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Stephen Sulkes Barbara LeRoy Elizabeth Hecht Helen Hendrickson Managed Care and Care Coordination: Ideas from the field.

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Presentation on theme: "Stephen Sulkes Barbara LeRoy Elizabeth Hecht Helen Hendrickson Managed Care and Care Coordination: Ideas from the field."— Presentation transcript:

1 Stephen Sulkes Barbara LeRoy Elizabeth Hecht Helen Hendrickson Managed Care and Care Coordination: Ideas from the field

2 Stephen Sulkes Strong Center for DD Rochester, NY New York State “People First” Waiver Program: Glacial Progress Toward a Managed Care Cliff

3 * Setting the Scene in NY State * 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

4 * Follow the Money…

5 * Keep following the money… OVERALL MEDICAID UTILIZATION TRENDS for People with DD (SFY 05-06 v. SFY 09-10) METRICSFY 05-06SFY 09-10 % CHANGE OVER 5 YEARS ANN GROWTH RATE EXPENDITURE (State, local & Federal) $8,033,131,667$10,217,391,89827%6.2% MEMBER YEARS89,987100,51212%2.8% PER MEMBER PER YEAR (PMPY) $89,270$101,65314%3.3%

6 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: all 95,000 persons with DD in New York

7 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.

8 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

9 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.

10 * 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

11 200920102011 People891969017690219 PMPM Range 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

12 * 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

13 * Council on Quality Leadership “Personal Outcome Measures®” * Emphasis on Individual, rather than System


15   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: Partial Capitation

16 * 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

17 * Rochester UCEDD Role * 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

18 * Ongoing Rochester UCEDD Health Disparities Effort * 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

19 THE MICHIGAN MODEL Integrated Care for People who are Medicare-Medicaid Enrollees

20 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)

21 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

22 Michigan Model Goals  Seamless service delivery  Reduced fragmentation  Reduced barriers to HCBS  Improved quality  Streamlined administration  Cost effective Michigan Integrated Healthcare Pilot Regions

23 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

24 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

25 Michigan Key Components (con’t) Statewide information dissemination & marketing State level Advisory Council Enrollee participation on governing boards Integrated care ombudsman

26 Michigan IC Advocacy Network Members Social Justice AIDD Network Partners Disability Advocacy Organizations THE MICHIGAN OLMSTEAD COALITION Working to Make Community-Based Long Term Care Available To All Who Need  Aging Coalition  Self Advocates  Labor Unions

27 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)

28 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

29 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

30 Points of Contact within States Medicaid Administration Office DD Services Administration MI Services Administration Office of Aging Departmental Advisory Groups Advocacy Coalitions Legislative Liaisons

31 Waisman Center UCEDD -ACA Involvement- AUCD November 18, 2013 Elizabeth Hecht Outreach Specialist for Public Policy 608-263-7148

32  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 Why we became involved in ACA 32

33  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 Wisconsin Approach to ACA 33

34  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 Staying informed 34

35 CORE FUNCTION-Community Education  Q&A on the ACA for people with disabilities with Survival Coalition  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) WI - UCEDD Activities 35

36 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 WI - UCEDD Activities, con’t 36

37 UCEDD Policy Seminar 37

38 UCEDD Webinar 38

39 39

40  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 The Future 40

41 Duals in Massachusetts A Perspective on Implementation Helen M. Hendrickson E.K. Shriver Center Massachusetts Eunice Kennedy Shriver Center

42  One of 15 states awarded a contract from CMS for a state demonstration to integrate care for dual eligible individuals  Enrollment began on October 1 st, 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

43 Initial Training Topics  Introduction to One Care  Contemporary Models of Disability (Independent Living, The Recovery Model, Self- Determination)  Enrollee Rights and Protections  ADA Compliance  Introduction to Cultural Competency Training Modalities 43 Live Webinars Recorded Webinars In Person Conferences

44 | | 44

45 www. 45

46 | | EventDateLive EventAttested Intro to One Care5/23/1395443 Models of Disability6/13/1369132 Enrollee Rights9/26/138984 (live only) ADA Compliance10/17/1379100 (live only) Cultural Competency11/14/13NA 46 Initial Webinar Statistics

47 | | 47 Webinar Satisfaction Survey Results

48 | | Shared Learning One Care Conference October 23, 2011Survey Respondent Totals (Average Scores) (96 Total Evaluations – Raw data is available) Plenary: a paradigm change in disability healthcare: what was and what we hope will be 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. How effective were the presenters?4.43 48 In Person Conference October 23, 2013

49 | |  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 Future Training Topics

50 Stephen Sulkes Barbara LeRoy Elizabeth Hecht Helen Hendrickson Managed Care and Care Coordination: Ideas from the field QUESTIONS?

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