Elizabeth Hecht Helen Hendrickson Managed Care and Care Coordination Ideas from the field Stephen Sulkes Strong Center for DD Rochester NY New York State People First Waiver Program ID: 1041439
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1. Stephen SulkesBarbara LeRoyElizabeth HechtHelen HendricksonManaged Care and Care Coordination: Ideas from the field
2. Stephen SulkesStrong Center for DDRochester, NYNew York State “People First” Waiver Program:Glacial Progress Toward a Managed Care Cliff
3. Setting the Scene in NY StateNY State Medicaid-$50 billion out of total State budget of $130 billion~$10 billion spent on DD populationNY Times Expose“Triple Aim”Better careBetter health outcomesReduced costs
4. Follow the Money…
5. Keep following the money…OVERALL MEDICAID UTILIZATION TRENDS for People with DD(SFY 05-06 v. SFY 09-10)METRICSFY 05-06SFY 09-10% CHANGE OVER 5 YEARSANN GROWTH RATEEXPENDITURE (State, local & Federal)$8,033,131,667$10,217,391,89827%6.2%MEMBER YEARS89,987100,51212%2.8%PER MEMBER PER YEAR (PMPY)$89,270$101,65314%3.3%
6. “People First” WaiverOverviewState’s Health Reform LandscapeParallel effort to MRT for DD population re health care delivery transformation: to provide integrated, coordinated & comprehensive services in a more efficient manner that improves outcomes of the population. 1915(b) and (c) Waiver (b): Authorize creation of managed care service delivery system for DD populations(c): Establish specific supports and services that will be providedImpacted population: all 95,000 persons with DD in New York
7. “People First” WaiverGoalsImproving access to services (“No Wrong Door”)Implementing a Uniform Needs Assessment. Implementing Care Management and Integrated Care Coordination. Establishing a Sustainable Fiscal Platform. The system would move from a fee-for-service to a capitated reimbursement system that pays for integration and coordination of care.Incorporating Robust Community Supports. Reducing Reliance on Institutional Settings. Enhancing Quality Assurance.
8. “People First” WaiverDISCOsDISCOs (Developmental Disabilities Individual Support and Care Coordination Organizations) = the core of OPWDD’s waiver proposal. essentially a managed care organization – will need Art. 44 licensureresponsible for developing and maintaining a network of providers, coordinating care of their members, ensuring quality standards are met, and serving as the fiscal intermediary (accepting capitated payments and paying contracted providers). partially- or fully-capitated Under either model, eventually the only excluded services remaining in Fee-For-Service would be school supported health, early intervention, and certain residential services (OPWDD ICF/DD-DC/SRU).private or public not-for-profit entities care coordination experienceCultural competence Regions
9. “People First” WaiverCapitationNeed to demonstrate an ability to manage risk. Will cover Medicaid services, including care coordination and the person’s individualized budget under the self-direction option. Rates will account for that DISCO’s member acuity level. DOH = rate setting authority, working with OPWDD.
10. DISCO Premium!Historical claim experienceCare coordination/management cost savings,Administrative costsRisk retention(possibly) Quality withholds Intrastate variationsGeographic regionMedicare statusHCBS waiver statusResidential settingIndividual age
11. Show me the data!200920102011People891969017690219PMPM RangeDay Hab$558-909$585-969$642-999Res Hab$1354-2227$1413-2318$1395-2240ICF/DD$375-1663$412-1765$360-1647Total$3282-6161$3450-6465$3453-6321Avg Per year:$39K – 74K$41K – 76K$41K – 76K
12. Assessment Tool: interRAIComponents:interRAI IDCommunity Health AssessmentCommunity Mental Health Self-Reported Quality of LifeToolPalliative Care ToolIncludes:Current functional infoHealth infoPersonal Preferences
13. Evaluation Tool: CQL POMSCouncil on Quality Leadership “Personal Outcome Measures®”Emphasis on Individual, rather than System
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15. Family and individual support, integration and community habilitation, flexible goods and services, Home and Community-based clinical and behavioral supports Adult Day Health Care / Assisted Living Facility / ICF-DD Clinic Social Worker Day Treatment Dentistry DME and Hearing AIDS Home Care (Nursing, Home Health Aide, PT, OT, SP, Medical Social Services) Non Emergency Transportation Nutrition OASAS Inpatient OMH Institutional Program (PC/RTF) & private psychiatric hospitalizations Optometry/Eyeglasses OT, PT, SLP (in any venue) Personal Care Personal Emergency Response System Podiatry Psychotherapy Respiratory Therapy Skilled Nursing Facility / Specialty HospitalBenefits: Partial Capitation
16. Benefits: Full CapitationAll services required in partially capitated rate PLUS:Chronic Renal DialysisEmergency TransportationInpatient Hospital Services (excluding private LT psychiatrichospitalizations)Laboratories ServicesOutpatient Hospital and Freestanding Clinic Services not identified in partially capitated ratePharmacyPhysician Services including services provided in an office setting, clinic, facility, or in the home.Radiology and Radioisotope ServicesRural Health Clinic Services
17. Rochester UCEDD RoleOnly UCEDD/only physician on State Planning CommitteeOrganized regional response in collaboration with Finger Lakes Health Systems Agency and Golisano Foundation“Fair broker”Coordinated local Request for Information writing teamExplain elements of managed careConsultation to DISCOs
18. Ongoing Rochester UCEDD Health Disparities EffortSpecial Olympics/Golisano Foundation Healthy CommunitiesDental Task ForceObesity EffortsAADMDHospital discharge planning/readmission prevention effortEducation across Medical CenterPhysician TrainingAccountable Care OrganizationHealth & Employment efforts
19. The Michigan ModelIntegrated Care for People who are Medicare-Medicaid Enrollees
20. BackgroundDefinition: Organized and coordinated service delivery for individuals who are dually eligible for both Medicare and Medicaid services and supports.Contract required between CMS, State, ICOs, and local service providers26 States eligible for the Demonstrations9 States have signed MOUs (10/2013): MA, IL, OH, NY, WA, CA, VA, MN, SCMichigan: in MOU negotiations (July 2014 start)
21. MOU ComponentsAssessment & Care Coordination PlanBenefit designProvider Network/CapacityFinancing and Payment modelImplementation strategyQuality and performance metricsEnrollment processEnrollee protections and appeals
22. Michigan Model GoalsSeamless service deliveryReduced fragmentationReduced barriers to HCBSImproved qualityStreamlined administrationCost effectiveMichigan Integrated Healthcare Pilot Regions
23. Michigan’s Guiding PrinciplesPerson centeredSelf-determinationArray of services appropriate to needsAccessible network of providersHigh quality supports and servicesInformation available and coordinatedPerformance monitoring
24. Michigan Key Components207,000 eligible participants (75% of DD population)4 region pilot (25 counties; n=102,000)ICOs will cover physical health, pharmacy, DME, and LTCPIHPs will cover behavioral health, substance abuse, and community supports & services (I/DD)New CMS Waiver(s) requiredCare bridge will integrate work of ICOs/PIHPsPassive enrollment w/ monthly opt-out option
25. Michigan Key Components (con’t)Statewide information dissemination & marketingState level Advisory CouncilEnrollee participation on governing boardsIntegrated care ombudsman
26. Michigan IC Advocacy Network MembersSocial JusticeAIDD Network PartnersDisability Advocacy OrganizationsTHE MICHIGAN OLMSTEAD COALITIONWorking to Make Community-Based Long Term Care Available To All Who NeedAging CoalitionSelf AdvocatesLabor Unions
27. Michigan IC Advocacy Network ActivitiesWeekly meetingsMonitor plan, negotiations, & implementationSit on work groupsTestify at hearingsWrite briefs on issuesProvide waiver development oversightSupport self-advocates in seeking Advisory rolesInform constituents (email, blog, tweets, calls)
28. Major Advocacy IssuesChoicePerson Centered Planning and CareEnrollment SafeguardsFull Array of Services and Supports Grievance, Appeals, and Rights ProcessesCitizen OversightIndependent EvaluationSavings Reinvestment
29. UCEDD OpportunitiesAdvocacySit on work groups to structure State model & waiver(s)Advisory/Oversight committeesTraining for ICOs, Providers, Benefit Participants, FamiliesStudent internships – teaching and monitoringMaterials Development and DisseminationEvaluationTechnical assistance to recipients/families
30. Points of Contact within StatesMedicaid Administration OfficeDD Services AdministrationMI Services AdministrationOffice of AgingDepartmental Advisory GroupsAdvocacy CoalitionsLegislative Liaisons
31. Waisman Center UCEDD-ACA Involvement-AUCD November 18, 2013Elizabeth HechtOutreach Specialist for Public Policyhecht@waisman.wisc.edu608-263-7148
32. Opportunity to strengthen a dimension of our involvement in health Health disparities for people with I/DDHealth disparities and public health data systemsMedical Home training and Learning CollaborativeSpecialty clinicsQuality improvement initiativesMajor systems change effort in stateWhy we became involved in ACA32
33. Governor declined federal planning grants Governor delayed discussion until after supreme court decision and 2012 electionSept 2012-WI declined to chose an EHB planNovember 2012- Governor defers to Federal ExchangeFebruary 2013- Medicaid expansion rejected, 78,000 will loose Medicaid September 2013- State certification for navigators requiredWisconsin Approach to ACA33
34. WI Access Network- A diverse coalition of patient advocate, consumer, provider and insurer-based organizations to learn together and create a more unified voice to achieve common goals of expanding access to affordable, quality health care in WI.Meet bi-monthly-share information, presentations on aspects of ACA, meet with CMS.Initial focus on Exchanges and EHBAUCD Health Reform HubInformation and technical assistance Staying informed34
35. CORE FUNCTION-Community Education Q&A on the ACA for people with disabilities with Survival Coalition http://www.survivalcoalitionwi.org/wp-content/uploads/2012/10/ACA-QA.pdfWaisman Center Policy Seminar on ACA and People with Disability with Connie GarnerWebinar on EHB 101 with speakers from Georgetown, Catalyst Center and WI - Office of the Commissioner of Insurance (OCI)WI - UCEDD Activities35
36. Pre-service education LEND-issue group on ACATechnical AssistanceSupport to CYSHCN Network on ACA OCI issues guidance on habilitation based on paper written by Waisman and DRW (P&A)Identify and convene disability strategy group Collaborate with Division of Public Health to draft and administer family survey on ACA Join regional enrollment networkWI - UCEDD Activities, con’t36
37. UCEDD Policy Seminar 37
38. UCEDD Webinar38
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40. Shift focus to support individuals and families to maintain and utilize coverageMonitor emerging issues Changes in employer coverageChanges in current plans and premiumsContinue to build relationship with policy-makersContinue to work with coalitions representing disability perspectiveThe Future 40
41. Duals in MassachusettsA Perspective on ImplementationHelen M. HendricksonE.K. Shriver Center MassachusettsEunice Kennedy Shriver Center
42. One of 15 states awarded a contract from CMS for a state demonstration to integrate care for dual eligible individualsEnrollment began on October 1st, 2013Three Health ICOs managing care: Commonwealth Care Alliance, Fallon Total Care, and Network Health.Three-pronged approach to education and outreach, including:General public awarenessTargeted outreach to key subpopulationsLearning collaborative for ICO staff and providers42
43. Initial Training Topics Introduction to One CareContemporary Models of Disability (Independent Living, The Recovery Model, Self-Determination)Enrollee Rights and ProtectionsADA ComplianceIntroduction to Cultural CompetencyTraining Modalities43
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45. www. Mass.gov/MassHealth/OneCare/Learning45
46. EventDateLive Event AttestedIntro to One Care5/23/1395443Models of Disability6/13/1369132Enrollee Rights9/26/138984 (live only)ADA Compliance10/17/1379100 (live only)Cultural Competency11/14/13NANA46Initial Webinar Statistics
47. 47Webinar Satisfaction Survey Results
48. Shared Learning One Care Conference October 23, 2011Survey Respondent Totals (Average Scores)(96 Total Evaluations – Raw data is available)Plenary: a paradigm change in disability healthcare: what was and what we hope will beScore (1= Unsatisfactory; 5= Excellent) - Robin Callahan, MA, Burton D. Pusch, RhD & Judith Steinberg, MD, MPH 1. Please evaluate the OVERALL quality of this CEU/CME session.4.27 2. How well did the presentation describe the goals and vision for the One Care Initiative?4.43 3. How useful was the discussion of the implications of the term “paradigm shift” for care of people with disabilities?4.36 4. How effective were the presenters?4.43 48In Person Conference October 23, 2013
49. Best practices in delivery of LTSS and other services to maximize independent livingBehavioral Health IntegrationCoordination of care within the provider networkManagement of depression and alcohol abuseHealth promotion and preventative care49Future Training Topics
50. Stephen SulkesBarbara LeRoyElizabeth HechtHelen HendricksonManaged Care and Care Coordination: Ideas from the fieldQUESTIONS?