Dual Eligible Beneficiaries

Sarika Aggarwal MD, MHCMSVP Population Health and Chief Medical Officer

xG Health Solutions

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saggarwal@xghealth.com

October, 2015

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Dual Eligible Beneficiaries

• 9.1 million Medicare and Medicaid eligible (seniors and younger individuals with disabilities)

• Account for 50 % of Medicaid and 30 % of Medicare spending

Source: Kaiser Family Foundation 2012

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Dual Eligible Compared to Other Medicare Beneficiaries

Income $10,00 or less

Cognitive/Mental Impairment

Less than High School Education

Fair/Poor Health

Nonelderly Disabled

Long-Term Care Resident

61%

57%

55%

51%

39%

15%

9%

23%

21%

23%

10%

2%

Comparison of Dual Eligible and Other Medicare Bene-ficiaries, 2006

Other Medicare Beneficiaries Dual Eligible Beneficiaries

Source: Kaiser Foundation analysis of the Medicare Current Beneficiary Survey, 2006

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Prevalence of Chronic Conditions in Dual Eligible

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

Source: Kaiser Family Foundation 2012

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Utilization by Dual Eligible Beneficiaries

1+ SNF Stay

1+ Home Health Visit

1+ ER Visit

1+ Inpatient Stay

4%

8%

12%

18%

9%

11%

17%

26%

Hospital, ER, home health and skilled nursing facility rates are higher for dual eligibles than for other beneficiaries

Dual Eligibles

All other Medicare benefi-ciaries

Source: Kaiser Foundation analysis of the Medicare current beneficiary survey 2008

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Utilization and Spending in Dual Eligible withChronic Conditions

37%

50%

42%

17%

38%

28%

19% 20% 20%

Selected Medicaid and Medicare Services Used by Duals w/ Chronic

ConditionsInpatient Hospital Nursing HomeCommunity based LTC

Source: KCMU study 2003 Source: KCMU study 2003

All Duals

> 1 P

hysical C

ondition

>1 Menta

l Conditi

on

Physical a

nd Menta

l Conditi

on

$10,800 $11,400 $23,200 $17,500

$8,600 $12,100

$15,300 $13,500 $19,400

$23,500

$38,500 $31,000

Total Medicaid and Medicare Spending Per Dual Eligible by Chronic Condition

Medicare Spending Medicaid Spending

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Currently, there is limited coordination of care between Medicare and Medicaid…providing significant opportunities in cost control

and care improvement

Medicare

Medicare covers services that are restorative or improve a beneficiary’s functional status

Medicare denies payment for services that are considered “maintenance”

No care coordination benefit in Medicare

Medicaid pays for services that prevent further deterioration

Ambiguity about whether a service helps maintain the status quo or is restorative

No care coordination benefit in Medicaid

Administered by private plan

Many duals are auto assigned to the plan, do not make an active choice

Plan has no relationship to other providers

Fragmented care due to enrollment in multiple plans

Little incentive to nursing homes to provide preventive care

Medicare Part D Medicaid

Dual Eligible Care Coordination Issues

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HealthCare Reform—Medicare-Medicaid Coordination Office

• Section 2602 of the Affordable Care Act

• Purpose:

– Develop innovative care coordination and integration models

– Ensure dually eligible individuals have full access to the services

– Improve the coordination between the federal government and states

– Eliminate financial misalignments that lead to poor quality and cost shifting

• Approach: Capitated Model and MFFS Model• Massachusetts and 11 other states are involved in this demonstration

which ends in 2016

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Massachusetts One Care Dual Demonstration,

• Massachusetts was the first state to launch a 3-year demonstration for duals ‘One

Care’ in 2013

• Serves full benefit duals, aged 21 – 64 years who eligible for both Medicare and

Medicaid in 9 counties

• Capitated model; 3-way contract between One Care Plans, CMS, and EOHHS

• Enrollment: self-selection followed by passive enrollment, with opt out capabilities

• Delivers care through three One Care health plans who will be responsible for the

delivery and management of all covered services

• One care plan will develop teams who will provide clinical care management and

care coordination

• The enrollees receive Medicare part A,B and D services along with state Medicaid

services including expanded services including behavioral health diversionary

services not previously available.

SOURCE: One Care: MassHealth plus Medicare 2014.;www.mass.gov

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One Care Population

• 70% with significant MH/SUD

• At least 75% smoke tobacco

• 40-60% of those with Schizophrenia are overweight

• 15% have diabetes

• Chronic/catastrophic Physical Conditions: 41.4%

• Developmental Disabilities: 16.4%

• Serious Mental Illness: 34.9%

• Substance Use Disorders: 28.1%

• Three or more inpatient admissions a year: 5.7%

• Use of long term services and supports: 30.7%SOURCE: One Care: MassHealth plus Medicare MassHealth. 2014;www.mass.gov.

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One Care Financial Alignment

• One Care plans receive a per member, per month global capitation payment intended to cover all costs of caring for One Care beneficiaries

• This global payment, which blends Medicare and Medicaid funding streams, consists of three monthly capitation payments:

a. CMS for Medicare Parts A and B services, risk adjusted using the CMS Hierarchical Condition Category (CMS-HCC)

b. CMS for Medicare Part D prescription drug services, risk adjusted using the RxHCC model used for Part D plans

c. Medicaid, which is based on the beneficiary’s assigned rating category.

• CMS and the state withhold a portion of the capitation which plans may earn back these funds if they meet certain quality standards

SOURCE: One Care: MassHealth plus Medicare MassHealth. 2014;www.mass.gov

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2014 One Care Medicaid Rating Definitions

• F1 (facility-based care): used for individuals residing in a long-term care facility for more than 90 days

• C3 subdivided into 2 categories: C3B includes individuals with a diagnosis of quadriplegia, amyotrophic lateral sclerosis (ALS), muscular dystrophy, and/or respirator dependence

C3A includes all individuals who meet overall C3 criteria but not C3B criteria;

• C2 subdivided into 2 categories:

C2B includes individuals with co-occurring diagnoses of substance use disorders and serious mental illness

C2A includes all individuals who meet overall C2 criteria but not C2B criteria.

• C1: used for individuals who do not meet criteria for F1, C3A, C3B, C2A, and C2B.

SOURCE: One Care: MassHealth plus Medicare MassHealth. 2014., www.mass.gov

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Overall Care Management Goals for the Dual Eligible

• Move from member centric to member directed

• Coordinate Medicare and Medicaid benefits

• Integrate medical and behavioral health care management

• Use long term services and supports to keep members independent in the community

• Maintain highly collaborative provider relationships

• Increase access to care

• Manage transitions of care

• Reduce utilization of ED and hospitals

• Maintain quality of life and autonomy of the individuals

• Involve ‘Medical Neighborhood’ which views the patient as a member of his/her family, job, social system and community network, in the treatment plan

SOURCE: One Care: MassHealth plus Medicare MassHealth. 2014.

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Care Coordinator

• Deals Directly with Patient

• Functions as a quarterback

• Strong PCP involvement

• Develops individualized care plans

• Integrates multidisciplinary team

CARE COORDINATOR

Source: Strategy& analysis

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Multidisciplinary Care Team

• Approaches patient care as a team• Seamless handoffs among care

providers and care transitions• Medical and behavioral providers• Medical and behavioral nurse case

manager• Pharmacists• Centralized enrollee record• Addresses the ‘Whole Person’:

Physical/Behavioral/Social

MULTI-DISCIPLINARY HEALTHCARE

TEAM

Source: Strategy& analysis

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Care Collaborators

• LTSS coordinator• Community based independent from

health planso Adult daycare/Foster careo Community groups/Faith groupso State agencieso Translator/interpreterso Transporto Home aideso Respite care

CARE COLLABORATOR

Source: Strategy& analysis

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Informatics

• Health Risk Assessments

• Stratification and predictive modeling

• Workflow and notification

• Centralized enrollee record

• Accessible patient information systems

• Performance measures

INFORMATICS

Source: Strategy& analysis

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Incentive structures

• Health plan is single accountable entity and responsible for all medical expenses

• 0 Co-pay for beneficiaries

• Medicare Part A,B,D and Medicaid benefits

• Expanded benefits

INCENTIVE STRUCTURES

Source: Strategy& analysis

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SOURCE: One Care: MassHealth plus Medicare – January Enrollment Report, MassHealth. January 2014. Available at http://www.mass.gov/eohhs/docs/masshealth/onecare/enrollment-reports/enrollment-report-january2014.pdf

Supplemental Benefits in One Care Demonstration

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Key Performance Measures Of Quality in Dual One Care Program

• Access and availability

• Care coordination and transitions of care

• Behavioral health management

• Integration of medical and behavioral health

• Advocacy

• Cultural competency and literacy

• Disease and complex case management

• Medication management

• Utilization management

• Quality of life assessment SOURCE: One Care: MassHealth plus Medicare 2014www.mass.gov

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Access, Coordination And Transitions Of Care (Withhold Measures)

• Getting appointments and care Quickly • Health Risk Assessments completed w/in 90 Days of Enrollment• Care plans completed within 90 days of enrollment• Care plans with documented discussion of care goals• Centralized enrollee record with tracking of demographics on race,

ethnicity, language, homelessness and disability• Members with LTSS Needs who have a LTSS coordinator• Care transitions problems identifies and prevented (SNP) • Transmission of transition record after inpatient to home or any other site

of care within 24 hours (withhold)• Medication reconciliation after discharge from inpatient (HEDIS)• Care coordinator training to support self-management

SOURCE: One Care: MassHealth plus Medicare 2014www.mass.gov

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Behavioral Health Management

• Screening for unhealthy alcohol use and counselling

• Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (HEDIS and Withhold)

• Tobacco Use Assessment and Tobacco Cessation Intervention

• Depression screening and follow up plan (withhold)

• Pain screening and management (HEDIS)

• Follow up after MH hospitalization (withhold)

SOURCE: One Care: MassHealth plus Medicare 2014www.mass.gov

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Integration Of Medical And Behavioral Services

• Exchange of information with behavioral health, and primary care physicians

• Ensuring appropriate use of psychopharmacological medications

• Management of treatment access and follow-up for enrollees with coexisting medical and behavioral disorders

• Behavioral health case managers working closely with the medical case manager for coordination of care

SOURCE: One Care: MassHealth plus Medicarewww.mass.gov

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Advocacy

• Establishment of consumer advisory board

• Compliance with the Americans with Disabilities Act

(ADA) and appointment of ADA compliance officer

• Provider training related to ADA compliance

• Demonstration of a work plan to ensure physical access

to buildings, services, and equipment

• Ombudsman program established to oversee functions

based on regional, language-based, and disability-based

capabilities Source: ‘One care’ Masshealth plus Medicarewww.mass.gov

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Cultural Competency

• Specific recruitment and training strategies representative of the demographics of the area

• Language assistance services, including bilingual staff and interpreter services

• Easily understood patient-related materials, in the languages of the common groups in the area

• Partnerships to facilitate community and patient involvement in initiatives

• Cultural competency training• Screening enrollees for their preferred language and the

time they waited to get interpreter services

Source: ‘One care’ Masshealth plus Medicarewww.mass.gov

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Health Management(HEDIS)

• Complex case management

• Prenatal and postpartum care(HEDIS)

• Screening of colorectal, cervical and breast cancer (HEDIS)

• Controlling Blood Pressure (withhold) ; Ischemic vascular disease (IVD): blood pressure

• Adult weight( BMI) screening and follow up plan

• Comprehensive diabetes care

• Cardiovascular care: lipid screening

• Use of Appropriate Medications for People with Asthma

• Avoidance of antibiotics

• Rheumatoid arthritis management

• High risk residents with pressure ulcers

• Care for adults functional status

Source: ‘One care’ Medicare plus Masshealth 2014www.mass.gov

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Medication Management (Part D)

• High risk medications

• Medication Adherence for oral diabetes medications, lipids(statins), hypertension(ACE/ARB)

• Depression medication adherence

• Care for adults medication review(HEDIS)

• Annual monitoring for persistent medications(HEDIS)

Source: One care’ Medicare plus Masshealth 2014www.mass.gov

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Utilization Management

• Plan All-Cause Readmissions(HEDIS, Withhold)

• Follow-up After Hospitalization for Mental Illness

• Emergency room utilization for medical health and

behavioral health

• Mental health admissions

• COPD admission rate

• CHF admissions rate

Source: ‘One care Masshealth plus Medicare 2014www.mass.gov

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Program Strengths

• Design and implementation of One Care was conducted in an open,

participatory, and transparent manner encouraging feedback from all

participants

• Involvement and encouragement of robust stakeholder and

beneficiary participation throughout the planning stages and

implementation

• Sufficient enrollment numbers were ensured through the passive

enrollment process, which was helpful in reducing financial concerns

of participating plans.

SOURCE: One Care: MassHealth plus Medicare . 2014;www.mass.gov.

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Early Challenges

• Poor health plan participation, due to concerns about infrastructure

costs

• Passive enrollment-related issues including tracking down reliable

contact information for new enrollees

• Health plan assessments showed several beneficiaries needed to be

placed in a higher rating category due to unmet needs

• Question whether the rates would be sufficient to cover the benefit

package, especially in individuals with high behavioral health needs

• Difficult building provider networks with sufficient primary care,

behavioral health, and LTSS capacity to meet the needs of the

population SOURCE: One Care: MassHealth plus Medicare . 2014. , www.mass.gov

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Outcomes and evaluations

• CMS has contracted with an independent evaluator to assess

the on cost, quality, utilization, and beneficiary experiences

with care.

• This evaluation will use a mixed-methods approach to capture

both qualitative and quantitative information on the impact of

demonstration activities.

• Savings from the demonstration are expected to result

primarily from reductions in ED and inpatient use on both the

behavioral health and medical side.

• Expectation is care coordination and greater reliance on

intermediate levels of care is to achieve such reductions

SOURCE: One Care: MassHealth plus Medicare 2014. Available at http://www.mass.gov/eohhs/docs/masshealth/onecare/enrollment-reports/enrollment-report-january2014.pdf

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THANK YOU !

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Dual Eligible Beneficiary Demographics

Hispanic

African American

Under Age 65 and Disabled

Female

Below 150% of the Federal Poverty Level

6%

7%

11%

53%

22%

7%

20%

39%

61%

86%

A larger share of dual eligibles than other beneficiaries is low-income, female, under age-65 disabled and minori-

ties

Dual Eligibles

All other Medicare benici-ciaries

Share of beneficiaries who are:

Source: Kaiser Foundation analysis of the Medicare current beneficiary survey 2008