1. http://www.dmas.virginia.gov/ 1 Department of Medical Assistance Services Gerald A. Craver, PhD Policy and Research Division Dual Eligible Best Practices Summit February 9, 2015 http://www.dmas.virginia.gov 1 Department of Medical Assistance Services Commonwealth Coordinated Care Program: Evaluation Overview, Initial Findings, and Next Steps

2. http://www.dmas.virginia.gov/ 2 Department of Medical Assistance Services Co-Authors Meredith Lee, MPH –Policy and Research Division Sarah Broughton, MSW –Office of Integrated Care and Behavioral Health

3. http://www.dmas.virginia.gov/ 3 Department of Medical Assistance Services Presentation Outline Commonwealth Coordinated Care (CCC) Overview Evaluation Overview Initial Evaluation Findings –Major Program Successes (2011 – 2014) –Implementation Challenges and Updates –Care Management Case Studies Evaluation Next Steps Take-Away Points Goals After Demonstration Ends

4. http://www.dmas.virginia.gov/ 4 Department of Medical Assistance Services Commonwealth Coordinated Care (CCC) Overview

5. http://www.dmas.virginia.gov/ 5 Department of Medical Assistance Services Commonwealth Coordinated Care (CCC) A four year financial alignment demonstration to test a new payment and service delivery model for full-benefit Medicare- Medicaid beneficiaries (>21 yrs.) (including Elderly or Disabled with Consumer Direction and Nursing Facility) that provides high quality, person-centered care through one entity responsible for coordinating all primary, preventive, acute, behavioral, and long-term services and supports

6. http://www.dmas.virginia.gov/ 6 Department of Medical Assistance Services CCC Enrollment Dual eligible beneficiaries may opt-out or change Medicare-Medicaid Plan (MMP) assignment at anytime Voluntary Enrollment Phase –Duals proactively enroll in CCC –Enroll by contacting state enrollment broker Passive (Automatic) Enrollment Phase –Duals automatically enrolled into CCC through an intelligent assignment algorithm

7. http://www.dmas.virginia.gov/ 7 Department of Medical Assistance Services Why is this Important? CCC is a new statewide coordinated care program authorized under the Affordable Care Act for improving health outcomes for some of Virginia’s most vulnerable citizens CCC represents the first time Virginia has included behavioral health and long-term services and supports in a managed care delivery system Virginia’s experiences implementing this program can inform the development of similar programs in other states

8. http://www.dmas.virginia.gov/ 8 Department of Medical Assistance Services Evaluation Overview

9. http://www.dmas.virginia.gov/ 9 Department of Medical Assistance Services CCC Evaluation Team and Advisory Committee Internal/External Evaluation Team composed of 5 staff from the Department of Medical Assistance Services (DMAS) and 2 faculty from George Mason University (Mason) Evaluation Advisory Committee composed of 14 members representing the aging, behavioral health, disability, enrollee, nursing facility, and state government communities

10. http://www.dmas.virginia.gov/ 10 Department of Medical Assistance Services CCC Evaluation Overview Longitudinal evaluation using a mixed methods research design –Qualitative (DMAS): Case studies using interviews, focus groups, observations, and document reviews to gain insights into how the program is working by studying it in person, over time, and from diverse perspectives –Quantitative (Mason): Enrollee panel survey and analysis of enrollment/disenrollment data to identify trends and a longitudinal analysis to determine impact on cost, quality, utilization, etc.

11. http://www.dmas.virginia.gov/ 11 Department of Medical Assistance Services CCC Evaluation Scope Presentation Focus

12. http://www.dmas.virginia.gov/ 12 Department of Medical Assistance Services Initial Evaluation Findings

13. http://www.dmas.virginia.gov/ 13 Department of Medical Assistance Services Major Pre-CCC Program Successes (2011-2014) 2011 Administration Support, Initial CMS/DMAS Conversations 2012 Initial Proposal, CMS/DMAS Workgroup, Program Scope, Stakeholder Outreach, & Advisory Committee 2014 Implemented March 2014 as a Phased In Program (>100 localities) 2013 New Directorate, RFP, MOU, Three-Way Contract, Readiness Reviews, Provider Networks, Training, Stakeholder Engagement & Outreach

14. http://www.dmas.virginia.gov/ 14 Department of Medical Assistance Services Major CCC Success (2014) CCC Region Total Population Voluntary Enrollment Automatic Enrollment Total Enrollment Central Virginia21,6981,6988,2979,995 Northern Virginia14,4382301,3521,582 Roanoke12,2374974,3174,814 Tidewater18,8311,3947,0138,407 Western/ Charlottesville6,2973482,3632,711 Total Enrollment73,5014,16723,34227,509 Note: Enrollment numbers current as of January 2, 2015. Of the 27,509 enrollees, 21,009 (76.4%) are Community Well, 3,803 (13.8%) are Nursing Facility, and 2,680 (9.8%) are Elderly or Disabled with Consumer Direction.

15. http://www.dmas.virginia.gov/ 15 Department of Medical Assistance Services Major CCC Success (2014) Hiring/Training Care Managers & Staffing Regional Care Teams Data Sharing & State/Federal Program Enrollment Processing Quarterly Advisory Committee Meetings Electronic Processing of Long Term Service & Support & Behavioral Health Claims Health Assessments, Care Plans, & Interdisciplinary Care Teams DMAS/MMP/ Stakeholder Workgroups Regional Provider & Enrollee Town Hall Meetings Multiple Stakeholder Outreach Avenues Quality Monitoring & Learning Collaborative

16. http://www.dmas.virginia.gov/ 16 Department of Medical Assistance Services CCC Enrollment Challenges & Updates Letters intended to inform duals about CCC, but some found them confusing Update: DMAS is working with CMS to resolve [Ongoing] CCC Enrollment/ Notification Letters CMS unable to reconcile disenrollments between MARx and MMIS Update: Automated process developed to reconcile disenrollments between systems [Completed] Medicare Processed CCC Disenrollment Requests Difficulty processing enrollment requests between CMS, DMAS, & MMPs Update: DMAS developed automated process to address at system entry [Completed] Enrollee Cancellation/ Disenrollment Programming

17. http://www.dmas.virginia.gov/ 17 Department of Medical Assistance Services Not all SAs honored due to Medicaid only medical transition reports Update: DMAS developed new monthly report containing SAs from all Medicare & Medicaid FFS providers prior to duals’ enrollment dates [Completed] Service Authorizations (SA)/ Continuity of Care Data needed for quality/continuity of care monitoring Update: CMS/MMP data sharing agreement in development, but DMAS still unable to obtain encounter data [Ongoing] Medicare Claims/ Encounter Data CCC Systems Challenges & Updates

18. http://www.dmas.virginia.gov/ 18 Department of Medical Assistance Services Provider network standards have not been achieved in some localities Update: Network development is ongoing and CMS/DMAS are working with the MMPs to address [Ongoing] Provider Network Adequacy Some providers encouraged duals to opt-out of CCC during initial stages Update: DMAS addressed through educational meetings, newsletters, conference calls, and Medicaid memo [Completed] Protecting Beneficiary Choice CCC Program Challenges & Updates

19. http://www.dmas.virginia.gov/ 19 Department of Medical Assistance Services CCC in Action – Case Study #1 Staff observed a visit by a 63 year old LTSS enrollee (Ms. A) to a cardiology office. Ms. A was accompanied by her care manager (CM) and personal care assistant. Upon arrival, Ms. A was informed that her PCP had not submitted a referral; however, the CM contacted the PCP for a referral so the enrollee could see the specialist. The CM reported that if she had not been present, Ms. A most likely would not have met with the specialist. She said events such as these discourage people from receiving medical care.

20. http://www.dmas.virginia.gov/ 20 Department of Medical Assistance Services CCC in Action – Case Study #1 The CM also reported that the PCP had changed some of Ms. A’s prescriptions, which the specialist was not aware of. As a result, the CM provided the specialist with a new list of prescriptions. The CM said information exchange between physicians is important because it “prevents people from having 50 different meds.”

21. http://www.dmas.virginia.gov/ 21 Department of Medical Assistance Services CCC in Action – Case Study #2 During the health risk assessment for a 65 yr. old LTSS enrollee recovering from basil carcinoma surgery (Ms. M), the CM noted that she was feeling guilty about her condition. The CM asked if Ms. M wanted to speak to a counselor. Ms. M declined initially, but later contacted the CM who generated a counseling referral so she could obtain assistance. During a follow-up visit with her CM, Ms. M stated that the counseling had helped enormously.

22. http://www.dmas.virginia.gov/ 22 Department of Medical Assistance Services CCC in Action – Case Study #2 However, she mentioned encountering some difficulty arranging transportation to the counseling sessions. The CM confirmed that transportation is available through CCC for counseling appointments and provided Ms. M with contact information. During the visit, Ms. M expressed interest in using other CCC benefits (e.g., gym membership and $35 OTC) offered by her MMP, which the CM helped to arrange.

23. http://www.dmas.virginia.gov/ 23 Department of Medical Assistance Services Takeaway Points, Evaluation Next Steps, and Long-Term Goals

24. http://www.dmas.virginia.gov/ 24 Department of Medical Assistance Services Takeaway Points Initial evaluation findings indicate that Virginia successfully developed and implemented a new payment and service delivery model for duals, but not without encountering certain enrollment, systems, and program challenges Virginia is interested in collaborating with other states and organizations on similar care models for duals –Please submit collaboration inquiries through the CCC Inbox: CCC@dmas.virginia.govCCC@dmas.virginia.gov

25. http://www.dmas.virginia.gov/ 25 Department of Medical Assistance Services Evaluation Next Steps Continue focus groups with dual eligibles and observations of LTSS care management activities –To date, 5 focus groups and 20 hrs. of observations conducted Begin case studies of MMPs’ CCC implementation activities and interviews of LTSS providers Conduct surveys of CCC enrollees and disenrollees and analyses of outcomes

26. http://www.dmas.virginia.gov/ 26 Department of Medical Assistance Services Long-Term Goals After Demonstration Ends Virginia may consider expanding CCC to the rest of the state after the demonstration ends and/or transitioning CCC to mandatory managed care on the Medicaid side However, these goals are subject to change and depend on many factors

27. http://www.dmas.virginia.gov/ 27 Department of Medical Assistance Services THANK YOU! For additional information on the CCC Evaluation, please contact Gerald Craver gerald.craver@dmas.virginia.gov 804-786-1754, –Or visit the CCC Evaluation website http://www.dmas.virginia.gov/ Content_pgs/ccc-eval.aspx