Section 1115 Waiver Renewal - Disability Health Coalition

David Maxwell-Jolly, Ph.D., Director
California Department of Health Care Services
P.O. Box 997413
Sacramento, CA,95899-7413

California’s disability community, as represented by the undersigned individuals and organizations, would like to address the “Summary of Approach to Seniors and Persons with Disabilities” (“Summary”) issued by the state’s Department of Health Care Services (DHCS) on March 3, 2010. The Summary unambiguously states that “the state will begin implementation in the first year of the five year waiver by enrolling Seniors and People with Disabilities into existing managed care plans upon approval of the waiver.” The mandatory and precipitous enrollment of people with disabilities into the state’s established managed care infrastructure will put thousands and thousands in our community at grave risk. Both DHCS and managed care plans are not even fully aware of the extent to which provider networks fail to comply with the physical and programmatic access requirements of federal and state law. Neither can present evidence of having significant or long-term successful experiences with medical homes or the degree of care coordination required to maintain maximum health and function for some people with disabilities who have complex medical and chronic conditions.

The undersigned collaborate in the Disability Health Coalition (DHC), and have developed principles which should govern the delivery of health care regardless of the specific delivery system.[1] We have been following the state’s 1115 Waiver Renewal Process with great interest and concern. This letter shares our principal concerns, outlines various health care delivery options other than fee-for-service (FSS) or managed care, and provides a focused application of our general principles to the Section 1115 waiver renewal process that is being advanced by the current state administration.

The first goals stated in the Summary are “improve access to and coordination of the most appropriate, cost effective care for Seniors and People with Disabilities” and “improve health outcomes and contain costs.” This language tracks that stated in the Welfare and Institutions Code section 14180(a), which codifies Assembly Bill ABx4 6 on the state’s 1115 Waver Renewal. We agree that achieving physical and programmatic access and care coordination is essential to improving the health outcomes of people with disabilities, and also agree that the delivery of quality, effective care in a timely manner goes hand-in-hand with containing costs over the long-term at the very least. However, little in the Summary addresses how access and care coordination will be achieved and maintained over time.

The Summary indicates that “the state will develop enhanced standards/requirements that organized systems of care must meet to ensure their standards reflect the needs and circumstances of the SPD population.” Considerable private and public resources have been spent over the last few years in a stakeholder process sponsored by California Health Care Foundation to develop enhanced disability specific standards for health plans. The state has not adopted these standards into its contracts with managed care plans, nor has it imbedded standards into statutory or regulatory language which would allow for beneficiary and advocacy enforcement. Similarly, the Medi-Cal Managed Care Division (MMCD) of DHCS does not monitor plans to ensure compliance with those legal requirements to which plans are already subject. DHCS could develop groundbreaking disability-specific standards for plans on paper, but they will make no difference if the Department does not put resources toward the periodic monitoring and effective enforcement of these standards. There also must be real consequences attached to the failure of plans and providers to meet the Department’s disability-specific standards, and not continuation with the status quo as in the fact that MMCD maintains contracts with plans that achieve only 25% of the national Medicaid rates.[2]

DHCS’s accelerated timetable for the anticipated mandatory enrollment of 380,000 Seniors and People with Disabilities[3] into managed care is all the more disappointing when compared to actions taken by other states to research, compile data and feedback, and conduct limited pilot projects to investigate the myriad possibilities for coordinating health care delivery effectively and efficiently to people with disabilities. The next section will go into greater detail concerning this nation-wide movement.

California’s actions in simply mandating state-wide enrollment of Seniors and People with Disabilities into an existing managed care infrastructure without at a minimum requiring plan and provider compliance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act may itself be a potential violation of those federal laws.[4]

Welfare and Institutions Code section 14180(a), which codifies Assembly Bill ABx4 6 setting out the state’s 1115 waiver renewal process, requires California’s Health and Human Services Agency or its designee to submit an “implementation” plan to the legislature that specifically addresses how the waiver will meet the “multiple and complex needs” of the target Senior and Disability Community population, and details “the specific strategies the agency . . . will use to ensure the provision of quality, accessible health care services under the waiver.” The implementation plan is to include the adoption of “[c]riteria, performance standards, and indicators “to ensure that plan services meet the multiple and complex needs of beneficiaries,” and requires standards in the areas of plan readiness, and “the availability and accessibility of services, including physical access and communication access” among others. The implementation plan must also address “strategies to be used to monitor performance of all contractors and to ensure compliance with all components of the waiver or demonstration project,” and “a framework for evaluation of the waiver or demonstration project, including the process, timelines, and criteria for evaluating implementation, as well as the method for providing periodic updates of outcomes and key implementation concerns.” Finally, the implementation plan is to be informed by input from an established stakeholder committee.

On the other hand, DHCS plans to enroll Seniors and People with Disabilities into managed care plans in the first year of the five year waiver. This timeline leaves little or no room for an effective implementation plan to be developed and reviewed by stakeholders prior to mandatory enrollment. As stated earlier, the vast majority of plans have not even taken account of the physical and programmatic accessibility of their providers’ delivery of health care services. Neither the plans, nor the public hospitals have committed to transparently and openly taking steps to ensure both the accessible delivery of health care services and care coordination that addresses systemic service gaps in areas critical to the disability community such as experienced specialists, community-based long-term care, wellness and health maintenance, disability cultural competence, and the provision of American Sign Language (ASL) translation. Mandatorily enrolling Seniors and People with Disabilities during or before the development of the very implementation plan that is supposed to safeguard their receipt of quality, accessible health care services endangers the lives and health of people with disabilities.

Many advocates and individuals with disabilities in managed care plans have experienced physical inaccessibility, lack of appropriate procedural and policy modifications, refusals to provide effective communication methods, insensitive and discriminatory treatment, and a dearth of care coordination. The disability community will not be pushed quickly into enrollment with plans that are not prepared to meet their health maintenance needs or their risk of acquiring secondary conditions. Our position against mandatory enrollment was reinforced by DHCS's long delay in response to, and minimum adoption of, the CHCF-sponsored standards proposed for inclusion in the Department’s contracts with managed care plans. If DHCS had acted quickly to adopt and enforce the standards, plans would at least have achieved some degree of readiness, and have some awareness of the ongoing service gaps that exist, for the large inflow of Seniors and People with Disabilities now being proposed through the 1115 waiver renewal. That opportunity is now lost.

The concerns stated above are especially conspicuous in the context of states across the country that are investigating and investing resources in developing coordinated health care delivery systems. Individuals with disabilities have a range of needs and secondary conditions that are not well served through a “one-size-fits-all” health care delivery model. The Summary has taken one small step towards achieving needed choice by indicating that:

Managed care counties (excluding County Organized Health System (COHS) counties) will have the option to establish an additional organized care delivery model that reflects and meets unique local needs and circumstances. This additional choice will be offered along with existing plans as an additional option for Seniors and People with Disabilities required to enroll in organized systems of care, per ABx4 6.

The shape and direction of this option, however, is left entirely in the hands of the counties and any entities that want to throw their hats into the ring. In order to design a “Medical Home” system that meets the needs of people with disabilities, the DHCS itself must examine a range of delivery models and provide needed direction and accountability. In addition, many individuals with disabilities may require moving from one model which utilizes more extensive services to one which requires less interventions depending on the status of their secondary conditions and general health status. We feel strongly that DHCS is required to ensure that people with disabilities are given real “options” for health care delivery and not simply required to enroll in existing, closed managed care systems. It is backwards to instead give counties the “option” to provide other health care delivery options, completely unfettered by such basic direction for what constitutes a medical home or home and community-based services (“HCBS”) in long-term care.

States such as Nevada have joined a nationwide movement in exploring innovative options to serve individuals with disabilities. Nevada’s Division of Health Care Financing and Policy (DHCFP) on February 11, 2010 issued a Request for Information (RFI), No. ME79, Medical Homes Collaborative. For a copy see: http://dhcfp.state.nv.us/pdf%20forms/ManagedCare/Medical%20Homes%20RFI%201410%20-%20Final%202-08-10.pdf

In developing the RFI Nevada consulted with a variety of both national and state resources, in addition to participating in collaborations like the Patient-Centered Primary Care Collaborative. DHCFP conducted a literature review of related research publications and obtained feedback from the Centers for Medicare and Medicaid Services (CMS), and other state medical home programs, including Indiana, Oklahoma, and Colorado. DHCFP also sought input from Nevada stakeholders such as Federally Qualified Health Centers (FQHCs), the State Health Division and the Nevada Health Care Coalition.

Illinois is another state that is preparing to pilot a “Medicaid Integrated Care Program” (“ICP”) in five counties through two managed care organizations (“MCOs”). ICP is intended to provide greater care coordination among primary and specialty medical provider organizations and home and HCBS

organizations. What is noteworthy about Illinois’ Request for Proposals on the ICP project is that it is a pilot project that is limited to implementation in five counties, and clearly recognizes that there must be coordination between the delivery of health care services generally and the long-term care services needed to successfully enable people with disabilities to live independently in their communities.

We are not holding up the examples of Nevada, Illinois or any other state as providing the model or process for California’s 1115 waiver proposal. Rather we are encouraging DHCS to follow the preparatory and investigative procedures in which other states have engaged. The Department’s efforts to gather input from stakeholders within the state is laudable. However, the state also needs to conduct a thorough examination of available research and innovative non-managed care model programs, including those developed locally within the state such as the City and County of San Francisco’s “Diversion and Community Integration Program” and “Community Living Fund” that works to divert people from institutionalization and ensure the provision of various services needed by people with disabilities to remain in the community.[5] DHCS must also investigate feedback available from other states’ experiences and CMS to develop a viable medical home model for California. In addition, forums such as the upcoming Fifth National Medicaid Congress, where the Medicaid Medical Home will be a core topic of discussion, also provide opportunities to gain access to national policy and industry expertise on medical homes and care coordination.[6]

The disability community is aware of several examples of studies and operating models that have achieved varying degrees of success in providing coordinated services and/or a medical home to persons with disabilities. Again, most of the examples below serve a smaller group of people with disabilities more limited in geographic or service needs scope than Seniors and People with Disabilities in California. We are not necessarily endorsing any one of them as the appropriate model for California’s state-wide 1115 waiver renewal, but results from every model are relevant to the research and work that DHCS must undertake to provide essential guidance and leadership to the organized care entities seeking to provided coordinated health care to people with disabilities.

Disability Care Coordination Organizations (DCCOs) combine attributes of the medical home model and community nursing. Teams of nurses and social workers collaborate with the client to arrange disability-competent medical and social services. Examples of disability care coordination organizations include:

Targeted Disease Management: For individuals with disabilities who have a specific secondary condition such as diabetes, COPD, and asthma, a targeted disease management program may be the most appropriate program. These programs combine self-management interventions and clinical monitoring to improve patient health outcomes. Evidence is growing that self-management interventions, such as self-monitoring and decision making, lead not only to improvements in health outcomes and health status, but also to increased patient satisfaction and reductions in hospital and emergency room costs.

This model was originally developed by Ed Wagner, MD, MPH, Director of the MacColl Institute for Healthcare Innovation, Group Health Cooperative of Puget Sound, and colleagues of the Improving Chronic Illness Care Program. With support from the Robert Wood Johnson Foundation various systems that have utilized the model have been studied. http://www.improvingchroniccare.org/

The model focuses on six essential elements required to transform a health care system to one that is responsive for managing care for individuals with chronic conditions including:

The Department of Veterans Affairs (VA) has developed a model for managing elderly veterans with chronic conditions in the home setting. The Home Based Primary Care (HBPC) program targets chronically ill veterans and delivers longitudinal health care services in the home. In contrast to delivering episodic home care (i.e.; the current Medicare home care benefit that is limited to 60-day episodes of care), the model provides ongoing, continuous monitoring for chronically ill patients. Use of an interdisciplinary team, including medical directors, program directors, nurse practitioners, physicians’ assistants, RNs, licensed practical nurses, social workers, dieticians, rehabilitation professionals, pharmacists, and program assistants, comprises a key component of the program. 2006 outcomes data reveal a 27% reduction in hospital admissions and a 69% reduction in inpatient days of care after admission to a HBPC program. http://www.visn2.va.gov/gec/hbpc.asp

The Care Transitions Model focuses on the events occurring between transfers from one health care setting to another, also known as transitional care. Transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing facilities, the patient's home, primary and specialty care offices, and long-term care facilities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient's goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs.[7] This model focuses on medication management; use of patient-centered personal health records; emphasis on timely physician follow up; both specialty and primary care; and an understanding of the red flags that indicate an exacerbation of a patient’s condition as well as responses. These models use interdisciplinary health teams, targeted technology, and home-based clinical monitoring.

The model was developed by Eric Coleman, M.D. from the University of Colorado and pilot projects were funded by the California Health Care Foundation in 2007. http://www.chcf.org/topics/view.cfm?itemID=128306

The disability community believes that a medical home model or any organized care delivery model for people with disabilities must be premised on the following core principles.

Individuals with disabilities must be able to preserve access to the health care services[8] and Fee-for-service (“FFS”) provider relationships that are critical to maintaining their health until any proposed new delivery system can unequivocally demonstrate its capacity to meet that individual’s health care needs as they evolve over time. Any proposed mandatory enrollment of part or all of California’s Seniors and People with Disabilities must be preceded with outreach and education about how the proposed delivery system(s) will operate, changes in how services will be provided, and grievance and exemption procedures. Outreach and education must include effective communication with those who have communication impairments requiring such accommodations as alternative print formats, ASL videos, and simplified English. There must be resources available to assist people with disabilities to make an informed delivery system choice based upon an assessment of their individualized medical needs.

The Summary’s reference to default assignment of Seniors and People with Disabilities who do not make an active choice, “based on factors such as the organization’s quality outcomes and support for the local safety net system” is simply not good enough. The enrollment timeline must allow for all of the above, as well as careful ongoing monitoring by the Department of the network and care coordination capacity of all delivery systems involved and troubleshooting of problems that will inevitably arise even during a gradual, deliberate enrollment process. Individuals with disabilities who have only a choice of enrollment in a closed delivery system must be able to quickly obtain an exemption from enrollment in the system if their ability to get access to effective quality care, maintain continuity of care, or continue to live in their community is at risk. General and specific consumer protections, such as those detailed in the March 2010 “Consumer Protections for Seniors and People with Disabilities on Medi-Cal Proposed for Mandatory Enrollment into Organized Delivery Systems” position paper authored by the Western Center on Law and Poverty and signed by numerous advocacy organizations,[9] must be in place prior to the mandatory enrollment of Seniors and People with Disabilities into any closed delivery system.

These are only the minimum standards that must be in place for people with disabilities to achieve the smoothest possible transition from fee-for-service (FSS) to any other health care delivery system. Without such a transition, not only will the potential for achieving the Department’s stated goal in the Summary to “improve health outcomes and contain costs” be lost, harm will come to Seniors and People with Disabilities.

Whether an individual is simply receiving healthcare through a one-on-one relationship with a primary care provider or working with a comprehensive treatment team and case manager to address multiple complex health conditions, that individual’s capacity to partner in his or her health care management and decision-making must be recognized to the fullest possible extent. People with various disabilities, including substance abuse and/or cognitive or mental health impairments, must not be wholly deprived of their right to participate in their health care treatment, even if some aspects of that participation may require assistance or be mediated through a health care power of attorney or some other legal device. The active participation in health care decision-making of family members and/or support persons designated by the individual with a disability may also be allowed in some instances where culturally appropriate and requested by the individual. Participants who are viewed by themselves and health care providers as equal partners will feel greater commitment to treatment plans and have a greater incentive for ongoing compliance, thereby increasing the chances of achieving improved health outcomes.

Health care that is not physically and programmatically accessible to people with various disabilities as required by federal and state law is not appropriate, effective or equal. Neither DHCS nor the vast majority of health care entities such as plans, hospitals, medical groups, and individual provider offices, is even aware of the extent to which they are inaccessible. The mandated state-wide use of a thorough survey tool to acquire this baseline information from all levels of the health care delivery system,[10] regardless of its specific form, is only the first necessary step to providing appropriate, quality health care for Seniors and People with Disabilities in the state. The following specific goals must also be achieved:

· Physically accessible health care facilities which will enable individuals with disabilities to approach, enter, move around and use the facilities (including facility parking lots, waiting rooms, examination and treatment rooms, food service facilities, and restrooms) as conveniently as everyone else.

· Physically accessible medical screening and diagnostic equipment, for example, lift equipment, adjustable high/low exam tables, wheelchair scales, and imaging equipment.

· Ubiquitous notification to health care beneficiaries of their right to an accommodation under The Americans with Disabilities Act, Section 504 of the Rehabilitation Act and state law.

· The wide availability of accessible technology such as “talking pill bottles; including all electronic communication (e.g., provider e-mail correspondence, billing, and filling prescriptions), and accessible web sites which can be used and understood by everyone regardless of whatever Internet browser or adaptive equipment is employed.[11]

· Maintaining patient access to their own records in a form that is accessible to the patient, even as the capacity for and use of Health Information Technology increases.

· The wide availability of all health information and education materials in alternative formats such as Braille, audio recording, large print, and CDs.

· The wide availability of transfer and dressing/undressing assistance when needed by seniors and people with disabilities.

· The common provision of modified appointment times and appointment windows when needed.

· Ongoing provider training to achieve culturally competent services, including awareness and hiring of language access services.

· Periodic ongoing monitoring and enforcement of all state and federal architectural and programmatic accessibility requirements under current state and federal law, at all levels of health care delivery, including medical groups and individual providers.

· The common wide provision of Sign Language interpreters when services are accessed

The longstanding and ongoing difficulty encountered by Deaf people and people who are hard of hearing in obtaining adequate health care communication merits particular recommendations for achieving redress. Communication access services are all too frequently not provided as plans and providers lack on-the-ground administrative mechanisms and coordination for meeting their obligations under federal and state law. 22 CCR § 51503.3 contains California’s only direct reimbursement mechanism for providing American Sign Language (ASL) services. It provides a billing code that enables Medi-Cal enrolled providers with fewer than fifteen employees to be reimbursed at specified rates for the provision of certified or non-certified ASL translation services. “Large” providers with more than fifteen employees cannot separately bill for ASL and other communication services because in theory translation services are “built into” the general cost of the provision of services

The Department should issue Policy Letter(s) and Guidance to Medi-Cal managed care plans clarifying that Medi-Cal managed care health plans and providers are required to provide communication access services within existing capitation rates, and reminding providers that the above reimbursement mechanism for small Medi-Cal providers exists. The Department should also develop an enhanced capitation rate for Medi-Cal managed care plans that voluntarily provide the Department with full information regarding the administrative policies and procedures through which plan providers are informed of, and reimbursed for meeting, their language access obligations, and with monitoring, tracking and enforcement information for how plan providers offer communication access services and fulfill their effective communication obligations under state and federal law. Finally, the Department should engage managed care plans and providers to study other options for the timely, consistent delivery of effective communication access services, such as the Department or plans contracting directly with language services agencies or directly with interpreters.

Disability is a common and natural feature of the human condition which is relevant to the lives of all people to different degrees and at different times in their lives. Truly effective health care for people with and without disabilities requires acknowledging and addressing all the health care needs of the whole person over his or her life. These needs may involve numerous providers focusing in such diverse areas as mental health, dental care, acute care, health maintenance and wellness (e.g., ranging from programs on exercise, obesity, and smoking cessation to disease-specific self-care education), and home and community-based long-term care services. The health care delivery system must therefore provide a comprehensive and seamless schedule of benefits and scope of coverage that includes all relevant health care services. This is especially important for those persons who have multiple disabilities or co-occurring conditions that require integrated systems of care as they must have access to multiple service systems.

Organized health care delivery system have the significant potential to improve care coordination for people with disabilities by providing a health care professional such as a primary care physician (“PCP”), nurse practitioner or social worker who is consistently available to assist an individual with disabilities manage the various providers and services that she or he may need. The Summary indicates that “[t]he entities providing services to Seniors and People with Disabilities will be required to provide essential elements of organized care delivery including arrangement of medical home providers, care management and member supports, home and community-based services, provider supports, and value based purchasing.” However, the rush to enroll thousands of Seniors and People with Disabilities in the first year of the waiver means that people with disabilities will very likely be working with untrained and/or inexperienced professionals who will lack critical information concerning at least some of the services needed for a holistic focus. PCPs, for example, may have the skills and expertise to coordinate health care for many Seniors and People with Disabilities but are likely to have only limited knowledge about community resources and HCBS; the same is true of the specialists who may be the best care coordinator for some persons with complex medical conditions. Managed care entities, as well as third party professional case management entities, may lack experience maintaining communication and managing collaboration with medically necessary providers and medical groups who lie outside of existing organizational structures. The transition to any organized delivery system, especially any closed system, must ensure that experienced, reliable integrated care is available to people with disabilities, and any schedule of enrollment must therefore be stopped and delayed in the event that such integrated care is not being efficiently and consistently provided.

Furthermore, enhanced care coordination cannot take place without changes in how reimbursement occurs. PCPs and other appropriate professional care coordinators such as nurse practitioners or social workers or mental health providers must receive appropriate payment for addressing a range of patient-centered care management services that fall outside of the face-to-face clinical services that take place in a “typical” office visit.[12] PCPs or nurse practitioners should receive payment for undertaking necessary coordination within any particular practice, including management needed to ensure programmatic access, as well as facilitating coordination between, and information exchange among, specialists, consultants, ancillary providers, and community resources. As well, organized care delivery systems need to explore how payments, capitated or non-capitated, can incentivize increased provider availability and flexibility, such as extending office hours, providing same-day appointments and/or extended appointment times, and engaging in email and phone consultations where appropriate. Payments could also be structured so as to incentivize the acquisition of disability specific cultural training by providers across the board. While the Summary outlines the need for value based purchasing reforms, the above basic reimbursement reforms needed to achieve the significant care coordination and accommodations needed by many Seniors and People with Disabilities is not actually acknowledged other than obliquely through reliance on the savings forecast through the use of Health Information Technology.[13]

DHCS has paid insufficient attention to Section 14180(a)(6) mandate to “[p]romote home and community-based care.” The subject is highly complex, raising numerous questions about how an organized systems of care will interact with elements of the state’s existing HCBS framework such as HCBS waivers, Regional Center services, In-Home Supportive Services and Adult Day Home Care, county mental health services, alcohol and substance abuse treatment, such community-based services as those provided by Independent Living Centers. The successful integration of long-term care and the existing managed care framework will require strong case management, thorough and timely (e.g., prior to actual enrollment into managed care) of a carefully defined population, and multi-disciplinary teams capable of addressing the needs of individuals with complex medical conditions. Moreover DHCS must take this opportunity to indelibly establish, at all levels of the health care system, the explicit preference for HCBS over institutional care for the delivery of long-term care services.[14]

7. Provision for Feedback, Filing of Grievances, and Investigation of Complaints

The state’s 1115 waiver renewal process, by implicating mandatory enrollment of Seniors and People with Disabilities into closed managed care systems, will have a dramatic impact on how Seniors and People with Disabilities receive health care. It is critical that the state ensure the provision and publicizing of effective and efficient ways to file complaints and grievances and otherwise provide feedback concerning the transition to organized care systems and the implementation of Seniors and People with Disabilities-specific standards by all levels of the health care delivery system. Plans should incorporate the disability-specific questions that have already been developed for the Consumer Assessment of Healthcare Providers and Systems (“CAHPS”), funded and administered by the U.S. Agency for Healthcare Research and Quality. Plans must also demonstrate that their policy is to modify their grievance and appeal procedures to enable people with disabilities to submit a grievance independently through the use of alternative formats, or receive requested assistance from trained plan personnel to submit a grievance. Finally, plans must compile information concerning complaints received and grievances filed relating to ADA/504 violations and make this information available to the state and current and potential enrollees.

Thank you for this opportunity to share our concerns over California’s 1115 waiver renewal, and our recommendations for the ongoing process. We will continue to urge the Department to maintain full transparency as the process continues, and to take the actions outlined in this letter to improve the physical and programmatic accessibility and outcomes of health care delivery for people with disabilities in the state. We also would be more than happy to meet with you to further discuss the 1115 waiver renewal process and ideas for how the waiver could be ultimately shaped. Recent federal healthcare reform will be bringing significant improvements to healthcare coverage for people with disabilities. California has the potential to play a leadership role in health care delivery across the nation if it embarks on the informed, measured, appropriately monitored and enforced enrollment of Seniors and People with Disabilities into an organized delivery system that is physically and programmatically accessible and otherwise prepared at all levels to provide care coordination to people with disabilities while respecting their capacity for self-direction and right to remain in their communities.

[1] The document is available at www.disabilityhealthcoalition.org.. It is our view that a health care delivery system that provides effective, timely, disability-competent health care to people with disabilities is a health delivery system that will work for all people.

[2] The national Medicaid rates are compiled by the National Committee on Quality Assurance and are based on meeting the Healthcare Effectiveness Data and Information Set (HEDIS) measures.

[3] This is the figure quoted in the Summary, but it is unclear whether it includes dual Medi-Cal and Medicare eligible beneficiaries, and the figure differs considerably from the estimate of 650,000 given in the Western Center on Law and Poverty’s March 2010 position paper on the state’s 1115 waiver proposal.

[4] In Anderson v. Department of Public Welfare, 1 F.Supp.2d 456 (E.D. Penn. 1998), a federal court endorsed the idea that the state’s Medicaid responsibility encompassed a responsibility to ensure that HMO managed care providers met the accessibility requirements of federal law. The Pennsylvania Medicaid agency mandated Medicaid recipients in five counties to receive healthcare services through a network of HMOs called “HealthChoices.” The state agency did not consider, either at the initial HMO bidding process or when the state conducted “readiness reviews” of the HMOs that were awarded contracts, whether Healthchoices providers practiced in accessible offices. Ultimately, the court found HealthChoices inaccessible because the program “does not comply with the minimum program accessibility regulations promulgated under Title II and Section 504” for new and existing construction. [4] The class plaintiffs had an actionable claim against the state agency because it failed to ensure that every HealthChoices providers met the “new construction” and “existing facilities” requirements of Title II, and thereby failed to ensure that individuals with disabilities had a meaningful opportunity to benefit from and participate in HealthChoices. In partially granting the Plaintiffs’ Motion for Summary Judgment, the Court issued an Order that required the state to ensure that every participating HealthChoices provider met the accessibility requirements of Title II of the ADA.

[5] See http://www.sfhsa.org/388.htm for more information about the Community Living Fund. Please also note that Anne Hinton, the Executive Director of San Francisco Department of Aging, provided testimony January 26, 2010 on San Francisco’s care coordination and long term care programs to the California Senate Committee on Human Services and the Senate Subcommittee on Aging and Long Term Care.

[6] See http://www.MedicaidCongress.com/brochures/medicaid2010.pdf for additional information.

[7] Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):556-557.

[8] This phrase is meant to encompass care as needed from a range of health care providers, including outpatient services, specialty services, medications, supplies, durable medical equipment (“DME”), assistive technology, mental health services, vision, hearing, and dental care, provided through a range of contexts (e.g., hospitals, home and community based service agencies, ambulatory specialty care clinics, supportive housing, long-term care facilities, etc.).

[9] This paper was presented to the SPD working group and is now available on DHCS’ 1115 waiver website.

[10] The Summary refers to the Departments intention to take action “so that existing Medi-Cal managed care plans in counties with public hospitals integrate public hospitals into their networks” and “will also be required to establish similar arrangements with private disproportionate share hospitals and Federally Qualified Health Centers.” All three of these entities should therefore also be required to use a survey tool and provide the state and consumers with baseline information concerning the physical and programmatic accessibility of their facilities.

[11] Accessible web sites are constructed in accordance with the guidelines formulated by the Web Accessibility Initiative of the World Wide Web Consortium (www.w3.org/WAI/).

[12] Note that Section 1202 of the Healthcare and Education Reconciliation Act of 2010, enacted as H.R. 4872, increases the Medicaid reimbursement rate for primary care physicians to the Medicare rate, for both FFS and managed care service delivery, giving the latter greater play for ensuring care coordination takes place for managed care members..

[13] Numerous principles needed for appropriate payment in a patient centered medical home delivery model are given in “Seven Joint Principles for Patient Centered Medical Homes” developed in 2007 by four major primary care physician groups (American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians, and American Osteopathic Association”

[14] It is worth noting that on the 10-year anniversary of the Supreme Court decision Olmstead v. L.C., President Obama proclaimed 2009 the “Year of Community Living.” The current administration continues to be interested and active in this area. Shortly after President Obama’s proclamation, HHS Secretary Kathleen Sebelius announced an initiative to make it easier for older people, younger adults, and their families to access health and long-term care options through Aging and Disability Resource Center (ADRC) programs. ADRCs serve as a comprehensive source of information, one-on-one counseling, and streamlined access to programs and services that can enable people to continue living in their own homes and communities. Henry Claypool, Director of the Office on Disability, leads a working partnership among the Administration on Aging (AoA), Centers for Medicare & Medicaid Services (CMS), the HHS Office of Civil Rights, the Office of the Assistant Secretary for Planning and Evaluation, and the Substance Abuse and Mental Health Services Administration that is charged with coordinating the Year of Community Living efforts.