Stephen Sulkes

Barbara LeRoy

Elizabeth Hecht

Helen Hendrickson

Managed Care and Care Coordination: Ideas from the field

Stephen SulkesStrong Center for DDRochester, NY

New York State “People First” Waiver Program:

Glacial Progress Toward a Managed Care Cliff

*Setting the Scene in NY State

*NY State Medicaid-$50 billion out of total State budget of $130 billion

*~$10 billion spent on DD population

*NY Times Expose

*“Triple Aim”

*Better care

*Better health outcomes

*Reduced costs

*Follow the Money…

*Keep following the money…

OVERALL MEDICAID UTILIZATION TRENDS for People with DD

(SFY 05-06 v. SFY 09-10)

METRIC SFY 05-06 SFY 09-10% CHANGE

OVER 5 YEARS

ANN GROWTH

RATE

EXPENDITURE (State, local & Federal) $8,033,131,667 $10,217,391,898 27% 6.2%

MEMBER YEARS 89,987 100,512 12% 2.8%

PER MEMBER PER YEAR (PMPY) $89,270 $101,653 14% 3.3%

*“People First” WaiverOverview

*State’s Health Reform Landscape

*Parallel 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 provided

*Impacted population: all 95,000 persons with DD in New York

*“People First” WaiverGoals

*Improving 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.

*“People First” Waiver

DISCOs

*DISCOs (Developmental Disabilities Individual Support and Care Coordination Organizations) = the core of OPWDD’s waiver proposal.

*essentially a managed care organization – will need Art. 44 licensure

*responsible 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 experience

*Cultural competence

*Regions

*“People First” WaiverCapitation

*Need 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.

*DISCO Premium!

*Historical claim experience

*Care coordination/management cost savings,

*Administrative costs

*Risk retention

*(possibly) Quality withholds

*Intrastate variations

*Geographic region

*Medicare status

*HCBS waiver status

*Residential setting

*Individual age

*Show me the data!

2009 2010 2011

People 89196 90176 90219

PMPM Range

Day Hab $558-909 $585-969 $642-999

Res Hab $1354-2227

$1413-2318 $1395-2240

ICF/DD $375-1663 $412-1765 $360-1647

Total $3282-6161

$3450-6465 $3453-6321

Avg Per year: $39K – 74K $41K – 76K $41K – 76K

*Assessment Tool: interRAI

*Components:

*interRAI ID

*Community Health Assessment

*Community Mental Health

*Self-Reported Quality of LifeTool

*Palliative Care Tool

*Includes:

*Current functional info

*Health info

*Personal Preferences

*Evaluation Tool: CQL POMS

*Council on Quality Leadership “Personal Outcome Measures®”

*Emphasis on Individual, rather than System

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 Hospital

*Benefits: Partial Capitation

*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 

*Rochester UCEDD Role

*Only UCEDD/only physician on State Planning Committee

*Organized regional response in collaboration with Finger Lakes Health Systems Agency and Golisano Foundation

*“Fair broker”

*Coordinated local Request for Information writing team

*Explain elements of managed care

*Consultation to DISCOs

*Ongoing Rochester UCEDD Health

Disparities Effort

*Special Olympics/Golisano Foundation Healthy Communities

*Dental Task Force

*Obesity Efforts

*AADMD

*Hospital discharge planning/readmission prevention effort

*Education across Medical Center

*Physician Training

*Accountable Care Organization

*Health & Employment efforts

THE MICHIGAN MODEL

Integrated Care for People who are Medicare-Medicaid Enrollees

Background

Definition: 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 providers

26 States eligible for the Demonstrations

9 States have signed MOUs (10/2013): MA, IL, OH, NY, WA, CA, VA, MN, SC

Michigan: in MOU negotiations (July 2014 start)

MOU Components

Assessment & Care Coordination PlanBenefit designProvider Network/CapacityFinancing and Payment modelImplementation strategyQuality and performance metricsEnrollment processEnrollee protections and appeals

Michigan Model Goals

Seamless service delivery

Reduced fragmentation Reduced barriers to

HCBS Improved quality Streamlined

administration Cost effective

Michigan Integrated Healthcare Pilot Regions

Michigan’s Guiding Principles

Person centeredSelf-determinationArray of services appropriate to needsAccessible network of providersHigh quality supports and servicesInformation available and coordinatedPerformance monitoring

Michigan Key Components

207,000 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

Michigan Key Components (con’t)

Statewide information dissemination & marketing

State level Advisory CouncilEnrollee participation on governing boardsIntegrated care ombudsman

Michigan IC Advocacy Network Members

Social JusticeAIDD Network Partners

Disability Advocacy Organizations

THE MICHIGAN OLMSTEAD COALITION

Working to Make Community-Based Long Term Care Available To All Who

Need Aging Coalition

Self Advocates

Labor Unions

Michigan IC Advocacy Network Activities

Weekly meetingsMonitor plan, negotiations, & implementationSit on work groupsTestify at hearings

Write briefs on issuesProvide waiver development oversightSupport self-advocates in seeking Advisory rolesInform constituents (email, blog, tweets, calls)

Major Advocacy Issues

ChoicePerson Centered Planning

and CareEnrollment SafeguardsFull Array of Services and

Supports Grievance, Appeals, and

Rights ProcessesCitizen OversightIndependent EvaluationSavings Reinvestment

UCEDD Opportunities

Advocacy

Sit on work groups to structure State model & waiver(s)

Advisory/Oversight committees

Training for ICOs, Providers, Benefit Participants, Families

Student internships – teaching and monitoring

Materials Development and Dissemination

Evaluation

Technical assistance to recipients/families

Points of Contact within States

Medicaid Administration Office

DD Services Administration

MI Services Administration

Office of AgingDepartmental Advisory

GroupsAdvocacy CoalitionsLegislative Liaisons

Waisman Center UCEDD-ACA Involvement-

AUCD November 18, 2013Elizabeth HechtOutreach Specialist for Public Policyhecht@waisman.wisc.edu608-263-7148

Opportunity to strengthen a dimension of our involvement in health

Health disparities for people with I/DD Health disparities and public health data systems Medical Home training and Learning Collaborative Specialty clinics Quality improvement initiatives

Major systems change effort in state

Why we became involved in ACA

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Governor declined federal planning grants

Governor delayed discussion until after supreme court decision and 2012 election

Sept 2012-WI declined to chose an EHB plan

November 2012- Governor defers to Federal Exchange

February 2013- Medicaid expansion rejected, 78,000 will loose Medicaid

September 2013- State certification for navigators required

Wisconsin Approach to ACA

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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 EHB AUCD Health Reform Hub

Information and technical assistance

Staying informed

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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.pdf

Waisman Center Policy Seminar on ACA and People with Disability with Connie Garner

Webinar on EHB 101 with speakers from Georgetown, Catalyst Center and WI - Office of the Commissioner of Insurance (OCI)

WI - UCEDD Activities

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Pre-service education LEND-issue group on ACA

Technical Assistance Support 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 network

WI - UCEDD Activities, con’t

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UCEDD Policy Seminar

37

UCEDD Webinar

38

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Shift focus to support individuals and families to maintain and utilize coverage

Monitor emerging issues Changes in employer coverage Changes in current plans and premiums

Continue to build relationship with policy-makers

Continue to work with coalitions representing disability perspective

The Future

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Duals in MassachusettsA Perspective on Implementation

Helen M. HendricksonE.K. Shriver Center Massachusetts

Eunice Kennedy Shriver Center

One of 15 states awarded a contract from CMS for a state demonstration to integrate care for dual eligible individuals

Enrollment began on October 1st, 2013

Three Health ICOs managing care: Commonwealth Care Alliance, Fallon Total Care, and Network Health.

Three-pronged approach to education and outreach, including:– General public awareness– Targeted outreach to key

subpopulations– Learning collaborative for ICO staff

and providers

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Initial Training Topics

Introduction to One Care Contemporary Models of

Disability (Independent Living, The Recovery Model, Self-Determination)

Enrollee Rights and Protections ADA Compliance Introduction to Cultural

Competency

Training Modalities

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Live Webinars

Recorded Webinars

In Person Conferences

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www. Mass.gov/MassHealth/OneCare/Learning

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Event Date Live Event Attested

Intro to One Care 5/23/13 95 443

Models of Disability 6/13/13 69 132

Enrollee Rights 9/26/13 89 84 (live only)

ADA Compliance 10/17/13 79 100 (live only)

Cultural Competency 11/14/13 NA NA

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Initial Webinar Statistics

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Webinar Satisfaction Survey Results

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Shared Learning One Care Conference October 23, 2011 Survey 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 be

Score (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 

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In Person Conference October 23, 2013

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Best practices in delivery of LTSS and other services to maximize independent living

Behavioral Health Integration Coordination of care within the provider

network Management of depression and alcohol

abuse Health promotion and preventative care

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Future Training Topics

Stephen Sulkes

Barbara LeRoy

Elizabeth Hecht

Helen Hendrickson

Managed Care and Care Coordination: Ideas from the fieldQUESTIONS?