aligning incentives between medicare and medicaid for dual eligibles february 2009 pamela parker...
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Aligning Incentives Between Medicare and Medicaid for
Dual Eligibles
February 2009Pamela Parker
Special Needs PurchasingMinnesota Department of
Human Services [email protected]
Systems for the Future States have increasing proportions of people age 65 years and
older and people with disabilities with chronic conditions. How can States prepare for this fiscal and care delivery challenge?
95% of seniors and about 50% of adults with disabilities on Medicaid are dually eligible for Medicare. Current care for dual eligibles is clinically fragmented and confusing to beneficiaries.
States need to focus on building systems that can address chronic care management across both Medicaid and Medicare including primary, acute, drug coverage, home and community services and other LTC.
The Medicare Advantage Special Needs Plan (SNP) option provides a vehicle for integrating Medicare and Medicaid benefits to develop clinical systems that manage underlying chronic conditions across primary, pharmacy, acute and long term care.
But barriers still remain for many States in contracting with SNPs, and stronger fiscal incentives are needed for more States to move forward with integrated arrangements.
MA-SNP Snapshot 769 Medicare Advantage SNPs operating in 2008: 1.1 million
enrollees Dual Eligible Chronic and Disabling Institutional
439 DE SNPs: 844,000 enrollees Coordinated dual eligible programs exist in MN, MA, WI,
NY, FL, TX, WA, AZ, CA, KY, OR, UT. VA, PA, MI, NM among States working on new programs Other States contracting with SNPs or MA plans for cost
sharing wrap Moratorium still in place for expansion of current DE SNPs
and for new SNPs for 2010 unless a state contract is in place Current DE SNPs encouraged but not required to have a state
contract CMS support for SNP/State relationships, tools and
resources: http://www.cms.hhs.gov/IntegratedCareInt/
Congress and CMS are Making SNPs “More Special” MIPPA and new SNP rules (9-15-08)hold SNPs to additional standards:
Clinical model of care designed for needs of enrolled population Network appropriate for population served Use of care plans, interdisciplinary teams, comprehensive initial
and annual assessments Use of nationally recognized clinical protocols Ongoing measurement of quality and health status improvement
indicators Dual SNPs to have relationship to State, Medicaid contracts required for new SNPs, States not required to
contract Cost sharing and Medicare coverage information to prospective
dually eligible enrollees MIPPA extends SNP authority through 2010 MIPPA also provides stricter marketing requirements CMS has directed NCQA to develop additional Structure and Process
measures including new measures on Medicare and Medicaid Integration
Opportunities for Aligning Incentives
SNP/State contracting with comprehensive Medicare/Medicaid capitations can align fiscal incentives and reduce cost shifting between acute and long term care: Reduce fragmentation of delivery and coverage
and simplify access (all drugs and medical services provided under the same plan)
Align incentives for assessment, early intervention and management of chronic conditions which cause hospitalizations and lead to additional Medicaid LTC placements
Support clinical systems improvement of outcomes, prevention, and chronic care management
Increase accountability for controlling total costs and tracking outcomes of care across payers and providers
Opportunities for Aligning Incentives
Access to primary care management and Medical Home models for duals not otherwise possible in FFS Medicare
State contracts can be used to leverage additional Medicare benefits, Medicare encounter data, information sharing about Part D, appropriate formularies, care coordination, etc.
Simplified enrollment, integrated member materials, clarify total benefits for duals available across both Medicare and Medicaid
Manage capitated long term care benefits to assist state with “rebalancing” goals (align SNP and State interests in managing risk for placement of community members in NFs)
Barriers to Aligning Incentives
Lack of clear financial incentives for States, such as sharing in Medicare savings
Uncertainty about future of SNPs, evolving SNP policy at CMS, not clear what authority exists after 2010.
Uncertainty about new administration plans for health reform, and impact on Medicare and Medicaid and roles for current DE SNPs
Uncertainty about future Medicare base rates, Medicare cuts and impact of changes in bid processes
Conflicts between mandatory Medicaid enrollment and voluntary Medicare enrollment
Difficult to align Medicaid and Medicare procurement and contracting processes and timing
Misaligned SNPs (may be different entities from established Medicaid managed care MCOs)
Conflicts or duplication between Medicare and Medicaid requirements may add complications
Very difficult to measure results, may take years to demonstrate change
Barriers to Aligning Incentives
Advocacy concerns about medical model and health plan lack of knowledge of community based services
Political opposition from institutional and residential providers
Loss of role for entities currently in charge of managing HCBS (AAAs or counties, etc)
Requires robust managed care infrastructure Takes planning, resources and many changes in
operations to take full advantage of the opportunities
Easy to recreate all of the misaligned incentives by following FFS patterns even in managed care
Future of Integrated Programs Better fiscal incentives needed to encourage more
States to coordinate with SNPs, Congress reluctant to allow share of Medicare savings
Potential Medicare marketplace instability due to cuts in Medicare payments for “rural floor”, increased requirements, reauthorization needed prior to 2010
MIPPA and SNP rules put pressure on SNPs to approach States for contracts, but States not required to contract
MIPPA requires CMS to provide support to States related to coordination of care for duals, but no money appropriated
Future of Integrated Programs CMS supportive of concepts but siloed
operations limit responsiveness New State Plan Preprint on coordination with
SNPs could be useful to States, SNPs and CMS in more formal recognition of integrated features
Models that integrate Medicare and Medicaid have made gains slowly but surely over the past 15 years
Bipartisan recognition of value of integrated SNP arrangements could be useful in any future health reform efforts
Demographics and fiscal crisis require change Has anyone got a better idea?
Minnesota’s Managed Minnesota’s Managed Care Programs Care Programs
How Minnesota’s Programs Align Incentives Between
Medicare and Medicaid
MN Managed Care Mandatory statewide Medicaid managed care program since 1985:
PMAP/Minnesota Care: DHS contracts with 9 local non profit HMOs/CBPs to provide services to about 447,000 families, non-disabled adults and children
Minnesota Senior Care Plus (MSC+): Most Medicaid seniors 65+ including dual eligible enrollees and NF residents required to enroll since 1985. Includes LTC services of PCA, home and community based and 180 days of nursing home services
Voluntary statewide integrated Medicare/Medicaid SNP programs, no special waivers required: Minnesota Senior Health Options (MSHO): Began 1997, 83
counties, includes LTC services, contracts with 9 dual SNPs Minnesota Disability Health Options (MnDHO): Began 2001,
includes LTC services, enrolls people with physical disabilities through contract with 1 SNP, operates in 7 county metro area only
SNBC: Began 2008, integrated Medicare/Medicaid for all people with disabilities, does NOT include PCA and most home and community based services, 83 counties, contracts with 7 SNPs
Seniors Managed Care Programs MSHO (83 counties)
36,500 members
MSC+ (87 counties, added 7 county metro 1/09 and phased out MSC )
11,400 members
Enrollment Voluntary (alternative to MSC/MSC+)
Mandatory
Medicare Services
All Medicare services including Part D drugs through Medicare Special Needs Plan (SNP)
Medicare A/B services through Medicare FFS.
Part D drugs through separate Medicare drug plan
Medicaid Basic Care Services
Medicaid basic care services (includes PCA) and remaining drugs through same SNP
Medicaid only plan provides basic care (includes PCA) and remaining drugs
Medicaid Long Term Care Services
Elderly Waiver (EW) through SNP plus 180 days of nursing home care
EW through same plan plus 180 days of nursing home care
MN Seniors Managed LTC Rate Setting Summary MSHO and MSC+
Rate CellServices
Institutional (SNF/NF) Community with HCBS
Community without HCBS
Medicare Risk Adjusted Risk Adjusted plus frailty factor (being phased out)
Risk Adjustment
Medicaid Primary/Acute
Plan specific rate based on blend of plan costs and external factors w age, sex, region, and Medicare status
Plan specific rate based on blend of plan costs and external factors, adjusted for age, sex, region and Medicare status
Long Term Care Health plan liable for 180 days SNF/NF care for all community enrollees FFS NF payment locked out until liability met Health plan liable for Medicare SNF stays for all members
NF Add-on (for Medicaid stays based on expected use- LOS, cost, admission rates as set by State) for community members
HCBS payment is based on average FFS cost, adjusted for age, sex and metro/non metro
NF for enrollees already in institution and for community member stays after liability is met is paid FFS by the State.
Recent Program Developments Original MSC (PMAP) program for seniors phased out effective
1/2009 MSC+ now operates statewide, all 97 counties Most Medicaid seniors now required to enrolled in managed long
term care through MSC+ or may choose MSHO as voluntary alternative
RFP issued February to re-procure for MSHO and expand MSHO to remaining four uncovered counties in north (Hubbard, Beltrami, Clearwater and Lake of the Woods).
All plans must respond to RFP to remain in MSHO in existing counties
RFP also issued for SNBC for 7 county metro area to allow for additional SNPs to participate in metro area and to expand to the four additional northern counties.
Responses due in late April
MN Integrated Program Features Coordinated access to ALL Medicare A,B, D and Medicaid drug
benefits under one source Integrated Medicare and Medicaid enrollment forms and process
and member materials, State model materials for all plans Initial and annual risk screening and follow up assessments for all
members Facilitation of physician relationship and annual primary care visits Care Coordination: Each enrollee assigned a care coordinator or
health service coordinator who assists with coordination of primary, acute and LTC services, or for SNBC, care navigation assistance
Coordinated authorization and approval for both benefit sets, providers bill one place for all services
PIP Collaboratives: SNPs collaborate on design of QI interventions to focus efforts on the same clinical topics
State led workgroups with all SNPs at the table on care coordination, audit requirements, best practices
State acts as TPA under contract with SNPs to process and submit Medicare enrollment, this enables enrollments to remain integrated
Typical Dual Eligible Drug Coverage
Dual Goes to Pharmacy for Drugs: Must Present 3 Different Cards
Medicare Part D Drugs Medicare Part B Drugs Medicaid Drugs
Medicaid Card
Medicare Card and Medicaid CardPart D Plan Card
Medicaid pays 20% cost sharing, pharmacy or provider bills DHS separately
Integrated Drug Coverage
MSHO, MnDHO, SNBC Enrollee Takes 1 Card to Pharmacy
Medicare Part D drugs
Medicare Part B drugs
Medicaid drugs
20% Medicare Cost Sharing covered
Care Management Strategies Initial risk screening and assessment of members for early identification Includes collection of ADLs/assessment info and direct entry to State
system Assigned follow up schedules for calls and home visits for members All community members screened for community services with quick
implementation Care coordinators facilitation of annual primary care preventive visits
State provides performance incentive payments for certain types of visits
Care coordinator attendance at key physician visits Nurse Practitioner models most effective for NF members
Requires cooperation of nursing facilities, monthly meetings with providers
Provider training and care coordinator back up Immediate starting of IVs for infections State sponsored workgroup on improved care management models
for NF members with focus on issues for rural areas Tiered subacute rates for certain SNF stays Waiver of 3 day hospital stay requirement Payment of in lieu of days or ISU in SNFs Additional provider training on falls prevention, urinary incontinence
management Fast track intervention strategies/protocols on key chronic conditions
Case Study Example MCO authorizes additional Intensive Service Day payment to
nursing home for 70 year old resident who needs highly intensive rehabilitative care, wheel chair bound, ventilator dependent, and post polio with tracheotomy and wound care. This reduces need for additional hospitalizations.
MCO provides regular check in by Care Manager with nursing facility to monitor care.
At first resident is expected to remain in nursing home long term because of dependence on vent so after 100 day Medicare stay is over, MCO pays for nursing home care under Medicaid managed care custodial care benefit.
Resident becomes more motivated to wean from vent and return home.
Additional respiratory therapy provided reduces need for ventilator. Care Coordinator develops Community Support Plan for return
home. Community based services are arranged (ramp, home health aide
and RN visits, Lifeline). About six months after entering nursing home, resident returns
home with more control over managing health and independence. This case study is courtesy of Blue PlusOther health plans also have similar case studies
Participating MSHO SNPs and MSC+ Health Plans for Seniors
Blue Plus First Plan Health Partners Itasca Medical Care Medica Metropolitan Health Plan Prime West South Country Health Alliance UCare Minnesota
46.8%
24.0%29.2%
51.2%
31.3%17.4%
34.9%39.6%25.5%
29.1%
35.7%
35.1%
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
Senior Enrollment by Program and Setting of Care March 2008
NF 1,882 1,116 1,143 12,461
NHC 1,549 2,007 1,774 12,677
CO 3,023 3,281 1,563 10,338
FFS MSC MSC + MSHO
86.0%
3.9%
10.1%
71.2%
28.8%
62.3%
33.0%
4.7%
74.5%
25.5%
68.3%
24.7%
7.1%
53.4%
42.9%
3.7%
88.6%
11.4%
70.1%
29.9%
85.0%
9.3%
5.6%
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
Managed Care Senior Enrollment by Health Plan March 2008
MSC + 1,178 389 192 158 875 55 262 826 545
MSC 453 - 1,357 - 3,051 638 - - 905
MSHO 10,029 960 2,563 462 8,444 795 2,042 1,935 8,246
Blue PlusFirst Plan
BlueHealthPartn
ers
Itasca Medical
CareMedica Metro HP
Primew est Health System
South Country Health
UCare Minnesota
Minnesota Medicaid Elderly Waiver Recipients March 2008
Fee-for-Service, 1,549, 9% MSC, 2,007,
11%
MSC +, 1,774, 10%
MSHO, 12,677, 70%
Total Recipients: 18,007
MnDHO (1,033 Enrollees)
Special Needs Basic Care (2672 Enrollees)
Enrollment Voluntary, people with primary physical disabilities in 7 county metro and with DD in 3 counties, limit of 120 DD
Voluntary, open to all Medicaid dually eligible and non dually eligible with disabilities in 83 counties)
Medicare Services
All Medicare services including Part D drugs through Medicare Advantage SNP
All Medicare services including Part D drugs through Medicare Advantage SNP
Medicaid Basic Care Services
Most Medicaid services provided through same SNP plan including remaining drugs and PCA services
Most Medicaid services provided through same SNP plan including remaining drugs except PCA and PDN which remain Fee for Service
Medicaid Long Term Care Services
Medicaid CADI/TBI waiver though same SNP plan plus 180 days of Medicaid nursing home care
Medicaid HCBS waivers and long term care services remain Fee for Service except for the first 100 days of nursing home care
Disability Managed Care Programs
Summary of Key SNBC Contract Requirements
Risk screening within 30 days of enrollment Medical home/Primary Care Clinic Facilitation of annual physician visits Broad availability and access to specialists, transportation and
specialty DME suppliers Additional case management or navigation assistance included.
Some plans have contracted with counties to provide this assistance. 24/7 RN call lines Coordination of Medicare and Medicaid drug coverage Simplified/integrated Medicare and Medicaid enrollments, materials
and appeals processes Disability training for member services Survey and provide information to enrollees about clinic accessibility Clinical measures appropriate to people with disabilities Accessibility surveys of primary care clinics Communication protocols for working with counties and providers
who are highly involved (eg residential, home health) Health plans will cover Medicaid co-pays for both duals and non
duals. Health plans required to provide provider training
Minnesota Disability Health Options (MnDHO)
Enrollment voluntary, 1100 enrollees Operating since 2001in 7 county metro only Includes Medicare and Medicaid services including all
drugs under one SNP Includes most long term care services (SNF/NF, PCA,
PDN and home and community based waivers including CADI andTBI services)
MnDHO-PD primarily enrolls people with physical disabilities but enrollees may have mental health needs as well
MnDHO payments for acute care through same CDPS risk adjustment system as for SNBC, LTC risk adjustment is through separately developed MN specific system.
Minnesota Disability Health Options (MnDHO)
One SNP, UCare, “UCare Complete”: Physical Disabilities Program: Axis HealthCare
provides care management for people with physical disabilities
DD Pilot: Partners Choice Network for DD pilot (MORA, Fraser, LSS) limited to maximum of 120 enrollees, includes DD waiver services
Very intensive care management and comprehensive services provided to high needs group, strong focus on chronic care issues and prevention.
Good evaluation results, however costs difficult to manage.
Expansion on hold per legislation until after July 2009 However, DHS does not plan any expansions for after
2009 at this time
Stakeholder Involvement DHS developed SNBC with the assistance of a broad
group of stakeholders, including disability advocates, consumers, counties, providers and health plan representatives.
This Statewide group will continue to meet to provide input to DHS in monitoring and oversight of SNBC. The group meets quarterly and meetings are open to the public. Contact Cindy Czech 651-431-2514 to be added to
the mailing list. Each health plan participating in SNBC is required
to have a similar local stakeholder’s group. This is a great opportunity for consumers and
health plans to work together to improve SNBC on an ongoing basis.
How Does SNBC Work? There are no premiums or additional costs for enrolling in SNBC. Members must volunteer to enroll by signing an enrollment form or
having their guardians or authorized representatives sign it and sending it to the health plan.
Members can drop out in any month by sending a written request to the State or the health plan (effective the 1st of the next month)
Health plans and DHS are responsible for outreach and marketing to potential enrollees.
Health plans must follow all CMS and DHS marketing requirements. All member materials must be reviewed and approved by CMS and DHS. County staff are not responsible for enrollment and marketing but may be
consulted by potential enrollees and may assist them if requested. SNBC plans will waive Medical Assistance co-pays for all members (CMS
will not allow plans to waive Part D co-pays) People with medical spenddowns can enroll but must pay their
spenddowns to a designated provider or to the State or be disenrolled SNBC plans may offer additional Medicare benefits such as fitness
programs, or home safety equipment, podiatry care, or extra dental care The Disability Linkage Line is available for consultation for people
seeking help with SNBC, MnDHO and other Part D choices. 1-866-333-2466
All current appeal rights are included as well as some additional protections including DHS Ombudsman for Managed Care services
1-800-657-3729
SNBC Payments Medicaid payments to the health plans are “risk
adjusted” based on the diagnoses and costs of each individual enrollee through the Chronic Disability Payment System
Payments have been specially adjusted to include additional provisions for mental health services and needs
This system will provide higher payments to health plans who enroll high cost enrollees, and lower payments for those who enroll more low cost enrollees
Payments are designed to be budget neutral to current fee for service costs for enrollees
Medicare also provides a separate risk adjusted payment for dual eligible enrollees
2008 SNBC Health Plans
Blue Plus CareBlue Special Needs Basic Care
First Plan First Plan Blue Basic
Medica AccessAbility Solution
Metropolitan Health Plan Cornerstone Solutions
Prime West Prime West Special Needs BasicCare
South Country Health Alliance Ability Care
UCare UCare Connect
Results of Integrated Programs
Several evaluations prior to MSHO expansion show some positive utilization results, no harm being done
MSHO showed increased access to HCBS, increased caregiver support, and reductions in expected use of nursing home
MSHO satisfaction higher than MSC, low disenrollment
Care coordination studies of MSHO show value to members in a variety of care coordination models
MSHO costs have been under control
Results of Integrated Programs
Too soon after large 2006 expansion to have new evaluation of MSHO
Recent evaluation of care coordination models in MSHO is on DHS website
MnDHO evaluation shows dramatic changes in consumer access to preventive and primary care, but also higher costs
SNBC evaluation planned Other States following MN in developing
similar programs
Contact InformationState Website:
http://dhsinfo.dhsintra.net/main/groups/public/documents/pub/infolink_dhs_today.hcsp
Pam Parker, ManagerSpecial Needs Purchasing [email protected]
Sue Kvendru, Program [email protected]
Deb Maruska, Program [email protected]
Cara Bailey, Policy [email protected]
Special Needs PurchasingSpecial Needs PurchasingMinnesota Department of Human Minnesota Department of Human
Services Services
Pamela Parker Pamela Parker [email protected] [email protected]
651-431-2512 651-431-2512