Long-Term Care Integration Project:Medi-Cal Redesign Update
Mark R. Meiners Ph. D. National Program Director
Robert Wood Johnson FoundationMedicare/Medicaid Integration Program
Physical & Behavioral Health Coordinator Conference, sponsored by Healthy San Diego Behavioral Health Work Group and
SD County Health and Human Services AgencyJanuary, 18, 2005, San Diego, CA
Background to MMIP Experiences
Robert Wood Johnson Foundation
15 Participating States: CO, FL, MN, NY, OR, TX, WA, WI, VA, CT, MA, ME, NH, RI, VT
For Background and Technical Assistance Documents see:
www.umd.edu/aging
Medi-Cal Redesign Medi-Cal Redesign and the and the San DiegoSan DiegoLong Term Care Long Term Care Integration ProjectIntegration Project
Medi-Cal Redsign BasicsMedi-Cal Redsign Basics Mandatory Medi-Cal Managed Care for Aged, Mandatory Medi-Cal Managed Care for Aged,
Blind, and Disabled (ABDs) clients in all current Blind, and Disabled (ABDs) clients in all current managed care countiesmanaged care counties
Implement Acute and LTC Integration Projects Implement Acute and LTC Integration Projects in Contra Costa, Orange, and San Diego to test in Contra Costa, Orange, and San Diego to test innovative approached for enabling more innovative approached for enabling more individuals to receive care in setting that individuals to receive care in setting that maximize community integration.maximize community integration.
San Diego Community San Diego Community Planning ProcessPlanning Process
From 50 to 400+ key stakeholders over From 50 to 400+ key stakeholders over past 4 years: 10,000past 4 years: 10,000+ hours + hours
Seeking to improve system of care for Seeking to improve system of care for consumers and providersconsumers and providers
Planning within state LTCIP authorization Planning within state LTCIP authorization (form follows funding)(form follows funding)
San Diego Stakeholder San Diego Stakeholder LTCIP Vision for Elderly & LTCIP Vision for Elderly & DisabledDisabled
Develop “system” that:Develop “system” that: provides continuum of health, social and provides continuum of health, social and
support services that “wrap around support services that “wrap around consumer” w/prevention & early consumer” w/prevention & early intervention focusintervention focus
pools associated (categorical) fundingpools associated (categorical) funding is consumer driven and responsiveis consumer driven and responsive expands access to/options for careexpands access to/options for care Utilizes existing providersUtilizes existing providers
Stakeholder Vision Stakeholder Vision (continued)(continued)
Fairly compensates all providers w/rate Fairly compensates all providers w/rate structure developed locallystructure developed locally
Engages MD as pivotal team memberEngages MD as pivotal team member Decreases fragmentation/duplication Decreases fragmentation/duplication
w/single point of entry, single plan of carew/single point of entry, single plan of care Improves quality & is budget neutralImproves quality & is budget neutral Implements Olmstead Decision locallyImplements Olmstead Decision locally Maximizes federal and state fundingMaximizes federal and state funding
SD LTCIP ComponentsSD LTCIP Components
BOS: “come back with 3 options” For BOS: “come back with 3 options” For LTCIPLTCIP
Since then: Strategy development:Since then: Strategy development: Network of CareNetwork of Care Physician Strategy Physician Strategy HSD Health Plan/Pilot Projects HSD Health Plan/Pilot Projects
Network of CareNetwork of Care Beta testing withBeta testing with
consumers and caregiversconsumers and caregivers community based organizationscommunity based organizations other providers, Call Center staffother providers, Call Center staff
To develop “continuous quality To develop “continuous quality improvement” programimprovement” program
Measure behavior changes of providers Measure behavior changes of providers and consumersand consumers
Physician StrategyPhysician Strategy Partner w/physicians vested in chronic carePartner w/physicians vested in chronic care Develop interest/incentive for support of “after Develop interest/incentive for support of “after
office” services (HCBC)office” services (HCBC) Identify care management resources to support Identify care management resources to support
physicians/office staff to link patients and physicians/office staff to link patients and communicate across systemscommunicate across systems
Train on healthy aging, geriatric/chronic Train on healthy aging, geriatric/chronic disease protocol, pharmacy, HCBC supportsdisease protocol, pharmacy, HCBC supports
Health San Diego PlusHealth San Diego Plus MediCal Aged, Blind, and Disabled offered MediCal Aged, Blind, and Disabled offered
voluntary enrollment in LTC Integrated Plan voluntary enrollment in LTC Integrated Plan Models of care integrated across the health, Models of care integrated across the health,
social, and supportive services continuum:social, and supportive services continuum: Private entity to contract with State through RFP Private entity to contract with State through RFP
with stakeholder supportwith stakeholder support Healthy San Diego Health Plus Plans to develop Healthy San Diego Health Plus Plans to develop
program details with consultant resourcesprogram details with consultant resources
Health Plan ReadinessHealth Plan Readiness Analysis of current use and cost dataAnalysis of current use and cost data Network adequacy assessmentNetwork adequacy assessment Care Coordination and carve outs Care Coordination and carve outs Quality monitoring and improvementQuality monitoring and improvement Linkage with non- Medi-Cal ServicesLinkage with non- Medi-Cal Services Access and availability of new treatmentsAccess and availability of new treatments Stakeholder input in implementationStakeholder input in implementation Compliance with Americans with Disabilities Compliance with Americans with Disabilities
Act of 1990Act of 1990
Why the Interest in acute and LTC Integration and Dual Eligibles?
•Important public financing considerations•An opportunity to do better with limited resources•Cost shifting in both directions•Unintended consumer consequences •Managed care implications•Aging of the population/Chronic Care Imperative
Key Dimensions of Dual Eligible Integrated Care Program Development
» Scope and flexibility of benefits - more than M&M fee-for-service
» Delivery system - broad, far reaching, options, experienced
» Care integration - care teams, central records, care coordination.
» Program administration - enroll, disenroll, data, payment incentives
» Quality management and accountability - unified, broad, CQI
» Financing and payment - flexible, aligned incentives
State Environmental Diversity
•Major differences in Medicaid programs•Wide variations in state managed care
infrastructure• Differences in state goals and target populations•States are in various stages of program
development• Divergent definitions of integration/coordination
Program Development Considerations
•Statewide or regional pilot (large vs. limited)•Mandatory or Optional•Duals/Medicaid-only Aged/Disabled Both? Timing?•Well, Community Frail, Nursing Home•National MCOs or Local Safety-Net Providers •Provider Networks – open or closed?•M/M Coordination or Integration•Benefits: Comprehensive/ Carve Outs•Waivers, Risk Adjustment, Enrollment Strategy•Budget Neutral or Cost Saving
Managed FFS Medicare Coordination Medicare Integration
Issues/Features•Medicaid and Medicare reimbursed FFS
•No waivers required
•Care coordinator link between programs and providers
•Use of incentives (fees, co-location, reporting)
Issues/Features•Medicaid LTC capitated
•Medicare HMO enroll encouraged
•Various Medicaid waivers/authorities
•Inability to capture Medicare savings
•Case management lacks authority over Medicare
Issues/Features•222 Medicare payment waiver &
•Various Medicaid waivers
•One contract for both payers
•Flexibility to use savings for non-traditional services
•Case management has control over both programs
Core Building Blocks - Targeting Beneficiaries: Risk vs. Reward - Case Management / Care Coordination- Integrating Information - Quality Methods and Measures- Primary Care / Chronic Care Management
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Improved Outcomes
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health SystemResources and Policies
Community Health Care Organization
Chronic Care Model
A PS D
A PS D
A PS D
D SP A
A PS D
A PS D
A PS D
D SP A
A PS D
A PS D
A PS D
D SP A
A P
S D
A PS D
A P
S D
D SP A
Community Resources and Policy
Self-Manage-ment Support
Delivery System Design
Clinical Information
Systems
Develop Strategies for Each Component of the CCM
Overall Aim: Implement the CCM for a specific Dual Eligible/Chronic Care Population
A PS D
A PS D
A PS D
D SP A
A PS D
A PS D
A PS D
D SP A
Organiz-ation of health care
Decision Support
MSHO: What’s Working • Enrollee/family relationship with care coordinator provides assistance with
navigation of the medical and LTC systems across all services in all settings for all types of enrollees
• Risk screening and early identification for community “well” provides preventive opportunities
• Dis-enrollment rate is less than 3%, low complaint and appeal rate, high consumer satisfaction, enrollment growth
• Lower inpatient use, especially for frail members, • Cost effective: 5% savings on community LTC, lower use of nursing home
after the 180 days• Increased access for ethnically diverse population to community services
(54% of community LTC population is nonwhite, SE Asians largest group)
MSHO: What’s Working • Plan and care system investment and long term commitment • Have built a viable market based infrastructure for improving chronic
care for duals, learning lab for new policies, spillover starting to happen• Plan and Care System Collaboratives:
– Quality Improvement initiatives with geriatric focus – Care Coordinator training – Specialized tools/protocols for Care Coordinators on chronic diseases– Development of standardized measures
• Plans and provider interest is growing, expanding to other counties and plans
CMS Evaluation: U of MN• MSHO community members have fewer preventable ER
visits, particularly with increased duration and are more likely to receive preventive services, therapy and home health nursing services and used less out of home care and lower levels of in home care than control groups.
• Nursing home members have fewer hospital admissions, days and preventable hospital admissions and were more likely to get some preventive services than control groups.
• Death rates were similar for MSHO and control groups, quality indicators for nursing home residents were also comparable among both groups.
MSHO/NHC Enrollees Are More Diverse Than FFS/NHC
Community LTC
0%10%20%30%40%
50%60%70%80%90%
MSHO 15% 1% 31% 4% 4% 46%
PMAP 9% 1% 5% 2% 2% 80%
African American
American Indian/Ala
Asian Hispanic Unable to Determine
White
MSHO Trends: Lower Inpatient Use
Minnesota Senior Health OptionsHospitalizations 1999 - 2003
0
50
100
Hos
pita
lizat
ions
per
1,0
00 M
M
Community 30 24 19 24 26
Comm. LTC 81 73 67 65 58
Nursing Home 27 26 24 23 24
1999 2000 2001 2002 2003
Trends: Lower Nursing Home Admissions for Frail
MSHO Community LTC
0
10
20
30
40
50
Adm
issi
ons
per 1
,000
MM
Plan A 32 23 13 23 18Plan B 35 15 12 17 20Plan C 41 46 36 33 35All Plans 37 33 26 28 28
1999 2000 2001 2002 2003
Measuring Outcomes of the WI Partnership Program
The Department of Health and Family Services is using several methods, both traditional and innovative, to measure quality & effectiveness:14 Member Outcomes Based on Member’s Input
about his/her Quality of Life;Incidence of ACSCs (ambulatory care sensitive
conditions);Utilization of Inpatient Hospital & Nursing Home
Care Before & After Partnership.
14 Member Outcomes
Developed by the Council on Quality and Leadership, a national accreditation agency for community disability programs.
Determines whether:members’ desired outcomes are being met, and the support the member needs to achieve the outcome has been put in place by the team.
Member Outcomes
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Outcomes Present Supports Provided
Self-Determination & Choice Outcomes
88.6%
78.9% 76.6%
70.9%
88.2% 92.1%85.7%
72.1%
51.5%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
People are Treated Fairly People Have Privacy Personal Dignity & Respect
Family Care Outcomes WPP Outcomes PACE Outcomes
Self-Determination & Choice Supports
87.9%
30.9%
74.7%74.6%78.8%
86.4%
80.7%
31.4%27.0%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
People are Treated Fairly People Have Privacy Personal Dignity & Respect
Family Care Supports WPP Supports PACE Supports
Health Care Outcomes Staff Compile & Trend Data On
Hospitalizations For Ambulatory Care Sensitive Conditions (ACSC):
ACSCs are defined by the Institute of Medicine as conditions for which good access to primary care should reduce the need for hospital admissions.
Result:Hospital Admission
The Rate of Hospital Admissions for Ambulatory Care Sensitive
Conditions Decreased by 41.1 % from 2000 to 2002.
Result:Hospital Admission
Result:Hospital Admission
Result: Access to Dental CareAccess to Medicaid funded dental care
remains difficult in Wisconsin.For example:
17% of home and community-based waiver programs’ for elderly and people with physical disabilities had dental visits in 2001.
72% of all participants in PACE and Wisconsin Partnership program had dental visits in 2001.
Result: Health Care Utilization Using the Hospital Discharge Data Base,
Staff are Able to Demonstrate Pre/Post Enrollment Hospital Utilization
Findings Show a Positive Reduction of Inpatient Hospitalization & Nursing Home Use
Comparing Hospital Use, Same People Before & After Enrollment
Comparing Nursing Home Use, Same People Before & After Enrollment
Physician Satisfaction
Survey Completed in April 2004.40 % of Surveys ReturnedStatistically Significant95% Confidence Level
Physician Satisfaction
Physician Satisfaction
Physician Satisfaction
Areas Needing ImprovementMember, Quality of Life, Outcomes.Further Impact on the Incidence of
Hospitalizations for ACSC.Comprehensive Evaluation.Demonstration of Cost Effectiveness.Provider Satisfaction.Interventions in Cases Where there is Mental
Heath and/or Chemical Dependency Concerns.
TEXAS STAR+PLUS
Medicaid pilot project designed to integrate delivery of acute and long-term care services through a managed care system
Requires two Medicaid waivers: 1915 (b) - to mandate participation 1915 (c) - to provide home and community-
based services
STAR+PLUS Objectives Integrate Acute & Long Term Care into Managed Care System
Provide the Right Amount & Type of Service to Help People Stay as Independent as Possible
Serve People in the Most Community-based Setting Consistent with their Personal Safety
Improve Access and Quality of Care Increase Accountability for Care Improve Outcomes of Care Control Costs
STAR+PLUS Eligibility Criteria
Mandatory Participation: HMO SSI-eligible (or would be except for COLA)
clients age 21 and over MAO clients who qualify for the Community
Based Alternatives (CBA) waiver Clients who are Medicaid-eligible because they
are in a Social Security exclusion program
Is STAR+PLUS Mandatory?
If you are in a required group You must enroll in a STAR+PLUS Plan
for Medicaid services
Medicare services may be obtained through the provider of choice
Enrollment Broker New Medicaid Clients
Enrollment Broker Contacts Clients by:
Telephone, Mail, In-person
STAR+PLUS Enrollment
1/1/02 54,895 Total25,323 Dual Eligibles 29,572 Medicaid Only
STAR+PLUS Services Acute care services (Medicaid only members) Long term care services
Personal Care Services Adult Day Health Services Nursing Facility Services
Behavioral Health Care Coordination Waiver Services - therapy, respite, adult foster care,
assisted living, DME/adaptive aids, minor home modification
Value added services - adult dental, waiver services for non-waiver members
CARE COORDINATION
HMO required to contact members within 30 days of enrollment
HMO makes home visit and assesses members needs, as appropriate
HMO assigns a care coordinator (or coordination team), as appropriate
EVALUATION CRITERIA
Consumer SatisfactionIntegration of CareAccess to CareQuality of CareEmphasis of Community
Based CareImpact on BudgetImpact on Providers
Utilization Analysis In 1999, Personal Assistance Services use was 32 % higher than
FFS projected. The Community Based Alternatives program increased almost
119 percent in Harris County, but only 3.4 percent statewide. Utilization of new generation medications by people with
serious mental illnesses increased both statewide and in Harris County, but the Harris County increase did not occur until the implementation of STAR+PLUS.
Inpatient hospital utilization decreased for this population.
Care Coordination Care Coordination Key Survey Findings
77% were aware of a care coordinator or person who helps them get services
74% reported it was ‘somewhat easy’ to ‘easy’ to get help from a care coordinator
58% reported being included in decision-making about their services
81% reported ease in obtaining services such as personal attendants or home health services
70% were satisfied with care coordination services and 84% would consider recommending their health plan to others
LTC Provider Satisfaction Tended to be more dissatisfied than neutral
or satisfied in the areas of Accuracy of claims payments Timeliness of claims payments Amount of phone work Overall satisfaction
Those with more service experience reported lower satisfaction than those with less
Challenges
Enrollment
Medicaid Population
LTC Providers Transition
Computer Systems
Dual Eligibles
Opportunities
Early Intervention
Disease Management
Care Coordination Home visits Integration of care
Flexibility in service delivery
Lessons Learned Care Coordination is the key to integration of acute
and LTC services Challenges coordinating care for dual eligibles
when HMOs are only responsible for LTC Education of all providers and stakeholders is key Increase in administrative complexity caused
provider dissatisfaction Collaboration between competing HMOs and State
is an essential piece of successful model
Summary Thoughts
•Integrated Care is hard and worth it!/?
•Future of MMIP Efforts and Accomplishments: Uncertain? Promising? Competing Agendas?
•Topics to watch: Special Needs Plans, Drugs, Disease Management, Care Coordination, Risk Adjustment, Consumer Directed Care; Cash Benefits, HCBS Waivers, Olmstead Decision, and Private LTC Insurance.
