Long-Term Care Integration Project:

Medi-Cal Redesign Update

Mark R. Meiners Ph. D. National Program Director

Robert Wood Johnson Foundation

Medicare/Medicaid Integration Program

Physical & Behavioral Health Coordinator Conference,

sponsored by Healthy San Diego Behavioral Health Work Group and

SD County Health and Human Services Agency

January, 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 FFSMedicare

CoordinationMedicare 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 System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

A P

S D

AP

SD

A P

S D

D S

P A

A P

S D

A PS D

A P

S D

D S

P A

A P

S D

AP

S D

A P

S D

D S

P A

A P

S D

AP

SD

A P

S D

D S

P 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 P

S D

AP

SD

A P

S D

D S

P A

A P

S D

AP

S D

A P

S D

D S

P 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 HispanicUnable to

DetermineWhite

MSHO Trends: Lower Inpatient Use

Minnesota Senior Health OptionsHospitalizations 1999 - 2003

0

50

100

Ho

spit

aliz

atio

ns

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

1,00

0 M

M

Plan A 32 23 13 23 18

Plan B 35 15 12 17 20

Plan C 41 46 36 33 35

All 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 Care

Access 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 Total

25,323 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.