medical assistance program oversight council april 12, 2013

Medical Assistance Program Oversight CouncilApril 12, 2013

Today’s Agenda

Duals Demonstration Update

Pre-Existing Condition Plan (PCIP) Update

State Innovation Model (SIM) Update

Obstetrics P4P

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Duals Demonstration: Overview

Through the Demonstration, stakeholders and the

Department seek to create and reward innovative local

systems of care and supports that provide better value

over time by:

integrating medical, behavioral and non-medical services and supports

providing financial incentives to achieve identified health and client satisfaction outcomes

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Duals Demonstration: Overview (cont.)

Connecticut’s Demonstration will feature two models:

An enhanced Administrative Services Organization (ASO) model (Model 1)

A “health neighborhood” model (Model 2)

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Duals Demonstration: Key Structural Features

Enhanced Administrative Services Organization (ASO) Model

Under the Demonstration, the ASO will address the need for more coordination in providing services and supports, through such means as:

integration of Medicaid and Medicare data predictive modeling Intensive Care Management (ICM) electronic tools to enable communication and use of data

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Duals Demonstration: Key Structural Features (cont.)

Expansion of Person-Centered Medical Homes (PCMH) pilot to serve dual eligible individuals (“MMEs”)

Under the Demonstration, the Department will extend the enhanced reimbursement and performance payments to primary care practices that serve MMEs

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Duals Demonstration: Key Structural Features (cont.)

Procurement of 3-5 “Health Neighborhoods” (HNs)

HNs will reflect local systems of care and support and will be rewarded for providing better value over time

HNs will be comprised of a broad array of providers, including primary care and physician specialty practices, behavioral health providers, long-term services and supports providers, hospitals, nursing facilities, home health providers, and pharmacists

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Duals Demonstration: Past Activities

The Department submitted the final application to CMMI on May 31, 2012

Final submission reflected revisions related to feedback received during the thirty-day public comment period

Application is posted on Department’s web site:

http://www.ct.gov/dss/lib/dss/pdfs/mmedemo.pdf8

Duals Demonstration: Past Activities (cont.)

The Department mapped best practices associated with other integrated care initiatives and produced white papers on:

care coordinationstructure of provider networksperformance measures

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Duals Demonstration: Past Activities (cont.)

Further, the Complex Care Committee heard presentations from Connecticut stakeholders on existing models of care coordination (medical and behavioral health ASOs, Access Agencies, behavioral health partnerships), as well as coordination of providers across disciplines

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Duals Demonstration: Current Activities

The Department and its state agency partners (DMHAS, DDS) are in process of drafting an operations plan for the proposed “health neighborhoods,” three to five of which are expected to be procured by RFP in 2013

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Duals Demonstration: Current Activities (cont.)

CMS and DSS must determine the most appropriate legal authorities under which to operate the demonstration

CMS has forwarded questions regarding Connecticut’s application and DSS has drafted responses for review by the Complex Care Committee

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Duals Demonstration: Procedural Update

CMS recently issued additional guidance for implementation funding

Each of the 15 states that received planning grants is being asked to submit an additional application detailing plans for implementation activities

Connecticut will submit this April 1

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Duals Demonstration: Procedural Update (cont.)

Implementation funding will be based on a reserved pool of $95 million

Application instructions are available at this link:

http://apply07.grants.gov/apply/opportunities/instructions/oppCMS-1I1-13-001-cfda93.628-cidCMS-1I1-13-001-016200-instructions.pdf

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Duals Demonstration: Procedural Update (cont.)

Note that the Demonstration project is distinguishable from the “health home” project, planning for which is being led by the Department of Mental Health and Addiction Services (DMHAS)

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Comparison of Health Neighborhood and Health Home Models:

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Feature Health Neighborhood(3-5 to be procured)

Health Home(number to be determined)

Provider composition Broad range of medical, behavioral health, and long-term services and supports

Teams will be based at behavioral health care providers and will include staff with primary care expertise

Population served Minimum of 5,000 dually-eligible individuals

Smaller scale, targeted for individuals with Serious and Persistent Mental Illness (SPMI), both dually-eligible and single-eligible individuals

Care Coordination Multi-disciplinary care team, PMPM to support costs of care coordination and supplemental services

Health home care team, PMPM to support costs of care coordination

Today’s Agenda




Obstetrics P4P

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CT Pre-existing Condition Insurance Plan (PCIP) Enrollment Suspension

On February 15, 2013, CMS notified states that enrollment in all Pre-existing Condition Insurance Plans (PCIP) must be suspended.

PCIPs are part of a temporary program for those unable to access the current insurance marketplace. The program has a limited amount of funding from Congress.

CT Pre-existing Condition Insurance Plan (PCIP) Enrollment Suspension (cont.)

This suspension will help ensure that funds are available through 2013 to continuously cover people currently enrolled in PCIP.


Under the terms of state contracts, enrollment may be suspended as early as the date of the notice but no later than Saturday, March 2, 2013.

CT PCIP cannot accept new applications received after Thursday February 28, 2013. DSS is continuing to process applications received on or before that date.


Applicants who are receiving benefits under a federal/state PCIP in another state and who are relocating to Connecticut are exempt from this suspension and will be considered for enrollment.

There are no changes to benefit coverage or premiums at this time.

CT Pre-existing Condition Insurance Plan (PCIP) Participation

CT Pre-existing Condition Insurance Plan (PCIP) Top Ten Presenting Conditions

Rank Condition Enrollee Count

1 High blood pressure 206

2 Diabetes or disorder of endocrine system or glands 140

3 Nervous, mental, depression, stress, anxiety or eating-related disorder

112

4 Chest pain, heart attack or other heart condition 82

5 Cancer, tumor or lymph node enlargement 59

6 Other 52

7 Disorder of lungs or respiratory system 44

8 Lupus or arthritis 44

9 Condition or disease of circulatory system 35

10 Neurologic conditions (brain disorder, epilepsy) 33


The Charter Oak Health Plan remains an option through December 2013 for many who qualify for the CT PCIP.

People will be able to apply for health insurance coverage choices in health insurance marketplaces when open enrollment begins on October 1, 2013. Coverage begins on January 1, 2014. Visit www.healthcare.gov/marketplace to learn more from the federal government.


In Connecticut, Access Health CT is preparing the health insurance exchange/marketplace. Please visit www.accesshealthct.com for further information.

Today’s Agenda




Obstetrics P4P

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On February 22nd, Lieutenant Governor Wyman announced that Connecticut has received notice from the Centers for Medicare and Medicaid Innovation (CMMI) of an award of up to $2,852,335 to develop a State Health Care Innovation Plan.

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State Innovation Model (SIM) Update (cont.)

Connecticut will collaborate with public and private stakeholders to design a transformed health care delivery system that incorporates:

promotion of integrated care models use of the Health Insurance Exchange to inform and

connect consumers to coverage expanded supply of primary care physicians and

other professionals increased engagement among regulators, providers

and consumers

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State Innovation Model (SIM) Update (cont.)

The resulting payment and delivery system model will advance greater alignment across multiple payers on contracting and payment strategies that promote value over volume, greater consistency in quality and other performance metrics, and expanded primary care.

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Today’s Agenda




Obstetrics P4P

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improving early access to prenatal care, improving birth outcomes and reducing the incidence of premature births

reducing Neonatal Intensive Care Unit (NICU) admissions and lengths of stay

reducing the percentage of births by Caesarean Section

reducing Medicaid costs

Obstetrics Pay for Performance (P4P) - Program Objectives

Medicaid pays for 38% of all births to Connecticut women

35% of Medicaid covered births are by C-section

in 2010, Medicaid payment for each C-section (not counting post-partum care of the baby) was $4,325 higher than for vaginal births ($13,327 vs. $9,002).

Background

during the past 12 months:

• 1,798 babies were admitted to a NICU within 24 hours of birth

• these babies spent 17,149 total days in the NICU

• average NICU length of stay was 9.54 days per baby

• Medicaid paid a total of $28.8 million for all NICU days

Background (cont.)

The proposed obstetrics pay-for-performance program (P4P), is designed to reward obstetrics providers with bonuses for documentation of care resulting in the following outcomes:

timely completion of online OB notification forms

timely first OB visit after confirmation of pregnancy

timely postpartum visit after delivery

Brief Program Summary

full-term, vaginal delivery after spontaneous labor whenever medically possible

appropriate use of 17-alpha hydroxyprogesterone when there is prior history of preterm labor

Brief Program Summary (cont.)

Online OB Notification Form

Provides an efficient means for OB providers to identify and enroll members in:

OB Pay for Performance (P4P)

ASO Intensive Care Management for members who present with high risk pregnancies

Low Risk Perinatal Coaching for members who present with normal (low) risk pregnancies

OB Notification Form

Provider Demographic Information Planned Hospital for

delivery Perinatal Appointments Completed Member

Screenings Depression/Behavioral

Health Social Risk Medical Risk Pre Term Labor/Delivery

Risk

Member Demographic Information OB History Risk Indicators

Social Behavioral Medical

BMI (Body Mass Index)

Measure Points Source Details

1. Timely completion of online OB Notification forms

5 OB Notification Form To receive points, a practice must do both of the following. Submit:Prenatal form within 14 business days of first visitPostnatal form submitted within 14 business days of postpartum visit

2. First visit within 14 days of practice notification of a medically confirmed pregnancy (See Details)

25 OB notification Form Claims if not globally billed

Pregnancy Notification = OB Practice confirms pregnancy or Member calls the office with a confirmed pregnancy

3. A minimum of one postpartum visit within 21-56 days after delivery

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4. Full term, non-induced, vaginal delivery.

30 OB Notification Form Claims

Points are received if delivery meets all of the following criteria:(1) Vaginal; (2) Full term; (3) Not induced

5. Appropriate screening and use of 17-alpha- hydroxyprogesterone caproate:

OB Notification Form Claims

a. Member screened:Did not have an indication for use.

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b. Member screened:Has an indication for use and 17 P was used per ACOG guidelines

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c. Member with an indication for use per ACOG guidelines, and 17 P was not used.

Allocation: Divide the total pool of available funds by total points accrued over all practices. Each practice then receives their share of the pool, according to their total accrued points.

Proposed OBP4P-Model for Performance Payment - DRAFT

In relation to care for each client, an obstetrics care provider can accrue the following:

2013

an investment of $1.2 million has been proposed to fund P4P incentives

the P4P initiative will operate between July 1, 2013 and June 30, 2014

during this period, P4P data will be collected and analyzed

OB P4P Investment Analysis

Performance payments will relate to achievement of two goals:

Goal 1: reduction in rates of unnecessary Cesarean section (C-section)

Goal 2: reduction in newborn ICU (NICU) days following birth

OB P4P Investment Analysis (cont.)

Investment of $1.2 million OB P4P Payment assumes:

0.43% C-section rate reduction (22 averted C-sections)

4% of overall NICU cost reduction (decreased length of stay of 0.35 days)

OB P4P Investment Analysis (cont.)

Questions or comments?

medical assistance program oversight council april 12, 2013

Documents

connecticuts demonstration

behavioral health providers

primary care practices

home health providers

identified health

behavioral health asos

behavioral health partnerships

coordination of providers