1 / 16

Integrated Financing and Managed Care for Special Populations

Integrated Financing and Managed Care for Special Populations . John Baackes NYSACRA Conference November 2012. Dual Eligible beneficiaries comprise 20% of the Medicare population and 15% of the Medicaid population. Dual Eligible 9 million. Medicare 37 million. Medicaid 51 million.

zarek
Download Presentation

Integrated Financing and Managed Care for Special Populations

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Integrated Financing and Managed Care for Special Populations John Baackes NYSACRA Conference November 2012

  2. Dual Eligible beneficiaries comprise 20% of the Medicare population and 15% of the Medicaid population Dual Eligible 9 million Medicare 37 million Medicaid 51 million Total Medicare beneficiaries: 46 million Total Medicaid beneficiaries: 60 million SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey 2008, and Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY2008 MSIS and CMS Form-64.

  3. Dual Eligible Beneficiaries Account for Disproportionate Shares of Medicare and Medicaid Spending Dual Eligibles as a Share of the Medicare Population and Medicare FFS Spending Dual Eligibles as a Share of the Medicaid Population and Medicaid Spending Total Medicaid Population, 2007: 58 Million Total Medicaid Spending, 2007:$311 Billion Total Medicare Population, 2006:43 Million Total Medicare FFS Spending, 2006:$299 Billion NOTES: FFS is fee-for-service. Excludes Medicare Advantage enrollees’ spending and Medicare prescription drug spending. SOURCES: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost and Use File, 2006, and Urban Institute estimates based on data from the 2007 MSIS and CMS Form-64, “The Role of Medicare for the People Dually Eligible for Medicare and Medicaid,” January 2011.

  4. They are called Special Needs Plans for a reason NOTE:  Mental impairments were defined as Alzheimer’s disease, dementia, depression, bipolar, schizophrenia, or mental retardation.  SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey, 2008

  5. How does a Medicare Plan serve dual eligibles? • A dual eligible currently receives their benefits through • Medicare Part A (hospital and Part B (Doctors) • Medicare Part D for prescription drugs • Medicaid for home health, long term care, dental, vision and other benefits not covered by Medicare • The MMA of 2003 provided for Special Needs Plans SNP to serve dual eligibles and other groupings • A Dual SNP (D SNP) combines Medicare Parts A, B and D in a single plan • Medicaid benefits remain Fee For Service • A Fully Integrated Dual SNP (FIDESNP) combines Medicare Parts A, B D and Medicaid into a single plan • IN NYS this is a Medicaid Advantage Plus (MAPS) plan

  6. Two plan types for dual eligibles

  7. History of managed Care in NYS for disadvantaged populations • Medicaid Managed Care in NYS for 20 years mandatory enrollment of mainstream Medicaid – TANF • Medicare has offered beneficiaries managed care options since the 1980s • CMS has sponsored demonstrations of integration of financing and care management for special populations of Medicare and Medicaid beneficiaries in a series of demonstrations for over 20 years.

  8. Existing programs • PACE started as a demonstration and became a standard regulated option in 1997 • MMA of 2003 created Medicare Special Needs Plans (SNP) for • Dual • Chronic conditions • Institutional • PPACA created an Office of Integration and an Office of Innovation • Both dedicated to integrating financing and care of dual eligibles in risk bearing managed care entities • NYS OPWDD has announced a Medicaid only demo for 2013 • DISCOs • Three fully integrated demonstrations planned as well

  9. Integrated vsNon integrated Managed Care options in NYS

  10. Integration and Managed Care Integration • Dual eligible beneficiaries have three benefit plans • Medicare A and B • Medicaid • Medicare D • Integrated financing means a single non government entity has pooled all three sources and takes financial risk for the benefits of all three plans Managed Care • CMS and NYS DOH license Managed Care Organizations on several criteria • Contracted network of providers who accept payment in full from plan except for specified copays if any. • Financial solvency – meets insurance company standards • Has a Model of Care and policies and procedures for measuring outcomes

  11. Care Management key to caring for Dual Eligible beneficiaries • In both the D SNP and FIDESNP the plan takes full financial risk • Both plan types require a strong care management process based on an integrated Model of Care approved by CMS • The best performing plans use a high touch model with a team headed by an RN Care Manager as the patient’s advocate and supplemented by community based support staff to address the non medical needs of the dual patient

  12. Model of Care Elements Prescribed by CMS for Special Needs PlansWhere DD considerations can be addressed • Description of target population – DD descriptor • Measurable goals - Tailored to DD including habilitation • Staff Structure and Care Management Goals – include habilitation • Interdisciplinary Care Team – include social workers • Provider network having specialized expertise and use of clinical practice guidelines – DD providers not in most networks • Model of Care Training for Personnel and Provider Network – emphasize habilitation • Health Risk Assessment – include environmental risks of poverty • Individualized Care Plan –include mitigation of poverty risks • Communication Network- care givers and employers • Care management for most vulnerable subpopulations – All DD • Performance and Health Outcome Measurement – include habilitation

  13. Care Management is a team effort Primary Care Physician (PCP) partners with the Nurse Care Manager (NCM)to form a real Medical Home to address the patients needs Each member has a Nurse Care Manager (NCM) who acts as the patients advocate and leads a team that works with the PCP, other providers and family care givers Community Service Coordinators are part of the team and assist members in non-medical needs like transportation safe housing, access to food, security, etc

  14. Data collection critical to financial stability

  15. Key elements for a Managed Care plan to serve Dual Eligibles • Managing and building a network • Can be tailored to population being served • Having a Model of Care • This is what will distinguish your organization • Having a Care Team for each member that knows and manages all Medicare and Medicaid benefits • This includes compliance • Having a system of controls on finances • You must be current on expenses and revenue optimization • Having a system to measure outcomes • Using finding to constantly improve care

  16. My lessons learned in the field • The most common diagnosis is poverty • MOC must address limited resources in all aspects of members life that will impact medical care and costs. • Care Management is another form of behavior modification • Bad habits interfacing with medical system based on Medicaid limitations • Transitions of Care are major events • Member transfers must be managed in detail • Caregiver involvement is critical • More objective than member

More Related