State as Integrating Entity for Dual Eligibles

1. State as Integrating Entity for Dual Eligibles June 3, 2010 Melanie Bella Center for Health Care Strategies

2. Presentation Overview • Benefits of the State as an Integrating Entity to: • Beneficiaries • Providers (acute and long-term care)/Plans • Federal government • Critical Components for Stakeholders • Administrative/Operational protocols • Financing arrangements • Beneficiary protections

3. State as Integrated Entity • Allows state to act as administrator of Medicare/Medicaid clinical care delivery and coordinate payment, coverage and benefits for duals. • Complete blending of funds • More potential savings can accrue to state • State can reinvest savings to better coordinate care • Flexibility to provide state-specific options • Increased accountability to improve care • Should provide more uniform, integrated set of rules for plans to follow

4. Core Elements of Integrated Care Models Integrated care models arrange for all Medicaid and Medicare services (including long-term supports and services). Core elements include: • Comprehensive assessment to determine needs, including screening for cognitive impairment/dementia; • Personalized (person-centered) plan of care, including a flexible range of benefits; • Multidisciplinary care team that puts the individual beneficiary at the center; • Involvement of the family caregiver, including an assessment of needs and competency; • Comprehensive provider network, including strong primary care base; • Strong home- and community-based service options, including personal care services; • Adequate consumer protections, including ombudsperson; • Robust data-sharing and communications system; and • Aligned financial incentives

5. Benefits of Integration • Creates a single point of accountability for the delivery, coordination and management of primary/preventive, acute, behavioral, and long-term care supports and services • Promotes and measures improvements in health outcomes • Promotes the use of home and community based long term- care supports and services • Uses performance incentives to providers to improve coordination of care • Blends and aligns Medicare and Medicaid’s services and financing to streamline care and eliminate cost shifting • Slows the rate of both Medicare and Medicaid cost growth

6. Critical Components for Stakeholders • Administrative/Operational • Enrollment • Medicare-Medicaid policy alignment • Contracting options: managed care, PCCM, county alternatives • Financing Arrangements • Level of risk (including stop loss/risk corridors) • Gain sharing • Discouraging adverse selection • Beneficiary & Provider Issues • Choice • Consumer protections (PACE has “Participant Bill of Rights”) • Network overlap • Payment levels • Credentialing (including LTSS providers)

7. Ultimate Goals • Develop organized, person-centered delivery systems in collaboration with stakeholders • Ensure systems are integrated and provide the full range of medical AND non-medical services Medi-Cal’s dual eligibles need • Leverage existing infrastructure and geographic variation

8. Questions? 8