ACCOUNTABILITY

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ACCOUNTABILITY

• Using Medicaid School Program monitoring and data
  to drive accountability and program improvement
• State and district perspectives

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• June Cohen
• Section Chief, Health Related Resources
• Maryland State Department of Education
• Benjamin Feldman
• Director, Third Party Billing
• Baltimore City Public School System

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• The Medicaid School Program returns about
  650,000,000 to schools per year.
• However, the program is not about money. Or at
  least, it should not be.

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The goals of the program should be these

• To support more and better services to children
  and families.
• To generate useful data to
• Enforce accountability
• Drive program improvement.

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• Cost recovery is the corollary benefit.

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This presentation will illuminate four questions

• How can managers get to accountability data?
• What kinds of data can be captured?
• How can this data be used?
• How does this benefit Medicaid?

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Getting to an Accountability Model

• There are two approaches to data collection
• Targeted and universal

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Targeted Data Collection

• Many states and districts understand and employ
  targeted data collection.
• Identify the known subset of children who fall
  under the purview of the Medicaid School Program.

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Targeted Data Collection

• Collect service data for these children, only.
• Perhaps use preprinted encounter forms,
  identifying the provider and client child of
  interest.

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Targeted Data Collection

• Targeted data collection makes some sense in
  small districts that serve a small and discrete
  Medical Assistance (MA) population.
• Or in very affluent districts where the Medicaid
  dollar is a minor contribution to the health and
  special education budget.
• This is basically a clerical model.

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Targeted Data Collection

• Targeted data collection is a dead end that
  yields a single product
• One-shot recovery.

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Targeted Data Collection

• There is no chance for
• Capturing services for children not recognized as
  eligible,
• Capturing services for children awarded
  retroactive eligibility,

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Targeted Data Collection

• There is no chance for
• Analysis of service delivery,
• Or any kind of accountability bonus.

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Universal Data Collection

• Collecting documentation for every service,
  billable or notrendered to every child yields an
  Ali Babas cave of information.
• Universal Medicaid School data
• MAPS
• Special Education service delivery.

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What kinds of data can be captured?

• Examples of performance measures that can be
  captured and tested
• Behaviors that are often not managed are made
  visible, e.g., the performance of itinerant
  staff, health related service staff, service
  coordinators.
• Congruence with mandated timelines.

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What kinds of data can be captured?

• More examples
• Congruence between the IEP and service delivery
  model.
• Support for document and complaint process.
• Interruptions in services.
• Direct services can be parsed cleanly by
  districts doing Administrative Claiming.

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What kinds of data can be captured?

• More examples
• Comparability of services rendered to similar
  categories of students in similar or dissimilar
  situations.
• Children who should be served and are not.
• Children who should not be served and are.
• Children who are not receiving the full measure
  of IEP-mandated services.
• Children who are being over-served.

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What kinds of data can be captured?

• More examples
• Compliance by service delivery staff and building
  administrators, to support recovery efforts.
• Support for recovery efforts can provide an
  objective and quantifiable performance measure to
  assess staff, building administration, area
  administration, and even district-wide
  administration.

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What kinds of data can be captured?

• More examples
• Performance between staff and contractual
  providers can be compared.
• Service delivery can be analyzed across LEAs.
• Compliance data, modeled against IEP data, can
  ensure maximized recovery.

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Where might problems lie?

• The accountability tools provided through data
  mining can be so powerful that Special Education
  may resist such exposure.
• Districts and States under judicial engagement
  are more vulnerable to scrutiny. Remember, in
  order to be accountable, one first has to count!

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Where might problems lie?

• Providers may not see the benefits of documenting
  services rendered to all students.
• For these reasons, one documented promising
  practice is to locate cost recovery efforts
  within Budget Finance, while not neglecting
  partnership with Special Education.

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How can these data be used?

• Maximization of recovery
• Resource allocation
• Strategic budgeting
• Personnel evaluation
• Demonstration of compliance with federal and
  state mandates

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How can these data be used?

• Identifying programs and districts with
  performance concerns
• Targeting technical assistance
• Supporting interest and advocacy groups
• Building exhibits for judicial disengagement

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How can these data be used?

• Dont forget the Office of the Inspector
  Generals Reviews!
• Maryland (and many other states) believed we were
  in complete compliance with federal regulations.
  Our experience has been substantially different.
• OIG is requesting significant penalties across
  the country.
• Maryland is in Phase II of monitoring all
  Medicaid providers for school-based services.

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How can these data be used?

• Dont forget the Office of the Inspector
  Generals Reviews!
• We have developed rigorous instruments and
  protocols.
• The state process mirrors the OIG process
  (documents provided).
• The state has required all districts to implement
  self-monitoring processes that mirror the state
  process.

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How can these data be used?

• Dont forget the Office of the Inspector
  Generals Reviews!
• The necessary commitment of time and human
  resources is tremendousbut the results justify
  the investment.
• The information amassed from monitoring provides
  critical information for the state and LEAs.

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How can these data be used?

• Dont forget the Office of the Inspector
  Generals Reviews!
• When Maryland negotiates with regional CMS, the
  states monitoring process and products will be
  the material demonstration of compliance with
  federal regulations.
• Monitoring is the mechanism for system
  improvement.

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How can these data be used?

• Dont forget the Office of the Inspector
  Generals Reviews!
• Monitoring will inform and direct technical
  assistance.
• Monitoring will direct and enforce
  self-improvement and procedural correction.
• If your state or district has not been
  monitoring, you should begin.

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• These all add up to
• PROGRAM
• IMPROVEMENT

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How does this benefit Medicaid?

• The original intent of Congress can be clearly
  delineated and argued that Medicaid dollars
  support the medical component of IDEA.
• All stakeholdersfederal and state Medicaid
  agencies, families, advocacy groups, professional
  associations, administrators, school system
  staffembrace accountability.

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How does this benefit Medicaid?

• Keeping the Medicaid dollars on the tablenot
  commingling them with other fundsenables state
  and district partners to articulate the goals and
  vision of the Medicaid School Program.
• Putting services to children and families first
  de-sensationalizes cost recovery efforts.

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How does this benefit Medicaid?

• All local stakeholder groups interests can be
  served, including
• State and district Boards
• State and district CFOs
• Special Education advocacy groups, e.g.,
  Disability Law Centers
• Professional associations, e.g., ASHA
• Judicial oversight entities, e.g., Consent
  Decrees, special masters

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How does this benefit Medicaid?

• More than to any other entity, CMS itself must
  recognize that their contribution to Education is
  medically necessary, purposeful, effective,
  efficient, and economical.