managed medicaid: cms 2390 impact
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Managed Medicaid: CMS 2390 Impact Donna CostanzaVice President, Value-Based Care Strategic SolutionsConifer Health Solutions
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Donna CostanzaVice President Strategic Solutions, Conifer Health Value-Based Care
Leads delivery and strategic solutions for clients which are responsible for providing high quality and effective delivery of Conifer Health services and technology to clients
Directs client management, network development and physician alignment strategies
Previously the Chief Operating Officer of Cap Management Systems, leading health plan operations and financial management of over 30 risk-bearing provider organizations and hospitals
Has more than 20 years experience with managed Medicaid, Medicare and commercial programs
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Significant Scale Advantage
Service Centers
Headquarters
14,500+ EMPLOYEES20 SERVICES CENTERS
800+ CLIENTS IN43 STATES
BILLION MEDICALLY MANAGED SPEND FOR EMPLOYERS19$ +
Facts based on data ending Q4 2015
5.7MILLION MANAGED LIVES
+MILLION PATIENT TOUCH-POINTS ANNUALLY25+
BILLION NET REVENUE PROCESSED ANNUALLY
28$ +
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CMS 2390-P Overview
Major proposed rule to align Medicaid managed care with Medicare Advantage and qualified health plans (QHPs) First significant revisions since 2002
Multiple statutory provisions on beneficiary protections and state and federal oversight for program accuracy and actuarial soundness related to payments
Expands federal role in rate setting at both the managed care organization and at the provider level
Mandates states to launch comprehensive quality strategies
Places special focus on long-term services and supports (LTSS)
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What’s driving CMS 2390-P? Explosion of Medicaid managed care populations
Medicaid now accounts for about 16 percent of total personal health care spending in the United States and will soon exceed $500 billion in annual expenditures. Payments for managed care account for 25-30 percent of all Medicaid benefit spending.
71.8% Medicaid enrollees in some type of managed care arrangement
63% of children
48% of adults
33% of people with disabilities
13.9% of seniors
13.2% percent of dual eligibles
Populations enrolled in risk-basedmanaged care
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Some variance by markets – but still impacting nearly every care community
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Major provisions of CMS-2390-P
Network adequacy – Sets minimum federal network adequacy standards (States may be required to adopt enforcement strategies)
Beneficiary support system State-directed provider payments – CMS would still prohibit states from directing plans to
make provider payments, but would allow them to: Place contracted provider payments under particular (value-based) payment methodologies to
promote quality, or Incent providers to participate in particular initiatives
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Major provisions, continued…
Medical loss ratio – Minimum of 85% Actuarial soundness – Significant change. States must certify actual payment
rates to CMS. Information standards – Plans would have to provide enrollees with member
handbooks and formulary information Grievance and appeals – Aligns Medicaid and CHIP grievance and appeals
processes with those that exist for MA and commercial coverage Marketing – Rule would clarify that Medicaid plans that also offer QHPs may
market both at the same time to the same individuals without violating the Medicaid marketing restriction on the sale of private insurance
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Major provisions, continued…
Plan choice – Would require states to provide beneficiaries with at least 14 calendar days and appropriate informational notices to make a decision on plan enrollment
Institutions of mental disease – Would permit capitation payments to plans for enrollees who have a short-term stay – 15 days or less – in an IMD
Quality of care – States would mandatorily need to launch comprehensive quality strategies for Medicaid and CHIP programs
Program integrity – Would require states to screen and enroll all Medicaid providers to address what CMS describes as a lack of consistency between managed care and FFS provider screening and enrollment
Prescription drug coverage – CMS proposes to require that states cover, through FFS, any Section 1927 covered outpatient drugs or classes of drugs that are excluded from the managed care contract
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Moving from Fee-for-Service to Fee-for-Value
Clinical Integration Upside ACO Full Capitation
Employer ACO
Episodic & Bundled
Payments
Commercial ACO
MSSP ACO
Managed Medicare / Medicaid
Clinically Integrated Network
Upside/Downside ACO Licensed product
NextGen ACO
Increasing expertise needed to manage risk and engage providers
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Conifer Health Services Services Union Employer Bundled Services ACO/IPA MSSP RBO
Consulting
Marketing •Payor and Provider Contracting • • • •Provider Network Development • • • •Provider Network Relations •
Data Storage
Data Warehouse • • • • • •Document Intake • • • •Eligibility Enrollment • • • • • •
Member Performance
Member Adherence • • • •Member Engagement • • • •Participant Portal • • • •
Population Health Member Risk Stratification • • • • • •Provider Performance Provider Portal • • •
Reporting
Financial Analytics • • • •Operating Performance •Quality Performance • • • •Regulatory Performance • • •Self-Serve Analytics • • • •
Transactions
Claims Processing • •Concurrent Review • •Credentialing •Grievance and Appeals •Member Enrollment Cards •Provider / Member Call Center • •Referral Determination • •
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Success with Managed MedicaidFive Areas for Consideration
• Contracting with Payers• Utilization Management and Care Coordination• Network Design and Adequacy• Risk Experience• Reporting and Compliance
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Successful IPAs, Health Systems, and Risk Bearing Organizations:
Operate, control, monitor, track, and trend financial levers which deliver high quality performance to its providers and members Payor Revenue Member Revenue and Expense Provider Expense Benchmark Analysis
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Revenue Levers
Revenue Payor Performance Attributed Populations (aid code, risk adjustment factor, age, sex). Incentive Programs (complex case, preventive measures, hierarchical condition codes). Shared Savings Programs (re-admissions, level of care, contracted services).
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Insights When Entering Risk Arrangements
Revenue Modeling Percent of Premiums Acuity Level/Risk Adjusted Factors Aid Code Age/Sex Adjustment Per Member Per Month
Expense Modeling Fee Schedules Design Division of Financial Responsibility Analysis Benefit Structure Consideration
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Division of Financial Responsibility (DOFR)Group Hospital Blue Shield
Services
Patient Counseling •Podiatry •Pre- and Post-Transplant Services •Radiation Therapy •Acute Detox •Psychiatric / Substance Abuse •Urgent Care Services - Within Group Service Area •
Urgent Care Service - Outside Group Service Area •
Health Care Professional
(inpatient)
Diagnosis, Treatment and Therapy •Emergency Services - Within Service Area •Emergency Services - Outside Service Area •Pathology / Radiology / Anesthesia •Transplant (all inclusive case rates) •Transplant (physician fees excluded from case rate payment) •
Urgent Care Services - Within Group Service Area •
Urgent Care Services - Outside Group Service Area •Visits / Consultations / Surgery •
Facility Services (inpatient)
Emergency Services - Within Service Area •Emergency Services - Outside Service Area •Facility and Supplies •Acute Detox •Psychiatric / Substance Abuse •Take Home Drugs •Transplant (includes kidney) •Urgent Care Services – Within Group Service Area •
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Expense Levers
Expense Provider Performance
Physician Performance (HEDIS, HCC, PQRS) Utilization Performance (Referral, Visits) Provider Utilization (ER usage, admissions, LOS)
Patient Performance Quality Performance(Preventive Measures) Complex Care Programs Patient Utilization (ER usage, adherence)
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$1.8m Group was losing $1M per year
Placed on Corrective Action by the Department of Managed Healthcare; threat of enrollment freeze and risk de-delegation.
Network maintenance Narrow network and renegotiated
provider contracts
Medical management Improved high-cost
pharmaceutical utilization
Financial risk design Renegotiated health plan
contracts
Increased profitability by shifting from annual loss of $1M to annual profit of $0.8M
90 PCPs receiving capitated payments for 30,000 managed Medicaid patientsThe Client
The Challenge How We Helped The Results
Case Example: Managed Medicaid
PP_ManagedMedicaid_080415
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$2k Health plan desired to reduce ER facility expense and offered grant to physicians for reducing
Physician group desired to create an incentive plan to help ER utilization and ensure capture of grant dollars Reduction in
ER utilization
California IPA with 54,000 lives200 primary care physicians serving the dual eligible population in a highly competitive market
The Client
The Challenge How We Helped The Results
Case Example: Medicaid
PP_ManagedMedicaid_080415
Financial risk design Created incentive structure to reduce
ER utilization
Medical Management After-hours access to PCP offices and
contracted with urgent care centers Enrolled top ER users in case
management program
Member engagement Educated patients about correct use of
ER vs urgent care through direct mail
Paid per physician through incentive programs
10%
Questions & Answers