Medicare Medicaid Enrollee Delivery System Transformation

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Updates from the Medicare Medicaid Financial Alignment Initiative Susan Castleberry Division of Medicare Health Plans

Transformation CURRENT STATE Provider and Payor Centered Fragmented Care Volume Driven Complicated Benefit Overlap

Update 2015 Implementation in the Capitated Model State Start date Number of Plans Total Enrollment as of October 30,

1 Updates from the Medicare Medicaid Financial Alignment Initiative Susan Castleberry Division of Medicare Health Plans Operations Centers for Medicare & Medicaid Services November 13, 2015 Medicare Medicaid Enrollee Delivery System Transformation CURRENT STATE Provider and Payor Centered Fragmented Care Volume Driven Complicated Benefit Overlap FUTURE STATE Person Centered Coordinated Care Outcomes Driven Simplified Processes 2 Financial Alignment Initiative Update 2015 Implementation in the Capitated Model State Start date Number of Plans Total Enrollment as of October 30, 2015 New York April ,859 Michigan May ,554 Texas April ,088 South Carolina June ,

2 Financial Alignment Initiative Update Enrollment, Age, and Preliminary 90 day Assessment Completion in Capitated Financial Alignment Model State Start Date Number of MMPs (6/15) Total Enrollment (9/15) Percentage of enrollees under age 65 Percentage of enrollees age 65+ Preliminary % of members with HRA completed within 90 days (6/15) MA 10/ ,503 99% 1% 64% IL 3/ ,677 43% 57% 69% CA 4/ ,039 31% 69% 89% VA 4/ ,094 53% 47% 93% OH 5/ ,426 50% 50% 74% Sum across all ,739 44% 56% 78% 4 Financial Alignment Initiative Update All demonstrations will be rigorously evaluated on their ability to improve quality and reduce costs. CMS has contracted with an external evaluator, RTI International, to lead the evaluation of each individual demonstration. CMC Plans are also required to report on Core Measures. All existing Medicare and Medicaid reporting, including CAHPs, HEDIS, HOS and Part C and D reporting is required. 5 Financial Alignment Initiative Update External evaluation (RTI International) Evaluation design reports are on MMCO website The annual and final evaluation reports for each demonstration, and for the Initiative overall, will be posted on the MMCO website (first annual reports expected in first half of 2016) Each demonstration will be separately evaluated, pre post evaluation design with a comparison group using an intent to treat framework RTI is using a mixed methods approach Qualitative methods include site visits, qualitative analysis of program data, and collection and analysis of focus group and stakeholder interview data Quantitative analyses include evaluating the impact of the demonstration on cost, quality, and utilization measures RTI plans to analyze certain sub populations within each demonstration 6 2

3 Financial Alignment Initiative Update California Demonstration Research Questions What are Primary design features and how do they differ from State s previous system? Was the demonstration implemented as designed? Factors contributing to Success? Barriers to implementation? Overall Beneficiary Experience Impact on Cost Impact on Utilization Impact on Healthcare Quality Overall and for specific subgroups Impact on Access to Care Policies or Practices to inform adaptation/replication in other states? 7 Financial Alignment Initiative Update Core Measures Health Risk Assessments Care Coordination Enrollee Protections Organizational Structure and Staffing Performance and Quality Improvement Provider Network Systems Utilization 8 Financial Alignment Initiative Update Core Measures State Specific Measures: Care Coordination Enrollee Protections Organization Structure and Staffing Utilization 9 3

Cal MediConnect Health Risk Assessment (HRA) Dashboard April 2014 June 2015 Cumulative HRA Breakdown www.calduals.

4 Cal MediConnect Health Risk Assessment (HRA) Dashboard April 2014 June 2015 Cumulative HRA Breakdown 10 Financial Alignment Initiative Update Positive momentum Dramatic increase in the number of Medicare Medicaid beneficiaries in financially integrated or total cost of care models 200,000+ assessments, increasing every day Major investments in new care coordination infrastructure (e.g., the plans hired over 2,500 care coordinators who supported demonstration enrollees in 2014) 11 More Information Medicare Medicaid Coordination Office Medicaid Coordination/Medicare and Medicaid Coordination/Medicare Medicaid Coordination Office/ Medicare 12 4

5 ICE 2015 Annual Conference: California s Coordinated Care Initiative Hilary Haycock President Harbage Consulting November 13, 2015 Harbage Consulting As a health policy firm with a focus on increasing value in health care delivery, we help our clients understand, navigate, and succeed in implementing a wide range of health policies and programs. Our core expertise is in public and safety net programs, and also system integration, including Medicare and Medicaid, long term services and supports, and behavioral health. HarbageConsulting.com 2 Roadmap Coordinated Care Initiative Overview Cal MediConnect Enrollment Data Health Risk Assessment Data Initial Evaluation Data Provider Engagement Ongoing Provider Needs 3 1

Coordinated Care Initiative: Brief Overview Program Design Integrates LTSS into Medi Cal managed care plans and mandatory enrollment into Medi Cal managed care plans Cal MediConnect (combined

6 Coordinated Care Initiative: Brief Overview Program Design Integrates LTSS into Medi Cal managed care plans and mandatory enrollment into Medi Cal managed care plans Cal MediConnect (combined Medicare and Medi Cal plan) option for dually eligible beneficiaries Seven counties most with a 12 month "passive" enrollment phase for dually eligible beneficiaries into Cal MediConnect Stakeholder Engagement and Education Statewide and local stakeholder coalitions funded by The SCAN Foundation Provider toolkit and provider outreach conducted by state contractors Online clearinghouse with resources for beneficiaries, providers and stakeholders Tele town halls and other beneficiary outreach Regular stakeholder calls and weekly e mail update Beneficiary Protections Multiple notices, and a dedicated call center Continuity of Care provisions Cal MediConnect Ombudsman Program Enhanced quality monitoring and enforcement 4 Cal MediConnect Enrollment Data Updated October 1, Health Risk Assessment Data Released in October 2015 o Data from April 2014 June % of HRAs completed within 90 days of enrollment o Beneficiaries who were able to be reached and willing to participate o 38% of beneficiaries unreachable/10% unwilling to participate DHCS working with health plans to get up to date beneficiary contact information Efforts involve partnering with pharmacies and other organizations that may have such information 6 2

7 Cal MediConnect Evaluation Efforts Several data analysis efforts are underway to better understand who is opting out and why as well as how the program is working for enrollees: DHCS Analysis of Opt Out Beneficiaries SCAN funded efforts Rapid Cycle Polling Project UCSF efforts Phone Surveys and Focus Groups CMS funded efforts RTI Focus Groups LA County Cal MediConnect Plan Focus Groups SEIU IHSS Consumer Focus Groups 7 Initial Evaluation Data Beneficiaries in Cal MediConnect plans are satisfied with: Their choice of doctors (77%) and hospitals (76%) The way different health care providers work together to give them services (77%) The amount of time doctors and staff spend with them (83%) The information provided by their plan to explain benefits (76%) 80% of beneficiaries were confident they can get their questions answered about their health needs 8 Initial Evaluation Data Transition issues often led to early disenrollment from Cal MediConnect Those who stayed enrolled were satisfied with how issues were resolved Beneficiaries often lack awareness about Cal MediConnect benefits, including the availability of a care coordinator or continuity of care Beneficiaries who opted out were wary of change in current health care services (84%) and losing their doctors (71%) 9 3

8 Providers Matter Physicians are essential to successful implementation Beneficiary trust/relationships Significant influence on community especially in diverse communities Impact enrollment, retention and care coordination efforts Non medical providers are also key Trusted community resources Know beneficiary needs sometimes better than anyone In home caregivers Staff at service organizations Often the first point of contact when someone needs help Overall, large need to help support duals networks of care and providers Examining Provider Resistance Disengaged Fear of change/distrust of managed care Misinformed Burdensome requirements Concerns about new financing structures Loss of autonomy Aversion to emphasis on data and rankings Provider Outreach Providers first and foremost need to feel HEARD Focusing outreach on trusted medical/non medical providers Collaborating with community based organizations Developing toolkits with provider specific information Using provider specific messengers Smoothing transitions Continuity of Care and Care Transitions 4

9 Culturally Competent Outreach Connecting with key leaders and providers in organizations & communities that serve beneficiaries with diverse backgrounds Example: The Network of Ethnic Physician Organizations Working with Ethnic Physician Organizations to inform their members Targeting organizations representing high opt out populations 13 Provider Toolkits Physician Toolkit General program overview Billing and contracting information Patient and physician protections, such as continuity of care Details of care coordination and how it works Working with people impacted by different parts of the program Case Management Toolkit Ensure case managers get relevant info specific to their role Health plan contacts for case managers to call when things don t work Quick reference guide with key info desk reference Fact sheets specific to case managers Developing messaging with feedback from case managers IHSS Consumers and Workers One of the largest areas of opt out Disconnect in data and communications Innovative approaches to bring IHSS participants in to the care model Tele town halls 15 5

Provider issues Pharmacists: Outreach around Part D continuity of care Nursing Facilities: Challenges around authorizations, rates and billing Office Staff: Different priorities/concerns than

10 Provider issues Pharmacists: Outreach around Part D continuity of care Nursing Facilities: Challenges around authorizations, rates and billing Office Staff: Different priorities/concerns than physicians CBAS: Lessons learned from previous transitions Balance Billing: Ensuring access for FFS Medicare patients Care Coordination: Need to carry through breaking down of silos, including through provider summits 16 For questions: me at hilary@harbageconsulting.com Web resources: CalDuals.org 6

Coordinated Care Initiative ICE 2015 Annual Conference - November 13, 2015 Presented by: Rohit Gupta, Director of Compliance Inland Empire Health Plan Inland Empire Health Plan Est.

Independent Physician Association (IPA) Direct Physician Contracting Medical Groups IEHP Membership by Line of Business Total Medi Cal 1,090,830 Healthy Kids 1,000 965 DualChoice (Dual Eligible

11 Coordinated Care Initiative ICE 2015 Annual Conference - November 13, 2015 Presented by: Rohit Gupta, Director of Compliance Inland Empire Health Plan Inland Empire Health Plan Est IEHP is a Local Initiative Medi-Cal Managed Care Plan Joint Powers Agency of Riverside and San Bernardino Counties (California) Organized as a Public Agency, Non-Profit HMO Mixed Model HMO: Independent Physician Association (IPA) Direct Physician Contracting Medical Groups IEHP Membership by Line of Business Total Medi Cal 1,090,830 Healthy Kids 1, DualChoice (Dual Eligible Special Needs Plan) Cal MediConnect 22,210 Total 1,115,005 1 (1) As of November 1, Our Mission and Core Values Mission Statement To organize and improve the delivery of quality, accessible and wellness based healthcare service for our community. Core Values Health and Quality before Cost: we believe in placing member's health care needs above all else. Team Culture: we are a dedicated and cohesive team focused on member care and supporting our providers. Think and Work Lean: we strive to continuously improve our daily operations and delivery of health care services. Partner with Providers: we recognize the necessity of a strong working relationship with our providers based on mutual respect and collaboration. Stewardship of Public Funds: we are accountable to the public and strive for transparency and prudent fiscal management. 3 1

Simplified & Coordinated Delivery Community Based Adult Services County Behavioral Health Services In Home Supportive Services (IHSS) Medicare IPAs (CBAS) Care Plan Option Services (CPO) Multipurpose

Medicare and Medi Cal, health plan and county Provider Access Member demographic and contact information Updated member contact information, including phone numbers and address High transient

care across all domains to integrate care with better health outcomes and reduced overall costs Focus on: team based care, complex care management and coordination, health information and technology,

12 Simplified & Coordinated Delivery Community Based Adult Services County Behavioral Health Services In Home Supportive Services (IHSS) Medicare IPAs (CBAS) Care Plan Option Services (CPO) Multipurpose Senior Services Program (MSSP) Community Based Organizations (CBO) MOUs Contracts w/ Health Plan Nursing Home Care (SNF/LTC) Simplified & Coordinated Care Delivery 4 Behavioral Health Integration Medicare and Medi Cal, health plan and county Provider Access Member demographic and contact information Updated member contact information, including phone numbers and address High transient population 5 Behavioral Health Integration Initiative (BHI I) Connects and integrates the physical health, behavioral health, and substance use care and services of IEHP members Goal is to connect care across all domains to integrate care with better health outcomes and reduced overall costs Focus on: team based care, complex care management and coordination, health information and technology, and health promotion and self management support Twelve (12) partner entities representing 31 potential pilot sites, including FQHCs, county primary care and behavioral health clinics, CBAS centers, assisted living centers and pain management clinics IEHP is currently in the process of finalizing MOUs with the 12 BHI I Health Care Organizations and 31 Pilot Sites Total 2 year Board approved budget for BHI I is $20 million 6 2

13 BHI I HCOs and Pilot Sites BHI I Health Care Organizations Riverside County RegionalMedical Center San Bernardino County Public Health Riverside County Department of Ambulatory Care San Bernardino CountyBehavioral Health Riverside County Dept. of Behavioral Health Social Action Community (SAC) Health System Clinic Borrego Community Health Orchid Court, Inc My Family Inc. Recovery Center San Bernardino Adult Day Health Care Family Arrowhead Regional Medical Center Medicine Clinics Telecare Corporation BHI I Pilot Sites RUHS Diabetes Clinic RCHS Indio FQHC MFI, SUD Recovery Center RUHS Coronary Heart Failure Clinic RCHS Jurupa FQHC ARMC Fontana RUHS Oncology Clinic RCHS Lake Elsinore FQHC ARMC McKee RUHS Family Care Clinic RCHS Palm Springs FQHC ARMC Westside RUHS Neurology Clinic RCHS Perris FQHC SB PH FQHC Hesperia RUHS Hepatology Clinic RCHS Riverside FQHC SB BH Adult Residential Services RUHS OB/GYN Clinic RCHS Rubidoux FQHC SAC Health System RUHS Pediatrics Clinic Riverside County BH Lake Elsinore Orchid Court Board and Care Center RCHS Banning FQHC Rustin Family Wellness Center SB Adult Day Care Center RCHS Corona FQHC Borrego FQHC, Cathedral City Telecare Corporation, BH Clinic RCHS Hemet FQHC 7 Network Expansion Fund (NEF) Program launched in September 2014 to support hiring/recruitment of PCPs, Specialists, and physician extenders (PA and NPs) to serve the growing Medi Cal population in the Inland Empire Focuses on expanding access for both PCPs and certain Specialists in specific geographic regions To date, 79 PCP, 56 specialist and 3 physician extender applications have been approved; 19 PCPs, 11 specialists and 3 physician extenders have been hired MOUs Physicians / Midlevels Signed PCP Signed Specialist Signed Mid-level 0 0 In Process PCP 9 23 In Process Specialist 7 18 In Process Mid-level 1 3 TOTAL Recuperative Care Housing Use of vendor to provide assessment and placement services for more permanent housing for homeless members Challenges: Inability to safely discharge members from an acute care or LTC facility due to unstable setting in the community Members residing in acute setting or LTC facility longer than medically needed Average daily acute inpatient stay: $1,850 Average daily LTC stay: $

Objective is to develop alternatives for homeless and marginally housed members to be safely discharged from inpatient settings via recuperative care housing Delivery of medical interventions

14 Objective is to develop alternatives for homeless and marginally housed members to be safely discharged from inpatient settings via recuperative care housing Delivery of medical interventions including home health services such as IV medications, etc. Short term housing ranging from seven (7) to twentyone (21) days Contracting with county Housing Authorities to have focused assessment and placement services for our homeless members, focusing on assessing the member s housing needs and attempting to find transitional or permanent housing utilizing recuperative care housing Finding housing for homeless members undergoing active treatment and/or that are high utilizers of ED or inpatient services partially due to their homeless status 10 Improving Access to Care Questions or Comments For Questions or Comments Contact: Rohit Gupta Director of Compliance - Inland Empire Health Plan Gupta-r@iehp.org 11 4

15 Duals Demonstration Update: Health Plan of San Mateo ICE 2015 Annual Conference November 13, 2015 Maya Altman, CEO Health Plan of San Mateo What is the Health Plan of San Mateo? Public agency created by San Mateo County in 1987 (County Organized Health System) Accountable to community Non-profit Entire Medicaid population always enrolled, including dual eligibles Public plans as vehicles for community problem solving Health Plan of San Mateo, October 2015 Programs Enrollment Medicaid 109,600 Medicare D-SNP 800 Cal MediConnect 9,900 HealthWorx 1,100 Healthy Kids 3,100 ACE (TPA) 18,500 Total 142, Medicare D-SNP enrollees included in Medicaid count. 1

Dual Eligibles in SMC Medicaid Medicare FFS or Other MA Kaiser HPSM HPSM Experience: Vulnerable Populations LTC Residents, SNF Diversion, and Community At-Risk Community Care Settings Pilot (CCSP)

16 Dual Eligibles in SMC Medicaid Medicare FFS or Other MA Kaiser HPSM HPSM Experience: Vulnerable Populations LTC Residents, SNF Diversion, and Community At-Risk Community Care Settings Pilot (CCSP) Coordinated approach to services for vulnerable members Two critical project elements: Intensive Transitional Case Management Housing Services & Retention Other Initiatives: Enhanced care management partnership with San Mateo County s personal care program (IHSS) Leveraged care coordination using community partnerships What is CCSP? Promotes community living Focused on deinstitutionalization and supports aging in a community setting Unique features for members include: 1:20 case management (MSW/LCSW) Significant face-to-face contact Housing services and retention Multi-disciplinary Core Group care planning and oversight For appropriate members, CCSP will deploy a full range of services necessary to migrate out of or avoid Long Term Care residency 2

17 Targeting Participants Member groupings with best fit: LTC Residents Needs Assessment ~10-30% of LTC residents able to migrate to lower level of care SNF Diversions LTC Avoidance Acute health incidents prompting change in health or functional status Community Diversions Extending Independence Individuals struggling in the community, at-risk of acute incident or LTC admission Lack of nursing facility beds in community Other vulnerable populations may be served as pilot evolves Populations (and referral sources) will expand as the project matures CCSP Structure Partnership with two community-based organizations Institute on Aging (IOA): case management and oversight Brilliant Corners: housing services and retention Housing Services (Brilliant Corners) Medical Services & Providers HPSM Community & County-Based Resources CCSP leverages a number of resources to support operations: IHSS, CBAS, MSSP State/federal programs (ALW, MFP, IHO) Care Plan Option services Intensive Transitional Case Mgmt. (IOA) Participant Engagement Once participants are identified, prep work begins: Intake Form Completed Scored by Case-Mix Indexing Tool Assessed Face-to- Face by CM Presented to Core Group Care Plan Created Service Connected Stepped case management phases: Once service is connected, participants receive intensive case management for 9-12 months: Implementation Phase Successful discharge Frequent home visits PCP engagement Home setup Stabilization Phase Problem solving Regular contact Skills development Crisis intervention Transition Phase Resolve unmet goals Promote independence Ensure safety Transfer of case IOA drives the intake and placement process 3

Housing Strategy Housing services deliver a range of supports for project participants: Owner-resident liaison Targeted residential settings: Existing Home Housing portfolio management Affordable

18 Housing Strategy Housing services deliver a range of supports for project participants: Owner-resident liaison Targeted residential settings: Existing Home Housing portfolio management Affordable Supportive Housing Unit habitability and wellness checks Scattered-Site Housing On-call/ 24-hour response RCFE/ ARF Assisted Living Partnership with County Department of Housing for setasides and waitlist management Brilliant Corners remains involved throughout project lifecycle Program Impacts Preliminary Results Total cost by population six months pre- and posttransition: Since Demonstration began 55 members placed in community settings 118 members in process (target: 850 over 5 years) Program Impacts - Member Stories Stroke Patient SNF (1 Year) Affordable Apt. Eviction prevented CBAS 5x per week, 4 other supportive services Socially engaged in community Stroke, Vision Loss, Diabetes SNF (2 Years) RCFE Bonded with house dog at RCFE Volunteering with the SPCA Self-managing diabetes Shoulder Replacement SNF (1 Year) Section 8 Apt. Lost apt. while in SNF Brilliant Corners secured new section 8 unit Overjoyed to be back in the community 4

19 Duals Demo: Other Successes Deeming period Transition of D-SNP to Cal MediConnect Risk adjustment adequacy? 5

2015 Annual Conference Health Risk Assessment Best Practices - CareMore Joyce Furlough, General Manager, Duals CareMore November 13, 2015 CareMore Overview 2015 Annual Conference CareMore Health Plan

20 2015 Annual Conference Health Risk Assessment Best Practices - CareMore Joyce Furlough, General Manager, Duals CareMore November 13, 2015 CareMore Overview 2015 Annual Conference CareMore Health Plan participates in the Coordinated Care Initiative (CCI)/Cal MediConnect in Los Angeles County 5 Los Angeles County Cal MediConnect plans Serving our Duals members through a network of contracted providers and CareMore s owned and operated care centers. 11 Care Centers throughout Los Angeles County Current Cal MediConnect Membership: HRA Reporting Requirement 2015 Annual Conference Report 2.1: Member with an assessment completed within 90 days of enrollment. Reporting Elements: A. Number of members whose 90 th day of enrollment occurs during the reporting period B. Number of members unwilling to participate C. Number of members unable to locate after required amount of attempts D. Number of members with completed HRA 3 1

The Challenge 2015 Annual Conference Passive Enrollment Cal Medi-Connect Passive enrollment Mail/Telephonic notification of enrollment Member unaware of Plan change Unwilling to participate

21 The Challenge 2015 Annual Conference Passive Enrollment Cal Medi-Connect Passive enrollment Mail/Telephonic notification of enrollment Member unaware of Plan change Unwilling to participate Outdated/missing demographics (phone, address) High % of unable to locate Direct Enrollment Personal engagement and assistant through enrollment process Member knowledge of Plan selection Member demographics via application submitted to Plan Members are reachable 4 Lessons Learned 2015 Annual Conference Dedicated HRA Task Force Reviewed statistics Revised outbound HRA script to simplify messaging: Simplified messaging Introduced the Plan Stressed the Value of the HRA to the member Highlighted what s in it for Them Outsourced vendor to find unable to locate members Identified multiple channels for HRA completion: Bed side, CareMore Care Centers, Phone, Mail, In-Home Appointments 5 HRA Completion by Channel Current Membership as of October, Annual Conference 6 2

Lessons Learned from the Dual Eligibles Demonstrations. Real-Life Takeaways from California and Other States

Lessons Learned from the Dual Eligibles Demonstrations 1 May 28, 2015 Real-Life Takeaways from California and Other States Introductions Toby Douglas Consultant, MAXIMUS Former Director of California Department