Next Meeting – September 19, 2005



STATE COUNCIL FOR PERSONS WTH DISABILITIES

FULL COUNCIL MEETING MINUTES

November 18, 2013 - 1:30 PM

Felton-Farmington Room, DelDOT, Dover

PRESENT

Daniese McMullin-Powell, Chair; Jamie Wolfe, Vice-Chair; Patsy Bennett-Brown, Amputee Support Group of Del.; Deborah Bradl, DOL/DVR; Ray Brouillette, Easter Seals; Anthony Carter, JEVS; Nick Fina, Advocate; Brian Hartman, DLP/DDC; Linda Heller, Advocate; Tony Horstman, Parent; Jody Hougentogler, Consumer/Parent; John McNeal, ADA-DelDOT; Dale Matusevich, DOE; Jim Miller, EDTAC and Post-Polio Support Group; Dan Muterspaw, AAB; Bob Osgood, Consumer; William Payne, AAPD; Steve Perales, DSCYF/DPBHS (for Susan Cycyk); Loretta Sarro, DOL/DVR DODHH & CODHHE; Liz Schantz, Consumer; Kristen Cosden (for Wendy Strauss-GACEC); Debra Veenema, National MS Society/DE Chapter; Kyle Hodges, Staff; and Jo Singles, Support Staff.

ABSENT

Ernest Cole, FCIL; Milton Daves, Consumer; Lisa Furber, State Rehabilitation Council; Bonnie Hitch, DART; Connie Hughes, DelARF; Christine Long, DHSS/DDDS; Kathy McCool, Consumer; Karen McGloughlin, DPH; Ann Phillips, Delaware Family Voices/Parent; J. Kevin Massey, DPH.

Interpreter: Lois Steele

GUESTS

Rita Landgraf, DHSS

Ken Sklenar, Easter Seals

Dan Chappell, DMMA

Monica Eger, UCP

Kim Marsh, United Health Care

Debby Pecoraro, United Health Care

Brian

Pat Maichle, DDC

Bonnie Millman, DelDOT

James Webb, DelDOT-ADA

Jill Fredel, DHSS

Thaddeus Williams, GACEC

CALL TO ORDER

Daniese called the meeting to order at 1:45 pm. Everyone introduced themselves.

ADDITION OR DELETIONS TO THE AGENDA

There were no additions or deletions to the agenda.

APPROVAL OF MINUTES

A motion was made and seconded to approve the June 17, 2013 minutes as submitted.

BUSINESS

DHSS Presentation – Cabinet Secretary Rita Landgraf

Daniese and Kyle welcomed Secretary Landgraf to the meeting. Rita provided updates on Delaware’s Health Insurance Marketplace and Delaware’s State Health Care Innovation Plan, which included PowerPoint presentations.

Affordable Care Act Implementation

Rita spoke about the Marketplace and referred to the website: . She stated that the website went live on October 1, 2013, but has been experiencing performance issues related to web-based portal. Delaware elected to become a state/federal partnership state (one of 36 states) and are utilizing the Federally Facilitated Marketplace. Delaware is responsible for the plans and products shown on the website and also responsible for consumer outreach. The Delaware Insurance Commissioner certified the 21 Delaware based products. While individuals are having difficulty accessing the website, there has been improvement and will be working smoothly by the end of November. Updates on functionality will be provided to the public through Delaware’s own website, with a portal to navigate to the federal website. Rita explained the benefits of the State/Federal Partnership. Consumers who enroll by March 31, 2014 will not have to pay a penalty. She reviewed the challenges and opportunities in detail including the following:

• Health Insurance Marketplace.

• Expansion of Medicaid.

• Rebalance long-term care system to community-based system.

• Patient-Centered Medical Home to treat “whole” person.

• Workforce development.

• Reward quality care and positive outcomes.

• Use electronic medical records to improve efficiency.

• Transform from “sick care system” to health care system.

• Individualized wellness plans for at-risk individuals.

Rita stated that currently 90,000 Delawareans are without health insurance. Delaware chose to expand Medicaid to 138% of the federal poverty level beginning January 1, 2014.

Rita reviewed the need for increased access as follows:

• ACA ends denial of coverage because of a pre-existing condition, including a disability.

• Young adults, including those with disabilities and chronic conditions, can stay on their parents’ plan up to age 26.

• More than 45 million adults had a mental illness in 2011, according to a federal Substance Abuse and Mental Health Services Administration survey.

• About 11 million had a serious illness.

• More than 40% did not get care.

Rita reviewed the goals for coverage:

• Be able to identify and treat individuals with disabilities, including mental illness and substance abuse disorders, in order to improve overall health.

• Services and programs should be person-centered and support health, recovery and resilience of individuals.

• Individuals and families should have choice.

• Services should be of high quality and consistent with clinical guidelines or evidence-based practices.

• Services should maximize community integration.

The current number of enrollments verified by DE Department of Insurance is 136 and the number released by the federal DHHS is 97. The differences reflect dates, lag between systems and manual validation by insurers. The number of individuals determined or assessed eligible for Medicaid/CHIP is 1,200. Further updates on the Medicaid program will be given at the December Health Care Commission meeting. The Health Care Commission provides oversight and direction to DHSS. Rita explained that the annual income limits up to 138% of Medicaid is $15,700 ($32,000 for a family of four) and will be slightly increased in January. There is also a FFM Contact Center available 24/7 (1-800-318-2596) to help people access the system. Jill distributed business cards with contact information.

Marketplace Guides are available to help people understand their options and apply for coverage. DHSS and DOI are providing direct support to consumers for complex cases. Tax credits are given to eligible consumers from 138% and up to 400% ($45,000 annual income) of the Federal Poverty Level. Rita stated that in order for the ACA to work effectively, healthy people and young people need to be enrolled. They will be reviewing enrollment data based on demographics and geography and adjust marketing and outreach. Rita stated that regular updates will be provided at the Health Care Commission meetings.

Rita explained the most efficient web portals to enroll in health care coverage:

• Delaware ASSIST (for Medicaid eligible).

• (139-399% FPL) and eligible for Federal subsidies.

• Insurers (Highmark, Coventry Life and Coventry Health), greater than 400% FPL) and not eligible for subsidies.

Rita recommended going to the website: first to get basic information (including premium estimator, subsidy calculator and access FAQs), compare plans and find assistance.

Pat noted that people have the option to complete paper enrollments. Rita commented that the information still needs to be entered into the computer system.

Rita provided a review of the Marketplace Guide Program and provided activities as of 11/12/13:

• 454 outreach activities have been held.

• More than 16,000 consumers have been engaged.

• Certified Guides (currently 51) have been assisting consumers in understanding options and eligibility, creating Marketplace accounts and applying for coverage. Guides are provided through contracts with four Delaware-based organizations: NCC: Brandywine Women’s Health, Westside, Christiana Care; Kent and Sussex: Delmarva Foundation. The number of certified Guides is expected to grow to 106 (full and part-time).

She spoke about various stories from the ground and what their direct experience has been. Jill will send the Powerpoint presentations shown during the meeting to Jo for distribution to Council members. Rita provided a brief overview of the specifics of the QHP (Qualified Health Plan) Standards and Monitoring. She explained that Delaware also offers Platinum and Catastrophic Plans in addition to the Bronze, Silver and Gold level Plans. These QHP Standards will be extended for the 2015 Plan Year, but will be revisited early in 2014 for the 2016 Plan Year; HCC will be engaged in this process.

Rita provided a review of the specific impacts of ACA on existing health plan policies for 2014 including:

• Coverage of all 10 essential health benefits and benchmark benefits, including habilitative services, hospitalization, maternity/newborn, and mental health parity.

• Removal of annual and lifetime limitations.

• 80/20 Medical/Loss Radio.

• Issuers cannot deny coverage due to pre-existing conditions.

• Rating factors that only include age, tobacco use and family composition.

Significant Dates:

• November 30, 2013 – Expected date for improvements

• December 15, 2013 – Last day to enroll for coverage beginning on January 1, 2014.

• March 31, 2014 – Must be enrolled in minimum essential coverage by this date to avoid penalty. Verification must be shown on the 2014 tax return.

Jill displayed a live viewing of the website.

Nick suggested putting a full-page supplement in the News Journal to get the word out on a monthly basis, especially for those who are uncomfortable or do not have access to computers/websites. Rita commented that Beth Miller did a supplement in the Sunday’s News Journal paper and will continue to update on a periodic basis. She stated that they are also participating with libraries and, radio interviews to get updated information distributed. Jim asked about affordable supplemental insurance for those receiving Medicare and the discrimination people face due to pre-existing conditions. Rita will take this recommendation to DHHS and encouraged people to speak to the U.S. legislative delegation regarding this. Jim spoke about his personal experience with paying for supplemental insurance.

Rita added that of the 90,000 people in Delaware without insurance, about 20,000-30,000 will be eligible for the Medicaid expansion. Also 35,000 are expected to enroll in the Marketplace or have access to commercial insurance; some will choose the penalty rather than sign up for health insurance because it is less costly for them in the first year. Rita stated that those living in Delaware who are undocumented will not be eligible for the ACA, but DHSS has programs that assist uninsured regardless of their status.

Bill asked about business that can self-insure. Rita stated that larger businesses are already self-insured under Employee Retirement Income Security Act (ERISA) so there is no impact to the majority of people. The small business market mandate has been delayed for a year. Nick also spoke about his personal experience with higher costs for health insurance and that he plans to check out the Marketplace.

Rita spoke about the essential benefits which resulted in increased costs for health insurance. Thaddeus asked about those unemployed and how they fit in. Rita stated that they would project their income for the upcoming year and would most likely be eligible for Medicaid, depending on their income or they may be eligible for a subsidy or tax credit. Daniese commented that people aged 60-64 will pay three to four times as much as someone younger with the same income. She noted that a person cannot buy insurance on the Marketplace if they receive Medicare. Rita spoke about people facing major life changes and the continuity of care plan needs to be consistent for these ebbs and flows. John asked about someone who loses their job and falls financially in regard to income and being Medicaid eligible, but has resources and asked if they will have to spend down those resources to become Medicaid eligible. Rita commented that the person would have to spend down for long term care. Kim commented that ASSIST has software built into the system where a person can look at trial eligibility before making a decision. Kim added that people without computer access can apply at a State Service Center. Jill stated that if anyone has further questions to contact her directly at jill.fredel@state.de.us.

State Healthcare Innovation Plan

Rita spoke about the creation of the CMI Office as part of the ACA. This enables states to compete to file for funding to look at how states come up with innovation plans that promote the transformation of the health care delivery system in order to promote quality of care and reduce the cost. Delaware was awarded an innovation grant in May, 2013 and will be submitting a plan to the feds by the end of this calendar year. If this plan is accepted, Delaware will receive additional funding to do a pilot. If the pilot goes well, Delaware will receive additional funding to bring this plan across the system. Rita spoke about the strengths including better coverage through better cancer screening, significant assets to support the health care system, and innovation yielding positive outcomes in specific efforts. Significant gaps remain including Delaware remains largely unhealthy, health care quality generally average and experience often below average, Delaware spends 25% more per capita than national average on health care. At this rate Delawareans will spend 40% of their income on healthcare in 2030. Premiums have gone up 5% per year for families between 2006 and 2011 and 22% of the State budget is spent on health care.

Rita spoke about structural barriers:

• Payment incentivizes volume of services – not quality.

• Care delivery is concentrated and highly fragmented.

• Population health approach not connected with care delivery.

Operational challenges:

• Workforce has major gaps in specialties, geographies and skills.

• Limited transparency on quality and cost for patients and providers.

• Lack of payer alignment on payment model, measures and areas of focus.

• Sustained preference for pilots vs. designing for scale.

• Community resources spread thin across many prevention areas.

• 10% of Delawareans remain uninsured.

Rita displayed many different examples of innovations in Delaware. She spoke about the continuing increase in spending despite innovations. She showed a breakdown of estimated health care spending in Delaware, and a map of the larger health systems and community health centers throughout the state which shows a larger cluster in New Castle County and a larger void going south. Rita noted that this chart does not show medical practices.

Rita reviewed a table showing Delaware’s health care workforce by county including Primary Care Physicians, Nurse Practitioners, Physicians Assistants and dentists. These figures are above the national average for these groups, except for psychiatrists which are below the national average. Rita noted that by 2030, Delaware will be the 9th oldest state and will need to bring in more aging specialists. Although Delaware has no in-state medical or dental school, we do have partnerships, for example, with Thomas Jefferson Medical School. She reviewed the breakdown by county. Rita will send copies of the presentation.

Goals for achieving the Triple Aim are:

• Delaware will be one of the healthiest states in the nation.

• Delaware will be a national leader in health care quality and patient experience.

• Delaware will significantly reduce health care costs.

Rita explained how the innovation plan got started and that it is multi-stakeholder, public/private and open and transparent. She reviewed a chart explaining the framework for the health transformation including team-based care, which facilitate into healthier neighborhoods. Included are: health information at point of care; multi-stakeholder governance; payment linked to outcomes; shared resources and services to support providers and flexible workforce. Rita reviewed a table showing the focus on areas that drive cost including effective diagnosis and treatment for all and care coordination for high risk adults/elderly and youth. These figures were broken down by Elderly, Adults, Adolescents/Pediatric and Infant populations.

Rita spoke about shared platforms to support transformation including IT-based shared services (risk stratification and care gaps) and other services (protocols/guidelines, care coordination, transformation support and learning collaboratives. She showed an illustrative example of a provider scorecard by category (Transformation, Access, Process, Outcomes, Patient satisfaction and Cost). Rita reviewed the proposed payment model that incentivizes both quality and lower costs including fee for service, pay for value, upside-only gain sharing, two-way risk sharing and prospective payment with potential on-ramps (goal of reaching a total cost of care model).

In the interest of time, Rita briefly reviewed organizing models, potential population health interventions, healthy neighborhoods (today and the vision), data and analytics needs for innovation, illustrative roles for care coordinators and community health workers, and public agencies and roles in health care. She said that a press release will be distributed when the plan is sent to the federal government.

Linda spoke about the mental health parity act which passed in 2008 and noticed that HHS has a new ruling on outpatient services and what impact on the current plan. Rita commented that they are receiving a lot of guidance on this and will have to modernize how we implement that framework. She added that they are building peer support system for individuals with serious and persistent mental illness, with talks about applying peer support systems to the addiction/drug abuse usage side.

Tony commented about not knowing the cost before-hand and said that he is glad this is being reviewed. He also commented about billing and that a large provider farms out their billing and there is a disconnect. He spoke of his personal experience. Rita commented that she thinks there is a good process and plan and have made a commitment to do this work regardless of the funding, although it will take longer. The fact that multi-stakeholders are engaged is a plus for Delaware. Daniese spoke about the changes in parity that will affect Medicaid and that Medicaid does not traditionally cover mental illness in most cases and asked if that will change so that people with mental illness can take part Rita commented that DSAMH is working closely with Medicaid and are working on a Medicaid-I waiver for those with mental illness. Rita added that more information will be forthcoming. Jamie spoke about the peer model for those with mental illness and substance abuse. She asked if this would cross disability for those with physical or intellectual disabilities that may not need the support and care of a social worker, but peer support and the federally funded models are outdated. Rita commented that they are looking at creating a profession that can draw down insurance to support that profession. There have been discussion on how to create a mechanism that the insurance would flow through, but currently they are not credentialed. If peers are considered part of the interdisciplinary team and become credentialed, then it becomes integrated into the entire system.

Anthony spoke about consumer education and health coaching and asked if there are any school programs to get the health information out to people before they reach adulthood. Rita commented that there is tension with the DOE on how to intersect that with what they are trying to accomplish relative to the academic core standards. She is trying to collaborate with the schools on the issue of addiction which is epidemic. She noted that Red Clay School District nurses have put together a phenomenal education and prevention program on addiction. There is difficulty in getting this embedded in a system that has so much going on between the standardized testing and core standards. She noted that Nemours has a program called “No Child Left Inside” which is dedicated to get kids outdoors. Rita commented that the College of Health Sciences at the University of Delaware now has an offering in health coaching. Loretta spoke about an article she read on Delawareonline regarding Highmark Blue Cross/Blue Shield and a cut-off of 5,000 and asked for clarification. Rita commented that of the 12,000 letters mailed to Delawareans (5,000 were Highmark Blue Cross/Blue Shield) advising people that they were canceling their plans because they were not going to meet the specifications of the ACA. A question was asked about the State mandating some type of required curriculum of exercise in schools. A question was asked about paying for a gym membership other than a doctor’s orders. Rita commented that they are looking at ways on how to incentivize and build in tools to promote physical activity. Rita commented that the focus has been largely on academics and that schools operate in a multi-faced government structure. She added that Secretary Kee (DoA) did some great work in bringing a farm to school program in the schools and promoting fresh local produce in the schools.

Linda asked about the status of Stockley. Rita commented that there is a concept-mapping plan on 200 ideas relative to expanded usage of Stockley. The next step is to create the Stockley Collaborative that will advance those priorities that have been identified with timelines and resources to accomplish it. Kyle added that the Report can be found on the DHSS website. Rita added that Kyle and Tony have participated in this endeavor.

The Joint Finance Budget Hearings for DHSS will be held on Tuesday, November 26, 2013 at 10 am.

Daniese thanked Rita for her informative presentations today.

OTHER BUSINESS

none

ANNOUCEMENTS

none

ADJOURNMENT

The meeting was adjourned at 4:00 pm. The next meeting will be held on January 27, 2013 at 1:30 pm, Appoquinimink State Service Center (large Conference Room), Middletown.

Respectfully submitted,

Jo Singles

Administrative Specialist

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