Bottom Line: Payers are implementing more value-based care programs specifically for intellectual and development disabilities (I/DD), including autism spectrum disorder. We expect there to be at least 20 states to have mandated a percentage of value-based care for I/DD in Medicaid by the end of 2023. With the right integrated care model in place and collection of data, providers should be able to improve their reimbursement and build successful partnerships with payers.

The I/DD population is very complex and requires ongoing care management over the long-term, which can take its toll on state budgets and payers outside of Medicaid if not coordinated appropriately.  For many years, the I/DD system of care has been fraught with unsustainable costs, lack of coordination and inconsistent services. Making matters worse, the fee for service reimbursement system did not encourage or promote efficient and high-quality care. The result was high utilization services that were expensive and not producing consistent care.

Medicaid annual spending for individuals with I/DD in home and community-based services (HCBS) waivers usually account for approximately 75% of all spending and average between $42,000 to $50,000 per enrollee.

Over the last several years, managed care plans have been slowly addressing this patient population, integrating physical and behavioral healthcare (“whole person care”) and have been creating programs with providers for I/DD services. Instead of care that is normally siloed and managed by separate systems of services, provider groups and payers are teaming up to provide more comprehensive and coordinated care. This usually includes, pharmacy, long-term supports, and home community-based services, along with physical and behavioral healthcare. The goal is reducing unnecessary acute care setting services and providing better care to the I/DD population.  

Integrated care models are still developing for I/DD, but payers are taking things a step further by rolling out plans specially tailored for I/DD. These plans are in a few states currently with North Carolina expected to roll out an I/DD plan in December 2022 with services starting on January 1, 2023.  The plan is designed for individuals with significant behavioral health needs and I/DD. It’s expected the NC plan will also serve other special populations, including traumatic brain injury waivers, and the state’s other non-Medicaid behavioral health and developmental disabilities and the uninsured populations with TBI.

Provider organizations involved in I/DD care need to be ready for the organizational, technological, and care management changes that will need to be in place to conduct business with payers. Providers should expect to collect data on services provided, create performance and quality metrics, and prepare different models of payment for value to partner and contract with payers. If set up effectively, payers are looking for the right partners to help manage the I/DD population.

Contact David Blaszczak for questions or comments about this week’s article.