south carolina hospital association august 14, 2014
DESCRIPTION
South Carolina Hospital Association August 14, 2014. WHAT IS PRIME?. Healthy Connections Prime is a new option for individuals 65 and older with Medicare and Medicaid. Prime offers all the health care services, fully managed by a coordinated and integrated care organization (CICO). - PowerPoint PPT PresentationTRANSCRIPT
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South Carolina Hospital AssociationAugust 14, 2014
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WHAT IS PRIME?
• Healthy Connections Prime is a new option for individuals 65 and older with Medicare and Medicaid.
• Prime offers all the health care services, fully managed by a coordinated and integrated care organization (CICO).
• Prime aligns with the Triple Aim and offers:
• Better care through a person-centered care model• Better value by focusing on quality and not quantity • Better health for the elderly population
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HISTORY
• Medicare and Medicaid programs were signed into law July 30, 1965.
• 1965 “three-layer cake”:
• Medicare Part A hospital services• Medicare Part B physician and other outpatient
services• Medicaid expending federal support for health
care services for poor elderly, disabled, and families with dependent children
• Medicare and Medicaid not initially designed to integrate and coordinate services for individuals served by both programs
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PRIME
WITHOUT INTEGRATED CARE: WITH INTEGRATED CARE
• Three ID cards: Medicare, Medicaid, and prescription drugs • One ID card
• Three different sets of benefits • Single set of benefits
• Poor communication among providers • Intentional communications, including hospital transition planning
• Health care neither coordinated nor person-centered
• Person-centered care model featuring a multi-disciplinary team; new palliative care benefit; three-day qualifying stay
• Incomplete knowledge of patient’s condition, medical records, medications and care plan
• Provider access to individualized care plan; medication reconciliation
• Limited time, staff resources or incentives to coordinate services
• Model of care promotes and incentivizes coordination; value-based purchasing
• Lack of appropriate incentives to provide care at the right time and in the least restrictive setting
• Rate structure and quality incentives address right time and right place for care
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1. The Henry J. Kaiser Family Foundation. (2013, August 1). State demonstration proposals to integrate care and align financing for dual eligible beneficiaries. Retrieved from http://kff.org/medicaid/fact-sheet/state-demonstration-proposals-to-integrate-care-and-align-financing-for-dual-eligible-beneficiaries/
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ELIGIBILITY
• Individuals may be eligible for this program if they meet the following criteria:
• 65 and older, and• Full benefit dual eligible or • Meeting the above criteria and are enrolled in
the following waivers: Community Choices, HIV/AIDS, and Mechanical Ventilation Waiver.
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ELIGIBILITY
• SCDHHS will not enroll individuals who:
• Elect the hospice benefit• Receive End-Stage Renal Disease services• Reside in a nursing facility
• Prime enrollees may still access the above services and remain in Prime
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ELIGIBILITY
• SCDHHS will not passively enroll individuals with comprehensive health insurance (i.e., Medicare Advantage, PACE or pension coverage)
• When an active choice to enroll in a CICO is made, disenrollment from existing comprehensive health insurance is triggered
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TIMELINE
• Original implementation schedule: July 1, 2014
• Revised Timeline: No earlier than January 1, 2015
Date Enrollment Waves
January 1 - March 30, 2015 Opt-In Enrollment Period
April 1 Passive Enrollment Wave #1 (Upstate to Northern Midlands)
June 1 Passive Enrollment Wave #2 (Southern Midlands to Low Country)
August 1 Passive Enrollment Wave #3 (Community Choices, HIV/AIDS, Mechanical Ventilation Waiver)
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BENEFITS OFFERED
• Medicaid services, including:
• Behavioral health• Home and community-based services• Nursing facility services
• Medicare services, including:
• Primary and acute care• Part D (prescription drugs)• Skilled nursing facility benefit
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CARVED-OUT SERVICES
• Medicaid services carved-out under Medicaid Managed and Medicare Advantage are also carved-out under Prime (i.e., non-medical transportation, adult dental, hospice)
• Carved-out services will be paid FFS
• CICOs are responsible for coordinating and fully integrated these services into the individualized care plan
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CICO CONTACTS
Absolute Total Care, Inc.Andrew Cain, Director of Contracting(803) 587-4392 | [email protected]
AdvicareDell Jeter(888) 781-4371 | [email protected]
Molina Healthcare of South Carolina, Inc.Brian Jans, VP of Network and Operations(843) 740-1785 | [email protected]
Select Health of South CarolinaKathy Williams, Provider Network Account Executive(843) 746-7499 | [email protected] Management Regional Map
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CICO
• CICOs currently undergoing readiness determination including review of network adequacy
• CICOs, CMS and SCDHHs will enter three-way contract
• Signed contract will be available on SCDHHS website• SCDHHS will share executive summary next week
• Prime Hospital workgroup established to address provider concerns and identify best practices for integrated models
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Capitation Rates
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CAPITATION RATES
• CICOs will receive PMPM capitation rates from CMS for Medicare services and SCDHHS for Medicaid services
• CICOs will then reimburse providers based upon the contract negotiated rates
• July 1, 2014 – December 31, 2104 Capitation Rates | Link
• Revised and updated rates will reflect CY2015 benefit period
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CAPITATION RATES
• Capitation rates are based upon historical FFS experience
• Rates are budget neutral prior to application of annual percent savings
• Savings percentage is applied to Medicare and Medicaid rate components regardless of whether savings accrue from reducing hospitalizations or reducing nursing facility placements
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MEDICARE BAD DEBT
• Payments associated with Medicare bad debt are included baseline estimates for capitation rates
• Medicare FFS does not reimburse facilities for bad debt associate with Medicare Advantage enrollees
• Providers will not bill Medicare separately for bad debt
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MEDICAL EDUCATION
• Medicare will continue to provide direct (DGME) and indirect (IME) payments to teaching hospitals for approved GME programs
• Both types of GME payments are calculated using fixed approaches regardless of whether Medicare beneficiaries are in FFS, Medicare Advantage or Prime
• Medicaid GME and Supplemental Teaching Payments will remain as it is today
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Managing Care and Managing Cost
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MANAGING CARE
• CICOs will offer care coordination services to all enrollees:
• To ensure effective linkages and coordination between medical home and other providers and services; and
• To coordinate the full range of medical and behavioral health services, preventive services, medications, long term services and supports and other enhanced benefits, as needed.
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MANAGING CARE
• At minimum, care coordination will include the following:
• Access to a single, toll-free point of contact serving as care coordinator;
• Development of an individualized care plan developed by multidisciplinary team;
• Disease self-management and coaching;• Medication review, including reconciliation
during care transitions;
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MANAGING CARE
• At minimum, care coordination will include the following (cont’d):
• Utilizing data analysis to measure medical compliance and to develop strategies to influence overall health;
• Collaborating with nursing facilities and other providers to promote adoption of evidence-based interventions to reduce avoidable hospitalizations and the management of chronic conditions.
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MANAGING COSTS
• CICOs are expected to manage cost through defined care coordination and cost effective alternatives services
• Increases in primary care, outpatient, behavioral health and home and community based services and decreases in institutional care
• Reductions in institutional care include ambulatory care sensitive hospital admissions and emergency department visits, other avoidable admissions and readmissions, and nursing facility care
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Service Alternatives
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SERVICE ALTERNATIVES
• Prime allows CICOS to utilize Medicare and Medicaid services in a non-traditional manner
• Cost effective service alternative are medically appropriate services that optimize patient experience and avoid or delay more costly institutional care
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3-DAY QUALIFYING STAY
• Three-day qualifying hospital stay for nursing facility placement may be waived under Prime, when clinically appropriate
• TB screening is not waived for nursing facility admissions
• CICOs must work together with hospitals and nursing facilities to ensure a PPD is administered within 48-hours of discharge
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HOME CARE SERVICES
• CICOs may authorize temporary use of services (i.e., home health or personal care) to delay admission to or facilitate transitions from acute care settings
• CICOs may waive homebound requirements as a prerequisite for home health
• Authorized use of waiver-like services to delay potential nursing facility placement for enrollees who may not be medically eligible for waiver services
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PALLIATIVE CARE
• Focuses on pain management and comfort care
• Optimizes quality of life of individuals living with serious or chronic illness who may not meet criteria for hospice benefit
• Services provided earlier in disease progression; may be provided in conjunction with curative therapies
• Treatment options may be explored while honoring enrollee’s values and preferences
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CARE TRANSITIONS
• Goals of care transitions:
• To improve transitions from institutional settings to other care settings
• To improve quality of care• To reduce readmissions for high risk beneficiaries
• Effective treatment and transition planning begins at admission to in-patient facility, including acute care, psychiatric hospitals and nursing facilities or presentation at the emergency department
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CARE TRANSITIONS
• Treatment and transition planning will include, at minimum:
• Establishment of transition planning protocols with network providers that identify a single point of contact for the clinical follow-up once the enrollee is transitioned;
• Coordination with facility staff to build upon existing care transition models and to avoid duplication and to assure full integration of services;
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CARE TRANSITIONS
• Treatment and transition planning will include, at minimum (cont’d):
• Scheduling of transition/aftercare appointments;
• Conducting a clinical follow up phone call or home visit within seventy-two (72) hours of transition; and
• Medication monitoring using evidence-based protocols, as clinically necessary.
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Questions?
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SOURCES
1. The Henry J. Kaiser Family Foundation. (2013, May 21). State demonstration proposals to integrate care and align financing for dual eligible beneficiaries. Retrieved from http://kff.org/medicaid/fact-sheet/state-demonstration-proposals-to-integrate-care-and-align-financing-for-dual-eligible-beneficiaries/
2. South Carolina Department of Health and Human Services. (2014, July). Healthy Connections Prime Capitation Rate Report (2014). Retrieved from https://msp.scdhhs.gov/SCDue2/sites/default/files/Healthy%20Connections%20Prime%20Capitation%20Rate%20Report%20(2014).pdf
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