My Care Ohio: Can Integrated Financing Lead to Enhanced Integrated Care?

Donald Mack, M.D.Ohio State University Medical Center

Gregg Warshaw, M.D.University of Cincinnati College of Medicine

Dual eligible beneficiaries comprise 20% of the Medicare population and 15% of the Medicaid population in 2008

Dual Eligible Beneficiaries

9 million

Medicare37 million

Medicaid51 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.

Total Medicare beneficiaries: 46 million

Total Medicaid beneficiaries: 60 million

Under Age 65

39%Facility

13%

Mental Impairment

49%0 or 1

Chronic Conditions

25%

Age 65-74

26%2 Chronic

Conditions

20%

Age 75-84

21%

Community

87%

No Mental Impairments

51%3 Chronic

Conditions

20%

Age 85+

14% 4 or more Chronic

Conditions

35%

Age Type ofResidence

MentalImpairments

Number of Chronic

Conditions

Dual eligible beneficiaries are a diverse population

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

26%

22%

44%

25%

44%

50%

55%

58%

Dual eligiblebeneficiaries

All other Medicarebeneficiaries

Dual eligible beneficiaries are sicker than other Medicare beneficiaries

SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008.

3+ Chronic Conditions

In Fair or Poor Health

Cognitively or Mentally Impaired

Functionally Impaired

5

The Problem

Limited care coordinationFragmented CareCurrent system is confusing and difficult

to navigateMultiple health care needs and high costThe health care and long-term care

systems are not connected very well, even though people use both

MyCare Ohio

Demonstration to test integrated care and financing model for individuals with Medicare and Medicaid

May 2014 to December 2017Federal and State partnership How it will work:

Approved ICDS Plans will provide integrated benefits to Medicare and Medicaid enrollees in seven targeted geographic areas

Plans must provide all necessary Medicare and Medicaid-covered services, including Medicaid waiver services

Single identification card to access services

MyCare Ohio

MyCare Ohio

Three-way contract (Health plan, CMS, State)Rolling start in mid-2014; passive enrollment

in Medicare delayed until January 1, 2015Capitated rates adjusted for State and CMS

upfront savings; also quality withholdComprehensive care plans required

incorporating client and family goals

Medicare Passive Enrollment (I)Beneficiaries must participate in MyCare Medicaid; but Medicare is optional

On 1-1-2015, individuals who have not indicated a choice, will be passively enrolled in MyCare Medicare with the same health plan as their MyCare Medicaid (integrated benefits and funding)

Medicare Passive Enrollment (II)Individuals can choose to stay with

traditional Medicare or another Medicare Advantage plan

Beneficiaries can switch from MyCare Medicare to traditional Medicare, or vice versa at anytime

This is all very confusing to consumers and public education has been poor

MyCareOhio

Benefits for Primary Care Providers

Identifiable care manager – phone and email contactAccess to all benefits and servicesOpportunity to enhance home and community-

based servicesWEB portal to access patient’s care planAssistance for your most complex patientsOpportunity to participate as part of Integrated

Care TeamPotential to shift hospital dollars to community-

based services

Continuity of Care and Transition Requirements

Health plans must ensure individuals have access to current providers and service levels at the time of enrollment.Length of transition period differs by service.

For prescription drugs, Medicare Part D transition requirements apply.Health Plans must provide a one-time fill- 30 day

supply- of an ongoing medication within the first 90 days of plan membership.

Residents in long term care facilities can receive multiple fills.

Continuity of Care Requirements (Continued)

During the transition, Health Plans will advise enrollees and providers that they have received care that would otherwise not have been covered.

Ongoing basis, Health Plans must contact providers not part of their network with information on being credentialed as in-network providers.

Health Plans must always reimburse an out-of-network provider of emergent or urgent care.

Details: Plan Payment Requirements

Ohio UHCAN (Ohio Consumer Voice for Integrated Care)Engaged in Monitoring implementation;

influencing consumer protectionsPassive enrollmentClinical networks; benefit limitationsLTSS, transportationConsumer engagement in plan implementation

UHCANOhio.org614 456-0060

MyCare Ohio Observations (I)Disruptive change: Impact on large number

of patients and their provider networksVery complex and the Ohio Medicaid office is

also expanding MedicaidCMS-State Medicaid Office-Health Plan

negotiations complexOhio has agreed to involve Area Agencies on

AgingHalf of the enrollees will be under 65; mental

health and disability groups very engaged

MyCare Ohio: Observations (II)Physician and provider reimbursement

stable, but for how long?Networks broad, but for how long?Health plans have limited experience with

this population across all settings of carePrimary care and geriatrics providers have

received limited education about upcoming changes

Critical Role of Provider and Consumer Engagement

Dual eligible patients will benefit from your participation in planning and direct care provision in MyCare Ohio

If MyCare Ohio is not successful, the alternatives may be less desireable for patients and providers

Primary care and Geriatrics providers’ clinical leadership, when combined with consumer advocacy efforts, is more likely to have an impact

How can Providers Get Involved? (I)

Learn about MyCare OhioDiscuss good and bad observations

with your health system, Area Agency on Aging, health plan medical directors, and State Medicaid office leadership

Join advocacy organization list-serves

Voices for Better Health: http://CommunityCatalyst.org

Why Learn More about MyCare Ohio?

YOU ARE:An important source of health system

infoA reliable and authoritative sourceAware of the clinical needs of the

personAware of the functional needs of the

personAware of the social needs of the person

To Achieve the Triple Aim: Better Care, Better Health, Lower Cost

Must form a partnership of Health Care Providers; Home and

Community-Based Providers, and Public