Letter to HCPF Long Term Care Unit, regarding SEP Rebid comments

Submitted by Anonymous on October 16, 2012 - 8:14am
October 10, 2012
To HCPF Long Term Care Unit:
From: Colorado Cross-Disability Coalition
RE: SEP Rebid comments
Please accept these comments from the Colorado Cross-Disability Coalition (CCDC) regarding
the Single Entry Point (SEP) rebid. CCDC is the only statewide organization that is run by and
for people with disabilities. Our mission is to advocate for social justice for people with all
types of disabilities and we have a significant interest in Medicaid, particularly in community
based long term care. CCDC is actively involved in numerous department initiatives related
to Community Based Long Term Care (CBLTC) including but not limited to the Community
Living Advisory Group (CLAG), The Community First Choice (CFC) Council, The Participant
Directed Programs Policy Collaborative (PDPPC), and the Long Term Care Advisory Committee
(LTCAC). By way of full disclosure, the CCDC Executive Director serves on the Board
of Adult Care Management Inc.,(ACMI), one of the SEP entities. CCDC has working
relationships with many other SEP entities. Because we provide individual advocacy to people
with disabilities including representation at the Administrative Law Judge Level we have been
in adversarial positions with all large and many smaller SEP agencies. We have been able to
maintain working relationships with the SEPs in most cases despite these dual roles. These
comments are solely on behalf of CCDC and do not reflect the views or interests of ACMI or any
other SEP.
CCDC understands that there must be a rebid and suggest that we make this as simple as
possible with the goal of not making any unnecessary changes in the next few years for the
reasons outlined below. This suggestion is not a wholesale endorsement of our current system,
rather a reflection of our assessment that there is no fire that justifies a rash change. CCDC
explains herein our reasons and suggestions for moving forward with achieving our goals
for comprehensive change that includes conflict free case management, consistent eligibility
determinations and utilization management and high quality care coordination services for our
citizens who require long term services and supports (LTSS).
CCDC supports the idea of conflict free case management. We believe that it is a conflict for
any Single Entry Point to provide direct services (other than case management) or to have a
financial relationship with an entity that provides services. Two of the three SEP agencies who
are up for a rebid have a conflicted relationship with the PACE program. We are aware of this
and also aware that all but one Community Centered Board (TRE) has conflicts. CCDC supports
a comprehensive solution. We understand that such a solution will take time and be a politically
difficult situation. CCDC is willing to work with HCPF as one of the few organizations that
does not provide services at all—to make this happen. We believe a system that is conflict free,
Colorado Cross-Disability Coalition (CCDC)
655 Broadway, Suite 775 Denver, CO 80203 / 303.839.1775 office / 303.952.0528 VP / 303.839.1782 fax
transparent, consistent, and that can provide high quality care management to an increasingly
complex population needs to happen systemically. We do not believe this can happen before
June of 2013.
CCDC believes that there are parts of our current SEP system that are excellent and worth
saving, and other parts in need of reform. The decisions and reforms should consider a statewide
approach, not only three of 20 even if the three represent a significant percentage of the client
population. We should not consider changing the SEP system in isolation of the CCB system,
particularly as we ponder waiver consolidation. The monopoly of the CCB system also creates
an interesting dynamic. Some CCBs do a good job, others do not. CCBs have a fair amount of
political power and have been regulated by an agency other than HCPF.
Moreover, there has been an acknowledged lack of training, messaging and appropriate oversight
of the SEP agencies. We support the efforts made by this administration to make substantial
improvements within the LTSS division. This has included increased staffing and attention from
management as well as commitments to implement training and written protocols to improve
consistency. The division has also been working with CMS on waiver issues. HCPF has taken
on these great challenges and is not yet fully staffed but is getting there. Because attention had
to first be directed to urgent problems and staff was below 50% capacity, HCPF is just getting
started on these initiatives.
There are other initiatives going on that affect LTSS including the SEPs. These include:
1) Health Care Reform-the Affordable Care Act will change how health care is delivered
in this country, particularly publicly funded health care. Specifically the states have
an option to implement the Community First Choice (CFC) option. Colorado has
established a council to work with HCPF consultants to assess whether CFC is in our best
interest. Whether or not we ultimately do CFC, the health care reform law specifically
and federal government, generally, are dramatically expanding the flexibility afforded
each state giving us more options for providing LTSS. For example, the idea that all
waivers should have a specific target population is rapidly becoming obsolete, and
combined waivers are being explored in Colorado and around the country. Colorado has
already begun discussions about waiver consolidation and there is wide support for this
concept, though working through the details will be a large project.
2) Dual Eligible Initiative: HCPF has submitted a substantial proposal to CMS regarding
care coordination for dual eligible (Medicaid and Medicare) clients. Most of these clients
use long term services and supports or are likely to require them in the near future. The
emphasis is on improved care coordination. This will include coordination not only
between Medicare and Medicaid but between acute and long term care. The Colorado
proposal relies on the recently established Regional Care Coordination Organizations
(RCCO) which are using the Accountable Care model.
3) Community Living Advisory Committee (CLAG). This initiative of the Governors’
office was in response to legislation to move the Division of Developmental Disabilities
to HCPF but has expanded into much more. However the issue of consistency among
waivers and the need for the single state agency to have authority over all LTSS remains
a key consideration. The CLAG will hopefully bring people together to determine a
process that will result in a cohesive case management system. Once DDD is part of
Colorado Cross-Disability Coalition (CCDC)
655 Broadway, Suite 775 Denver, CO 80203 / 303.839.1775 office / 303.952.0528 VP / 303.839.1782 fax
HCPF, an assessment about the best way to provide entry to and management of all LTSS
clients regardless of IQ can be addressed comprehensively.
4) Long Term Care Advisory Committee LTCAC: This committee was commissioned by
former HCPF Executive Director Joan Henneberry and was reinvented/reinvigorated
by the current Executive Director Sue Birch. Under Director Birch the committee has
created four subgroups; resources for facilitation and staff support for each subgroup
have been allocated. One of the subgroups is specific to entry point modernization,
and another to care coordination. These groups have not yet identified their goals, and
they certainly will not be even close to a responsible recommendation within the next
few months. There have been commitments made to the legislature and community at
large that this LTCAC, which is open to the public and has ample opportunity for citizen
involvement, will have meaningful input and involvement in all changes related to the
LTSS delivery system.
5) HB 12-1281 allows HCPF to explore various payment methodologies that includes LTSS
and care coordination in general.
6) HCPF is implementing a large transition grant program under the Money Follows the
Person grant program that will be evaluating the role of intensive case management.
When one studies the efficacy of an intervention it is important to only change one thing
a time so you know what is actually working or not working.
All of these opportunities on the horizon represents a landscape that creates both great
opportunity to get Colorado LTSS programs back among the best in the nation, where they once
were, or could catapult us into a crisis of unbelievable proportion. This must be considered
amidst the backdrop of aging boomers who will be entering the system at the same time as our
programs are expended due to health care reform. While most individuals who enter the system
under health care reform will not be part of the LTSS system some will and the awareness
of LTSS will naturally increase simply from the increased attention as a result of health care
CCDC is appreciative of the changes made by this administration, particularly by Medicaid
director Suzanne Brennan to improve some structural deficits in the LTSS unit that have built up
over the past 6-7 years or longer. CCDC appreciates that this administration has made LTSS
a priority, and believe that Director Birch’s life work and perspective have a lot to do with
this change in direction. These problems include lack of clear direction and training to SEP
agencies, lack of contract management capacity at HCPF, constant staff and leadership changes
at HCPF including several long periods without people in positions essential to appropriate SEP
management, and the need to address serious CMS quality concerns.
On a national level there are also changes in process: The whole LTSS industry is in a state of
flux, moving from a compliance oriented to an outcome model, moving away from a medical
model to a functional model and most important moving from a vendor/provider centric model
of care to a person centered care model. All of these changes are significant. States that have
undertaken meaningful and lasting reform caution that it is a multi year process and must be
comprehensive. Positive changes cannot be done overnight. It must be transparent and must
be done with a strong communication plan and change management strategy. HCPF has not
yet developed on an organizational level, enough key people in the department with the skills to
Colorado Cross-Disability Coalition (CCDC)
655 Broadway, Suite 775 Denver, CO 80203 / 303.839.1775 office / 303.952.0528 VP / 303.839.1782 fax
effectuate massive change at this point. The above initiatives coupled with the work Suzanne
Brennan and Director Birch are doing by implementing LEAN and other staff capacity programs
will get HCPF to a place where they have such skills, but this cannot happen in the next six
We understand that there must be a rebid. However, a rebid can happen without a call or intent
to make changes. The only reason to make a change with one of the three SEP agencies at issue
right now would be consistent performance problems with no response to plans of correction or
some action so egregious that clients are being put in harms way. We are not aware of any such
problems. We agree that the conflict caused by two of the three private SEP agencies running
a PACE program is a serious problem, but does not rise to the level where the disruption caused
by making a change at this point in time can be justified. We believe that HCPF can manage
this conflict with contractual amendments or special conditions that as a funder, HCPF has every
right to impose. HCPF can do secret shopper or client surveys to make sure that clients are
not being unduly influenced to join PACE or to use other related providers.. HCPF can impose
corrective action if that is happening. If the SEP fails to respond to HCPF conditions, that can
and should be considered when entities are selected (or ruled out) when more global changes are
made. If there are inappropriate referrals or pressures to join PACE HCPF should report this to
their legislative oversight committees as PACE has sought legislative attention and would likely
be responsive and motivated to avoid legislative complaints.
A rebid without any major changes means we OPPOSE allowing one entity to cover all three
areas and do NOT think that the functions should be divided at this time. We believe that the
work of the LTCAC, CLAG and CFC council must include work on what system or model is
the best for the whole state, how to assure not only conflict free case management but to define
what we want from case management. This may result in fewer actual contracts to manage or
may result in increased providers of case management allowing for market responses to quality
issues. We have not sufficiently defined what we want, let alone studied the best method for
providing it. We need to figure out what we want to buy, for whom, how much it costs, and
what we can afford. The answer will not be a one size fits all system but will likely involve tiers
or levels. We may choose to separate eligibility and UM from care coordination. Hopefully
we will provide different levels of care coordination for clients with different needs. Surely
under a 21st century system we will create systems for people based on real functional need, not
diagnosis or etiology of impairment. These changes need to be done in concert with the other
areas of change and improvement and as part of a statewide strategy. Once we identify what we
want, we then determine the criteria and the specific scope of work, educational requirements,
tools, etc. We also must identify and define the elements, skills, and conditions associated with
provision of these functions. We have to determine how we will be serving clients, will be
consolidate waivers and if so how? Once these questions are answered we will be in a better
position to determine what kind of system we want to build and if there are elements of our
current system we keep in whole or in part. This is a long term process and decisions should be
made deliberately and openly, understanding that change is necessary and will be hard but can be
done responsibly with the needs of our citizenry as the sole motivator.
There are great possibilities and with adequate time, resources and creativity we can move
mountains in the LTSS expanse.
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