CA Duals Demonstration: Bringing Coordination to a Fragmented System

Transcription

1 CA Duals Demonstration: Bringing Coordination to a Fragmented System Martha Smith Health Net s Chief Dual Eligible Program Officer Integrated Healthcare Association & California Association of Physician Groups October 30, 2012

2 Health Net Footprint: 2012 Del Norte Siskiyou Modoc Trinity Humboldt Shasta Tehama Lassen Plumas All Products Mendocino Glenn Sierra Nevada ColusaSut- Yuba Placer Lake ter Yolo El Dorado Sonoma* Napa Sacra- Alpine mento Amador Solano Cala- Marin Contra San verastuolumne Costa* Joaquin** San Francisco Alameda* Stanislaus Mariposa San Mateo Santa Clara Merced Madera** Santa Cruz Butte San Benito Monterey Medi-Cal and Commercial only Medicare and Commercial only Commercial only San Luis Obispo Fresno Kings** Mono Tulare Kern Santa Barbara Los Ventura* Angeles Orange^^ San Bernardino^^ Riverside^^ San Diego Imperial California: Medicaid (Medi-Cal), MAPD, Commercial Western Region (OR, AZ, WA): MAPD, Commercial TRICARE: North Region 2

3 Health Net Programs and Enrollment: Commercial programs (HMO, PPO, etc.): 1.3 million Medicare Advantage: 230,000 (including 19,000 Dual-Eligible Special Needs Plan (D-SNP) members Medicaid (Medi-Cal)/Healthy Families: (including 86,000 Seniors and Persons with Disabilities) 1.1 million TRICARE: 3 million TOTAL: 5.6 million Health Net is uniquely qualified and well positioned to manage the Dual Eligible population 3

4 Benefits of Managed Care Managed Care brings coordinated care to California s highest-need populations: Dual eligible beneficiaries and Medi-Cal seniors and persons with disabilities (SPDs) The current fragmented delivery of care leads to Beneficiary confusion Poor care coordination Inappropriate utilization Unnecessary costs. A Person-Centered Approach, delivered in a Managed Care environment, aims to improve the coordination of care, minimize beneficiary confusion, and ensure that the best care is delivered in the most appropriate setting From: Burwell and Saucier. Care Management Practices in Integrated Care Models for Dual Eligibles. AARP,

5 Care Delivery Spectrum Care Delivery Under the Demonstration, Health Plans will be responsible for the full spectrum of care delivery Traditional Medical SNF s LTC HCBS Community Well Benefit Professional services Acute Hospital Etc. Skilled Nursing Skilled therapy Custodial Care CBAS MSSP IHSS Other HCBS Traditional Payer Medicare Medicare for 1 st 100 days Medi-Cal Currently carved out of Managed Care Medi-Cal Currently carved out As of 10/1, CBAS accessed only through Managed Medi-Cal Inter-disciplinary Care Teams (IDCT) provide one point of accountability for the delivery, coordination, and management of benefits and services. Comprised of Member and Caregivers, Primary Care Physician, Nurse, Behavioral Health Clinician, Pharmacist, Case manager, and Social worker 5

6 Implementation: Operational Readiness Developing a model that provides for meaningful interaction with the stakeholder community County and other public agencies Advocates Programs that are not technically benefits, but provide support for this population Technology platforms to support the meaningful integration and accessibility of data Complex model of care, interacting with the delegated delivery system Long term services and supports IHSS Compliance programs that address the requirements of both Medicare and Medi-Cal Oversight of delegates 6

7 Implementation: Network Adequacy Organized Care Delivery System built off Medi-Cal Managed Care & Medicare Dual Eligible Special Needs Plan (D-SNP) Model for traditional medical services Behavioral Health integration with Department of Mental Health Long-Term Services & Supports (LTSS) provider network including Long-Term Care facilities, Multi-Purpose Senior Services Programs (MSSP), Community Based Adult Services (CBAS), In Home Supportive Services (IHSS) and other community based organizations intended to mirror current system (at least initially) Plans have to meet State and Federal requirements for Readiness Reviews Network capacity Geo-access Timeliness Cultural and Linguistic 7

8 Implementation: Network Adequacy (cont.) Increases in contracted physicians (primary care and specialists) needed over the next two years Dually Eligible beneficiaries are currently receiving services, mostly in Fee- For-Service As the Dual Eligibles are not new residents in their respective Counties, the physicians needed to deliver quality and timely care are already in the system Contract with high quality, provider networks with capacity and programs to meet needs of this population Held to high standards Robust clinical program and quality incentives Committed to exceeding access standards for medical services, prescription drugs, and LTSS The final network composition is dependent on the development of adequate rates and the subsequent contracting process that will occur 8

9 Implementation: Development and Communication Activities Communications Meeting with currently contracted providers (medical groups/ipas, hospitals) FAQs have been posted publicly and are routinely distributed to providers Educational presentations targeted toward non-contracted providers, often through hospital medical staff forums Network teams have established procedures for handling provider inquiries related to network contracting Interested providers that may not be in the network are being referred to local medical groups/ipa s for anchoring purposes with these contracted organizations 9

10 Implementation: Development and Communication Activities (cont.) Contracting Plans are drafting contract documents/amendments, inclusive of participation requirements Execution of network contracts will commence upon receiving rate information Health plan staff are ready to begin credentialing of new providers Training Provider training curriculums are being developed, specific to the Demonstration with emphasis on LTSS to be used after contracts are executed 10

11 Questions? 11