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Strategies to Improve Care Management for Beneficiaries with Complex Needs Managing the Care and Costs of High-Cost Beneficiaries in Medi-Cal Fee-for-Service.

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Presentation on theme: "Strategies to Improve Care Management for Beneficiaries with Complex Needs Managing the Care and Costs of High-Cost Beneficiaries in Medi-Cal Fee-for-Service."— Presentation transcript:

1 Strategies to Improve Care Management for Beneficiaries with Complex Needs Managing the Care and Costs of High-Cost Beneficiaries in Medi-Cal Fee-for-Service June 9, 2009 Alice Lind Associate Vice President Center for Health Care Strategies

2 CHCS Mission To improve health care quality for low-income children and adults, people with chronic illnesses and disabilities, frail elders, and racially and ethnically diverse populations experiencing disparities in care. Our Priorities Advancing Health Care Quality and Cost Effectiveness Reducing Racial and Ethnic Disparities Integrating Care for People with Complex and Special Needs 2

3 Managing Care in Medicaid Goals: Improve or maintain health status Create accountable medical homes Coordinate care for those with complex conditions Control cost 3

4 Purchasing Strategies Used by States Interviews with Medicaid officials in 12 states to examine innovations in care management for the SSI/ABD population. Key Themes: 1. Growing momentum to move beyond FFS to more coordinated approaches (e.g., EPCCM, medical home). 2. Increasing interest in alternative financing methods (e.g., shared risk/savings, P4P, etc.). 3. Emerging efforts to develop and test more appropriate performance measurement and monitoring strategies. 4

5 Common Elements: Emerging Models of Care Identifying and stratifying target populations Targeting tailored interventions Integrating/coordinating services (e.g., physical & mental health) Creating better connections between patients and providers Using appropriate measures to promote accountability Structuring financing to support care management 5

6 Key Issues: Emerging Models of Care Predictive Modeling Health Risk Assessments Physical-Behavioral Health Integration Role of Medical Homes Engagement Strategies (Patients and Providers) Accountability 6

7 Elements of Medical Home A participant is linked with a physician, non-physician medical practitioner, clinic, or other safety net provider who will serve as their medical home. The medical home acts as a team to: 1.Assess the participants health care needs 2.Coordinate and plan the participants care 3.Provide quality primary care services and preventive screenings 4.Authorize referrals to specialists, and 5.Provide linkages to other care and equipment providers The team has a whole person orientation: Success depends on their ability to focus on the needs of a patient or family one case at a time. The medical home integrates IT to support quality and safety. 7

8 Typical Medical Home Enhancements Beneficiaries are offered: Toll-free health advice, 24/7; In person health education and counseling; Linkages to community-based services (housing, behavioral health, etc.); Integrated care management for those identified as having complex medical and social needs. Providers are offered: Practice support as needed; Training and education on Patient-Centered Medical Home; Technical assistance on quality improvement, evidence-based medicine, IT resources. 8

9 Medical Home – current literature Evidence indicates that medical homes improves health outcomes and reduce access disparities. 1 Physician-based organizations support the medical home because it provides an on-going relationship with the patient that improves quality. 2 National Demonstration on Patient-Centered Medical Home 3 : Transformation requires a strategic developmental approach. Cautious optimism despite the challenges of implementation. Complex care management in Medicare demos 4 : Programs that reduced hospital costs for Medicare beneficiaries with multiple chronic conditions who were generally not cognitively impaired included key features (next slide). 1 Rosenthal TC. The Medical Home: growing evidence to support a new approach to primary care. J Am Board Fam Med. 2008; 21(5): Joint Principles of the Patient-Centered Medical Home, March 2007; American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association. 3 Nutting et al. Initial Lessons from the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home, Annals of Family Medicine, Brown R et al. The Promise of Care Coordination. Located at 9

10 Care Coordination in Enhanced PCCM Programs Care coordination in PCCM programs has some of these characteristics, but not all (upcoming article by Verdier): Targeting of patients at substantial but not extremely high risk of hospitalization (OK, PA, IN) In person contact with patients (some in OK, PA, NC, and IN, but most is by telephone) Close interaction between care coordinators and physicians (best in NC, more limited in other states) Access to timely information on hospital and ER admissions (generally lacking in all states) Medical education and social services to patients, including education on self- management of care, especially medications (some in all states but AR) In considering lessons from Medicare, keep in mind differences between Medicare and Medicaid beneficiaries Medicaid ABD PCCM beneficiaries generally are younger, have lower education and income levels, fewer family and community supports, more mental health and substance abuse problems, and more housing problems 10

11 Proposed Medi-Cal Model: Enhanced Medical Home (EMH) Starting with high level concept: Target population: 360,000 high cost Medi-Cal Fee- for-Service enrollees CA will contract with one or more entities to administer Enhanced Medical Home model Best practices from other states will be integrated Mandatory statewide: where managed care is available individuals can select the Medical Home model or a managed care model. 11

12 Model Option 1: State-operated Oklahomas Sooner Care Choice: Builds on, supports, and strengthens the existing primary care provider network Provides supports to beneficiaries and providers (nurse advice; education) Provides care coordination to high risk beneficiaries P4P model rewards providers Difference for CA: OK pays Medicare rates to providers; fully capitated managed care was not viable 12

13 Model Option 2: Single Private Vendor State of Illinois: Single contractor provides all operations Vendor forms and operates provider network Vendor provides supports for beneficiaries and providers Care coordination through subcontracted arrangement for high risk population Is relatively quick to implement & can be contracted at risk Difference for CA: local involvement not a priority in IL, except for Disease Management 13

14 Model Option 3: Local Public/Private Partnership Community Care of North Carolina: Gradually developed local public/private entities in 14 geographic locations Local entities responsible for network, provider and beneficiary supports Local determination of QI efforts State funds are split between providers and regional partnerships Difference for CA: NC had many years to develop model before cost neutrality was required 14

15 Model Option 4: Blended Model Washingtons King County Care Partners: Local entities given preference if willing and able to contract for enhanced medical home Statewide contract awarded to cover remaining geographical regions Statewide vendors role diminished over time, shifting responsibility to local and state staff as they developed capacity Difference for CA: WA grew out of totally unmanaged care for ABD population; cost neutrality a goal but not required 15

16 Your Role in the Medi-Cal Project You are a key informant! Respond by June 10 (tomorrow) with your availability to interview on June 22, 23, or 24 CHCS will reply with your time & directions by June 15 Optional: Review documents on CHCS or CHCF website from December 15 meeting with questions: 16

17 Visit CHCS.org to… Download practical resources to improve the quality and efficiency of Medicaid services. Subscribe to CHCS Updates to find out about new CHCS programs and resources. Learn about cutting-edge state/health plan efforts to improve care for Medicaids highest- risk, highest-cost members. 17


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