MassHealth Initiatives:

Transcription

1 MassHealth Initiatives: PCMHI, DUALS, PCC/BH Integration, PCPR Dr. Julian Harris CBHI and CYF Advisory Committee Joint Meeting November 5, 2012

2 Our Mission To improve the health outcomes of our diverse members, their families and their communities, by providing access to integrated health care services that sustainably promote health, well-being, independence, and quality of life. 2

3 Strategic Goals and Top Ten Strategic Initiatives Community Members Maintain our commitment to careful stewardship of public resources through innovative program integrity initiatives Program Integrity Optimization Deliver a seamless, streamlined, and accessible member experience Operations and Customer Service Enhancement Integrated Eligibility System/ Health Insurance Exchange ACA Expansion Promote integrated care systems that share accountability for better health, better care, and lower costs Duals Demonstration Delivery System Transformation Primary Care Payment Reform Health Information Exchange/Technology Shift the balance toward preventative, patientcentered primary care, and community-based services and supports PCC/ Behavioral Health Integration Money Follows the Person 5 Create an internal culture and infrastructure to support our ability to meet the evolving needs of our members and partners Meet members where they are Focus on stewardship and fiscal responsibility Be data driven Model a team based approach 3

4 Care integration is defined by the coordination of providers and services across the continuum of care to support the patient Level 3 Community hospitals and other specialists, post acute care, etc. Tertiary and Quaternary Specialists and Hospitals Goal of level of integration Improved transitions across settings Level 2 Major specialists (orthopedics, cardiology, general surgery obstetrics, etc.) Home care and other community supports Improved outcomes, efficiencies, and coordination Improved management of and outcomes for complex patients Prevention & early diagnosis Level 1 Primary Care Medical Home Behavioral Health Improved access to care Appropriate use of tests, referrals, and ED Decreased preventable acute events 4

5 Payment Methodology MassHealth has begun a number of initiatives to move towards true accountable care Global Payment Payment Innovation True Accountable Care Duals PCPR Asthma Pilot Business as Usual Current Market PCMHI Health Homes Delivery System Transformation MBHP Care Mgmt DSTI FFS Limited Integration Full Care Integration Degree of Integration 5

6 Primary Care Payment Reform, Health Homes, and services for children with BH conditions The Comprehensive Primary Care Payment is meant to provide practices with the flexibility, independent of FFS billing restrictions, to provide the services their patients require, tailored to the specific needs of the patient; practices could use the CPCP to support family partner supports where appropriate Risk adjustment of the CPCP to reflects the needs of all patients, especially children, is something MassHealth is very focused on; we have purchased Verisk s PCAL model (developed by Randy Ellis and Arlene Ash) to measure primary care burden, taking into account the unique effect of behavioral health needs. Our hope is that an effective risk adjustment process can enhance access for children with significant needs Our health homes initiative is a complementary program to support funding care management and care coordination for members (adults and children) with severe and persistent mental illness. It will support PCPR, our current CBHI program, and offer funding to behavioral health providers to be a health home as well. Currently, only 20% of children with SED receive the Intensive Care Coordination (ICC) services in CBHI at any given time the health home service could provide an ongoing source of care coordination, care management, and family supports to children with SED who do not require ICC services 6

7 PCC is one of the managed care plans that our members can select Percent of MassHealth enrollment 100% 100% = 1.3 million members 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% MCO PCC 65 plus duals Under 65 duals Other FFS Primary Care Clinician (PCC): MassHealth requires most members under age 65 to enroll in managed care. The PCC Plan is one option members can choose. The PCC Plan is a statewide network of over 1000 Primary Care Clinicians (PCC). The hospital, pharmacy and specialty network for the PCC Plan includes all MassHealth participating providers. Members select a PCC who is responsible for providing primary care and referrals to specialists and other MassHealth providers. 7

8 Payment innovation is defined by providers taking on financial incentives to provide lower cost, higher quality services to patients PCC and Behavioral Health PCC/BH Integration All PCC Plan Enrollees receive behavioral health services through the managed behavioral health vendor, MBHP. MBHP also manages BH services for MassHealth Members enrolled through DCF and DYS but not in the PCC Plan and children under 21 with other primary insurance and MassHealth MBHP will strengthen communication and collaboration between PCCs/PCPs and behavioral health providers to treat the whole patient. Encourage providers to address the medical needs for those with behavioral health conditions and to address the behavioral health needs of those with medical conditions. EOHHS will offer incentives to encourage the vendor to improve integration at the clinical level in DMH Member P4P. 8

9 To encourage the vendor to increase integration, EOHHS will offer Pay for Performance Incentives BH HEDIS Measures 1. Follow-Up after Hospitalization for Mental Illness 2. Initiation and Engagement for Treatment of Alcohol and other Drug Dependency 3. Follow-up Care for Children Prescribed ADHD Medication DMH Client Focused 4. Improving the percentage of Primary care visits for PCC Plan Members who are clients of DMH with diabetes and improving measures of compliance with standards of diabetes care 9

10 MassHealth s primary care reforms are built from work on the patient-centered medical home Expanding to other providers Patient Centered Medical Home Aligned payors around concept of medical home Provided experience / learning in practice transformation Primary Care Payment Reform Builds off medical home and integrates behavioral health Aligns payors around a more dramatic shift in payment structures than PCMHI Mechanisms for practices to affiliate with each other and BH providers ACOs may grow to include more than primary care / BH Hospital payment reform may included enhanced admissions to reduce readmissions, acute care bundled payments Current initiative How does this support our strategic goals? Use alternative payment methodologies to promote care delivery innovations such as team based care, group visits, tele-health, virtual office visits, and community health workers Promote and scale the patient-centered medical home model across all MassHealth programs Operationalize primary-care behavioral health integration 10

11 Summary of Primary Care Payment Reform The goal of our strategy is improving access, patient experience, quality, and efficiency through care management and coordination and integration of behavioral health We believe that primary care is important in improving quality and efficiency while preserving access, through the patient centered medical home with integrated behavioral health services The payment mechanism that supports that delivery model is a comprehensive primary care payment combined with shared savings +/- risk arrangement and quality incentives This program would span MassHealth managed care lives across the PCC Plan and the Managed Care Organizations. We propose to launch a procurement for PCCs to participate in the program and MCOs will participate in a similar payment structure with these organizations. We plan to implement on an aggressive timeframe, with an RFP release planned in January 2013 and with 25% of member participating by July 2013, 50% of members participating by July 2014, and 80% by July

12 Proposed payment structure A Comprehensive Primary Care Payment Risk-adjusted capitated payment for primary care services May include some behavioral health services B Quality Incentive Payment Annual incentive for quality performance, based on primary care performance C Shared savings payment Primary care providers share in savings on non primary care spend, including hospital and specialist services The payment structure will not change billing for non-primary care services (specialists, hospital); PCP s will not be responsible for paying claims for these services. However, we are evaluating complementary alternative payment methodologies to hospitals and specialists for acute services. 12

13 Overview of clinical delivery model 1. Participants will have the functional capacity to provide 12 PCMH components, all of which are fundamental to care integration. 2. Participants will integrate behavioral health and primary care by implementing defined integration elements. 3. The approach to care integration may vary, based on practice setting and patient need, and may form a continuum of care. 4. With components of the PCMH and care integration elements in place, participants will routinely assess patient complexity and develop care approaches that are customized to the individual patient and his/her needs. 13

14 In a fully integrated medical home, primary care and behavioral health providers work side by side as part of the health care team. Element 1: Relationship and Communication Practices Element 2: Patient Care and Population Impact Non-Colocated Approaches Co-located Co-located & Fully Integrated Element 5: Clinic System Integration Approaches Element 3: Community Integration Element 4: Care Management 14

15 Overview of health homes The Health Homes opportunity provides states the opportunity to create a new state plan benefit to support health home services for eligible beneficiaries; Health home services are Comprehensive care management Care coordination and health promotion Comprehensive transitional care, including appropriate follow-up, from inpatient to other settings Patient and family support (including authorized representatives) Referral to community and social support services, if relevant Use of health information technology to link services, as feasible and appropriate 15

16 Together, with Health Homes and PCC/BH Integration, we can create a better integrated care model for CBHI Under PCC/Behavioral Health Integration, MBHP will manage of CSAs and other CBHI services to promote: Family Focused, Strength Based approach Compliance with National Wraparound Initiative Principles and fidelity monitoring Coordination with other managed care entities in joint management In the CBHI program, CSAs already provide most health home services to children. As CSAs enroll as health homes, we would expand access to the CBHI population and enhance FFP on those services

17 A small proportion of dual eligible members accounted for a large proportion of total duals spending SHARE OF ENROLLEES PROPORTIONS OF DUALS AGES AND EXPENDITURES, 2008 $0 $20K SHARE OF SPENDING $20 $50K $50 $100K > $100K Six percent of duals had annual per capita health care spending of more than $100,000, accounting for 37 percent of combined Medicaid and Medicare expenditures for duals. Seventy percent of duals had annual per capita health care spending less than $20,000, accounting for 16 percent of combined Medicaid and Medicare expenditures for duals. Most duals are in fee-forservice programs RANGE OF ANNUAL PER CAPITA SPENDING LEVELS 17

18 The Dual Eligible Demonstration Project provides integrated care to vulnerable members Duals cost more than double the average for Medicaid patients Enrollment and spending by member type (percentage of total) And need far greater medical and community-based support Members requiring assistance with activities of daily living (percentage of total) Program Features Contracts with integrated care organization to provide medical, behavioral health and community-based services coordinated by an integrated care team Uses an integrated global payment funded by MassHealth and Medicare and encourages alternative payment mechanisms How does this support our strategic goals? Prioritize access to integrated care delivery for high cost members with complex needs Use alternative payment methodologies to promote care delivery innovations 18

19 Meeting our generation s moral test DME LTSS Integration Secondary Prevention Integrated Care Team Care Coordination BH 19