Richard Edley Reflects On What Managed Care Means for Pennsylvania Providers

Managed Care is coming to Pennsylvania, like it or not. Many agencies in Pennsylvania will shortly be required to interact with Managed Care organizations for the first time. Providers are going to need to get authorized, acquire new technology, introduce new systems and work with new organizations. This is uncharted water for many providers. Richard Edley, President and CEO of RCPA, has been working with the state, MCOs, and agencies regarding the expansion of Managed Care in Pennsylvania. Since 1994, Richard has been working to support health care in Pennsylvania.

When asked what challenges he foresees when adapting to Managed Care, Richard notes that Managed Care isn’t actually new to Pennsylvania. “Behavioral and physical health care providers have had Managed Care for a long time. It is the move toward Managed Long Term Services and Support (LTSS) that is a new initiative. You’re now talking about social services, rather than medical services. The expansion of Managed Care does not apply to the Intellectual/Developmental Disabilities agencies, even though there has been a lot of talk over the years. It’s bound to come back.”

“However, while Managed Care isn’t new to Pennsylvania, there are new challenges presented by Managed Care for LTSS. Physical health has its challenges, but it is much more standardized. If a patient has symptoms that meet a certain criteria, and the treatment suggested is criteria based, the process of submitting for approval is fairly straightforward. With long term care, you’re talking about such things as in-home services, supports for people to get employment, or care for the elderly, so applying criteria and authorizing services is a grey area. It is much harder to manage.”

“Managed Care Organizations (MCOs) have to learn about how the system works to focus on efficiency and services. It’s a very complex system, and MCOs will have a learning curve.”

“In the previous structure, clients would seek out agencies. The agencies would then get authorization through the state. Now, clients will seek out the MCOs or an agency. If the client contacts an MCO, the MCO will put the client in touch with an agency and work directly with the state. If the client contacts an agency, the agency will have to contact the MCO to get an authorization.”

“For many of the affected agencies, this is the first time they’ll be touching managed care in any way. This is the first time they are dealing with the notion of getting credentials/accreditations, submitting for authorization, tracking, submitting claims that match, need for appeal, or the need to submit for additional services. This is a whole new world.”

“From the IT standpoint, many providers are still very much paper and pencil. A few may have relied on a very basic system or the state system to help them. Now, these providers are going to need Electronic Visit Verification (EVV), electronic health records, and need to get the data to the MCOs in real-time. It will be stressful for small providers, and they’re going to face a real struggle.”

“The way it works right now for agencies without EVV, a person goes into the home and there is no way to verify the visit. If the provider sees a problem with the time, they have someone go back to the office, fill out some things in a system, submit a fax, and eventually authorization happens. If that’s the situation, you are losing valuable time. Technology can be given to attendants to verify the presence of the caregiver and submit requests online. It speeds everything up, saves money, and prevents delays in receiving necessary treatment. Agencies need to be better prepared to take on the technological burden.”

“There is an additional pressure on agency providers: this is the first time the state Community Health Choices has released a procurement where the MCOs are not required to have an Any Willing Provider Network. If a Pennsylvania service area starts with ten providers, after the six month transition period the MCO may only use two.”

“We have to ask providers, ‘How are you going to differentiate yourself?’ We’ve looked at raising the bar on credentials and standards as well as data outcomes. If agencies could track in real-time, it could help them survive the transition period. There is an uncertain future for providers. There is risk for personal attendant services and service coordination entities; some might not survive.”
“In terms of resources, no one is talking about funding as of yet. The state and MCOs are going to be hosting a lot of trainings and meetings, but providing resources for agencies to learn about managed care is also the role of the associations.”

“RCP-SO is being organized to represent the providers who are affected. In the mid-1990s, the precursor to RCPA founded Community Behavioral HealthCare Network of Pennsylvania, Inc. I worked there as CEO for many years before coming to RCPA. It was a provider owned company, and it proved that if you have managed care coming to a state, providers can come together and manage it themselves, rather than wait what MCOs are mandating.”

“With that background, it wasn’t out of left field for RCPA to meet with providers, or suggest building a company managing CHC. However, we aren’t competing against large physical health plans. Community HealthChoices has billions in expenditures; that wouldn’t be feasible. We are coming together to create specific products to improve quality and be more cost-effective proving viability in the long-term for MCOs.”

“We’re seeking to help providers in four fields: Brain Injury, Service Coordination, Personal Attendant Services, and Vocational and Day Programs.”

“All of the products, at a high level, streamline administration and work toward alternative reimbursement and unified quality indicators. As an example, with Brain Injury providers, we represent all the post-acute care providers in the state. They have their own outcomes measure and tools, and are all CARF accredited. It wasn’t hard to go to the MCOs and tell them we can manage Brain Injury services for them.”

“It would be more difficult for MCOs to manage Brain Injury providers on day one because they aren’t familiar with how they operate, and there are so many competing interests and priorities (e.g., nursing home admissions). MCOs are contracting with us to standardize quality outcomes, and define quality reimbursement services.”