Fiscal Administrative and Organizational Structure

Fiscal Administrative and Organizational Structure:

Question #1: To effectively manage a network within a capitation reimbursement model, based on a consistently administered needs assessment tool, it will be necessary to provide supports and services to a minimum number of individuals with variation in defined support needs. Based on your historic knowledge or initial research, approximately how large would a DISCO’s enrollee pool need to be to remain fiscally viable and still implement effective care plans derived from person-centered planning practices?

While this seems a question for risk experts, most SANYS forum participants worried that DISCOs might need tobe quite large to manage their financial risk. The worry is that the large DISCOs in a capitated system willdiminish attention to person centeredness and individualization; that DISCOs’ care coordination functions will be dominated by the fiscal implications of their decisions. The consensus of forum contributors was that very stringent safeguards from OPWDD would be needed to ensure that “People First” values do not become “Fiscal First” in practice.

SANYS forum participants were deeply troubled by the downsides of DISCOs being service providers. SANYS believes it is entirely feasible for DISCOs to perform care coordination, funding and oversight functions without being a service provider. We urge that in the pilot phase OPWDD set up at least one DISCO that does not provide services to its enrollees.

SANYS favors a regional distribution of DISCOs that reflects the demographic and cultural variations across the state. From the perspectives of practical convenience most individuals will want to relate to DISCOs that are reasonably near them.

SANYS stakeholders made these comment about the size of DISCOs:

• There was concern about the imposition of large, potentially bureaucratic entities into the lives of individuals. Everyday experience with large managed care organizations suggests that they are not consumer oriented and focus on bottom line fiscal impact when making service approval decisions. The matter of size should be analyzed sharply through the lens of People First values: individualization, choice, outcomes and quality. In all other aspects of the People First waiver, personal relationships are valued – how will large DISCOs achieve this?
• The right size of DISCOs for fiscally viability could be influenced by approaches to risk sharing. Risk sharing, if well conceived, could lessen the need for large DISCOs whose size offset their fiscal risks. Smaller DISCOs would allow a broader regional distribution and enable more personal engagement with individuals and providers.
• In thinking about size, fiscal risks and regional distribution of DISCOs, it is important to remember that need levels of individuals are spread unevenly across the state. In counties where large numbers of formerly institutionalized individuals reside (like Fulton County, Oneida County, Hamilton County, etc.) there is a higher need level proportionate to general population.
• Similarly, existing services (particularly residential) are not distributed evenly across the state. Waiting lists are not proportional to population across regions. This raises serious concerns about equity of access to resources and services. The size of DISCOs must be centered on assuring equal access to services no matter where one resides in the state.
• A corollary issue to size and managing capitated resources is enrollment decisions. What safeguards will there be to prevent DISCOs from denying enrollment or access to needed services due to high costs? There should be an appeals process for denials that is independent from the DISCOs.

Question 2(b): Please provide a general description of how OPWDD should evaluate whether a DISCO pilot applicant is proposing a provider network that is sufficiently inclusive of self directed support models, habilitative supports that are responsive to individuals’ and families’ interests and needs for services that include family supports, care coordination, medical care, behavioral care and dental care.

SANYS forum participants agreed that carefully designed applications willyield multi dimensional insights on DISCO applicants’ potential to achieve the aims of the People First waiver. Applicants “proposed provider networks” is one criterion, but there are many other factors that forum contributors commented on. As with every other aspect of the new waiver, conformance to People First values must dominate judgments about worth. Applicants must demonstrate with the highest degree of credibility understanding of, and adherence to, waiver values.

It is vitally important to consider that the People First waiver is intended to be transformative. Applicants must show convincingly that they can transform the present system to achieve People First goals with sensitivity and respect for individuals served or to be served.

SANYS believes that, while all services and supports must conform to People First values and goals, it is applicants’ attention to, and plans for, individualized and self directed services that will be most telling of their potential to achieve transformation.

SANYS forum contributors felt strongly that OPWDD should invite self advocates and other stakeholders to participate in the application review process.

The following comments summarize the SANYS forums’ response to this question:

• If service providers are permitted to be DISCOs, applicants’ experience in services for persons with developmental disabilities is, obviously, critically important to assess. Do they have a reputation for top caliber quality? Have they demonstrated person centeredness in their relationships with individuals? Have they engaged in innovative approaches to services and supports, been willing to think and act outside the box? Have they taken advantage of opportunities for innovation, e.g. OPTS, Learning Institute, etc.? What do people who know them say about them?
• DISCOs will to a large degree contract with others for services. Their applications should demonstrate whether or how they have formed collaborative, productive relationships with other entities.
• Applicants’ views on, and (if they are providers) their track record with, individualized and self directed services is a vitally important matter. Since so few providers have experience with self directed services, applicants must present thoughtful and practical plans that show how they would support the growth of self directed services in NYS.
• Fiscal incentives are to be a key element of system transformation. DISCO applicants should be asked how they would develop and apply fiscal incentives to the provider network.
• What incentives and assistance will DISCOs offer directly to individuals to “transform” their own services and supports, e.g. trading off high cost congregate services for flexibility, customization and control over less costly individualized and self directed services?
• Every region hasproviders with service specialization “niches”, e.g. medical frailty, behavioral supports, family support, employment, etc. Applicants should demonstrate how they will coordinate the various service specialties in the most appropriate fashion. How will they fill gaps in services within their region? Where over capacity or duplication exists how will DISCOs make adjustments to balance the provide networks?
• Particular scrutiny should be paid to how DISCOs and their provider contractors will deal with high needs persons, e.g. those with medical needs, dual diagnosis, etc.
• Applicants must clearly demonstrate that their provider networks are inclusive of services (and agencies) that are culturally oriented. DISCOs must demonstrate how they will be culturally sensitive in their internal operations and connections with cultural communities.
• In every region at any time there are providers who are under performing, who are in fiscal jeopardy or show programmatic deficiencies. DISCO applicants must demonstrate what actions (positive and/or sanctions) they would take to address provider shortcomings.
• Applicants should demonstrate what measures they would take through and with providers to achieve administrative efficiencies. In particular, what would be their strategies in dealing with small agencies?
• Since respect and responsiveness to individuals are cornerstones of People First values, applicants should be asked how they will support self advocacy. Applicants who are providers should be asked about their experience in supporting self advocates. Have they engaged formally with self advocates? Have they brought self advocates into advisory, decision making or governance functions? How will they do so in their DISCO structures? How will they involve other stakeholders in ongoing functions and governance – families, community members, etc?
• SANYS believes that the credibility and effectiveness of evaluating DISCO applications will immensely benefit by including self advocates in the review process.

Question #3: How would you suggest that DISCOs incorporate programmatic and administrative efficiencies into their network model while ensuring that individuals receive quality, person centered supports and services and that direct support professionals receive competitive benefits and wages, meet core competencies and are well trained?

People in the SANYS forums who responded to this question immediately saw the relationship of its three components: programmatic and administrative efficiencies, quality supports and services and well trained and fairly compensated direct support professionals. They were concerned that “programmatic and administrative efficiencies” not be achieved on the backs of individuals served or the DSPs. They felt programmatic and administrative efficiencies,if thoughtfully conceived and applied, do not inevitably result in diminution of services and could actually lead to strengthening the direct support workforce.

The points raised in the forums are summarized as follows:

• First and foremost, DISCOs must demonstrate their own programmatic and administrative efficiencies. There is substantial concern that a new layer of bureaucracy will add costs that come out of resources for supports and services. OPWDD should closely scrutinize the administrative structures and overhead costs of DISCOs to ensure that they are as lean as possible. There was frequent mention of executive salaries.
• There should be clear expectations for reinvesting savings from programmatic and administrative efficiencies into supports and services and compensation for DSPs. Being express and explicit about the opportunities achieving, reinvestment could stimulate much creativity in all system stakeholders.
• One powerful means to find and adoptefficiencies and programmatic alternatives is to publicize the costs of existing services and supports. The majority of individuals and families have very little awareness about how much the various forms of services actually cost. While a significant proportion of costs are necessary and appropriate to need, it is a mistake to assume existing costs are appropriately aligned with all people being served, are relevant and/or are immutable. Given the chance to consider how (at least a portion) of existing costs could be redirected to alternative supports and services,providers, individuals and other stakeholders might produce amazingly imaginative thinking.
• It is widely perceived that OPWDD believes that administrative efficiencies will be gained by reducing the number of agencies through elimination or merger. There was concern that this will fall most heavily on smaller agencies. Forum contributors felt that small agencies are often the most person centered, culturally focused and creative and that their disappearance would damage the quality of services. Experience shows that mergers, despite stated intentions to the contrary, usually result in loss of the identity and culture of the agency being taken over. Great care should be taken by OPWDD and DISCOs with this strategy. At the least, every method should be explored to find savings that do not depend on eliminating agencies.
• One method of finding administrative efficiencies would be for providers to share administrative functions such as: business operations, information technology, marketing, human resources, training, etc.
• Many commentators expressed concern that “fiscal incentives for system transformation” are simply code words for blunt edged fee and rate reductions. They worried that OPWDD’s and DISCO’s strategy is to reduce payments with the expectation that, somehow, good things will result. The concept of fiscal incentives (to find efficiencies and restructure programs) is a good one, but it must be applied thoughtfully and in a purposeful planned way.
• Providing fair compensation and appropriate benefits to the direct support workforce is essential if the system is to meet its People First objectives. As the range of services becomes more diverse, less structured and more individualized, the skills and commitment DSPs becomes significantly more important. Careful scrutiny of DSP compensation packages, revised and update training curricula, and close attention to the well being and satisfaction of DSPs should be required of every DISCO.

Question #4: Please provide suggestions regarding what controls/firewalls should be applied to DISCOs that also functions as direct providers of service to ensure adequate network choice and not unduly influence care coordination efforts toward their own provider agency.

• See our comments above about the risks of DISCOs being service providers and well as funders. SANYS forum participants were unanimously opposed to the idea that any degree of controls/firewalls could prevent conflicts of interest and self referrals by DISCOs that are also service providers. Many mentioned experiences with Medicaid Service Coordination by agencies who were also providers where, despite purported independence of function, MSC’s were pressured to take care of their own agency’s referral needs.

These are among their observations:

• Why would you create a system that needs a “firewall”? Complete separation of fiscal decisions and care coordination from service provision solves this problem completely.
• We believe that DISCOs should not serve their own enrollees. Let them contract with other DISCOs if they want to provide services.
• If you are going to do this, you must have close monitoring of referrals to ensure absence of favoritism.
• Consider establishing three separate entities for three functions: needs assessment, care coordination (including referrals) and fiscal management. Each should have fixed rates for its services with no financial incentives for service provision.

Question #5: What incentives, disincentives and strategies do you recommend to ensure that individuals who present with more complex needs are not excluded from participation in a DISCO of their choice and that high quality expectation for all individuals is achieved and maintained at both the DISCO and provider level?

In the view of SANYS forum attendees this important matter requires multiple measures to avoid its occurrence. In addition to the obvious cost disincentives to the DISCOs there are other factors that bear on it: 1) a dearth of services for people with complex needs within particular regions; 2) the unwillingness/refusal of providers to serve certain individuals; 3) the uneven distribution of persons with specialized needs across the regions of the state; 4) the limitations on choice of providers that persons with complex needs encounter; and 5) the consequences to DISCOs and providers if/when state operations cease to be a fall back option for individuals with challenging needs.

Forum contributors felt that the following issues must be addressed in dealing with this matter:

• Structuring of per capita rates must include careful weighting of the costs of high needs individuals.
• Where capacity within a DISCO for specialized services is weak the DISCO must have an achievable plan to improve the availability of competent providers.
• Risk sharing through pooled risk or contingency schemes must be in place to offset any DISCO’s extraordinary experiences with high cost individuals.
• OPWDD and DISCOs must have a no refusal policy regarding persons with complex needs. Contract providers should have very limited grounds upon which to refuse a person they have the programmatic capacity to serve. DISCO and provider decisions on admissions should be closely monitored.
• If OPWDD is anticipating transferring auspice from state operations to the voluntary sector, there must be in depth analysis of capacity and skills among providers to support the more challenging individuals found in state operated programs. This is especially the case in regions of the state with a large concentration of state operations due to institution closures (Central New York, Finger Lakes, Sunmount, Hudson Valley, Taconic).

Question #6: How would you ensure that the network of providers established by the DISCO is sufficiently multi-cultural and able to serve the diverse interests and needs of the enrolled individuals?

OPWDD should take pride in its historical support for the multi-cultural interests of New Yorkers with developmental disabilities and their families. The SANYS participants urged that the richness of the multi-cultural network of providers and their culturally sensitive services not be sacrificed for efficiencies and that system transformation efforts have cultural respect as a key benchmark.