Presentation Transcript

1. FEASIBILITY OF CARE COORDINATION FOR DUAL ELIGIBLES

   THE PACIFIC HEALTH POLICY GROUP DECEMBER 2013
2. CHARACTERISTICS OF DUAL ELIGIBLES Eligible for both Medicaid and Medicare Disabled and/or age 65 and older, AND Have low incomes and limited financial resources High rates of complex and chronic physical and mental health conditions 67% have a chronic health condition; 31% have three or more conditions 47% percent have a mental health condition; increases to 70% for members with five or more chronic physical conditions Account for disproportionate share of spending in both programs PHPG – Care Coordination for Duals
3. CHARACTERISTICS OF DUAL ELIGIBLES cont’d Share of Medicare and Medicaid Enrollment and Expenditures for Oklahoma’s Dual Eligibles PHPG – Care Coordination for Duals
4. CHARACTERISTICS OF DUAL ELIGIBLES cont’d Medicare is the primary payer Covers most of the costs of services provided under both programs (e.g., hospital, physician, pharmacy) Medicaid covers mostly long-term care Includes most nursing facility costs and home- and community-based services (HCBS) PHPG – Care Coordination for Duals
5. CHARACTERISTICS OF DUAL ELIGIBLES cont’d Distribution of Medicare and Medicaid Expenditures for Dual Eligibles by Service Type PHPG – Care Coordination for Duals
6. OPPORTUNITIES FOR COORDINATION AND INTEGRATION Service delivery for dual eligibles is often fragmented Example: Judy has a Medicaid primary care physician; a Medicare primary care physician; receives home health aide services through a Medicaid HCBS waiver; and gets her prescription drugs through a Medicare Part D plan. Medicare and Medicaid are responsible for different services for dual eligibles, but even rules governing similar services vary Example: Short-term skilled nursing facility care under Medicare vs. long-term nursing facility stays under Medicaid PHPG – Care Coordination for Duals
7. OPPORTUNITIES FOR COORDINATION AND INTEGRATION cont’d Financial incentives to shift costs and lack of incentives to coordinate care Example: Medicaid programs do not stand to reap significant savings from reducing hospitalizations for dual eligibles, as these services are covered mostly by Medicare. The same is true in reverse for Medicare and appropriate utilization of long-term care services. PHPG – Care Coordination for Duals
8. HEALTH CARE NEEDS Health care needs of dual eligibles vary Acute and chronic; physical and mental; can be met in the community or require institutionalization Five distinct populations based on need: Nursing facility residents HCBS waiver participants Intellectually/developmentally disabled (I/DD) Includes both members receiving care in an intermediate care facility for the intellectually/developmentally disabled (ICF-DD) or through HCBS waiver Other chronically ill members Healthy seniors Frail elderly and physically disabled adults who require long-term care PHPG – Care Coordination for Duals
9. HEALTH CARE NEEDS cont’d Distribution of Medicaid and Medicare Expenditures for Dual Eligibles by Population PHPG – Care Coordination for Duals
10. HEALTH CARE NEEDS cont’d Distribution of Medicaid and Medicare Expenditures for Dual Eligibles: Nursing Facility Residents PHPG – Care Coordination for Duals
11. HEALTH CARE NEEDS cont’d Distribution of Medicaid and Medicare Expenditures for Dual Eligibles: ADvantage HCBS Waiver Participants PHPG – Care Coordination for Duals
12. HEALTH CARE NEEDS cont’d Distribution of Medicaid and Medicare Expenditures for Dual Eligibles: I/DD Population PHPG – Care Coordination for Duals
13. HEALTH CARE NEEDS cont’d Distribution of Medicaid and Medicare Expenditures for Dual Eligibles: Other Chronically Ill Members PHPG – Care Coordination for Duals
14. HEALTH CARE NEEDS cont’d Distribution of Medicaid and Medicare Expenditures for Dual Eligibles: Healthy Seniors PHPG – Care Coordination for Duals
15. HEALTH CARE NEEDS cont’d Distribution of Medicaid and Medicare Expenditures for Dual Eligibles: Summary of Populations PHPG – Care Coordination for Duals
16. CARE COORDINATION IN OKLAHOMA Existing Programs SoonerCare currently has programs for members with chronic conditions (both duals and non-duals) similar to those offered by private MCOs, for example: PHPG – Care Coordination for Duals
17. CARE COORDINATION IN OKLAHOMA cont’d Planned Initiatives Oklahoma is developing multiple care coordination models for dual eligibles through the federal demonstration grant opportunities to integrate care and align financing between Medicare and Medicaid States have two broad options: Managed fee-for-service (MFFS) Capitated To address financial disincentives to coordinate care, CMS will share demonstrated Medicare savings with states Oklahoma is pursuing several models: MFFS - Health Homes MFFS – SoonerCare Silver Capitated – Integrated Care Sites (ICS) PHPG – Care Coordination for Duals
18. CARE COORDINATION IN OKLAHOMA cont’d Planned Initiatives Health Homes – MFFS Partnership between SMHA and DMHSAS for management of members with mental health needs Nurse care manager coordinates care with a team of providers, including community mental health center staff Enhanced 90 percent federal matching rate available SoonerCare Silver – MFFS Care coordinator will serve as “bridge” between Medicare and Medicaid programs and providers Interdisciplinary care team will develop and implement a member-specific care plan PHPG – Care Coordination for Duals
19. CARE COORDINATION IN OKLAHOMA cont’d Planned Initiatives Integrated Care Sites (ICS) – Capitated Member receives care at single site, overseen by an interdisciplinary care team, including member, physician, nurse, and social worker Provider receives blended capitation rate from Medicare and Medicaid Flexibility for provider to provide services not covered by Medicare or Medicaid, including nurse practitioner services Member does not have to require nursing facility level of care, but must have two or more complex and chronic conditions, including functional limitations PHPG – Care Coordination for Duals
20. MEDICARE MANAGED CARE IN OKLAHOMA Background Medicare Part C program created in 1997; became known as Medicare Advantage (MA) in 2003 Under Part C, Medicare recipients can voluntarily enroll in an MA plan with a private MCO for their Medicare benefits, if available National enrollment in MA plans increased 10% in the past year, up 30% in the past three years Three types of plans: closed network MCO (also known as health maintenance organization [HMO]), preferred provider organization (PPO), and private fee-for-service (PPFS) PHPG – Care Coordination for Duals
21. MEDICARE MANAGED CARE IN OKLAHOMA cont’d Background Special Needs Plans (SNPs) – MA plans open only to certain types of Medicare recipients Dual eligibles D-SNP – May include only small subset of Medicaid services FIDE-SNP – Created by Affordable Care Act (ACA); integrates delivery and financing of most Medicaid services, including long-term care; only available in seven states Certain chronic conditions (C-SNP) Institutionalized recipients (I-SNP) PHPG – Care Coordination for Duals
22. MEDICARE MANAGED CARE IN OKLAHOMA cont’d Background Special Needs Plans (SNPs)cont’d Most popular is regular D-SNP Medicare Payment Advisory Committee (MedPAC) advised Congress in March 2013 to permanently reauthorize FIDE-SNPs and I-SNPs and let authorization expire for all other SNPS, excluding some C-SNPs (those for enrollees with HIV/AIDS, ESRD, chronic/disabling mental condition) PHPG – Care Coordination for Duals
23. MEDICARE MANAGED CARE IN OKLAHOMA cont’d Oklahoma Market Nationally, 29% of Medicare recipients are enrolled in an MA plan; only 16% in Oklahoma. 12 MCOs (nine national, three local) currently have MA enrollees in Oklahoma, though none have enrollment statewide PHPG – Care Coordination for Duals
24. MEDICARE MANAGED CARE IN OKLAHOMA cont’d Oklahoma Market cont’d PHPG – Care Coordination for Duals
25. MEDICARE MANAGED CARE IN OKLAHOMA cont’d Oklahoma Market cont’d Closed network MCO plans are dominant in urban areas (Tulsa, OKC), where 24% of Medicare recipients are enrolled in an MA plan PPO plans consistently enroll approximately 4,000 to 6,000 across all regions Enrollees in PFFS plans live almost exclusively in rural areas PHPG – Care Coordination for Duals
26. MEDICARE MANAGED CARE IN OKLAHOMA cont’d Oklahoma Market cont’d Rates Rates paid to MA plans are calculated based on the experience of Medicare recipients enrolled in traditional (i.e., fee-for-service), or “benchmarks” Include a competitive bid component Risk adjusted based on acuity Based on risk scores, plans could receive around 50% higher payments per dual eligible compared to non-duals Based on recently published benchmarks, urban Medicare recipients in Oklahoma can be slightly higher cost ($814) on the whole than rural recipients ($794); though recipients in mixed counties are higher cost ($850) than urban recipients PHPG – Care Coordination for Duals
27. MEDICARE MANAGED CARE IN OKLAHOMA cont’d Oklahoma Market cont’d Benefits Vary from plan to plan, county to county In general closed network MCOs have lower monthly premiums than PPOs, but have more restrictive requirements relating to provider networks and referrals Value-added benefits offered by plans not available in traditional Medicare include preventive dental services (e.g., annual cleanings) or vision-related benefits (e.g., glasses). PHPG – Care Coordination for Duals
28. MEDICARE MANAGED CARE IN OKLAHOMA cont’d Oklahoma Market cont’d Provider Networks MA plans are subject to federal provider network adequacy requirements, e.g., minimum number of providers/facilities and maximum travel time/distance Most national plans in Oklahoma have agreements with a number of several Centers of Excellence (COEs), as summarized below: Note: Four MA MCOs do not have any agreements with COEs: Ardent, Cherokee Nation, OKC Clinic, Wellpoint PHPG – Care Coordination for Duals
29. MEDICARE MANAGED CARE IN OKLAHOMA cont’d Oklahoma Market cont’d MCOs with MA plans in Oklahoma are participating in care coordination initiatives in other states Federal duals alignment demonstrations SNPs Chronic care management Medicaid managed long-term care PHPG – Care Coordination for Duals
30. OTHER STATES’ MODELS Historically, Medicaid managed care models have excluded dual eligibles Medicare and Medicaid share payment responsibility MCO experience with providing long-term care is limited compared to acute care experience National trends Federal demonstrations to integrate service delivery and financing for dual eligibles between Medicare and Medicaid Many states are enrolling dual eligibles in managed care (usually but exclusively through MCOs) Many states also are beginning to enroll LTC recipients PHPG – Care Coordination for Duals
31. OTHER STATES’ MODELS cont’d Federal Duals Alignment Demonstrations Three-year demonstration CMS will share demonstrated Medicare savings with states Originally 39 states were interested in pursuing a demonstration; however, only eight states’ demonstrations currently are approved PHPG – Care Coordination for Duals
32. OTHER STATES’ MODELS cont’d Federal Duals Alignment Demonstrations cont’d Most states pursuing capitated models with MCOs Most have chosen to implement statewide Most states have carved-out and/or delayed implementation for the I/DD population (e.g., New Mexico) Implementation has taken two to three years Percent savings increase over the three-year demonstration period, generally increasing from 1% in the first year to 4%-5% in year three Some states are requiring MCOs to engage with community and specialized providers to ensure access to care (e.g., CA, MA, OH) PHPG – Care Coordination for Duals
33. OTHER STATES’ MODELS cont’d Federal Duals Alignment Demonstrations cont’d Managed fee-for-service (MFFS) Primary model being pursued by Oklahoma Washington is only state with approved demonstration pursuing MFFS model, using health home model Can be used in conjunction with federal Health Home initiative to reduce state costs for care coordination services/start up Coordination services can be provided by state staff, providers, or third party contractor Seeks to adopt managed care principles while building on existing programs and/or community-based infrastructure PHPG – Care Coordination for Duals
34. OTHER STATES’ MODELS cont’d Managed Care for Duals 24 states enroll duals in Medicaid managed care 39 states have duals enrolled in D-SNPs 21 states contract with Medicare SNPs 7 states offer FIDE-SNPs States have encouraged enrollment by requiring MA plans to offer SNPs in each county they serve States have required plans to engage with community and specialized providers in specific ways to ensure access to care (e.g., CA, MA, OH) PHPG – Care Coordination for Duals
35. OTHER STATES’ MODELS cont’d Managed Long-Term Care Only 8 states had MLTC programs 10 years ago; 16 states have such programs today; and that number is expected to grow to 26 by 2014 State contracts with MCO to coordinate and provide, at a minimum, long-term care services to Medicaid beneficiaries Capitated payments to MCOs can include: Only Medicaid long-term care services All Medicaid services, including long-term care All Medicare and Medicaid services PHPG – Care Coordination for Duals
36. OTHER STATES’ MODELS cont’d Managed Long-Term Care cont’d Out of the 16 states with MLTC programs: Most states: Enroll both aged and disabled beneficiaries (12) Do not include the I/DD population (10) Do not fully integrate with Medicare (11) Two states require Medicaid plains to offer D-SNPs and coordinate with Medicare; four states require coordination only; and four states have no requirements States are split on: Requiring enrollees to need institutional level of care Making enrollment mandatory vs. voluntary Implementing program statewide vs. only certain region(s) Including all Medicaid services or excluding major service types PHPG – Care Coordination for Duals
37. Medicaid Managed Long-Term Care Programs PHPG – Care Coordination for Duals
38. OPTIONS/CONSIDERATIONS Two key decision points: What populations, i.e., “enrollment groups,” should be targeted? Under what model should care coordination be implemented? PHPG – Care Coordination for Duals
39. OPTIONS/CONSIDERATIONS cont’d Enrollment Groups LTC Responsible for most of Medicaid’s spending on dual eligibles, therefore greatest opportunity for fiscal impact Approximately10% of population is Medicaid-only I/DD Service needs often non-medical Services often provided by small, non-profit providers MCOs lack expertise providing these services Only small number of states have elected to include this population; some states have taken “middle road” by enrolling this population in MCOs for acute care services only Approximately 37% of I/DD population is Medicaid-only May be beneficial to enroll last, if included PHPG – Care Coordination for Duals
40. OPTIONS/CONSIDERATIONS cont’d Enrollment Groups cont’d Other (chronically ill and healthy seniors) Majority of dual eligibles Every state that has enrolled the LTC population has enrolled this population – opportunity to forestall needs for LTC Do not have to be served under same model Should emphasize integration, as most Medicaid payments are for cost sharing, transportation, and mental health PHPG – Care Coordination for Duals
41. OPTIONS/CONSIDERATIONS cont’d Potential Models Option 1: Implement MCO/Capitated Model Most states have elected this option, both for LTC and acute-only populations Leverage expertise of national organizations Evidence-based practices Well-defined care management systems Plans have exited markets if profitability targets are not met PHPG – Care Coordination for Duals
42. OPTIONS/CONSIDERATIONS cont’d Potential Models cont’d Option 1: Implement MCO/Capitated Model cont’d Platform for integration of Medicare and Medicaid Can encourage or require plans to have MA contracts – members can enroll in the same plan for both Medicare and Medicaid benefits Option will require new federal authority (up to 12 months), and plans will need advance notice from the State, as plans can only submit applications to become MA plans in a given county once per year Potential changes at federal level should be considered, e.g., potential expiration of SNP authorization Fiscal/budget predictability PHPG – Care Coordination for Duals
43. OPTIONS/CONSIDERATIONS cont’d Potential Models cont’d Option 1: Implement MCO/Capitated Model cont’d Fiscal/budget predictability State can better predict and limit its expenditures by placing MCOs at risk Funding must cover MCOs’ administrative expenses and profits (average of 11.6% in recent survey, compared to 5.5% for Oklahoma Medicaid) Other considerations: In first year, State will be paying capitation and claims “run out,” therefore increasing payments in the short-term Savings from MCOs should not be demanded during the first two years to give MCOs the opportunity to achieve savings through “rebalancing,” which will occur over the first 24 to 36 months (encourage with financial incentives) Artificially low capitation rates in year one and/or two will cause reduction in services to members and/or payments to providers PHPG – Care Coordination for Duals
44. OPTIONS/CONSIDERATIONS cont’d Potential Models cont’d Option 2: Expand Existing Community-Based Programs and Infrastructure Can be achieved through expansion of the initiatives already underway Example: Under SoonerCare Silver, State could replicate PACE/ICS in additional locations and in conjunction with care management from OHCA Direct contracts with provider and care management organizations under MFFS, risk-sharing, or full risk arrangements PHPG – Care Coordination for Duals
45. OPTIONS/CONSIDERATIONS cont’d Potential Models cont’d Option 2: Expand Existing Community-Based Programs and Infrastructure cont’d Advantages: Lower administrative expenses State retains savings for reinvestment or reduction of general fund needs More provider choice Faster program expansion, especially in rural areas Greater potential for targeting high-cost members Greater flexibility to implement and replicate successful innovations PHPG – Care Coordination for Duals
46. OPTIONS/CONSIDERATIONS cont’d Potential Models cont’d Option 2: Expand Existing Community-Based Programs and Infrastructure cont’d Disadvantages: Less spending certainty – disadvantage could dissipate over time, depending on MCO demands for rate increases should profits not meet expectations Full integration with Medicare is more difficult – disadvantage could be overcome through alternative model where State receives capitation payments from CMS for all Medicare/Medicaid services (e.g., as proposed by Vermont) PHPG – Care Coordination for Duals
47. OPTIONS/CONSIDERATIONS cont’d Other Considerations Mixed model Oklahoma is not limited to choosing one approach to the exclusion of the other Can vary approach by population Establish realistic timeframes Steps can include: legislation, waiver submission/negotiation, procurement (if using MCOs), and readiness activities Florida: legislation passage to enrollment start – 27 months Kansas: program design to enrollment start – 24 months New Mexico: program design to enrollment start – 33 months PHPG – Care Coordination for Duals
48. OPTIONS/CONSIDERATIONS cont’d Other Considerations cont’d Emphasize person-centered care management Comprehensive assessments of need (regardless of payer) Rigorous care planning and monitoring of services Reduce fragmentation of care, including through establishment of single system for: dual eligibles and LTC (including Medicaid-only LTC) Define appropriate role for doctors (center of care team) Create opportunities for nursing facilities Converting bed space to new uses: respite, adult day Offering financial incentives for identification and transition of residents back to the community (share in savings) PHPG – Care Coordination for Duals
49. OPTIONS/CONSIDERATIONS cont’d Potential Savings Average utilization/expenditures for CY 2011 and 2012 were trended forward by population for the five-year period 2015 to 2019 Assumed nursing facility bed capacity would grow in proportion to program enrollment PHPG developed “high” and “low” scenarios Low – LTC system would rebalance from current level to 60% HCBS; overall utilization/expenditures would be reduced by 10% due to service delivery reform High – LTC system would rebalance to levels since in the Arizona program, i.e., 70 % HCBS:;overall utilization/expenditures would be reduced by 10% due to service delivery reform PHPG – Care Coordination for Duals
50. OPTIONS/CONSIDERATIONS cont’d Potential Savings cont’d Savings due to rebalancing are achieved over the long term PHPG – Care Coordination for Duals
51. OPTIONS/CONSIDERATIONS cont’d Potential Savings cont’d Summary of potential savings (2015-2019) PHPG – Care Coordination for Duals
52. CONCLUSION Oklahoma has multiple feasible pathways to increase care coordination for dual eligibles Care coordination has potential to “rebalance” services over time – will yield both savings to the State and better outcomes/quality of life for members, especially LTC recipients Decision making process should emphasize inclusion of all major stakeholders Expectations should be realistic regarding time for implementation and sustainable savings PHPG – Care Coordination for Duals