INTEGRATED CARE ORGANIZATIONS--CONNECTICUT'S PLANNING PROCESS CT's Department of Social Services has been awarded a $1 million planning grant to design the following: " The ICO will create a single point of accountability for the delivery, coordination and management of primary/preventive, acute, behavioral, long-term supports and services and medication management through the creation of primary care centers or 'hubs'. Through these local primary care centers, ICOs will make available a broad array of providers and services to support, integrate and coordinate care for dual eligibles." This is one of 15 planning grants awarded nationally by CMS. If CT's design is accepted, CMS will then fund the demonstration. This grant is part of CMS new Innovation Center: " On November 16th, the Centers for Medicare and Medicaid Services (CMS) formally announced the establishment of the Center for Medicare and Medicaid Innovation (Innovation Center). The Innovation Center is charged with exploring new health care delivery and payment models that will enhance the quality of care for Medicare and Medicaid beneficiaries, improve the health of the population, and lower costs through improvement." So the focus of the federal government, as healthcare reform has begun to be implemented, is focusing on the most expensive populations, namely Medicare beneficiaries, the dually eligible population, and people with chronic illnesses who are solely Medicaid eligible. There are three initiatives that are directly relevant to these populations: 1. Accountable Care Organizations: ACOs are networks of physicians and hospitals that coordinate patient care with the aim of achieving three core goals: (1) better health for individuals; (2) better health for populations with respect to educating Medicare beneficiaries about the upstream causes of ill health; and (3) lower growth in health care costs by eliminating waste and inefficiencies while not withholding needed care that helps beneficiaries. ACOs must serve at least 5,000 Medicare Beneficiaries, with "shared savings" between CMS and providers. 2. s, an optional service which states can apply for as a state plan amendment. at least two chronic conditions, or one chronic condition and be at risk for another, or one serious and persistent mental health condition State may elect to limit health home to individuals with particular chronic conditions-- with higher numbers or severity of chronic or mental health conditions. Must serve dually eligible individuals FMAP of 90% for first 8 fiscal quarters state plan amendment is in effect Broader description of providers than "medical homes" but must be able to provide required health home services, "a whole person approach," addressing all clinical and non-clinical needs. (States must consult and coordinate with SAMHSA around their provision of MH/SU prevention, treatment, and recovery services.)
3. Integrated Care Organizations which also coordinates care, targeting the dually eligible population and also will have a shared savings model with providers. Intertwined with these initiatives is the federal stimulus and incentive funding to develop Electronic Health Records among all Medicare and Medicaid providers, and overlapping with all of these initiatives is the push to develop Medical Homes. The planning for the Integrated Care Organization will be advised by the Aged, Blind, and Disabled Subcommittee of the Medicaid Care Management Oversight Council, which I co-chair with Representative Peter Villano. We are in the process of designing a planning structure with Dr. Mark Schaefer of DSS, and DSS will be engaging a consultant to assist in the process. In 2007, dual eligible individuals represented 19% of Connecticut s Medicaid beneficiaries (compared to 15% in the US) and 19% of its Medicare population (21% in the US). However, they accounted for 58% of Connecticut s Medicaid expenditures, fully 50% higher than the national rate of 39% in the US) and about 25% of Medicare s expenditures. The population is primarily low income, with 94% living below 200% of poverty. Approximately, 60% are over 65 and 40% are disabled or chronically ill. Medicaid spending per dual eligible in Connecticut is nearly twice the national average ($27,619 compared to $15,900 nationally and Medicaid spending per disabled dual eligible was $25,902 compared to $14,755 nationally). Connecticut estimates approximately 13,000 to 20,000 individuals will participate in the initial implementation of the demonstration, representing approximately 20% to 30% of dual eligibles ages 65 and over. The design of the ICO is supposed to "person centered." The state's application described the initiative as follows: If awarded, Connecticut s demonstration proposal will establish local Integrated Care Organizations ( ICOs ) to establish a single point of accountability for the delivery, coordination and management of primary/preventive, acute, and behavioral health integrated with longterm supports and services and medication management for dual eligibles. The ICO model features partnerships among multiple provider types and is facilitated by health information technology and electronic data gathering. This new integrated care program will offer dual eligibles a health home where they may access a seamless continuum of enhanced medical, pharmacy, behavioral, and long-term services and supports, under one program. In addition, because Connecticut s primary care system is predominantly comprised of small group practices, this application will demonstrate how these practices can affiliate with a larger primary care hub, a model that can be applied to other states with similar systems. Most importantly, the State will align financial incentives to promote value the enhancement of quality of care, the care experience and health outcomes at lower overall cost to the Medicare and Medicaid programs. Quality and outcome measures will focus both on health and service outcomes as well as the effectiveness of home- and community-based services (HCBS)
and supports, emphasizing individual satisfaction with the person-centered and disability competent care process. The State will establish risk-adjusted global budgets for the purpose of assessing the ICO s effectiveness in managing overall cost, while retaining existing Medicare and Medicaid benefits and FFS reimbursement. Connecticut considered a capitated model to integrate care, similar to the Medicare Advantage Special Needs Plans (SNPs) for Dual Eligibles; however, such a model was felt not to be in the best interest of either dual eligibles or the Medicare and Medicaid providers serving them at this time. Thus far, Connecticut s two participating SNPs do not have significant dual eligible participation (3,908 dually eligible enrollees as of January 1, 2011). Instead, attribution of duals to local systems in a FFS model that supports person-centered planning and reliable measurement of value are the most significant structural innovations of this proposal. These elements will provide the accountability and transparency to drive improvements in performance over time. Questions that will be addressed during the planning will include: 1. Opt-in or Opt-out for beneficiaries 2. Possible additional services under Medicaid available to demonstration participants, depending on savings generated--for example, home and community based services for people who don't qualify for the current waivers, but have similar needs. 3. Adopting standards for the new ACOs to apply to the ICOs 4. Differences in services between those in Tier 1 ICOs and those in Tier 2 (not medical homes but smaller medical practices) 5. Methods for shared savings The model is shown as follows in the grant:
Integrated Care Organization Small Group Primary Care s At a minimum, ICO qualifications will include: Primary care centers (Tier 1) that are certified as patient-centered primary care medical homes by NCQA (at least Level 1 upon entry with eventual progression to Level 3), or another model accepted by the State such as the Joint Commission Comprehensive network of ICO provider partners that utilize person-centered multidisciplinary teams with input from family caregivers Shared IT and electronic health record (EHR) interoperability for PCPs and associated specialty providers, web-based EMRs, encrypted e-mail for all providers and ability to access an electronic person-centered care plan maintained by an administrative service organization (ASO) or other entity An advisory board with representation that includes dual eligibles, family caregivers and advocates The State will continue to provide such functions as claims payment, oversight, audit functions and administrative hearings. The State will contract with an administrative services organization for functions such as attribution, customer call-center, satisfaction surveys, and data aggregation and analytics.
Integrated Care Organization Hub and Spoke Hospital Specialist Network Home and Community Service Agency Pharmacy Patient Centered s (Tier 1) Small Group Primary Care s (Tier 2) Ancillary Services (laboratory, DME, transportation) Nursing Facilities Home Health Agency Behavioral Health