MassHealth Capitated Managed Care

1. MassHealth Capitated Managed Care Integrating Medicare and Medicaid for Dual Eligibles Consumer Advocates Meeting September 20th, 2010

2. Today’s Discussion • Goals: • Address prior meeting questions regarding MassHealth managed care products, covered services, care coordination, etc. • Discuss implications for integrated care for younger duals

3. Where the <65 Duals Strategy fits in the Patrick Administration Health Care Priorities • Increase Access • Improve access to primary care* • Maintain universal coverage • Decrease costs for consumers • Address non-financial barriers* • Improve Quality • Improve patient safety • Improve care management & care transitions* • Eliminate disparities* • Improve patient centered end of life care • Reduce Costs • Encourage and promote integrated financing* • Transition from FFS towards global payments* • Implement Health Information Technology* * Integrating Medicare and Medicaid for Dual Eligibles

4. EOHHS Health Care Improvement Initiatives: Progress since we last met • Integrated Systems of Coordinated Care • PCMHI procurement to be completed in early October • Completed federal Medicare PCMH proposal • Statewide Payment Reform for All Payers • Health Care Reform Cross-Secretariat Implementation Workgroup formed; website established; quarterly public meetings begin tomorrow • Behavioral Health Access Improvement • Focus groups for MassHealth Behavioral Health procurement completed • Long Term Support Services Access Improvement Strategies • Direct care core competencies / training grant approved; awaiting funding level; two additional workforce development grants submitted • Two care transition / ADRC grants submitted • Money Follows the Person planning grant submitted • Health Information Technology Improvement Efforts

5. Design Elements for Integrated <65 Duals Plan • Patient Centered • Care Integration/Coordination • Single Entity Accountability • Financial Integration • Improved Health Information Technology • Administrative Simplicity

6. A View of the Proposed Integrated Care Model: A Work in Progress

7. Managed Care Overview • MassHealth members under age 65 who: • Do not have other insurance (including Medicare) • Are not in a facility for a long-term stay Must enroll in one of the following plans: • MassHealth Managed Care Organization (MMCOs); currently approx 440,000 members • The state-managed Primary Care Clinician Plan (PCC Plan); currently approx 320,000 members • MassHealth members age 55/65 or older have two plan options: • Senior Care Organization (SCO); currently approximately 15,000 members • Program of All-inclusive Care for the Elderly (PACE); currently approximately 2,500 members

8. Primary Care Clinician Plan (PCC Plan) • The PCC Plan provides services statewide and is the MassHealth administered managed care plan that: • Provides medical and pharmacy coverage through a network of MassHealth contracted providers • Contracts with a managed behavioral health vendor (currently MBHP) that also provides some network management support services to the PCC Plan

9. MMCOs Boston Medical Center HealthNet Plan (BMCHP) Operates statewide with the exception of Nantucket and Martha’s Vineyard Fallon Community Health Plan(FCHP) Operates in Central MA only Health New England (HNE) Operates in Western MA only Neighborhood Health Plan (NHP) Operates statewide Network Health (NH) Operates statewide with limited coverage in Western MA: available in Springfield, Holyoke and Westfield SCOs Commonwealth Care Alliance Operates in Essex, Hampden, Middlesex, Norfolk, Plymouth and Suffolk Counties Evercare Operates in Bristol, Essex, Hampden, Middlesex, Norfolk, Plymouth, Suffolk, and Worcester counties NaviCare (Fallon Community Health Plan) Operates in Worcester County Senior Whole Health Operates in Bristol, Essex, Middlesex, Norfolk, Plymouth, Suffolk, and Worcester Counties Capitated Managed Care MassHealth currently contracts with the following organizations (PACE programs excluded)

10. MMCOs Provide a full spectrum of services including: Primary Care and other preventative services Acute – Inpatient/Outpatient Services Behavioral Health Services Pharmacy Other Ancillary Services (Labs, DME, Emergency Transportation, etc.) The following services are coordinated by the MMCOs, but paid on a fee-for-service by MassHealth (aka wrap services) PCA Continuous Skilled Nursing Long Term Care Services Non-emergency transportation Vision Dental SCOs Provide all MassHealth and Medicare covered services: Primary Care and other preventative services Acute – Inpatient/Outpatient Services Behavioral Health Services Pharmacy Other Ancillary Services (Labs, DME, Emergency Transportation etc. ) PCA Continuous Skilled Nursing Nursing Facility Services Non-emergency transportation Vision Dental Home and Community Based Services What services are covered?

11. MMCOs and SCOs: Manage all covered behavioral health services and promote access to services Identify behavioral health needs through screening tools and refer members to specialty behavioral health services as needed Ensure members with serious and persistent mental illnesses have access to ongoing medication review and monitoring, day treatment, and alternatives to conventional therapy; qualified behavioral health clinician must be part of the primary care team and care is coordinated with the Department of Mental Health Coordinate with primary care providers including services ranging from acute inpatient treatment to intermittent professional and supportive care for members residing in the community Coordinate diversionary services Evaluate prescriptions for any psychotropic medications for interactions with medications already prescribed for the member How are behavioral health services managed?

12. What additional benefits are provided? • Free car seats, bike helmets, and other safety equipment (MMCO) • Reimbursement for childbirth classes (MMCO) • Discounts at facilities that provide early education and child care (MMCO) • Gift cards and other member incentives for getting certain health screenings and immunizations (MMCO) • Free over-the-counter medications (MMCO) • Fitness benefits, gym memberships and weight loss programs (MMCO) • 24/7 access to a Nurse Case Manager who has immediate access to the member’s medical record, has the experience to provide clinical triage, and is able to provide options other than waiting until business hours or going to the emergency room (SCO) MMCOs and SCOs are able to provide additional (plan specific) benefits i.e.:

13. How are the provider networks managed? MMCOs and SCOs are required to maintain a provider network that ensures adequate access to the full range of covered services and ensures that the network: • Is appropriately credentialed and has accessible locations to provide covered services • Is responsive to the linguistic, cultural, and other needs of members served, including the capacity to communicate with populations in languages other than English, as well as with members who are deaf, hard-of-hearing, or blind • Includes providers, where applicable, with specific expertise in treating children, adolescents, people with disabilities, elders, people with HIV, and homeless persons • SCOs must, additionally, contract with the Aging Services Access Points (ASAPS) in their service areas; SCOs generally purchase home and community based services (e.g. personal care, homemaker, chore) through ASAP provider network • SCO networks may include “alternative” providers such as massage therapists and acupuncturists as well as vendors such as exterminators

14. Are there health promotion, wellness, and disease management services? Examples of programs developed by MMCOs and SCOs: • Wellness Programs • Culturally and linguistically appropriate health education materials provide member specific and population specific information on the availability of care, and the importance of self-care and early intervention to managing health conditions • SCOs provide a range of health promotion and wellness activities focused on the specific needs of elders (e.g. falls prevention, adjustment to changes in functional ability, adjustment to changes in life roles, smoking, coping with Alzheimer’s Disease) • Health Promotion Programs • Maternal and Child Health • Well-Child/Adolescent Care, Prenatal and Postpartum Care • Chronic diseases/conditions including but not limited to: • Asthma; CHF, Diabetes, Hypertension • Cancer (Breast, Cervical, Prostate, Colorectal) • Serious and Persistent Mental illness Depression; Substance Use Disorders • HIV/AIDS • Targeted services/programs for members with complex health care needs

15. What care coordination and care management services are provided? MMCOs and SCOs are required to: • Maintain a Care Management structure capable of meeting a wide range of member needs across the care continuum • Perform initial/ongoing assessments: • evaluation of clinical, functional and nutritional status and physical well being • medical history • screenings for mental-health status, and tobacco, alcohol and drug use • long term care service needs, including the availability of informal supports • Develop individual care plans tailored to each member’s unique needs • Ensure that care coordination and services include the other individuals identified by the member as involved in providing care and/or assistance to the member (family members/caregivers), primary care, specialty providers, state agencies, schools, etc. • Ensure timely/coordinated access to all medically necessary covered services • Coordinate with staff in other state agencies or community service organizations that are involved in meeting the member’s needs • Provide information and referral services

16. MMCOs: members with multiple, long-term health conditions with elevated risk of complications and significant impairment to independent daily living have a dedicated Care Management Coordinator to help develop/implement an individualized care plan, coordinate services across health care providers and provider settings including members’ homes, direct a multidisciplinary team approach to addressing physical health, behavioral health, long term supports, and social needs SCOs: a Primary Care Team is created for each member who is identified - through the initial assessment - as having complex care needs; the PCT, which is responsible for developing an individualized plan of care for each member, is: the member, her/his designee the PCP, a nurse practitioner, a registered nurse, or physician's assistant, (experienced in geriatric practice), a geriatric social worker and any other specialist depending upon the member’s need (e.g. behavioral health provider) How are members with complex health care needs met? Members with complex care needs receive appropriate clinical care and support services to optimize functioning, minimize the burden of illness, and enhance life experience within the community

17. Are there quality management andperformance standards for MMCOs? MMCOs are required to deliver quality care that enables members to stay healthy, get better, and manage chronic illnesses or disabilities • Member-centric quality of care measurement domains are implemented to ensure that members have access to: • Integrated and appropriate physical and BH services focused on prevention and safety, early intervention, recovery, resiliency and rehabilitation • Adequate access and availability to primary and specialty health care providers and services • Evidence based protocols of care • Continuity and coordination of care across care settings • Culturally competent health care delivery systems

18. Are there quality management andperformance standards for MMCOs? Components used to measure and assess clinical/quality outcomes are: • MassHealth MCO Quality Improvement Goals – five priority areas • Asthma • Behavioral Health • Care Management • Diabetes • Maternal and Child Health • HEDIS Indicators (Asthma, Diabetes, Perinatal/Well Child CHF, BH) • Health Disparities Collaborative • Member Satisfaction Survey • Independent External Quality Review of MCO performance (CMS requirement) • Health Outcomes for at-risk sub groups (members with disabilities and those with complex health care needs) • Quality Management Overview of Utilization Management Activities

19. Are there quality management andperformance standards for SCOs? SCOs’ Clinical Measurement and Quality Initiatives: Components used to measure and assess clinical/quality outcomes are: • HEDIS Indicators (Colorectal Cancer Screening, COPD, High BP) • Clinical Indicator Data (Preventative Medicine, Acute and Chronic Disease, etc) • Complaints and Appeals • Independent External Quality Review of SCO performance (CMS requirement) All SCOs must have and comply with protocols surrounding the following initiatives: • Reduce Preventable Hospitalizations • Discharge Planning Initiative • Preventative Immunizations • Screening for Early Identification of Cancer • Disease Management • Management of Dementia • Appropriate Nursing Facility Institutionalization • Alcohol Abuse Prevention and Treatment Initiative • Abuse and Neglect Identification Initiative

20. What is the future direction for quality measurement? • Use member outcomes data to more effectively monitor and manage Contractors • Continue to identify and implement robust clinical/quality measures for members with complex health care needs • Engage members and key stakeholders (internal and external) in the feedback/review loop and incorporate such feedback in program design, outcomes measurement, and ongoing monitoring activities

21. Discussion • Questions • Lessons learned from MMCOs and SCOs • Design elements to replicate • Quality/performance measures

22. Next Steps • CMS Discussions • Center for Medicare and Medicaid Innovation (CMI), January 1, 2011 • Test payment and service delivery models for effect on expenditures and quality of care • Selection of models to be tested • Allowing States to test and evaluate fully integrated care for dual eligible individuals in the State, including the management and oversight of all funds under Medicare and Medicaid • 9/23/10 - present basic concepts of the service delivery and financing models and establish a process for developing terms of an agreement • Request for Information Target Release Date by October 31, 2010 • Collect a broad spectrum of stakeholder input on a range of issues i.e. • Service delivery model design, financing, benefit structure, capacity, quality measures • Identify potential bidders

23. Next Steps • Establish Consumer Input Process and Vehicles • Medicare and Medicaid Date Analysis • Integrated data base • Analytical plan to include • Characteristics of Younger Dual Eligibles • Utilization and spending information for Medicare and Medicaid • Care Integration Opportunities i.e. transitions, nursing facility stays, avoidable hospitalizations and ED visits, behavioral health services, community and long term support services • Finalize timeline with target enrollment beginning September 2011 • Next Consumer Advocates Meeting planned for Thursday, December 16th from 3-5PM