State Demonstrations to Integrate Care for Dual Eligible Individuals Interim Progress Report- Oklahoma

Transcription

1 State Demonstrations to Integrate Care for Dual Eligible Individuals Interim Progress Report- Oklahoma Since the Oklahoma project is divided into three (3) distinct components in the initial proposal, for purposes of this report, they will be identified as project concepts # 1-Tulsa Health Innovation Zone (THIZ, #2 new benefit Model, and # 3, PACE expansion. Progress to Date The Tulsa Health Information Zone (THIZ) is a proposed organization created to provide high quality affordable care to serve our dually eligible population. The THIZ planning group is comprised of leadership from the University Of Oklahoma School Of Community Medicine, local community service providers and other interested stakeholders from the broader Tulsa community. The THIZ working group has meet fourteen (14) times over the last few months and a smaller executive planning group has meet multiple times in between, including a half day planning session in October. Top two to three milestones/accomplishments achieved to date: 1. Interviews with Dual Eligible Patients: Ric Munoz, JD, MSW has completed 12 interviews in either Individual or Focus Group sessions. Patients have identified several common themes, including: Communication between Medicare/Medicaid service providers is poor. Improving communication would improve care and reduce cost. Elevating the patient s role in directing their own care would improve health care and lower costs. Right now, patients must wait for approval from Medicare/Medicaid for nearly all health interventions which is a protracted and tiresome process for many. A designated advocate or care coordinator at the local level would be helpful to the patient, especially if that person where designated for the patient as an independent advocate apart from the insurance or health care plan 2. Progress on the care model: We have made significant strides toward defining the elements of the care model. The Patient Centered Medical Home model of care most closely resembles the comprehensive support structure for members with each member identified with a single coordinating care team of physicians, social workers, and other providers all function as single integrated care team. The key addition to this model is the matching of each patient enrolled in the THIZ Dual ACO with a single care coordinator who is embedded in a primary care PCMH and who serves as a hub for a comprehensive assessment of needs (including behavioral health, medical care, and social services), develops an integrated care plan, and coordinates care for the member, ensuring smooth movement through the community and assures adherence to care plans. By embedding the care coordinator in the member s PCMH, the care coordinator will develop strong relationships with both providers and members, and will substantially impact member behavior, producing better health outcomes and improved member quality of life.

2 3. Financial Model: The delivery of the final ruling on ACOs provides much needed clarification of how members may traverse in and out of an ACO and how their subsequent risk & shared savings is calculated. Prospective assignment and corresponding termed risk calculation models addresses many of the concerns of the THIZ regarding how to mitigate risk when individuals still maintain choice in providers. We are currently evaluating a a blended model that provides two-sides risk as well a capitated payment to providers for base functions such as care coordination and focused care management. The assumption that a two-sided risk model must include insurance risk has influenced many in the group, particularly the hospital partners, toward a one-sided model. However, all recognize that the two-sided model has the advantage of better alignment of providers and public payers. We are discussing blended models of capitation for outpatient work; with fee-for-service/shared savings plan for hospitalization, fully integrated capitated models similar to PACE, as well as a transition between the two. We are preparing financial models that can be discussed with the ACO hospital partners as part of the decision process. We have included the possibility of a prepaid account similar- to a flexible medical spending account- that could be accessed by the clinical care coordinator and the patient to access social services that are felt to be important in health maintenance. 4. Governance Structure: Two Governance documents have been developed and are under refinement. A Board governance document outlining the structure and potential bylaws for an organization which meets both the legislative requirements of an Accountable Care Organization as well as the unique requirements necessary to ensure membership and participation of necessary stakeholder organizations has been developed. With the release of the final rules for ACOs this document will undergo refinement and then be presented to the THIZ for approval. A document outlaying the operational plan has been penned. This document provides detailed guidance on the expectations, measurement, and alignment of member organization behavior within the ACO. These two documents together will effectively govern the organization, allowing effective board action and member involvement at all levels. Top two to three challenges encountered and strategies to address these challenges: 1. Challenge: Lack of Medicaid and Medicare Data Strategy: Alternative small sample data from OU clinics Compress Analysis of data by adding staffing during analysis period. 2. Challenge: Payment Model research Strategy: We are planning to use a time derived activity based costing (TDABC) model that has recently been reported. We will be able to have a better understanding of the costs of the care delivery change and will give a better understanding to value along the chain. We plan to use this data in future iteration of care design in order to maximize value of the care. 3. Challenge: Defining ACO Legal Agency 2

3 Strategy: We have thought it prudent to investigate providing governance that would fulfill the criteria set forth in section 3022 of the ACA as well as the Medicare ACO Rule. Our governance will most likely be either a separate 501(c)3 entity, an Authority, or a subsidiary of an existing 501(c)3 entity or Authority. Concept #2-New Benefit Model The dual eligible project was fully staffed at OHCA mid-july. We begin immediately becoming familiar with dual eligible terms and conditions, and closely examining Medicaid program offerings and existing benefit plans. Because OHCA hosts Soonercare (Oklahoma Medicaid,) a rich bank of resources is available from data program history to program staff regarding program offerings and infrastructure, within the agency. Medicare information is located in numerous places, Oklahoma s Department of Insurance, Oklahoma State Department of Health, and the Social Security Administration, which is also located in the same office building. Program staff members spent the balance of July and the month of August cataloging available services, eligibility and definitions, and obtaining participating members geographic and demographic data. Staff also coordinated with the Tulsa s Health Innovation Zone (THIZ) of the project and developed a scope of work for the contractor who will be conducting the dual data analysis functions. Top two to three milestones/accomplishments achieved to date: 1. Completed data requests/permissions to CMS 2. Completed contracts with Tulsa HIZ and with Pacific Health Policy group (PHPG) 3. Reviewed existing programs offerings and determined number of dual eligibles who are not receiving care coordination, and are therefore available for care coordination Top two to three challenges encountered and strategies to address these challenges: 1. Challenge: Best recommendation for service delivery is neither purely capitated nor Fee for service models as described Strategy: Build case for Oklahoma s strong history with care coordination, including state record of cost savings by coordination of care internally and its relevance to blending CMS models 2. Challenge: Delay in obtaining previous data for Tulsa model hampered development of full partnership and information exchange Strategy: Historical data issues resolved, developing ongoing information exchange and partnership 3. Challenge: Process for requesting and obtaining CMS permissions presenting potential delay in review of project data Strategy: Ensure data parameters and processes are fully developed so that project may advance as quickly as possible when data is accessible. 4. CMS has indicated challenges to the viability of the state serving as its own manager of health care plans for care coordination. It may be perceived as unfavorably as expanding government s role, rather than increasing possible partnership with the private sector/business community. Concept #3-PACE Expansion 3

4 Progress to date So far, we have identified five (5) interested parties who have documented their commitment to becoming PACE providers. They are as follows: 1. Cherokee Elder Care Cherokee Elder Care is in the process of expanding their current PACE program to Muskogee, Oklahoma (Wagoner County). They are have indicated a need for funding for full Implementation; however, they did make a strong commitment that they will build another center regardless of governmental financial assistance. 2. Life Senior Services Life Senior Services is a Tulsa based entity who has expressed interest in PACE before the Dual Eligible contract was received. They will also pursue implementation with or without governmental financial assistance. 3. Morton Healthcare Systems Morton is another entity from Tulsa who has expressed interest in PACE and will also pursue implementation, regardless of governmental financial assistance. 4. Daily Living Centers Oklahoma City has a few entities that have expressed a great deal of interest in providing PACE services in the metropolitan areas of Oklahoma City. They have asked about possible assistance for start-up costs and with PACE membership. They did attend the PACE national conference and are planning implementation as well. 5. Share Medical Center Share medical Center is located in Alva (Woods County), and this unique entity has nonetheless all of the tools to put together a successful PACE center. However, they have few numbers in dual eligible population and potential PACE participants. PACE staff have indicated that this could serve as a strong location for a PACE site, providing they do a market analysis outlining who they will serve in and the geographic parameters of that service area. There are more entities that have shown interest, however some of their barriers are a major concern and would have to be addressed before implementation. They are: Metropolitan Better Living Center Oklahoma City Shawnee Senior Center Pottawatomie county St. John s Missionary Baptist Church Oklahoma City, OK Chickasaw Nation We are set to present the PACE model to the Commerce Division for final approval on Tuesday, November 1 st, 2011 Some of the top three challenges with PACE and getting various entities to bear the responsibility are: Challenges 1. Financial hardships with startup costs, location (existing infrastructures) and lack of collaborative effort. Encouraging interested entities to co-locate and partner within their community where possible to reduce costs 2. Lack of knowledge in the senior services community within PACE providers, and the steep learning curve of Fully education every potential PACE provider and partner. Creating checklists and forms to inform about PACE to ensure that interested entities are full aware of PACE and the depth of resources needed for full implementation. 3. Lack of community involvement, shared partnerships and resources in the rural areas. 4

5 Using strategies that build partnerships in local communities, and identify untapped resources that may be used to support PACE implementation. State Legislative Developments and Anticipated Challenges At this point, OHCA staff members have not identified any specific legislative developments that will impact the demonstration design. Project staff members are always in close contact legislative liaison and with communications staff about state government in order to be aware of any policy issues legislative changes that will affect any of the SoonerCare programs. One possible challenge to the further development of the duals project implementation would be if the legislature did not approve the hiring of additional staff FTEs needed to implement the program. Regardless of the funding source, the OHCA is required to get approval for additional FTE. In light of the current freeze on hiring of new state employees, the request for new staff could be denied. An additional potential challenge would be the funding needed for any state match required to pay for the additional care management services. In a time of tight state budgets, any request for increased funding will be carefully scrutinized. By showing the potential for better outcomes and possible savings from better care management of these individuals, it is hoped that requests for the staff and state match funding for this proposal will be favorably received. 5

6 Workplan/Timeline Benefit Analysis and PACE Timeframe Key Activities/Milestones* Responsible Parties 10/1/11 10/31/11 Identify data needs and complete data requests to CMS Complete data tasking for contractor analyzing claims data Identify target populations for data analysis Continue stakeholder engagement process Identify care coordination features with potential impact for project design Dual eligible benefit (insurance and behavioral health) staff Confirm PACE participating communities Identify PACE populations and potential impact on dual eligibles services PACE staff 11/1/11 11/30/11 Analyze usage data for identified population, Identify external and internal projects with potential for replicating services for dual eligible populations Create website and public information vehicles Meet with stakeholders and compile comments for impact on proposal development Conduct costs benefit analyses to identify potential costs savings measures and utilizations features for use in project design Identify next steps for PACE and expand PACE target communities and partner resources Conduct focus groups to obtain feedback re: PACE expansion Dual eligible benefit staff 12/01/11 12/31/11 Compile results of data analysis, costs savings measures Begin proposal design, resources and budget 01/01/12-01/31/12 Develop outcome measures for proposal design Dual eligible staff Dual eligible staff 6

7 02/01/11-02/29/12 Finalize project proposal design, budget, outcome measures 03/01/12-03/31/12 Present proposal design for public review and comment 04/01/12 04/30/12 Submit final demonstration proposal Dual eligible staff Dual eligible staff Dual eligible staff Tulsa THIZ (only) Timeframe Key Activities/Milestones Responsible Parties 10/3/11 11/1/11 Aggregate the Medicaid and Medicare data for this population BI Group 10/3/11 02/16/12 Analyze Usage data for identified population 09/30/11 11/18/11 Define Medical Coordination Education 10/05/11-11/03/11 Create Governance Model & Governance Pilot Document 10/03/11-11/03/11 10/03/11-11/03/11 Develop outcome measures for assessing efficacy of new care models Develop the payment model for the ACO integrating Medicaid and Medicare payment and eligibility policies Epidemiologists Education Committee Governance Committee Epidemiologists 11/14/11 01/27/11 Perform rapid cycle tests of the policies and procedures 01/30/12 02/27/12 Analyze the results of the rapid cycle tests of change 01/23/12 03/21/12 01/23/12 03/21/12 04/12/12 04/20/12 Write the policies and procedures for reporting provider performance to payers Write the dissemination plan for implementing the plan across the THIZ Final Report Evaluating Demonstration Proposal Submitted to OCHA & Lessons Learned End dates not indicated 7

8 Proposed Approach: For each component of the State s proposed approach to better coordinating care for Medicare-Medicaid enrollees (as reflected in the rows below), update the information in the column Proposed Approach as needed. For any significant changes made, briefly provide the context for any changes in the column Notes on Any Key Changes. Overview of Proposed Approach Proposed Approach (Update Any Key Changes) Oklahoma s proposal involves taking a three-pronged approach to determining the most efficient methods of care integration. Each of the three proposed concepts identifies a different aspect of care for the dual eligibles and will be developed to identify the feasibility and effectiveness of each concept. Concept #1 involves creating an Accountable Care Organization (ACO) with embedded medical education programs (Health Innovation Zone) that specifically serves high cost patients that are eligible for both Medicare and Medicaid. Concept #2 involves exploring the feasibility of establishing a benefit plan and network, administered and operated by the State. Oklahoma proposes combining the funding streams from Medicare and the Oklahoma Health Care Authority (OHCA) and using these funds to purchase coverage through a plan and network developed and administered by OHCA. Concept #3 looks at the expansion of Oklahoma s Cherokee Elder Care Program of All-inclusive Care for the Elderly (PACE) program Statewide. The PACE model combines the services of an adult day health center, primary care office, and rehabilitation facility into a single location. PACE provides an all-inclusive and comprehensive continuum of care designed to maintain and ideally to improve the quality of life for the elderly. Notes on Any Key Changes Concept #1-No change Concept #2- Oklahoma is building a plan to obtain cost savings for all dually eligible members obtained through a combination of predictive modeling and extensive care coordination. Although the initial proposal identified the development of a model for new benefits, the model will use the existing range of benefits and coordinate care uniformly for dual eligible beneficiaries. Much of the review of existing benefits packages will take activity will take place, but instead, with the ultimate intent of obtaining costs savings by synthesizing a process and flow of the two service delivery systems to coordinate and improve care for the dually eligible. Concept #3- OHCA staff have decided to approach a two tier system in order to increase enrollment and make PACE a unique model. This two tier model will capture those individuals who are not quite nursing home level of care but still have the 8

9 Target Population Concept #1 would target individuals from north, east and west Tulsa who are dually eligible for Medicare and Medicaid coverage. Concept #2 would target all dual eligibles with a particular focus on those dual eligibles with behavioral health needs. Concept #3 would target dual eligibles certified to need nursing level of care. minimum age of 55 and live in a community setting. To identify the dual eligible, waiver participants we need to change the dynamics of a structure where we will receive a lesser capitated amount (then a PACE eligible Participant) and use that to managed the care of that individual in terms of preventative care. So we are looking at the population who have high utilizations costs and/or use medical services more than normal and take what each person averages out in dollars spent for health care and compare that to the same number if they were in a PACE care setting. Concept #3- Will be including those dual eligible, waiver participants who are 55 and older in community setting, who are high utilizers, but not quite nursing level of care for the possibility of establishing a two tier PACE system. Estimated Enrollment Estimated enrollment for Concept #1 is about 2,200 individuals from north, east and west Tulsa. The estimated enrollment numbers for the other two design concepts will be determined as the planning and design process moves forward. No Change 9

10 Planned Geographic Service Area Planned Proposal Submission Date Concept #1 will be centered in the Tulsa region. The remaining two concepts will be exploring a Statewide service area during the design process. April 2012 No Change No Change Proposed Implementation Date December 2012 No Change 10

11 Status of Medicare Data Requests and Related Analysis: Data Requested from CMS or ResDAC Data Received by State Analysis In Progress or Planned (if State will not be requesting data at this time, please describe the alternative approach the State will be taking to analyzing Medicare data for design contract work) Medicare Parts A&B Current/Ongoing (COBA) YES Waiting on approval from CMS The Medicare data will be used for utilization analysis, financial modeling and risk stratification, including analysis of paid claims primary care utilization and value stream mapping of current delivery stream. Medicare Parts A&B Historical YES Waiting on approval from CMS The Medicare data will be used for utilization analysis, financial modeling and risk stratification, including analysis of paid claims primary care utilization and value stream mapping of current delivery stream. Medicare Part D Current/Ongoing and Historical YES Waiting on CMS approval PDE data will allow the state to establish and track medication utilization trends as part of an effort to determine the optimal composition of the pharmaceutical component of a new benefit plan for dual eligible members and detect patterns of inappropriate usage which may be managed through care coordination models. The historical PDE data will be required for forecasting utilization trends for the dual eligible population following the introduction of the new health benefit program, giving insight into the potential impact of the program, which is designed to reduce health care costs while improving population health through case management and care coordination. PDE data, in conjunction with other Medicare data, will aid the state in assembling a risk profile of the dual-eligible population, identifying the high-risk, high-cost members that could benefit most from fully integrated care coordination. 11

12 Data will be used in conjunction with Medicaid paid claims data to construct new, integrated benefit plan for dual eligibles Evaluate efficacy of primary care in management of dual eligible members Determine how comorbidities effect health care consumption and outcomes. Literature reflects that individuals with three or more comorbidities are at higher risk for readmission to the hospital, increases costs, and increased complexities in medication and medication interactions. This analysis will allow us to assess how these comorbidities, coupled with complex medication profiles result in increased cost and poor outcomes. Once this is thoroughly understood we can develop appropriate models for effective management of this member and their medications. 12

13 Technical Assistance Needs: For each area of technical assistance listed below, please indicate with an X in the first column if the State needs/anticipates needing technical assistance in this area. Do not include technical assistance needs which the State is addressing/plans to address through subcontracts or other resources funded by the design contract. In the column Description of Assistance Needed provide a brief description of the types of assistance needed. Area of Technical Assistance Stakeholder Engagement Description of Assistance Needed X Medicare Data, Linked Dataset Analysis X Financial Alignment and Modeling X Actuarial Analysis X Medicare 101 Medicare Advantage and SNPs X Measurement and Evaluation Measurement and Evaluation harmonization between State Demonstration participants. Provider Contracting X Long-Term Care Integration Models X Behavioral Health Integration Models Development of Medicaid Health Home Information Technology/Systems Implementation/Readiness Review Other 13

14 Stakeholder Engagement: Provide brief answers to the questions below regarding stakeholder engagement work that has taken place or is planned in the State. OHCA Stakeholder Advisory Committee Does the State have (or plan to establish) a stakeholder advisory committee or similar group to obtain input on the State s design proposal? Yes/No If yes, what is the name of this group? Dual Eligible Stakeholder Workgroups If no, what are the State s alternative plans for gaining input from stakeholders? How often does this group meet and over what timeframe? If this group has not yet begun to meet, when will meetings begin? Meetings began in September, and will continue monthly until March. The sub-groups and the large groups meet in alternating months, so the next full stakeholder meeting will be in November. Are the meetings of this group open to the public? Yes/No Are beneficiaries a part of this group? Yes/No Are advocates a part of this group? Yes/No Are family members and caregivers a part of this group? Yes/No Are providers a part of this group? Yes/No If applicable, who else is part of this group? State level staff who administer waivers and other programs that have dual eligible members, staff from federally qualified health centers; OHCA member advisories. Public Meetings Is the State holding/has the State held other public meetings? Yes/No If yes, when will/did these meetings take place and how will/did the State inform stakeholders of these events? Focus Groups Has the State/is the State planning to conduct focus groups to inform its design proposal? Yes/No If yes, please briefly describe the population(s) participating in the focus groups and key topic areas of discussion. Focus groups and be proposal and developers and reviewers. They will be asked to address the feasibility of the proposal, and be asked to closely examine its relevance to members. 14

15 Other Stakeholder Engagement Activities If applicable, briefly describe any other stakeholder engagement activities that have taken place or are planned. OU Stakeholder Advisory Committee Does the State have (or plan to establish) a stakeholder advisory committee or similar group to obtain input on the State s design proposal? Yes/No If yes, what is the name of this group? Long Term Care Authority, LIFE Senior Services, Healthcare Resource Center, Morton Community Comprehensive Health Services, Focus Groups, and Hospitals and discharge planners. If no, what are the State s alternative plans for gaining input from stakeholders? How often does this group meet and over what timeframe? If this group has not yet begun to meet, when will meetings begin? Monthly, started in July Are the meetings of this group open to the public? Yes/No Are beneficiaries a part of this group? Yes/No Separate Group Are advocates a part of this group? Yes/No Are family members and caregivers a part of this group? Yes/No Are providers a part of this group? Yes/No If applicable, who else is part of this group? Public Meetings Is the State holding/has the State held other public meetings? Yes/No If yes, when will/did these meetings take place and how will/did the State inform stakeholders of these events? Focus Groups Has the State/is the State planning to conduct focus groups to inform its design proposal? Yes/No If yes, please briefly describe the population(s) participating in the focus groups and key topic areas of discussion. Our dual eligible interview participants have been recruited with the assistance of medical 15

16 and social service agencies in the Tulsa area that are a part of the HIZ. Our sampling goal is to have a representative mix of dual eligibles that spans race, age, and medical condition. As a means to engage the perspective of the dual eligible population in program development, HIZ workgroup is engaging in qualitative research into the attitudes of a sample of dual eligibles through in depth key informant interviews and focus groups. Our research questions that have guided the project thus far surround the following themes: 1.) What are your perspectives on Medicare and Medicaid, including its strengths and weaknesses? 2.) What reforms would you suggest that could provide better health care at a lower cost? Other Stakeholder Engagement Activities If applicable, briefly describe any other stakeholder engagement activities that have taken place or are planned. 16