Ohio Update & Overview of States Care Coordination Initiatives

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1 Ohio Update & Overview of States Care Coordination Initiatives Maureen M. Corcoran President Daphne Kackloudis Saneholtz Senior Advisor Vorys Health Care Advisors, LLC

2 Today s Teleseminar Logistics Purpose Update: Ohio Governor s Office of Health Transformation & Ohio Medicaid Examples from other states plans & experience Managed Care Other care coordination models: health homes, duals, ACOs, etc. Participants

3 Setting The Stage For Payment Reform ACCOUNTABILITY & QUALITY INTEGRATION FOCUS Hot Spots CARE COORDINATION MANAGEMENT OF CARE

4 Health Care Reform Humor

5 Office of Health Transformation Leads health care work on behalf of Ohio Medicaid, ODMH, ODADAS, ODH, ODA, and ODI Three tier strategy: 1. Modernize Medicaid 2. Streamline health and human services 3. Improve health system performance

6 Backdrop: Ohio s Operating Budget Effective July 2011 Focused on coordinating care for Ohio Medicaid consumers: 1. Managed care 2. Dual eligibles proposal 3. Expanding/streamlining HCBS 4. Elevating behavioral health financing 5. Pediatric ACOs 6. Health home initiatives, inc. individuals SPMI

7 Medicaid Tools and Authorities E P S D T 2703 (ACA) Health Home 1115 Waiver 1915, including (b) & (c) waivers, TCM 1932 Managed Care 1905 Medical Assistance

8 Ohio s Managed Care Policy Persons who are ABD & (the following): NOT NOW INCLUDED: MAY BE ADDED/ INCLUDED: <21 yrs. old Institutionalized Spend down Dual eligible On waivers <21 yrs. old NF (not ICFMR) (Not spend down) Dual eligible (if not otherwise excluded) On NF waivers (not ICFMR waivers) (NOT BCMH kids with CF, cancer, hemophilia, who were not in managed care on ~7/1)

9 Managed Care Reprocurement Reprocurement process underway Flexibility to add/change later without reprocurement services or groups included Want to push MCPs to innovate NOT included: BCMH kids, dual ABD kids, waiver kids & Title IV-E kids (i.e. kids in the child welfare system) BH elevation raises questions re: carve in/carve out; no changes announced

10 Managed Care Reprocurement Expanding those to be included. Result will be: 1.6 million enrolled in CFC 125,000 enrolled in ABD 37,000 children with special needs Reducing from 8 to 3 regions Intend to select 4 MCPs per region MCPs bids will be combined for the CFC and ABD populations; previously separate

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12 Changes to Ohio MCP - Effective 10/1/11 Care Management Requirements MCP Provider Agreements must include for those assessed high risk stratification Care Manager/Care Management Team: Team composition & ratio of 1 FTE/ 25 members - high risk Required Activities: MCPs must help members: obtain medically necessary care assist with health-related services coordinate care disseminate information and implement & monitor the care treatment plan. Note: See complete summary at Interaction with the member: MCPs must complete one successful face-to-face contact with the member each quarter. Identification Strategy: MCP must use an industrystandard predictive model, health risk assessment tool and MD referrals. Health assessment: Comprehensive health assessment, evaluate members physical, BH, social & psychological needs. Care treatment plan: MCPs care treatment plans must be individualized and based on the health assessment.

13 Ohio Proposal for Dual Eligibles Medicaid & Medicare Ohio Medicaid is seeking federal approval to design and implement a Medicare/Medicaid Integrated Care Delivery System (ICDS) Concept paper released January 2012 Proposed managed care structure, but particulars not confirmed Goal: implementing the new ICDS in September 2012

14 Ohio Proposal for Dual Eligibles Individuals can opt out Target population = all beneficiaries fully enrolled in both Medicare and Medicaid (i.e. not QMBs, etc.) in selected regions/counties DD individuals and duals under the age of 18 are excluded Duals with SMI will be phased in

15 Ohio Proposal for Dual Eligibles Includes full continuum of Medicare and Medicaid benefits ICDS accountable for providing access to all services covered by both programs Required to provide, at minimum, all HCBS provided under current 1915(c) waivers for the aged and disabled Coordinated with initiative to consolidate HCBS waivers

16 Today Expand and Streamline HCBS: Single NF LOC Waiver NF level of care five different HCBS waivers Different enrollment requirements, services, providers; administered by different agencies Solution Streamlined HCBS waiver program (i.e., one single waiver) in January 2013 Concept paper released January 2012 Seeking public input; establishing benefit package

17 Expand and Streamline HCBS: Single NF LOC Waiver (cont d) Combines: PASSPORT, Choices and Assisted Living waivers (ODA), and Ohio Home Care and Transitions II Aging Carve-Out waivers (ODJFS) Will NOT affect individuals enrolled on the I/O, Level One and SELF waivers (DoDD) Considering 1915(b)/(c) waiver

18 Restructuring BH System Financing Responsibility for Medicaid match has been returned to the state; no longer the ADAMH Board responsibility Service redesign underway Unlikely the state will continue current FFS/risk long term, but No decision about structural changes carve in to managed care? Some? All?

19 Health Homes 2703 of ACA & CMS Guidance: Health Home for Enrollees with Chronic Conditions SMDL # /16/10 Population Criteria At least two chronic conditions, or One chronic condition and at risk for another, or One serious and persistent mental health condition Power is ability to tailor to those with high cost/complex needs

20 Health Home Services: Qualify for 90% Federal Match for 8 Quarters 1. Comprehensive care management 2. Care coordination and health promotion 3. Comprehensive transitional care from inpatient to other settings, including appropriate follow-up 4. Individual and family support, including authorized representatives 5. Referral to community and social support services 6. Use of health information technology to link services Note: these are the prescribed services but states can tailor the definitions as well as the team specs

21 Health Homes: Three Provider Types 1. Designated providers 2. Team of health care professionals, which links to a designated provider 3. Health team In Ohio, for example, community behavioral health centers will serve as designated providers for individuals with SPMI and will deliver services through a team of health care professionals.

22 Ohio s Health Home Designed to improve care coordination for high-risk beneficiaries with SPMI Submitted SPA December 2011 Goal is to implement in July 2012

23 Ohio s Health Home - SPMI is Top Priority Extensive stakeholder process ODJFS & ODMH Ohio Medicaid s top priority: SPMI consumers Estimate ~200,000 Ohioans Health home for individuals with other chronic conditions will be a subsequent phase of work; no timeline specified? Possibility for shared savings

24 Ohio s Health Home HH services will be provided by community behavioral health centers (CBHC) in targeted geographic areas Initially use regional approach SPMI includes adults and kids Individuals with SPMI who currently receive services at a CBHC will be assigned to that CBHC HH; can change to another in the region or opt out

25 Ohio s Health Home (cont d) Individuals with SPMI not currently receiving services at a CBHC will be referred to the CBHC of their choice If they make no choice, will be assigned to a CBHC in their geographic area Can opt out Referrals will be made based on analysis of Medicaid claims and encounter data

26 Ohio s Health Home (cont d) Individual does not have to continue receiving services at the CBHC to which referred; CBHC HH must establish relationships with preferred CBHC Team led by a dedicated care manager; composition of the rest of the team is flexible Core HH team members: HH team leader (administrative and clinical leadership) Embedded primary care clinician (can be PCP, pediatrician, OB, GYN, Certified Nurse Practitioner with primary care scope focus, PA) Care manager Care manager aides

27 Ohio s Health Home (cont d) HH must perform minimum level of medical screening and treatment (to be defined by state) HH will be required to establish written agreements with PCPs that support integrated, bidirectional care Must also establish partnerships with other providers (e.g. hospitals, specialists, LTCSS providers, MCPs, and others as appropriate)

28 Approved/pending Missouri x 2 Rhode Island x2 Oregon Other States Health Home Initiatives Many others in the works IA, OH, KS, NY, NC, WA

29 Other States Health Home Initiatives (cont d) Example: 2 states Monthly case rate $40 Monthly case rate $200 Example: Ohio SPMI Provider specific rate Monthly case rate Don t want to dictate the model

30 Arizona Modified their existing 1115 waiver CMS dual eligible planning grant Specialty RBHA Starting with Maricopa County For adults with SPMI: integrate all physical and behavioral health services into full risk managed care Goal: Operational by 10/1/13 Includes Medicare SNP RBHA continues behavioral health/carve out responsibilities for Title IX & non-medicaid

31 North Carolina NC physical/medical care is a PCCM program North Carolina Community Care is statewide coordinating agency/corporation with 14 regional, provider based nonprofit community networks Physicians, hospitals, social service agencies, and county health departments Designated care management priorities (twice as many NCQA practices as Ohio) Health home & ACO being pursued Carve out: MH, SUD, IDD; full risk managed care through Local Management Entities

32 Rhode Island Two chronic conditions or one and at risk for another or one serious mental illness Adds Developmental Disabilities as a chronic condition Targeting is facilitated by specifying DESIGNATED PROVIDERS of HH services; CEDARR Family Centers A place where families get help and support for children with special needs

33 Arkansas: DD Health Home PCPs and specialists will continue to provide medical treatment as needed Developmental disability HHs will coordinate care, promote compliance with treatment regimens, assist with medication adherence and detecting side-effects, and promote health and wellness

34 Arkansas: Payment Model Population-Based Payment (PMPM) for HH services ONLY PMPM payments for each enrollee to cover the costs for nurse care manager, health home director, physician consultant, and new support staff; may be adjusted later or tiered based on patient condition

35 Arkansas: Payment Model (cont d) Time-limited infrastructure payments to cover the costs associated with recruiting, training new and existing staff, and IT changes. (In Missouri, the amount based on 2/3 of projected autoenrollment.) Bonus payments linked to quality/cost metrics PLUS Episode-Based Payment for core DD services Episode-based retrospective reconciliation or Single bundled prospective payment for episode:

36 New York s 1115 People First Waiver

37 New York s 1115 People First Waiver DD Individual Support & Care Coordination Organization (DISCO) nonprofit entity, experience working with individuals with IDD Choice of at least two DISCOs per area DISCOs receive a simplified and predictable revenue stream to cover all service costs Risk sharing in beginning likely, with a transition to actuarially based rates DISCO network provides a full range of services; LTSS, self-directed services to acute health care services

38 Movement Toward Accountable Care Organizations Part of ACA Medicare shared savings program and Pediatric ACO ( 2706) Minimum 3 yrs participation Must specify savings when apply ACO: performance requirements and receives incentive payment

39 ACO Requirements ( 3022) Network sufficient to serve beneficiaries. Patient-centeredness criteria Formal legal structure to allow receipt/distribution of shared savings Minimum of 5,000 beneficiaries Quality and other reporting requirements Proper leadership and management structure (clinical and administrative) Processes defined to promote patient engagement, reporting quality/cost and coordinating care

40 Ohio Pediatric ACO Part of the discussion in HB 153 regarding mandating managed care enrollment for ABD kids (37,000) If ABD kids included in managed care, then ODJFS shall recognize pediatric ACOs Rules to be adopted not later than July 1, 2012 Goal: new approaches to care coordination; especially to meet complex medical and behavioral needs of disabled children

41 Ohio Pediatric ACO (cont d) P-ACO contract directly or subcontract with the state to provide services to any kids ( ) who are under 21 yrs old Does not need to be a HIC Outline for requirements to be developed in rules; consistent with federal ACA 2706 and 3022 Some examples exist today (e.g., Partners For Kids)

42 ACO, CCO, DISCO?? An ACO is an organization of providers that is accountable for the care of beneficiaries assigned to it. There is a strong emphasis on primary care and reducing overall costs of care. A CCO/other is a community based organization using patient centered primary care homes, fixed global budgets and efficiency and quality improvements to reduce costs for Medicaid. CCOs align and integrate the care of duals.

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44 CMMI Health Care Innovation Funding Partnership for Patients Hospital Engagement Networks Goal: targeting and reducing the millions of preventable injuries and complications from healthcare acquired conditions OCHSPS Health Care Innovation Challenge Up to $1 B for innovative projects that test creative ways to deliver high quality care and save money Preference for projects that rapidly hire, train and deploy health care workers

45 Setting The Stage For Payment Reform ACCOUNTABILITY & QUALITY INTEGRATION FOCUS CARE COORDINATION MANAGEMENT OF CARE

46 About Vorys Health Care Advisors Vorys Health Care Advisors, LLC helps health care providers, business decision makers and professional associations to achieve their objectives in a constantly changing governmental and business health care environment and to assist them in making well informed, strategic and tactical decisions tailored to their individual goals, needs and aspirations. Contact Information: Maureen Corcoran, MSN, MBA mmcorcoran@voryshcadvisors.com Daphne K. Saneholtz, JD dksaneholtz@voryshcadvisors.com Vorys Health Care Advisors 52 E. Gay Street, Columbus, OH