Oklahoma Health Care Authority Managed Care Coordination for Oklahoma Aged, Blind, and Disabled

Transcription

1 Oklahoma Health Care Authority Managed Care Coordination for Oklahoma Aged, Blind, and Disabled August 27, 2015 Presented by: David Pollack Regional VP Michelle Bentzien- Purrington VP, MLTSS Dennis Sandoval, M.D. Senior Medical Director Kelly Giardina AVP, Healthcare Services Kim Sweers VP Network Strategy and Services

2 Agenda Molina History and Experience The Molina Care Management Model Provider Programs Q&A 2

3 Molina Healthcare Founded in 1980 by Dr. C. David Molina Single clinic Commitment to provide quality healthcare to those most in need and least able to afford it Fortune 500 company that touches over 7 million Medicaid beneficiaries 16 states & 2 territories 3

4 Presence in Key Medicaid Markets ¹Effective membership as of June 30, 2015 Health Plan footprint includes 4 of 5 largest Medicaid markets 3.4M¹ Members 4

5 Medicare D-SNP membership The Big Picture 4,000 9,200 9,000² ~41,000 Members¹ 2,100 4, , ,400 Celebrations Nearly a decade of experience serving dual eligibles 9 th largest D-SNP plan in the country 5 th largest D-SNP plan in our markets All plans 3 Stars or better ¹As of August 2015 ²Includes MAPD & D-SNP 5

6 Molina - #1 in MMP Awards and Membership California (CalMediConnect) Molina is participating in 4 counties (San Diego, Riverside, San Bernardino and Los Angeles). Started voluntary enrollment in April 2014, passive enrollment in May Texas (Texas Dual Eligible Integration Project) Molina is participating in 5 large counties with significant duals Star+Plus membership. Voluntary enrollment started March Passive enrollment started April ¹August 2015 Illinois (MMAI) Molina is participating in 15 counties in the Central Region. Voluntary enrollment started in March Passive enrollment started in June Molina has the most states awarded (6) and the most MMP members among all plans. 54,051 Molina MMP Members¹ Michigan (Michigan Healthy Link) Molina is participating in the 2 largest counties (Wayne and Macomb). Voluntary enrollment started March Passive enrollment started May Ohio (MyCare Ohio) Molina is in 3 regions (Southwest, Central and West Central), 13 counties. Voluntary enrollment started June Passive enrollment started January South Carolina (Healthy Connections Prime) The state initially set a statewide service area. Molina s primary focus is 20 counties. Voluntary enrollment started Feb Passive enrollment is on hold. 6

7 Duals Growth 7 Source link:

8 ABD Care Coordination Model Recommendation Financing Model Service Delivery Framework Statewide MCO fully capitated model Budget predictability Administrative simplification Service continuity throughout the state Full Integration of physical health, behavioral health and LTSS to address the individualized care needs of the most vulnerable members. 8

9 Lessons Learned: Transitioning to Managed Care What We ve Experienced Provider/Advocacy Concerns Successful Solutions Build relationships early and maintain ongoing Collaborative forums with state, other plans Collaboration with associations One on one interactions Share common goals, identify concerns and collaborate to develop solutions Tailor collaborative forums and communication to the audience (e.g. nursing homes, home health agencies, behavioral health providers) Member Confusion Simple, clear communications Face to face education Provider, advocate support Change Management Administrative Complexities Early identification of changes Engage stakeholders in planning transition Eligibility data Cost share administration Electronic Visit Verification MLTSS claims processing 9

10 Managed Care: Assisting Oklahoma in Achieving the Triple Aim Experience of Care Safe & effective Patient-centered Timely Efficient & equitable Population Health Per Capita Cost Social determinants of health Health outcomes Disease prevalence Health risk Value total per member costs Reduce cost Reduce fraud and waste 10

11 Effective Care Management: Two Ends of the Continuum TANF Breaks in eligibility Episodic care Pregnancy Greater ethnic diversity Larger support system at clinic visits Demographics 1 Over Age 65 25% Under Age 65 75% TANF Over Age 65 62% Under Age 65 38% ABD/Duals ABD/Duals More continuous eligibility Chronic illnesses Behavioral health More likely to have greater limitations in activities of daily living (ADL) Require more focused care including home care Person Centered Care member, caregiver and family centric TANF ABD/Duals 11 Source: 1. KFF.org

12 Member Centric Holistic Care Management Section 8 Housing Molina Care Model Integration Deaf and Hard of Hearing Independent Living Service Programs Transportation Resource for People with Intellectual and Developmental Disabilities Area Agencies on Aging Meals Respite Care Continuity of Care Adult Day Services and Adult Day Health Behavioral Health Specialist Supplies Health Consumer Centers Social Workers Hospital Services Personal Attendant Care Providers Department of Behavioral Health RNs with Mental Health Specialties Primary Care and Specialist Centers for Independent Living Medication Review/ Reconciliation Pharmacy Aging & Disability Resource Centers Behavioral Health Hotline Recovery Learning Centers Assessment of each member s medical, behavioral and social needs when they join the plan Individualized care plan Multi-disciplinary care team Care transitions program Self-directed services Setting goals and measuring outcomes Medical Services (Molina Provides) Home and Community Based Services and Long-Term Services & Supports Community Based Partners 12

13 Effective Care Management: Meet Members Where They Are Opportunity: 40 50% of ABD populations do not respond to telephonic, mailed communications Solution: Research teams and Community Connectors Research teams Mine data to find member information: claims data (including Rx), community databases, public databases, internet searches Outreach: member (including family, friends), physicians, pharmacies, housing authorities, community organizations Community Connectors Local, non-clinical members of the community Strong relationships with community based organizations, Aging and Disability Resource Centers, others Feet on the street find the members, build relationships, pave the way for Care Coordinators 13

14 Effective Care Management: Satisfaction Managed care success is measured by transitions of care, goals met, quality results and outcomes, and satisfaction. 250k Members >100k ABDs w/mltss 2014 Case Management Satisfaction Survey - Texas 91% 90% 93% Case manager spent enough time with member and listened when member spoke Happy with services received from case manager Would recommend program to someone else 14

15 Shanna 15

16 Value Based Strategies: The Continuum Pay for Performance Pay for Performance Rewards providers if they demonstrate core competencies to provide quality care, enhance access, and improve health outcomes (e.g. after hours care, open panel, etc.) often used as a stepping stone to PCMH. Pay for Quality Pay for Quality Rewards providers for achieving better performance on a broad spectrum of HEDIS/STAR measures and utilization metrics for their member panel. Patient Centered Medical Home Patient Centered Medical Home (PCMH) Rewards providers who achieve PCMH accreditation status. Compensates providers for engaging in practice and team-based transformation that increases the level of care coordination for our members while having them agree to do key activities that have shown to improve quality of care, access to care and improves health outcomes and member satisfaction. Accountable Care Arrangements Accountable Care Arrangements Gain share and/or risk share arrangements that reward providers for improving quality of care, affordability of care and member care coordination. Progressive Risk Arrangements Progressive Risk Arrangements For providers with deeper experience in PCMH and other value based payment models, we will offer shared savings models that progressively move to risk arrangements over time. 16

17 Value Based Reimbursement (VBR) Continuum Phase Payment Opportunity Description Base Pay for Performance Pay for Quality Medical Home/PCMH Accountable Care / Progressive Risk Arrangements Medicaid / Medicare Compensation Quality Bonus Partner Programs: Pay-For-Performance PCMH Incentive Quality Bonus Partner Programs: Coordination of Services Incentive Hospital Improved Outcomes Risk Sharing and ACOs Gain Share or Shared Risk Models Accountable Care Contracting Initial contracting period of FFS payments and expertise with government-sponsored health program fee schedules (Medicaid/Medicare) Additional compensation opportunity for (i) PCP performance tied to quality measures such as HEDIS and CAPHS, and (ii) PCMH qualification with credentials and modules certifications Additional compensation opportunity for (i) provider coordination of services care transition support, and (ii) hospital outcomes based measures such as ER visits and readmissions Additional compensation from share in savings or risk resulting from improved care quality and outcomes with potential to move to accountable care contract including upside/downside risk based on benchmark data and quality measures Progression thru Phase 4 is contingent on membership* and accomplishment of quality metrics. Providers demonstrating 75th percentile of HEDIS can immediately be considered for PCMH & gain share. *minimum of 500 members to ensure statistical significance of data in gainshare/aco models. 17

18 Managed Care: Assisting Oklahoma in Achieving the Triple Aim Improving Care for Individuals: Innovation is Key Improving Population Health: Focus on Quality Provider partnerships, multi disciplinary collaboration across care systems Integration of services for better care coordination and member experience Member-centric goals: prevention, self-management and primary care 3-8% positive impact during the first year on preventive screenings, immunizations, diabetes, hypertension, prescription drug use, hospitalizations, readmissions, and ER use 18

19 Managed Care: Assisting Oklahoma in Achieving the Triple Aim (cont ) Reducing Per Capita Cost: Right Services, Right setting, Right time Company wide, Molina has successfully transitioned 8% of long term care nursing home residents back to the community in 2015 Highest transition rates occur (8 18%) where Molina directly manages all aspects of care acute, behavioral health and LTSS Impact to hospital days and admits Percent change Stat Florida¹ Ohio¹ Texas¹ California¹ Days/ % -14.9% % -20.6% Admits/ % -4.0% -8.67% -26.0% 19

20 Care Coordination the Molina Way 20

21 Questions 21