Can Participant-Directed Services Work in a Managed Care World?

BACKGROUND AND PURPOSE: Over a two-year period, twenty-six states have moved, or have publicly declared they intend to move, their home and community-based services for people with disabilities to managed care. Many fear that this will undermine commitment to participant direction. 

METHODS: Since 2012, the National Resource Center for Participant-Directed Services (NRCPDS) at Boston College has conducted a series of studies to assess the state of participant direction in Medicaid managed care settings and in programs that integrate services provided to individuals dually eligible for both Medicare and Medicaid.

The NRCPDS reviewed participant direction provisions from requests for proposals, contracts, and other policy and procedure documents related to Medicaid managed long-term services and supports (MLTSS) programs in the first 12 states to implement MLTSS. Researchers then went on to conduct in-depth case studies in five of those states, interviewing state program staff, administrators of managed care organizations (MCOs), MCO service coordinators, financial management services agencies, and advocates in each state.

The NRCPDS also examined the memoranda of understanding and three-way contracts for the first eight states participating in the financial alignment demonstration for the Medicare and Medicare dually eligible.

 KEY FINDINGS 

1. Contractual language for participant direction services in managed and integrated health care settings varies substantially among states. Less than half the states offer a participant-directed option, which includes the “budget authority” or “Cash & Counseling” option where participants can purchase goods and services, as well as hire the worker of their choice (“employer authority”).  Even when “budget authority” is an option, the choices are quite limited.
2. There are very few requirements specific to monitoring of participant direction services. In six of the “dual demonstrations” states, the only quality measure for participant direction is that the service coordinators have been trained in participant direction, but the content of the training is not specified.
3. Guidance from health plans regarding training for service coordinators in participant direction is inconsistent. Take-up of the “participant direction option” can vary from 0 to 25% depending on the service coordinator.

 IMPLICATIONS OF THESE FINDINGS 

1. Lack of participant direction standards and requirements impacts the design, operation, and evaluation of these programs. Examples of “best practices” could help states.
2. The implementation of participant direction is delegated to health plans that may or may not understand the philosophy or roles and responsibilities of participant direction.
3. Lack of standardized service coordinator training results in participant experiences varying widely within and across states.
4. Lack of participant-directed quality measures prevents most states from evaluating program performance and distinguishing high-quality programs from low-quality ones. In at least two states that switched to a managed care approach, data are no longer accessible on the number of self-directing participants.