Managed Care in Oregon: the Impact to Hospice Providers

Jeffrey McWilliams, MD

Medical Director, Bristol Hospice of Oregon

Medical Director, APS Healthcare, Oregon

Objectives

• Define managed care and its current structure in Oregon.

• Describe how managed care systems impact health outcomes through population management.

• Understand how hospice care operates in a managed care environment

• Improve interactions with managed care providers.

Definition of Managed Care

• Managed Care is a health care delivery system organized to manage cost, utilization, and quality.

• Medicaid managed care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs) that accept a set per member per month (capitation)payment for these services. (Medicaid.gov)

History of Managed Care in the United States

• 1929-Dr. Michael Shadid establishes a health cooperative in Elk City, Oklahoma selling shares to build a hospital and annual membership for health care. 600 families, PCP, 4 specialists and one

dentist

Early HMOs

• 1929-Drs. Donald Ross and Clifford Loos create the Ross-Loos Clinic First HMO in America Prepaid care for 2000 employees of LA Co. Water and Power 29 clinics, one large multi-specialty hospital

• 1937-Group Health Association of Washington, DC

• 1942-Kaiser-Permanente Medical Program

• 1947-Health Cooperative of Puget Sound

• 1947-Health Insurance Plan of Greater New York

• 1957-Group Health Plan of Minneapolis

Washington Gets Involved

• Health Maintenance organization Act of 1973 Nixon Administration $375,000,000 to establish/expand HMOs Employers with >25 employees must offer an HMO option

• 1982-Congress caps Medicare hospital rates and creates DRGs

1990's: Growth of Commercial Managed Care Plans

• 1993-51% of Americans with employer provided insurance are in HMOs

• Benefit denials and disallowances of medically necessary services lead to public outcry.

• Nearly 900 state laws governing managed health practices in the 1990's. Right to emergency visits "Drive Through Delivery" laws

The Affordable Care Act: Managed Care Explosion

• Signed into law on March 23, 2010 Largest bill ever sent to Congress 314,900 words

• Requires most US Citizens and legal residents to have health insurance

• Created state-based exchanges for purchasing coverage

• Credits for 133%-400% of FPL

• Requirements for employer-covered health insurance

• Expanded Medicaid to all non-Medicare eligible up to 133% of FPL 1million Oregonians

Managed Care in Oregon

• 1994-The Oregon Health Plan is created Prioritized List of Health Services goes live

• 2011-Managed Care Organizations (MCOs) started

• 2012-The CCO (Coordinated Care Organization) era begins. Medicaid beneficiaries are assigned to Coordinated Care or Fee for Service

16 CCOs in Oregon

• AllCare Health Plan

• Cascade Health Alliance

• Columbia Pacific Coordinated Care Organization

• Eastern Oregon Coordinated Care Organization

• Family Care, Inc

• Healthshare of Oregon

• Intercommunity Health Network Coordinated Care Organization

• Jackson Care Connect

• Pacific Source Community Solutions CCO, Central Oregon Region

• Pacific Source Community Solutions CCO, Columbia Gorge Region

• Primary Health of Josephine County, LLC

• Trillium Community Health Plan

• Umpqua Health Alliance

• Western Oregon Advanced Health, LLC

• Willamette Valley Community Health, LLC

• Yamhill Community Care Organization

Population Management

• Patient Centered Primary Care Homes (PCPCHs)

• Metrics and Benchmarks

• Incentives

• APS Healthcare as an example

• Key Attributes for Recognition Accessible: Care is available when

patients need it. Accountable: Clinics take responsibility

for the population and community they serve and provide quality, evidence-based care.

Comprehensive: Patients get the care, information and services they need to stay healthy.

Continuous: Providers know their patients and work with them to improve their health over time.

Coordinated: Care is integrated and clinics help patients navigate the health care system to get the care they need in a safe and timely way.

Patient & Family Centered: Individuals and families are the most important part of a patient’s health care. Care should draw on a patient’s strengths to set goals and communication should be culturally competent and understandable for all.

PCPCHs

PCPCHs• More than 500 clinics across Oregon in 34 of 36 Oregon

Counties

Accountability

• 2% withhold

• Metrics and benchmarks

• Improvement goals

• Distribution of withholds

Metrics - 2015

• Access to care (CAHPS)

• Adolescent well-care visits

• Alcohol and other substance misuse screening (SBIRT)*

• Ambulatory care: emergency department utilization

• Colorectal cancer screening

• Controlling hypertension

• Depression screening and follow-up plan*

• Developmental screenings in the first 36 months of life

• Diabetes HbA1c poor control*

• Early elective delivery

• Electronic health record (EHR) adoption

• Follow-up after hospitalization for mental illness

• Follow-up for children prescribed ADHD medication (initiation phase)

• Mental and physical health assessments for children in DHS custody

• Patient-centered primary care home (PCPCH) enrollment

• Prenatal and postpartum care: timeliness of prenatal care

• Satisfaction with care (CAHPS)

Example: APS Healthcare• Managed care for the fee-for-service and Dual-eligible Medicaid populations.

• Oregon Health Plan Care Coordination Program

APS Healthcare’s Client-Centered Model for the Oregon Health Plan Care Coordination Program

OHPCC Serves Clients in all Counties in Oregon

OHPCC Serves >120K FFS & FFS Dual-Eligible Clients Out of ~ 1 Million Medicaid Clients in

Oregon

OHPCC Program Activities & Functions Focus on the Triple Aim With People Who are Served at

the Center

OHPCC’s Program Flow is Made to Look Simple in This Diagram…

But, the Following Slide Shows the Complexity of the OHPCC Workflow Process…

% of Healthcare Costs for % of Population

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 1000

10

20

30

40

50

60

70

80

90

100

% of Population

% o

f H

ealt

hcare

Costs

Population Health Principle: A small % of any population experiences the majority of the healthcare costs (e.g., 20%:70% or 5%:50%)

APS Healthcare’s Systematic Approach to OHPCC Client Selection, Referral & Engagement

We Tailor Interventions for Risk Levels

Lowest 80% (No Acuity Rating)

Clients in this cohort have low rates of chronic conditions and very low rates of uncoordinated care.

Population interventions include screening and referral for wellness care, encouraging early access to prenatal care, and promotion of the Nurse Advice Line to address rates of avoidable ER utilization.

We Tailor Interventions for Risk Levels

Moderate 15% (Acuity 1, 2 or 3)

Clients in this cohort have similar chronic primary and co-occurring conditions, and lower rates of uncoordinated care. They are “at risk to become high-risk.”

Interventions for this group emphasize engagement with a medical home and development of health literacy and self-management skills.

We Tailor Interventions for Risk Levels

Highest 5% (Acuity 4-5)

High-risk clients use facility-based care, are reliant on ER for services, and have high rates of readmission.

Interventions focus on face-to-face interaction, identification of unmet needs and gaps in care, and access to social services/home and community-based services to protect community tenure, improve health literacy and self-management skill, and establish “medical homes” for clients.

APS Healthcare’s Systematic Approach to OHPCC Client Selection, Referral &

Engagement

OHPCC Services to Clients

OHPCC Specific Metrics

Clinical Metric Benchmark FFS Result Dual Result

All Cause Readmissions 10.5% 14.3% 24.1%

ED Utilization 41.3% 37.1% 48.2%

Ambulatory Care: Outpatient Utilization 439 209.1 461

Comprehensive Diabetic Care: Hemoglobin A1c Testing 86% 63.5% 73.9%

Diabetic Short Term Complication Admission Rate PQI-1 203.4 97.9 95.1

COPD/Asthma Older Adult Admission Rate PQI-5 329.5 634.8 676.3

CHF Admission Rates per 100k PQI-8 238.5 367 616.4

Young Adult Asthma Admission PQI-15 35.9 33.2 93.3

OHPCC Reduces Costs for the State of Oregon & Provides a Positive ROI > 3:1

OHPCC Program Savings & ROI for Each of 5 Program Years (2009-14)

Hospice and Managed Medicare

• After beneficiary makes hospice election: Medicare pays for hospice services Medicare pays for services of managed care attending physician Medicare pays for services not related to the terminal illness through

the fee-for-service system A managed care patient may choose a provider outside his/her MCO

• Fee-for-service Medicare after hospice election

• Upon discharge or revocation, FFS continues through the end of the month that the discharge or revocation occurred

Hospice and Managed Medicaid

• States must pay for hospice care in amounts no lower than the amounts used under Medicare Part A

• Medicaid hospice rates do not include a co-pay for repite care or medications

• Concurrent care for children is available

Medicaid Dual Eligible Demonstrations• Fifteen states

California, Colorado, Connecticut, Massachusetts, Michigan, Minnesota, New York, North Carolina, Oklahoma, Oregon, South Carolina, Tennessee, Vermont, Washington, and Wisconsin.

• To design new approaches to better coordinate care for dual-eligible individuals

• Goal is to identify and validate delivery system and payment coordination models that can be tested and replicated.

• Oregon's demonstration is for managed fee-for-service duals via contract with APS Healthcare

What's in it for the CCOs?

• New partnerships

• Allies in cost control and population management

• Improved end of life centered metrics

• Contracting opportunities

• Possibility of bundled payments, sharing of risk, etc.

• Shifting the cost of end of life care out of the CCO to Medicare

Interacting with CCOs

• Establish referral process

• Determine if hospice is a carve-in or carve-out for the CCO

• Obtain a list of what is inside the plan and what is fee-for-service

• Good relationship with Provider Relations contact(s)

• If contract negotiations, be specific about who pays for items like transfusion, certain drugs

• How does the CCO determine hospice eligibility?

• Are there medication limits? Can they be waived?

• Clarify the CCO's billing process

• IT systems information

• Provider and beneficiary appeal rights and process

• Define quality measures and accountability

Future Directions

• Hospice Referal as a metric

• Concurrent care model

• Hospices as PCPCHs?

• Hospice-specific metrics

Conclusions

• Systems of delivery of medical care continue to get more complex

• The recent Medicaid expansion has increased the number of individuals cared for in a managed care environment

• Partnerships with hospice agencies can be very beneficial to CCOs

• The current managed health care environment has the potential to spawn innovative approaches to the delivery of end of life care

Questions?