Macro Models and Micro Strategies for Long Term Care Integration: An Action Agenda For San Diego

Mark R. Meiners Ph. D.

National Program Director

RWJF Medicare/Medicaid Integration Program

LTCI Planning Committee Meeting

San Diego, CA, July 17, 2002

MMIP Overview

$10+ million Initiative

Robert Wood Johnson Foundation

14 Participating States: CO, FL, MN, NY, OR, TX, WA, WI, CT, MA, ME, NH, RI, VT

www.umd.edu/aging

Dual Eligibility for Medicare and Medicaid

• 17/19% of Medicaid population 35% of cost• 16/17% of Medicare population 30/24% of cost

But Medicare and Medicaid

don’t work well together!

Why the Interest in Dual Eligibles?• Important public financing considerations• Cost shifting in both directions• Unintended consumer consequences • An opportunity to do better with limited resources• Managed care implications• Aging of the population/Chronic Care Imperative

Environmental Challenges• Waiver challenges - HCFA and OMB oversight• Balanced Budget Act and Y2K

-New Rate Book for Medicare HMOs

-Risk Adjustment for Medicare managed care

-Prospective payment for nursing home and home health

• Volatile HMO marketplace/HMO backlash• State turf battles and competing agendas• Uncertain economy – business cycles

Key Dimensions of Program Development» Scope and flexibility of benefits - more than M&M fee-for-service

» Delivery system - broad, far reaching, options, experience

» Care integration - CM, care teams, central records, coordination.

» Program administration - enroll, disenroll, data, payment incentives

» Quality management and accountability - unified, broad

» Financing and payment - flexible, aligned incentives

Models of Integrated Care•Social HMO/SHMO

•Program for all inclusive care of the elderly/PACE

•Evercare

Program Diversity• Divergent definitions of integration/coordination• Wide variations in state managed care

infrastructure• Differences in state goals and target populations• Major differences in Medicaid programs• States are in various stages of program

development

Managed FFSMedicare

CoordinationMedicare Integration

Issues/Features

•Medicaid and Medicare reimbursed FFS

•No waivers required

•Care coordinator link between programs and providers

•Use of incentives (fees, co-location, reporting)

Issues/Features

•Medicaid LTC capitated

•Medicare HMO enroll encouraged

•Various Medicaid waivers/authorities

•Inability to capture Medicare savings

•Case management lacks authority over Medicare

Issues/Features

•222 Medicare payment waiver &

•Various Medicaid waivers

•One contract for both payers

•Flexibility to use savings for non-traditional services

•Case management has control over both programs

The demonstration operates under Section 402 Medicare Wavier and Medicaid 1915(a) authority and 1915(c) waivers and fully integrates acute and LTC services

Provided to dually eligible seniors as a voluntary option to the state's Medicaid managed care program (PMAP)

Enrollment began in February, 1997. Current enrollment is 4,602, which is about 25% of total PMAP seniors eligible to join in counties where it is offered

Plans are at risk for all Medicare and Medicaid services, including 180 days of nursing facility care for community enrollees

Each enrollee gets a “care coordinator” to assist with care planning and service access

As measured by CAHPS, MSHO enrollees rate their health care higher than a control group of PMAP seniors; MSHO enrollees also reported fewer problems with their care than the PMAP group

The program operates in seven counties around the Minneapolis/St. Paul area and three rural counties.

In September 2001, the state launched Minnesota Disability Health Options (MNDHO) for physically disabled under age 65

Minnesota

The Partnership Program is a fully integrated PACE-type Medicare/Medicaid program at four sites designed to coordinate across multiple delivery of care settings using

interdisciplinary teams

The program consists of two innovative models of care, one for the elderly and one for people with disabilities

The benefits of the Medicare/Medicaid system are combined into one program through an 1115/222 dual waiver

Service is home based and involves the consumer in decision-making

Wisconsin

New York

County Continuing Care Network (CCN) 

Part of the overall state legislative agenda for managed long-term care (MLTC) 

Partnership between state and the Community Coalition for Long-Term Care (CCLTC) 

Received Medicare Payment Waiver from CMS; implementation planned for 2003 

The demonstration intends to enroll approximately 9,000 Medicare-only and over 1,000 Medicare/Medicaid dual eligible persons age 65 and older

 Will enroll individuals living in nursing facilities as well as those living in the community

 CCNs will be at full risk for all Medicare and Medicaid covered services

Denver metro area: Adams, Arapahoe, Denver, Douglas, and Jefferson Counties

All Medicaid - only and dual eligibles residing in Denver metro area will be eligible for voluntary enrollment

All Medicaid acute, LTC services, and Medicare Part A and B services will be covered by a capitated plan

Planned model is a partnership between Kaiser Permanente and a local PACE site

•Eligible Kaiser members will enroll in PACE to receive risk adjusted payment•All primary care, preventive and LTC services will be provided by PACE•Kaiser will provide specialty, hospital and pharmacy services•Kaiser and PACE will share risk

Colorado

A fully integrated managed care program covering the full range of acute and long-term care benefits for elderly dually eligibles and Medicaid-only recipients

Through an innovative partnership the State and CMS will jointly contract with SCOs

Massachusetts and CMS wish to stimulate the entrance into the health care marketplace of new kinds of organizations and will allow SCOs to be developed out of different configurations of provider networks

Primary Care Teams, consisting of a Primary Care Physician, a nurse, nurse practitioner or physician's assistant, and a Geriatric Support Services Coordinator (GSSC) will be responsible for arranging, integrating and delivering care for enrollees with complex care needs

Implementation of SCOs is projected in 2002.

Massachusetts

STAR+PLUS is a mandatory program for SSI Medicaid enrollees in Harris County

STAR+PLUS operates under a 1915(b) and (c) waiver combination

An enhanced prescription drug benefit is available for Medicare-eligible participants who choose the same HMO for both Medicaid and Medicare services

A care coordinator is responsible for coordinating the client's acute and long term care services, even if the client is a dual eligible who receives Medicare from a provider who is not affiliated

with the STAR+PLUS HMO's Medicare risk product

Each STAR+PLUS HMO also offers its own set of additional "value added" services

HMOs retain the first 3% of any profit, but split equally with the state any profit between 3% and 7%. Any profit over 7% must be returned to the state.

Current enrollment is approximately 54,000; nearly half are dual eligibles

Texas

Florida

The Diversion Project seeks to provide home and

community-based long-term care to a population

truly at-risk of institutionalization

The preference is for HMOs with Medicare risk contracts

who are paid a monthly Medicaid capitated payment

The waiver granted is 1915(c)

Voluntary enrollment began on December 1, 1998 in Orlando.

Enrollment in the Palm Beach area began on August 1, 1999

Current enrollment: 653 in Orlando and 601 in Palm Beach County; Enrollment cap has been reached and the state has approached the legislature for increased funding

• Contracting PCP is responsible for coordinating all acute and primary care Medicaid services on a non-risk basis with a focus on managing pharmacy services

• All elderly and disabled Medicaid beneficiaries whose physician is participating in five operational pilot sites are eligible if the patient is in long term care or has diabetes, congestive heart failure or other cardiovascular disease

• There are 1200 beneficiaries participating-approximately 65% are dual eligible

• The PCP receives pharmacy and quality indicator reports on each patient and the patient receives educational information on their conditions

• There are centralized care coordinators that support the role of the PCP through population-based interventions

Maine

Vermont Independence Project: Care Partner Program is a managed fee-for-service program involving case managers working in seven primary care

provider offices performing the full range of medical and social case management and interfacing with the primary care provider.

Co-location has resulted in service integration and relationship building between the case manager, primary provider, and patient.

The program operates in three counties: Franklin, Grand Isle, and Windham.

Vermont

Goals of the project include:

     - improved quality of health care for dual eligibles;

  - increased focus on care coordination; and

  - systems alignment to improve the efficiency and effectiveness of the service continuum

New care management strategies will be tested among 3 groups of dual eligibles who are currently receiving long-term care services:

        - those being served by both a Medicare and Medicaid HMO;

  - those being served by a Medicaid HMO and receiving Medicare on a fee-for-service basis;  

- those receiving both Medicare and Medicaid on a fee-for-service basis

Existing data will be improved by:

  - merging significant data on dual eligibles from all current Medicare and Medicaid systems, including long-term care; 

     - measuring and analyzing the cost and service utilization impacts of further integration of the systems; and- developing a process to integrate information and make it available to policy makers and to case managers and care providers across the continuum

Oregon

Rhode Island will have a dynamic long-term care system that supports high quality, independence, choice, and coordination of services with the necessary public and private funding.

Voluntarily program that will provide consumers with services in local convenient familiar community settings called CARRE (Coordination -

Assessment - Referral - Reassessment - Evaluation) Centers.

- Level I will provide information and referral services

- Level II will help consumers navigate funding sources and provide care coordination between social, environmental and medical services - Level III will offer fully integrated services

Focusing on quality, appropriateness, access to care and team work, Living RIte hopes to encourage creative systems of care with a core component of care coordination with consumers at the helm.

Rhode Island

Washington is planning the development of seamless health care models that integrate the full spectrum of acute and long-term care services for dual eligible seniors

Project demonstration models include the following:

1) contracting with a health care organization for all Medicare and Medicaid acute and long-term care services on a fully capitated basis

2) developing a senior care network that incorporates medical, home care, case management, residential, and specialty providers, in partnership with an M+C entity

3) expanding upon the existing PACE model.

JEN Associates has been hired to build an integrated database to allow project staff the ability to analyze expenditure patterns and utilization of services

and to develop risk adjusted rates

Washington

• Pilot Health is an incorporated managed long term care provider coordinating with fee-for-service medical providers in the community for all Medicaid-only and dual eligible in Cheshire County. To date, there is no plan to pursue this model for further integration or enhancements

• Current focus is on redesigning the State’s long term care system for elderly and disabled persons to promote greater coordination between primary/acute care and long term care supports

• A series of fifteen “town” meetings have been held across the State for consumer input

• A survey of acute and primary care providers in Monadnock Region is being conducted to determine the status of coordination between acute, primary, and long term care in that area

• There are projects to analyze Medicare and Medicaid linked utilization data

New Hampshire

The Connecticut project will build on the foundation of a PACE model with significant variations including: 1) developing capitated rates related to

functional need and 2) expanding the target population to include persons at risk but not yet eligible for nursing home care

Recent Accomplishments:

• conducted focus groups with potential consumers/caregivers

• field tested consumer survey based on CAHPS focused specifically on the frail

elderly

Next Steps:

• finalize contracting standards and waiver applications (now that federal PACE regulations have been published)

•develop risk - adjusted, actuarially sound rates

•analyze merged data

•develop provider materials

Connecticut

Core Building Blocks -Case Management / Care Coordination

-Targeting Beneficiaries Who are Most at Risk

-Primary Care for People with Chronic Conditions

-Quality Methods and Measures

-Integrating Information

What is the Problem your are trying to solve?

Waivers: Chicken and Egg

Consensus Development

Winners and Losers

Political Support

CMS / OMB

Demographic Imperative - Still in future!

Many Complimentary Agendas: (drugs, uninsured, pre/partial duals, Olmstead, chronic care management, consumer

focus/frustration)

Market Timing - Invest now!