Barrier Brainstorm by LDI Publications https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66 Use the + icon to add the reasons why many of these policy recommendations have not been implemented. en-us 2024-07-16 17:04:15 UTC 2024-07-23 19:41:47 UTC hello@padlet.com https://padlet.net/icons/png/1f4cd.png Timing https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946440 Loooooong investment of time and energy before states are likely to see results.

]]> 2024-07-22 18:48:19 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946440 Brokers https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946471 Brokers have misaligned incentives with consumers

]]> 2024-07-22 18:48:25 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946471 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946477 State bandwidth expertise and data infrastructure

]]> 2024-07-22 18:48:27 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946477 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946615 Political entrenchment in states keeping program carve outs in place that degrades value of integrated or aligned care

]]> 2024-07-22 18:48:55 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946615 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946624 Federal statutory constraints

]]> 2024-07-22 18:48:58 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946624 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946625 variability in state resources and expertise in managed care (Medicare and MLTSS) and managing contracts with plans (eg, SMACS)




]]> 2024-07-22 18:48:59 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946625 Competing priorities and funding needs at state level. https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946626 2024-07-22 18:48:59 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946626 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946633 Lack of dedicated resources for states

]]> 2024-07-22 18:49:01 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946633 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946636 In part because people are not knowledgeable enough to know that it’s needed.

]]> 2024-07-22 18:49:02 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946636 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946672 Lack of state staff resources to implement and pursue significant change without assured/improved outcomes.

]]> 2024-07-22 18:49:11 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946672 Medicare program rigidity https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946687 2024-07-22 18:49:15 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946687 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946707 Lack of up front capital and complexity of negotiating shared savings models with the highly risk averse folks who represent Medicare

]]> 2024-07-22 18:49:19 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946707 SDOH / Partisanism https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946708 Technology (Internet access)

Transportation

Literacy / Education

Politics

Extensive wait lists

Bandwidth of staff

]]> 2024-07-22 18:49:19 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946708 Need to balance choice and complexity https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946712 2024-07-22 18:49:19 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946712 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946728 Most of it take multiple years, yet most health leaders - especially in states - turn over faster than that.

]]> 2024-07-22 18:49:23 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946728 Savvy marketplace undercuts integrated plans with nonintegrated but attractive options to consumers https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946796 2024-07-22 18:49:45 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946796 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946821 We need to keep in mind that people make decisions that are immediately gratifying, and the benefits of integration aren’t necessarily immediate.

]]> 2024-07-22 18:49:51 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946821 Medicare freedom of choice (not bc choice isn’t important but it’s resulted in so many plans and complexity) https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946849 2024-07-22 18:49:58 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946849 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946850 Challenges with managed care plans infrastructure to fully integrate

]]> 2024-07-22 18:49:58 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946850 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946853 dynamic Medicare environment, for beneficiaries, providers, health systems, plans

]]> 2024-07-22 18:49:59 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946853 Follow the money https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946863 There are powerful players in the system who don’t want change(eg nursing homes, brokers). And they block progress

]]> 2024-07-22 18:50:03 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946863 Market dominance of large national plans https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946917 2024-07-22 18:50:17 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946917 Medicare Politics https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946945 With all the focus on states it is easy to forget (although the state folks reminded us) that there is a tremendous amount of $$$$$ to be made in poorly integrated or non-integrated plans and achieving integration is dependent upon states standing in front of the gravy train with a big sign that says “no gravy for you.”

]]> 2024-07-22 18:50:21 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946945 Potential Barrier https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946948 To the extent that proposals increase federal and state funding, securing legislative support (or federal offsets should PAYGO rules apply) may be challenging

]]> 2024-07-22 18:50:22 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946948 Siloed P&Ls https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946951 Even in fully aligned models, many health plans aren’t actually integrated

]]> 2024-07-22 18:50:22 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946951 Lack of expertise and effective models of Geriatrics and display team Kaehr and limited influence by clinicians on the model of care implemented by plans for achieving integration. The role of positions is often relegated to utilization management and not clinical leadership. https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946958 2024-07-22 18:50:24 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946958 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946992 Crowd out of these issues by matters that are stratifying higher on state radar screens (BH, maternal health, HRSN work)

]]> 2024-07-22 18:50:31 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058946992 Conflicts of interests and external influence on policy priorities https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947003 2024-07-22 18:50:33 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947003 Lack of plan penalties at federal level; should require them to share savings/rebates with states or to reinvest them back into the communities they made the money off of https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947011 2024-07-22 18:50:35 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947011 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947110 Competing priorities for resources post pandemic in Medicaid space

]]> 2024-07-22 18:50:50 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947110 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947183 Two fundamentally different programs with different reporting structures, payment, bid processes, etc. Regulatory environment does not efficiently allow for integration

]]> 2024-07-22 18:51:09 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947183 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947229 Lack of incentives for states to prioritize a focus here. To do this well takes more resource and understanding than most states have

]]> 2024-07-22 18:51:19 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947229 Provider shortages in rural areas/certain specialities aren’t solved by integrated models https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947233 2024-07-22 18:51:22 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947233 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947293 Despite great work by CMMI to outline how to access it, lack of uptake and use of Medicare data by states

]]> 2024-07-22 18:51:38 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947293 Some states won’t have stakeholder support for full integration / seen as threat to longstanding programs valued by Bh and/or disability communities https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947494 2024-07-22 18:52:13 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947494 Concept of integration is often not explained or operationalized in a way that communicates value to the end user https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947495 2024-07-22 18:52:13 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947495 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947505 Financial integration doesn’t solve beneficiary experience of care

]]> 2024-07-22 18:52:15 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947505 Primacy of payer. Absent a blended dollar it is near impossible to align incentives at a person level. https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947511 2024-07-22 18:52:16 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947511 Need for more focus on outcomes https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947522 If financial incentives aren’t enough, maybe it’s because we have the wrong incentives. Why can’t we hold feet to the fire on keeping people in the community, high satisfaction, and other outcomes?

]]> 2024-07-22 18:52:19 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947522 Death of chevron https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947559 Will CMS have the ability to regulate anymore? What regs will die? Likely this will lead to more disintegration

]]> 2024-07-22 18:52:24 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947559 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947626 Heterogeneous nature of the population and fragmentation in state and local government for delivery of important services

]]> 2024-07-22 18:52:39 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947626 Lack of compliance options for states to enforce state requirements in integrated models https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947650 2024-07-22 18:52:47 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947650 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947732 Inequities in state HCBs design and instituí bias could be eliminated with standardized Medicare LTSS packages but financial impact too big for trust fund

]]> 2024-07-22 18:52:52 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947732 Hospitals https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947774 They are still the locus of energy and money. They have zero incentive to work on integration.

]]> 2024-07-22 18:53:04 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947774 We’ve decided that integration is best for dual eligible people, but they don’t necessarily agree. We have a real messaging problem. https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947795 2024-07-22 18:53:10 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947795 Siloed downstream entities - integration is bifurcated at local level https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947798 2024-07-22 18:53:10 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947798 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947951 Inertia/satisfaction with the way things are

lack of understanding among providers

Misunderstanding among recipients

Payment rates

Difficulty in assessing savings and the inability to attribute them to specific actions, policies or providers

Difficulty in convincing health providers to engage with MLTSS


]]> 2024-07-22 18:53:15 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947951 Federal rules https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947952 The ACA requirements to demonstrate savings for MMP demonstrations and CBO scoring guidelines can sometimes stymie progress

]]> 2024-07-22 18:53:15 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058947952 https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058948099 Duals and their choices do not exist in a vacuum… they can and do consistently opt out

]]> 2024-07-22 18:53:54 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3058948099 Data https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3059765266 We need data to drive the process including, data on
where the money goes

quality of services


]]> 2024-07-23 17:59:21 UTC https://padlet.com/PennLDIConvening/jhppt5m3mewsfx66/wish/3059765266