whichmay happen through a peer relationship, not a professional,highly professional outside of the community relationship,you can start to address concerns such as CO P. D, ace asMay, diabetes, things that Cal cause people significantmental illness when they are about 40 or 50 to becomehighly expensive, highly unhealthy, with a very highmorbidity rate.

Studies will show people with schizophrenia die young,and there's ways to prevent that.There are opportunities for community support, how tointerest grace Olmstead principles to how the healthcareplan operates, to innocencivize payments even to theprovider for people staying out of a community instead ofgoing into a nursing home.

> MERRILL FRIEDMAN: Exactly.And part of that, I mean we can actually spend the nexthour and a half on that last statement.Know, you keyed up there.

Part of this, because you mentioned provider piece of itI think that new managed care, I don't know, you know,really needs to embrace, you know, kind of a new providersystem and a new provider network.

And we have addressed that in, you no e several statesrecently.And it's really not perfected yet.There are a lot of issues with it.

And it's going to continue to create a lot of fear anddistrust of both states and managed care organizations asthese things get hashed out around case management and caremanagement and some other, you know, pieces to it.So there is a lot of work ahead to resolve some of theseissues and to get more savvy with dealing with them from amanaged care and center perspective