My Care Ohio: Ohio s Duals Demonstration Lessons Learned

Transcription

1 My Care Ohio: Ohio s Duals Demonstration Lessons Learned Kim Donica-Ohio Department of Medicaid Matt Hobbs-Ohio Department of Medicaid Christi Pepe-Ohio Department of Medicaid Hope Roberts-Ohio Department of Aging Brenda Jackson-Mercer Mary Sowers-Mercer

2 Current Outlook in Ohio Ohio currently operates nine 1915 c waivers.

3 Current Outlook in Ohio NF Level of Care Waivers Enrollment PASSPORT 33,323 Choices 542 Assisted Living 4,077 Ohio Home Care 8,651 Transitions Carve-Out 2,323 ICF-IID Level of Care Waivers Individual Options 17,212 Level One 12,368 SELF 117 Transitions DD 3,020 3

4 Current Outlook in Ohio Almost 75% of all Medicaid recipients in Ohio are enrolled in managed care 1,682,873 Current Medicaid Managed Care Enrollment

5 Ohio s Duals Demo Why must we act? The current system is confusing & difficult to navigate. No entity accountable for the whole person. The aging of Ohio s population has arrived and is accelerating rapidly

6 The Vision for Better Care Coordination The vision is to create a person-centered care management approach not a provider, program, or payer approach Services are integrated for all physical, behavioral, longterm care, and social needs Services are provided in the setting of choice Easy to navigate for consumers and providers Transition seamlessly among settings as needs change Link payment to person-centered performance outcomes

7 Ohio s Duals Demo Ohio s Medicare/Medicaid financial alignment demonstration called (My Care Ohio) will begin voluntary enrollment on 3/1/14.

8 1915 B/C Waiver It was determined Ohio would need 1915 b/c waiver authority in order to operationalize the model for My Care Ohio.

9 B/C Waiver Development Challenges presented, how they were addressed and lessons learned.

10 Challenge # 1 Ohio had little experience with managed long term services and supports

11 Challenge # 1 Ohio addressed challenge by: Identifying key staff in the Medicaid managed care and long term services and supports areas to work as a team on demonstration Involvement from sister agencies, particularly the Ohio Department of Aging, in the project development team Procuring a well qualified vendor who had experience working with states on the development of managed LTSS

12 Challenge #1 Lesson Learned Our history is both a strength and a weakness. You cannot protect the current state at the expense of the future. States have to be willing to expose the weaknesses in their processes. Find shared values. Willing to respect and trust one another.

13 Challenge #2 Ohio Stakeholders Were Afraid of a Managed Care Model

14 Challenge # 2 Ohio addressed challenge by: Conducting forums with stakeholders across the state to obtain input on the design of demonstration and then actually making changes to the demo based on that feedback. Providing on-going opportunities for stakeholders to provide input during the development phase though such mechanisms as an enrollment advisory group. Providing on-going opportunities for stakeholder feedback to the Plans directly once the demo is operational via required consumer advisory councils.

15 Challenge # 2 Lesson Learned Meaningful stakeholder engagement early and often is essential for stakeholder buy-in.

16 Challenge #3 Managed Care models and 1915c waivers have differing views on the definition and measurement of quality

17 Challenge # 3 Ohio addressed challenge by: Acknowledging the validity and the need for both approaches to quality Working with National Quality Enterprise on the development of waiver QIS measures that meet the 1915 c waiver requirements that also align with a managed care model

18 Challenge # 3 Lesson Learned Establishing the quality framework for the demo required an and rather than an or solution We found a traditional managed care resource to help support 1915 c waiver over sight.

19 Challenge # 4 Defining the scope and lines of authority within care management in order to reduce conflicts of interest and optimize the use of expertise and resources.

20 Challenge # 4 Ohio addressed challenge by: Integrating conflict free case management principles into the contracts for the My Care Ohio Plans. Plans will not be responsible for level of care determinations. Developing firewalls for the AAA s to clearly define roles and separate lines of authority.

21 Challenge # 4 Lesson Learned Conflicts of interest can be addressed through the use of contract language and firewall documents.

22 Challenge # 5 Assuring Waiver Consumers Health and Welfare During Transition to Managed Care

23 Challenge # 5 Ohio addressed challenge by: Robust Transition Requirements Data Sharing Incident Management Plan Staffing Requirements

24 Challenge # 5 Lesson Learned Continuity of care and testing a new service delivery model are not mutually exclusive.

25 Challenge # 6 How to establish a qualified community based LTSS provider network.

26 Challenge # 6 Ohio addressed challenge by: A new provider contract type was not established for the ICDS waiver. Rather providers who are certified by ODA or approved by ODM to provide traditional waiver services will be deemed eligible to provide services in the ICDS waiver. When building their provider panel, requiring plans to contract only with approved ODM or certified ODA providers for the provision of waiver services

27 Challenge # 6 Lesson Learned - Ohio will explore opportunities to align processes, service definitions, and provider requirements.

28 Mercer s Role Mercer provided Ohio with actuarial support for the development of rates for managed care and in the development of the required financial information supporting the Medicaid authority applications including: the Medicaid ICDS capitated rates; negotiations with the Medicare actuaries regarding joint program savings adjustments on the demonstration; the 1915(b) cost-effectiveness calculations; and the 1915(c) cost-neutrality calculations. In addition, Mercer provided technical support/advice on the Medicaid structures and operations that could be utilized to achieve the desired program goals, as well as key clinical advice on strong program design, including in the area of evidence-based practices and person-centered systems of care including: Assistance with development of 1915(b) and 1915(c) waiver applications; and Advice on clinical and operational aspects of the program including risk mitigation, care management, enrollment, eligibility, marketing, etc. 28

29 Ohio s Lessons Applicable in all States Ohio's success in overcoming challenges stemmed from the clear vision and commitment to an understandable, person-centered system of care. Each state may have different drivers for system redesign and articulating the end vision and desired outcomes is key. Ohio leveraged many elements of the existing infrastructure as key partners and building blocks in the design of the program, furthering opportunities to infuse existing system values into a new delivery model. 29

30 Ohio s Lessons Applicable in all States Ohio was deliberate in their program's design to ensure a personcentered approach within a managed care delivery system. Thinking of each desired element/attribute as an essential building block to be integrated into authority and contract design is key (for example, conflict free case management, meaningful person-centered planning and service delivery, design and implementation of selfdirection, etc.). As Ohio noted, the Medicaid authorities are not always an exact match for desired program elements, but partnering with CMS to brainstorm possibilities and identify solutions is a strong strategy to achieve desired structures within the parameters of the authorities. 30

31 Program Design and Financial Issues Bridging the Chasm "You get what you pay for" is more than an old adage. Setting Rates: Capitation payments in Medicaid must be actuarial sound; Deriving a methodology that met this test and accommodated the three party arrangements made this effort more complex, requiring a strong working relationship between CMS and the State; Ensuring all potential financial incentives support program goals is essential; and Meeting the requirements of the demonstration, capitation rates, as well as the individual Medicaid authorities in the 1915(b) and (c) waivers necessitated understanding of the requirements of each statutory authority and how financially the pieces fit together. 31

32 Program Design and Financial Issues Bridging the Chasm Program and Finance and Necessary Partnership: Understanding the building blocks of capitation, as well as waiver financing is key to ensure strong design; Analyzing current and expected patterns of service utilization, unmet needs/high demand and other system aspects such as changes in eligibility and services likely to impact overall program rate and cost information is a key step to a fiscally sound program design; and Strong communication between program and finance staff is essential at every step. Dot Connection: It is important to encourage team members to connect the dots in program design and implementation. System redesigns include interlocking pieces, where any change or decision is likely to have implications elsewhere; This manifests itself in relationship to program design, finances, systems requirements and design specifications, and quality. 32

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34 Implementation Challenges Still to Be Addressed: Implementing HCBS provider monitoring across the fee-for-service and managed care delivery system. Managing the enormity of the implementation of the demonstration while maintaining the current service delivery model. Developing IT systems required to support demonstration activities.

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