Integrated Care System Partnerships. Best Practices Symposium January 28, 2013

Transcription

1 Integrated Care System Partnerships Best Practices Symposium January 28, 2013 Pamela Parker, MPA Special Needs Purchasing Minnesota Department of Human Services

2 Integrated Programs for Dual Eligibles in MN Medicaid managed care since 1985, about 600,000 total enrollees. Seniors enrolled since 1985, includes Medicare-Medicaid dual eligibles, began adding people with disabilities in MN first state to be approved for integrated Medicare/Medicaid demonstration in 1995, added people with disabilities in Transitioned to Medicare Advantage Dual Eligible Special Needs Plan (DE-SNP) platform in , expanded seniors MLTSS program statewide. 90% of seniors (49,000) enrolled in managed long term care, includes all home and community based and behavioral health services. 70% of seniors enrolled in Medicare SNPs. Average age % eligible for LTSS. Two options: Minnesota SeniorCare Plus (MSC+): 12,500 seniors in same 8 Medicaid MCOs, mandatory enrollment unless enrolled in MSHO, Medicare FFS. Minnesota Senior Health Options (MSHO): 36,500 dual seniors in 8 fully integrated Medicare/Medicaid SNPs, voluntary alternative to mandatory enrollment in MSC+ 43% of people with disabilities (36,500) enrolled in Special Needs BasicCare sponsored by 5 Medicaid MCOs, LTSS carved out, all behavioral health included. Only 3% in 3 integrated SNPs, 5 other SNPs dropped Medicare for disability group. MSHO now moving back to Dual Demonstration status under new CMS options. 2

3 Alternative Rules for Duals Demo State proposing alternative Demonstration to Align Administrative Systems for Improvements in Beneficiary Experience Builds on current SNP platform along with some new CMS demonstration parameters Current SNP and Medicaid financing and rates Phase 1: Seniors enrolled in MSHO SNPs, implementation to start in 2013 Phase 2: People with Disabilities, ongoing discussions with CMS for 2014 Goals Improved platform for dual eligibles to align with and support State Payment and Delivery Reforms as developed through stakeholder efforts Provide State a clearer joint role with CMS in Medicare SNP oversight in order to preserve/enhance integrated administrative and operational features and reduce reliance on informal CMS Medicare SNP policy agreements which often change and threaten disintegration Provide learning laboratory for State and CMS efforts to improve integrated D- SNP administrative efficiency and alignment for beneficiaries Provide access to Medicare data to create and maintain an integrated Medicare and Medicaid data base for performance metrics and risk adjustment 3

4 MN Payment/Delivery Reform Initiatives Health Care Home (HCH): Medicaid benefit provides additional payments to clinics and practitioners certified by MDH Multi Payer Advanced Primary Care Practice (MAPCP) Demo: 8 state demo providing added Medicare payments to HCH for FFS patients including duals Private Sector and Medicare ACOs: History of HMO/Provider ACO type subcontracting, also 3 Medicare Pioneer ACOs Health Care Delivery System (HCDS): Primary/acute Medicaid ACO like delivery models operating in and outside of managed care State Innovation Model (SIM): State s CMS proposal builds on above models to improve care coordination, population health, patient experience and costs Dual Demo and Integrated Care System Partnerships (ICSPs): SIM/HCDS aligned relationships for provider payment and delivery reforms for dually eligible enrollees within DE-SNPs.

5 Payment/Delivery Reforms for MSHO Seniors SNPs provide MSHO care coordination directly or through contracts with counties, Care Systems/Health Care Homes or community case management organizations. Unlike typical HCBS case management, care coordination models include clinical support for care coordinators to increase monitoring of chronic medical conditions. SNPs and providers rely on integrated benefit determinations and the flexibility provided in Medicare Advantage to provide additional care coordination, waive 3 day hospital stays, provide in lieu of days, substitute services and support increased use of physician extenders in order to obtain these results. Under MSHO, integrated financing has resulted in creative Care System (mini- ACO like) subcontracts for integrated service delivery and payment reforms across Medicare, Medicaid, primary acute and long term care with a range of arrangements such as: Shared incentive pools or performance based payments with LTC providers Combined Medicare and Medicaid care coordination PMPM payments Combined Medicare and Medicaid primary care, Health Care Home and care coordination PMPM payments Total cost of care sub-capitations or virtual sub-capitations with shared performance pools across all services State goal is to increase the use of these payment and delivery reforms Cooperation of Medicare SNPs and the Dual Demo are key to that goal. 5

6 Revised Dual Demo Original Design Model Special Needs Plan/Medicare Medicaid Integrated Care Organizations 8/13/2012 CMS Medicare Contract and Payment to SNP Medicare Primary and Acute Acute Care State Medicaid Contract and Payment to MCO/SNP Medicaid State Plan and LTSS Joint CMS/DHS Memorandum of Understanding (MOU) MSC+: Medicaid coordinates with Original Medicare SNP MMICO DEMO PLANS Special Needs Plan Medicare and Medicaid Integrated Care Organizations Virtual Care Systems Communication Tools Model 1 PAC/NF LTSS Demo under Medicare Advantage Special Needs Plan (SNP) platform and payment structures Includes Medicare, Part D, current Medicaid State plan and LTSS (seniors) starting 2013 SNBC TBD for 2014 Phase 2 MOU to outline State/CMS oversight roles CMS acknowledgement of State payment and delivery reform goals Rules for duals supports features needed to continue and improve integrated operational features including quality and outcomes measurement and integrated benefit determinations, provider billing and protection from premiums for enrollees Acronyms CD Chemical Dependency CMS=Centers for Medicare and Medicaid FFS=fee for service HCH=Health Care Home HH=Health Home ICSP=Integrated Care System Partnership LTSS=Long Term Services and Supports MMICO=Medicare Medicaid Integrated Care Organization MSC+=Minnesota SeniorCare Plus MSHO=Minnesota Senior Health Options NF= Nursing Facility PAC=Post Acute Care SNBC=Special Needs BasicCare SNP=Medicare Advantage Special Needs Plan SMI=Serious Mental Illness TCOC= Total Cost of Care Model 3: Specialized ICSPs Mental, Chemical and Physical Health DHS establishes criteria for integrated chemical, mental and physical health care system models for people with SMI enrolled in SNBC under the demonstration DHS issues RFP Requires partnership between county, MMICO, primary care, chemical and mental health providers Could also include non dual SNBC members Additional details TBD with Chemical and Mental Health and Continuing Care Exploring Health Homes and/or HCH as part of model Standardized outcome measures Dependent on viable Medicare financing under demo for dual eligibles with disabilities Contract Requirements and Risk Model 2: Integrated Care System Partnerships (ICSP) DHS establishes criteria for model options for ICSPs including: Primary care/payment reforms Integrated care delivery TCOC accountability and options for risk/gain sharing arrangements Opportunities for PAC/NF/LTSS/MH/CD providers HCH Certification/Transition to HCH Enrollee choice of ICSP Incentives to serve people across all settings Standardized outcome measures New ICSPs DHS Issues RFPs to stimulate additional ICSPs Provider/MMICO Partnership required for response DHS sets payment and risk/gain options and parameters Existing Care Systems DHS evaluates current care systems arrangements, those meeting or exceeding criteria would be considered ICSPs Transition to HCH if not already HCH Standardized outcome measures Care Coordination MMICO/Counties/ Tribes/Community Organizations HCH/Clinic and/or HH Market Incentives and Stimulation Chemical & Mental Health Acute Care

7 Integrated Care System Partnerships New contract provisions for SNP/MCOs participating in MSHO/MSC+/SNBC Builds from current MCO/Provider Care System contracting arrangements (current providers may convert to ICSPs) Combined Medicare and Medicaid financing provides incentives for provider level payment and delivery reforms stimulating new subcontracting arrangements and affiliations across services. All models to incent improved health outcomes and choice of care setting Seniors: Encourages involvement of long term care providers under shared pooled incentives or payment reform models People with Disabilities: Encourages coordination of physical and behavioral health for people with disabilities in SNBC Tied to a range of quality and financial performance metrics Clinical workgroups developing quality measure options Financial metrics to be proposed according to broad State parameters SNP/MCO/Provider proposals due July 2013, review of proposals by State, implementation of new arrangements no later than January All proposals subject to State contract requirements for care coordination, quality metrics, financial performance measurement and reporting 7

8 MSHO/MSC+ ICSP Payment Types Payment Types Type A Type B Type C Type D Model Options Performance rewards: performance pool or pay for performance Primary Care Coordination of Care Payment; or partial subcapitation for primary care and Care Coordination by Primary Care Provider or other Care Coordinator within ICSP. Sub capitation or Virtual Capitation for Total Cost of Care across multiple defined services including primary, acute and long term care Alternative Proposals Model 1.1 Model 1.2 Model 2 MCO contracts with LTC providers and/or Primary Care Providers. MCO contracts with Primary Care Providers or Care Systems to include payment for Care Coordination, as an alternative to Health Care Home care coordination fees. MCO contracts with providers Care System or a collaborative (primary care providers affiliated with long term care providers) with delegated management of care to the provider Care System or a collaborative, using risk/gain/ performance payment models across services. Model 3 MCO contracts with providers under payment arrangements that can provide financial and/or performance incentives for integration / coordination of Chemical and/or Mental Health services with acute / primary care services. May include certified HCH or Health Homes. Model 4Alternative defined by proposal

9 SNBC ICSP Payment Types Payment Types Type A Type B Type C Type D Model Options Performance rewards: performance pool or pay for performance Primary Care Coordination of Care Payment; or partial subcapitation for primary care and Care Coordination by Primary Care Provider or other Care Coordinator within ICSP. Sub capitation or Virtual Capitation for Total Cost of Care across multiple defined services including primary, acute and long term care Alternative Proposals Model 1.1 Model 1.2 Model 2 MCO contracts with behavioral health providers and/or Primary Care Providers.. MCO contracts with Primary Care Providers or Care Systems to include payment for Care Coordination, as an alternative to Health Care Home care coordination fees. MCO contracts with providers Care System or a collaborative (primary care providers affiliated with behavioral health providers) with delegated management of care to the provider Care System or a collaborative, using risk/gain/ performance payment models across services. Model 3 MCO contracts with providers under payment arrangements that can provide financial and/or performance incentives for integration / coordination of Chemical and/or Mental Health services with acute / primary care services. May include certified HCH or Health Homes. Model 4Alternative defined by proposal 9

10 Request for Public Input (RFPI) RFPI to solicit public input for best practices for ICSPs published 1/22/2013 Full document available on web: New MSHO/MSC+ and SNBC contract language included in 2013 contracts (model contracts available) AMIC_CONVERSION&RevisionSelectionMethod=LatestReleas ed&ddocname=dhs16_ List of proposed ICSP measures January 28, 2013: Joint HCA/CCA Best Practice Policy Symposium Comments due: Friday February 22, 2013 by 4PM CST. PDF format requested Submit to Questions to Comments will be posted, shared with SNP/MCOs and used by DHS staff in ICSP development, policy and review. 10

11 RFPI Best Practice Focus Areas Opportunities to increase value: Opportunities for provider collaboration across service types, place and time Mechanisms for consumer protection Practices appropriate to cycles of care (new enrollees, transitions, end of life, etc.) How to consider size of population impact on payment models and performance measures Care strategies specific to population, differences in care needs geography and setting? Seniors People with disabilities Physical and behavioral health integration Community settings Residential settings Rural Urban 11

12 RFPI Best Practice Focus Areas Communications Strategies Across Providers and Services and Settings Communication strategies among diverse providers, especially in rural areas to create virtual care systems (Model 1) for transitions, EHR and HIT strategies, standard post discharge follow up communications, etc. Communication Strategies in Aligned or Partially Aligned Systems Efficient communications strategies among diverse provider types, transitions, EHR and HIT, standard post discharge, follow up (especially for Models 2 or 3) Payment Models Are there additional payment models to be considered or avoided for improved alignment? What levels of risk and gain are providers willing to consider? What works best for smaller numbers of enrollees? Measures See proposed measures, feedback requested 12

13 Proposed ICSP Measures ICSP Measure Identification and Development Process Clinical workgroup of DHS/SNP Medical Directors and QA staff Alignment discussions with local and national measurement experts (NCQA, MDH, Minnesota Community Measurement, Stratis QIO, Board on Aging, etc) Discussion with Provider Care Systems Discussion with Stakeholders groups (Best Practice Symposium, Dual Demo and Disability Stakeholders groups ) RFPI Comments: Appropriateness of measures proposed? Feedback mechanisms between SNPs and providers for metrics support? Data and analytics needed? Advice on capturing disparate data sources (claims, care plans, assessments, evidence of process)? Sources of data providers use in self evaluation of performance? 13

14 Proposed ICSP Measures Proposed ICSP Measures for all populations/settings Hospital Utilization All cause readmits ED utilization Especially for MSHO Institutional Members Use of antipsychotics for people with Dementia Falls with Fx Pressure Ulcers S&P: Evidence of POLST with person specific goals for residents with 90 day+ stays S&P: Follow Triage Protocol prior to sending to ED or inpatient stay 14

15 Proposed ICSP Measures Especially for MSHO Community Frail Elderly (average age 80+) Flu/pneumovax Use of High Risk Drugs Annual Monitoring of patients on persistent meds Med reconciliation post discharge Care of Older Adults S&P: Reduced Risk of Falls/Falls Screenings (TBD) Best Practice Incentive S&P: Care Transitions (TBD) *Best Practice Incentive S&P: Evidence of Functional Assessment Response by PCP *Best Practice Incentive S&P: Evidence of ongoing PCP/Care Coordinator communication *Best Practice Incentive S&P: Evidence of Integrated Care Plan for Community Members * Aspirational-Potential collaboration with NCQA 15

16 Minnesota s Proposed ICSP Measures Especially for People with Disabilities in SNBC (all settings) Anti-depressant Monitoring Follow Up after Hospitalization related to Mental Illness (and Substance Abuse) Primary Care Visits Basic Preventive Screenings SA/MH Screenings Pressure sores S&P: Evidence of behavioral and physical health integration, communications and care planning (TBD) Being discussed with Disability Stakeholders group 16

17 Participating Health Plans MSHO SNPs/MSC+ MCOs* Blue Plus Health Partners Itasca Medical Care Medica Metropolitan Health Plan Prime West South Country Health Alliance UCare Minnesota *All plans offer both MSHO SNP and MSC+ Medicaid plans SNBC SNPs/MCOs Medica Metropolitan Health Plan * Prime West* South Country Health Alliance* UCare Minnesota * Offers Dual Eligible SNBC SNP 17

18 QUESTIONS? 18

19 Minnesota Medicare Medicaid Integrated Programs and Dual Demo Contact Information: Pamela Parker, MPA, Manager Sue Kvendru, Seniors Managed Care Coordinator Deb Maruska, Project Manager, Dual Demo/Disability Managed Care Dual Demo Stakeholders Website: Disability Managed Care Stakeholders Group