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MassHealth Senior Care Options. Diane Flanders, Director, Coordinated Care Systems MA Division of Medical Assistance. Background. High rates of nursing facility utilization and expenditures Primary, acute, long term care systems “generous” but fragmented
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MassHealth Senior Care Options Diane Flanders, Director, Coordinated Care Systems MA Division of Medical Assistance
Background • High rates of nursing facility utilization and expenditures • Primary, acute, long term care systems “generous” but fragmented • Need for coordination and accountability in care of high-risk population • Desire for integration between Medicare and Medicaid (MassHealth) • Strong provider interest
Program of All-inclusive Care for the Elderly: PACE • Series of federal legislative acts,beginning in 1987, to replicate OnLok • Originally Medicare and Medicaid waivers – now transitioning to provider status per BBA • Nursing home eligible enrollees • Adult day health model • Large interdisciplinary team
PACE: Medicare-Medicaid “Laboratory” • 6 Massachusetts PACE contracts developed since 1990 • 10 PACE centers served 1450 enrollees in 2002 • Transitioned demonstration PACE organizations to provider status effective November 1, 2003 per BBA requirements
PACE Has Done Well in Massachusetts • Performance measurement documents excellent results in preventable hospitalizations and long term nursing facility placement • Continuous quality management studies show performance above national benchmarks for diabetes and CHF care • Comparison with fee-for-service populations – no contest!
Complexities and Realities • Prescriptive, complex PACE structure (e.g. PACE interdisciplinary team, center, etc) • Potential enrollees’ resistance to changing doctors and entering the day care model • BBA regulations burdensome • Population limited to NF eligibles in the community • Aging industry unenthusiastic
Moving to Senior Care Options • Important lessons from PACE (state-federal interface, MIS, CQI, etc.) • Will serve populations PACE does not - community well & nursing facility residents • Rates vary reflecting levels of need & settings of care • Emphasis on home services • Keeping/choosing own PCP • Potential for statewide service areas
SCO Rate Development • Linked Medicare-Medicaid data • Six rating categories established for Medicaid per common utilization & cost groupings, with financial incentives to encourage community based care • Three rating categories negotiated with CMS and OMB per M+C and risk-frailty adjustors • Actuarially sound rates from historical data, trended and certified by Mercer.
SCO History Highlights • 1997: Initial waiver request to CMS • 1998: Addendum to CMS • 1999: Medicare Rate Agreement • 2000: DMA-CMS MOU • 2001: State Legislative Task Force • 2002: State Legislative Authorization • 2003: SCO Procurement
Key Components of Senior Care Options • Provider networks known as Senior Care Organizations (SCOs) • Medicare & Medicaid capitation payments-multiple rating categories • Incorporation of AAAs into model • Care management by PCP/PCT • Voluntary enrollment • Consumer sign-off on care plan • Aggressive quality management based on geriatric model of care
Benefits to MassHealth Seniors • Expert geriatric care from own doctor with the support of a PCT • Full spectrum of care from wellness to end-of-life • Support and education for families and caregivers • 24/7 access for help with health issues • “Peace of mind” as wishes are honored and carried out
SCO Time Lines • Jan 2, 2003 SCO RFR issued • Jan 23,2003 Responders Conf. • Mar 20,2003 Responses due • June 16, 2003 SCOs recommended • Sept 8-12, 03 Onsite reviews • November 2003 Contract(s) • December 2003 SCO enrollment begins