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Family Care is a long-term care program for
Expenditures and Services
Family Care expanded from
5 to 53 counties during the five-year
period we reviewed, and
program expenditures increased
More than 90 percent of program
expenditures have been payments
to MCOs that reflect the capitation
rates they are paid for each enrolled
Participants’ care needs vary widely,
as do the services they receive. In
Nearly 60 percent of program
participants receive care in their
own homes. Most others receive
residential services in small,
community-based facilities or adult
family homes. Residential services
DHS is planning to establish uniform residential rates for participants with similar needs within and across counties. However, the proposed residential rate-setting methodology has become controversial, and the ability or willingness of residential care providers to accept the rates DHS has proposed is not clear.
MCOs’ administrative expenditures
for salaries, supplies and services,
and rent and facilities costs more
than tripled during the period we
reviewed and were
Costs per Participant
Most of the
The number of developmentally disabled participants with high-cost needs grew significantly during the period we reviewed. MCOs contend that the capitation payments they receive to fund care for these participants are insufficient. DHS has made some rate adjustments, but disputes will likely continue.
DHS and the Office of the Commissioner of Insurance have identified three MCOs whose ongoing negative net assets and reserve fund shortages place them at greater risk for insolvency: Care Wisconsin First, Inc., Community Health Partnership, Inc., and NorthernBridges.
DHS established corrective action plans with Community Health Partnership and NorthernBridges late in 2010, and shortly before the publication of our report we were informed that Community Health Partnership would also be subject to a heightened level of monitoring.
A "functional screen" assessment
tool is used to evaluate participants’
eligibility for Family Care services.
We compared the results of all
30,425 functional screen assessments
MCOs are required to annually reassess participants’ eligibility. We did not find patterns to suggest that MCOs were systematically decreasing participants’ level of care in order to limit their own costs.
MCO care management staff complete comprehensive health and social assessments every six months and work with participants and their families to develop a plan of care to meet desired health and social outcomes. We reviewed the most recent assessments and care plans for a random sample of 50 participants and found that comprehensive assessments had been completed as frequently as required in all but three cases. All but two care plans had also been updated appropriately.
Quality of Care
As required by federal law, DHS
contracts for annual reviews of each
MCO’s compliance with federal and
state program rules. In
DHS did not formally evaluate the personal outcomes of Family Care participants while the new system was being developed and tested. However, more than 80 percent of participants surveyed by the MCOs expressed satisfaction with Family Care in 2009.
Our findings indicate the program has improved access to long-term care, ensured thorough care planning, and provided choices tailored to participants’ individual needs. However, we could not definitively determine its cost-effectiveness, in part because the type and quality of services available under Family Care may be prompting enrollment by some individuals who would otherwise not seek public assistance.
Given the program’s increasing enrollment and costs, substantial public interest in long-term care services, and the increased authority that DHS may be granted to promulgate administrative rules governing programs funded by Medical Assistance, the future of Family Care is likely to be debated in the current legislative session.
To assist the Legislature in framing its debate, we have provided a series of questions related to sustainability, rate-setting, long-term care strategies, and the provision of acute care services in a managed care model. We also include a series of recommendations to improve program administration and ensure the Legislature is in a position to assess the effects of any program changes DHS may put in place in the near future.
We recommend that DHS report
to the Joint Legislative Audit
We also recommend that DHS
report to the Joint Legislative Audit