Managed Care and Care Coordination: Ideas from the field
Stephen Sulkes
Barbara LeRoy
Elizabeth Hecht
Helen Hendrickson
New York State “People
First” Waiver Program:
Glacial Progress Toward a
Managed Care Cliff
Stephen Sulkes
Strong Center for DD
Rochester, NY
*NY State Medicaid-$50 billion out of total
State budget of $130 billion
*~$10 billion spent on DD population
*NY Times Expose
*“Triple Aim”
*Better care
*Better health outcomes
*Reduced costs
*Setting the Scene in NY State
*Follow the Money…
*Keep following the money…
OVERALL MEDICAID UTILIZATION TRENDS for People with DD
(SFY 05-06 v. SFY 09-10)
METRIC
EXPENDITURE (State,
local & Federal)
MEMBER YEARS
PER MEMBER PER
YEAR (PMPY)
SFY 05-06
SFY 09-10
% CHANGE
OVER 5
YEARS
ANN
GROWTH
RATE
$8,033,131,667
$10,217,391,898
27%
6.2%
89,987
100,512
12%
2.8%
$89,270
$101,653
14%
3.3%
*
Overview
* State’s Health Reform Landscape
* Parallel effort to MRT for DD population re health care
delivery transformation: to provide integrated, coordinated
& comprehensive services in a more efficient manner that
improves outcomes of the population.
* 1915(b) and (c) Waiver
* (b):
Authorize creation of managed care service delivery
system for DD populations
* (c):
Establish specific supports and services that will be
provided
* Impacted population:
York
all 95,000 persons with DD in New
*
Goals
* Improving access to services (“No Wrong Door”)
* Implementing a Uniform Needs Assessment.
* Implementing Care Management and Integrated Care
Coordination.
* Establishing a Sustainable Fiscal Platform. The system
would move from a fee-for-service to a capitated
reimbursement system that pays for integration and
coordination of care.
* Incorporating Robust Community Supports.
* Reducing Reliance on Institutional Settings.
* Enhancing Quality Assurance.
DISCOs
* DISCOs (Developmental Disabilities Individual Support and Care
Coordination Organizations) = the core of OPWDD’s waiver proposal.
* essentially a managed care organization – will need Art. 44 licensure
* responsible for developing and maintaining a network of providers,
coordinating care of their members, ensuring quality standards are
met, and serving as the fiscal intermediary (accepting capitated
payments and paying contracted providers).
* partially- or fully-capitated
*
Under either model, eventually the only excluded services remaining in
Fee-For-Service would be school supported health, early intervention, and
certain residential services (OPWDD ICF/DD-DC/SRU).
* private or public not-for-profit entities
* care coordination experience
* Cultural competence
* Regions
*
*
Capitation
*Need to demonstrate an ability to manage risk.
*Will cover Medicaid services, including care
coordination and the person’s individualized budget
under the self-direction option.
*Rates will account for that DISCO’s member acuity
level.
*DOH = rate setting authority, working with OPWDD.
* Historical claim experience
* Care coordination/management cost savings,
* Administrative costs
* Risk retention
* (possibly) Quality withholds
* Intrastate variations
* Geographic region
* Medicare status
* HCBS waiver status
* Residential setting
* Individual age
*
2009
2010
2011
89196
90176
90219
Day Hab
$558-909
$585-969
$642-999
Res Hab
$1354-2227
$1413-2318
$1395-2240
ICF/DD
$375-1663
$412-1765
$360-1647
Total
$3282-6161
$3450-6465
$3453-6321
Avg Per year:
$39K – 74K
$41K – 76K
$41K – 76K
People
PMPM Range
*
* Components:
* interRAI ID
* Community Health Assessment
* Community Mental Health
* Self-Reported Quality of LifeTool
* Palliative Care Tool
* Includes:
* Current functional info
* Health info
* Personal Preferences
*
* Council on Quality Leadership “Personal Outcome
Measures®”
* Emphasis on Individual, rather than System
*
*Benefits: Partial Capitation
 Family and individual support, integration and community habilitation, flexible
goods and services, Home and Community-based clinical and behavioral supports
 Adult Day Health Care / Assisted Living Facility / ICF-DD
 Clinic Social Worker
 Day Treatment
 Dentistry
 DME and Hearing AIDS
 Home Care (Nursing, Home Health Aide, PT, OT, SP, Medical Social Services)
 Non Emergency Transportation
 Nutrition
 OASAS Inpatient
 OMH Institutional Program (PC/RTF) & private psychiatric hospitalizations
 Optometry/Eyeglasses
 OT, PT, SLP (in any venue)
 Personal Care
 Personal Emergency Response System
 Podiatry
 Psychotherapy
 Respiratory Therapy
 Skilled Nursing Facility / Specialty Hospital
*Benefits: Full Capitation
All services required in partially capitated rate PLUS:
Chronic Renal Dialysis
Emergency Transportation
Inpatient Hospital Services (excluding private LT psychiatric
hospitalizations)
Laboratories Services
Outpatient Hospital and Freestanding Clinic Services not
identified in partially capitated rate
Pharmacy
Physician Services including services provided in an office
setting, clinic, facility, or in the home.
Radiology and Radioisotope Services
Rural Health Clinic Services
* Only UCEDD/only physician on State Planning
Committee
* Organized regional response in collaboration with
Finger Lakes Health Systems Agency and Golisano
Foundation
* “Fair broker”
* Coordinated local Request for Information
writing team
* Explain elements of managed care
* Consultation to DISCOs
*Rochester UCEDD Role
* Special Olympics/Golisano Foundation Healthy Communities
* Dental Task Force
* Obesity Efforts
* AADMD
* Hospital discharge planning/readmission prevention effort
* Education across Medical Center
* Physician Training
* Accountable Care Organization
* Health & Employment efforts
*Ongoing Rochester UCEDD
Health Disparities Effort
Integrated Care for People who are
Medicare-Medicaid Enrollees
THE MICHIGAN MODEL
Background
 Definition: Organized and coordinated service
delivery for individuals who are dually eligible for
both Medicare and Medicaid services and supports.
 Contract required between CMS, State, ICOs, and
local service providers
 26 States eligible for the Demonstrations
 9 States have signed MOUs (10/2013): MA, IL, OH,
NY, WA, CA, VA, MN, SC
 Michigan: in MOU negotiations (July 2014 start)
MOU Components
 Assessment & Care Coordination Plan
 Benefit design
 Provider Network/Capacity
 Financing and Payment model
 Implementation strategy
 Quality and performance metrics
 Enrollment process
 Enrollee protections and appeals
Michigan Model Goals
 Seamless service delivery
 Reduced fragmentation
 Reduced barriers to
Michigan
Integrated
Healthcare
Pilot Regions
HCBS
 Improved quality
 Streamlined
administration
 Cost effective
Michigan’s Guiding Principles
 Person centered
 Self-determination
 Array of services appropriate to needs
 Accessible network of providers
 High quality supports and services
 Information available and coordinated
 Performance monitoring
Michigan Key Components
 207,000 eligible participants (75% of DD






population)
4 region pilot (25 counties; n=102,000)
ICOs will cover physical health, pharmacy, DME,
and LTC
PIHPs will cover behavioral health, substance abuse,
and community supports & services (I/DD)
New CMS Waiver(s) required
Care bridge will integrate work of ICOs/PIHPs
Passive enrollment w/ monthly opt-out option
Michigan Key Components (con’t)
 Statewide information dissemination & marketing
 State level Advisory Council
 Enrollee participation on governing boards
 Integrated care ombudsman
Michigan IC Advocacy Network Members
AIDD Network
Partners
Disability Advocacy Organizations
Social Justice
THE MICHIGAN OLMSTEAD
COALITION
Working to Make Community-Based Long
Term Care Available To All Who Need
Aging
Coalition
 Self
Advocates
 Labor Unions

Michigan IC Advocacy Network Activities
 Weekly meetings
 Monitor plan, negotiations, & implementation
 Sit on work groups
 Testify at hearings
 Write briefs on issues
 Provide waiver development oversight
 Support self-advocates in seeking Advisory roles
 Inform constituents (email, blog, tweets, calls)
Major Advocacy Issues
 Choice
 Person Centered Planning and






Care
Enrollment Safeguards
Full Array of Services and
Supports
Grievance, Appeals, and
Rights Processes
Citizen Oversight
Independent Evaluation
Savings Reinvestment
UCEDD Opportunities
 Advocacy
 Sit on work groups to structure
State model & waiver(s)
 Advisory/Oversight committees
 Training for ICOs, Providers,
Benefit Participants, Families
 Student internships – teaching and
monitoring
 Materials Development and
Dissemination
 Evaluation
 Technical assistance to
recipients/families
Points of Contact within States
 Medicaid Administration






Office
DD Services Administration
MI Services Administration
Office of Aging
Departmental Advisory
Groups
Advocacy Coalitions
Legislative Liaisons
Waisman Center UCEDD
-ACA InvolvementAUCD November 18, 2013
Elizabeth Hecht
Outreach Specialist for Public Policy
hecht@waisman.wisc.edu
608-263-7148
Why we became involved in ACA
 Opportunity to strengthen a dimension of our
involvement in health





Health disparities for people with I/DD
Health disparities and public health data systems
Medical Home training and Learning Collaborative
Specialty clinics
Quality improvement initiatives
 Major systems change effort in state
32
Wisconsin Approach to ACA
 Governor declined federal planning grants
 Governor delayed discussion until after supreme
court decision and 2012 election
 Sept 2012-WI declined to chose an EHB plan
 November 2012- Governor defers to Federal
Exchange
 February 2013- Medicaid expansion rejected,
78,000 will loose Medicaid
 September 2013- State certification for navigators
required
33
Staying informed
 WI Access Network- A diverse coalition of patient
advocate, consumer, provider and insurer-based
organizations to learn together and create a more
unified voice to achieve common goals of expanding
access to affordable, quality health care in WI.
 Meet bi-monthly-share information, presentations on
aspects of ACA, meet with CMS.
 Initial focus on Exchanges and EHB
 AUCD Health Reform Hub
 Information and technical assistance
34
WI - UCEDD Activities
CORE FUNCTION-Community Education
 Q&A on the ACA for people with disabilities with
Survival Coalition http://www.survivalcoalitionwi.org/wp-content/uploads/2012/10/ACA-QA.pdf
 Waisman Center Policy Seminar on ACA and People
with Disability with Connie Garner
 Webinar on EHB 101 with speakers from Georgetown,
Catalyst Center and WI - Office of the Commissioner
of Insurance (OCI)
35
WI - UCEDD Activities, con’t
Pre-service education
LEND-issue group on ACA
Technical Assistance
 Support to CYSHCN Network on ACA
 OCI issues guidance on habilitation based on paper written
by Waisman and DRW (P&A)
 Identify and convene disability strategy group
 Collaborate with Division of Public Health to draft and
administer family survey on ACA
 Join regional enrollment network
36
UCEDD Policy Seminar
37
UCEDD Webinar
38
39
The Future
 Shift focus to support individuals and families to
maintain and utilize coverage
 Monitor emerging issues
 Changes in employer coverage
 Changes in current plans and premiums
 Continue to build relationship with policy-makers
 Continue to work with coalitions representing
disability perspective
40
Duals in Massachusetts
A Perspective on Implementation
Helen M. Hendrickson
E.K. Shriver Center
Massachusetts
Eunice Kennedy Shriver Center
 One of 15 states awarded a contract
from CMS for a state demonstration
to integrate care for dual eligible
individuals
 Enrollment began on October 1st,
2013
 Three Health ICOs managing care:
Commonwealth Care Alliance, Fallon
Total Care, and Network Health.
 Three-pronged approach to
education and outreach, including:
– General public awareness
– Targeted outreach to key
subpopulations
– Learning collaborative for ICO staff
and providers
42
Initial Training Topics
 Introduction to One Care
 Contemporary Models of
Disability (Independent Living,
The Recovery Model, SelfDetermination)
 Enrollee Rights and Protections
 ADA Compliance
 Introduction to Cultural
Competency
Training Modalities
In Person
Conferences
Recorded
Webinars
Live Webinars
43
44
|
|
www. Mass.gov/MassHealth/OneCare/Learning
45
Initial Webinar Statistics
Event
Date
Live Event
Attested
Intro to One Care
5/23/13
95
443
Models of Disability
6/13/13
69
132
Enrollee Rights
9/26/13
89
84
(live only)
ADA Compliance
10/17/13
79
100
(live only)
Cultural Competency
46
|
11/14/13
|
NA
NA
Webinar Satisfaction Survey Results
47
|
|
In Person Conference
October 23, 2013
Shared Learning One Care Conference October 23, 2011
Plenary: a paradigm change in disability healthcare: what was and what we hope
will be
Survey Respondent Totals (Average
Scores)
(96 Total Evaluations – Raw data is
available)
Score (1= Unsatisfactory; 5= Excellent)
- Robin Callahan, MA, Burton D. Pusch, RhD & Judith Steinberg, MD, MPH
1.
Please evaluate the OVERALL quality of this CEU/CME session.
4.27
2.
How well did the presentation describe the goals and vision for the One Care
Initiative?
4.43
3.
How useful was the discussion of the implications of the term “paradigm shift”
for care of people with disabilities?
4.36
4.
4.43
48
How effective were the presenters?
|
|
Future Training Topics
 Best practices in delivery of LTSS and other services
to maximize independent living
 Behavioral Health Integration
 Coordination of care within the provider network
 Management of depression and alcohol abuse
 Health promotion and preventative care
49
|
|
Managed Care and Care Coordination: Ideas from the field
QUESTIONS?
Stephen Sulkes
Barbara LeRoy
Elizabeth Hecht
Helen Hendrickson