Area Agency on Aging for Napa and Solano Counties June 19, 2012 Challenges and Opportunities For California s Aging Services Network Sarah Steenhausen, M.S. Senior Policy Advisor
About The SCAN Foundation Mission: To advance the development of a sustainable continuum of quality care for seniors. Funding Priorities: - Public Engagement - Policy Development - Promising Programs
Presentation Overview Overview: Medicare and Medi-Cal, Long-Term Services/Supports Dual Eligibles Dual Eligibles and Chronic Conditions California s Medi-Cal Service Delivery System System Issues Past Efforts to Integrate Care for Dual Eligibles Current Efforts, Challenges and Opportunities Discussion: Pathways to Success
System Overview Medicare Medi-Cal Medi-Cal Long-Term Services and Supports (LTSS0 Dual Eligibles
Medicare: Federal health care program for: Individuals age 65+ Overview: Medicare Individuals under 65 with disabilities meeting specified requirements (Social Security Disability/24 months) Individuals with End Stage Renal Disease (ESRD) Part A: Hospital Insurance (hospital inpatient, skilled nursing) Part B: Medical Insurance (outpatient, DME, home health) Part C: Medicare Advantage plans (managed care plan covering Parts A, B and D) Part D: Medicare prescription drug coverage Medicare Doesn t Cover Long-Term Services and Supports
Overview: Medi-Cal Medi-Cal: California s Medicaid Program State/Federal program for low-income individuals, including families with children, seniors and people with disabilities Required services: hospital inpatient, outpatient, nursing home Optional Medi-Cal services: Prescription drugs Durable Medical Equipment Home and Community-Based Services (HCBS)
Overview: LTSS and Medi-Cal Long-Term Services and Supports: Broad range of non-medical services and supports needed for an extended period of time Commonly categorized into two types: (1) institutional care, such as Skilled Nursing Facilities (SNFs), and (2) Home and Community-Based Services (HCBS) Medi-Cal s Coverage of LTSS: Entitlement to institutional care HCBS are optional in most cases While people prefer to remain at home and avoid institutionalization, federal Medicaid law provides an entitlement to institutionalization, but only optional coverage of HCBS.
Overview: Dual Eligibles Low-income individuals who qualify for Medicare & Medi-Cal Dual eligibles are among the poorest and sickest in the U.S. 37% have both chronic conditions & functional limitations (vs. 9% of Medicare-only beneficiaries) 1 Utilize more Medicare dollars than non-duals More likely than non-duals to have a chronic condition High utilizers of Medicaid services: 18% of Medicaid population, 46% of Medicaid spending 2 33% of dual eligibles suffer from diabetes, stroke, dementia, and/or COPD -TSF DataBrief Number 1. 2010 1 TSF DataBrief Number 21 2 Center for Health Care Strategies, Inc. citation of Urban Institute analysis, 2008
Dual Eligibles: Medi-Cal Wrap-Around of Medicare Medi-Cal is payor of last resort for health care Medicare covers Part A hospital and Part B outpatient services, Medi-Cal provides wrap-around coverage, including cost-sharing Medicare Part C: Special Needs Plans for Duals (D-SNPs) Medicare pays for Part D (prescription drug), Medi-Cal reimburses federal government through state clawback Medicare and Medi-Cal have different payment rules and cover different services. For beneficiaries, the fragmentation across the medical care and LTSS systems can make it difficult to access services, with no single entity is responsible for ensuring the necessary services and supports are received.
Dual Eligibles: Division of Services Covered by Medicare and Medi-Cal
Overview California s Medi-Cal Service Delivery System
California s Medi-Cal Delivery System Two Medi-Cal systems administer the delivery of health care Medi-Cal Fee-for-Service: Provider receives payment for each service Beneficiaries obtain services from any participating provider Medi-Cal Managed Care: Managed care organizations responsible for Medi-Cal benefits; enrollees obtain coverage from plan providers Capitated payments per member/per month
Medi-Cal Managed Care: What it Does and Doesn t Cover Medi-Cal Managed Care coverage includes: Medi-Cal covered health care services Carve-Outs: Medicare services (for dual eligibles) Long-Term Services and Supports (LTSS), though some COHS cover long-term nursing home care. Community-Based Adult Services (CBAS) will soon be a benefit. Behavioral health services
Medi-Cal Managed Care: Mandatory vs. Voluntary Enrollment Mandatory Enrollment: Medi-Cal managed care enrollment is mandatory for Medi- Cal only seniors and persons with disabilities for health care services only, not including LTSS Voluntary Enrollment: Dual eligibles: not mandated to enroll in Medi-cal managed care; can choose to receive both Medi-Cal and Medicare services in FFS system (except in COHS, where Medi-Cal coverage is mandated for all Medi-Cal beneficiaries) Of California s 1.2 million dual eligibles, approximately 15% are enrolled in a Medi-cal managed care plan.
Current Medi-Cal Managed Care Models Two Plan Model: State contracts with 2 plans: a local initiative (locally developed and operated), and a commercial plan. Available in 14 counties, serving 3 million beneficiaries County Organized Health System: One health plan administered by a public agency and governed by an independent board. 6 health plans available in 14 counties, serving 850,000 beneficiaries Geographic Managed Care: State contracts with several commercial plans in a county Available in 2 counties, serving 450,000 beneficiaries
Dual Eligibles Dual Eligibles, Chronic Conditions and Functional Impairments
Disabling conditions more prevalent among dual eligibles than Medicare-only beneficiaries. DataBrief (2010) No. 1 Page 17
Dual Eligibles, Chronic Conditions and Functional Impairment Dual eligibles (65+) have higher rates of chronic conditions Dual eligibles (65+) have higher rates of both chronic conditions and functional impairment 37% of duals age 65 or older have both chronic conditions and functional impairment (vs. 9% of Medicare-only) Duals comprise 14% of the Medicare population age 65 or older, but represent 40% of those with chronic conditions and functional impairment http://www.thescanfoundation.org/foundation-publications/databrief-no-1-characteristics-dual-eligibles.
Dual Eligibles, Chronic Conditions and Functional Impairment People with chronic conditions often have functional impairment that creates need for Long-Term Services and Supports Examples: Individual needs help managing multiple medications Difficulty eating, bathing, walking due to a chronic condition What happens when these needs aren t met? ~15% of Medicare beneficiaries age 65+ with chronic conditions also had functional impairment. -TSF DataBrief Number 22. 2011
Dual Eligibles, Chronic Conditions and Functional Impairment: Case Study: Mrs. Smith Dual eligible 83 year-old widow Lives alone in two-story home Multiple chronic conditions: - High blood pressure, stroke - Heart failure - Diabetes Source: Steven Counsell, M.D., TSF Webinar, 2011
Mrs. Smith Complex Medical Care: Multiple physicians and specialists 2 hospitalizations and an ER visit Used nursing facility services and home health in past year Long-Term Services and Supports: Needs assistance with dressing, bathing, managing meds Daughter provides some support, faces caregiver burden At-risk of long-term nursing home placement Source: Steven Counsell, M.D., TSF Webinar 2011
Dual Eligibles, Chronic Conditions and Functional Impairment: Policy Implications System Costs: Medicare spending 3 times greater for beneficiaries with chronic conditions and functional impairment than those with chronic conditions alone. Beneficiaries with chronic conditions and functional impairment More likely to use inpatient hospital services than their peers with chronic conditions alone. Source: The SCAN Foundation DataBrief Numbers 22 and 25, 2011
Dual Eligibles, Chronic Conditions and Functional Impairment: Addressing Unmet Needs How can Mrs. Smith be better served by the health care system? Focus on addressing and identifying medical and LTSS needs Develop care plans that meet range of needs, both medical and social Identify needs of family caregiver, provide support Develop mechanism to coordinate care across range of services Identify interdisciplinary team for consultation - Geriatrician - Pharmacist - Mental Health Liaison
Dual Eligilbes, Chronic Conditions and Functional Impairment: Addressing Unmet Needs Outcomes of success: Improvements in quality of care and patient experience Improved access to and coordination of care Improved ability for individuals to self-manage their care Lower ER and hospitalization rates over time Potential for lower system-wide costs over time
California s System Challenges Fragmentation Lack of Access to HCBS Medicare/Medicaid Misalignment
System Challenges: Fragmentation LTSS program development has occurred in silos Fragmentation across individual programs and services Fragmentation between medical care and social service system Separate assessments, separate data systems What does this mean for the consumer? The fragmentation between the medical care and LTSS systems makes it difficult for consumers to access services.
Insert graphic on fragmentation between medical and LTSS systems (wilber)
System Challenges: Lack of Access to Home and Community-Based Services Federal entitlement to institutional care, optional for HCBS Not all HCBS are available on a statewide basis Long wait lists Implications for consumers and state budget
System Challenges: Medicare/Medicaid Misalignment Gaps and misalignment between Medicaid and Medicare Durable Medical Equipment (DME) Tangled web of authorization requirements Prescription Drug Coverage Difficulty navigating transitions from Medicaid to Medicare (Part D) Skilled Nursing Transitions (hospital to skilled nursing) impact care Language Access As a result of the misalignment between Medicare/Medicaid, dual eligible individuals encounter obstacles to accessing necessary care.
Dual Eligibles Exploring Opportunities
Exploring Opportunities: Linking Medical Care and LTSS Address fragmentation through system coordination Responsibility for range of medical care and LTSS provided by a risk-bearing entity Goals Improve system efficiency Avoid institutional care, such as avoidable ED visits, hospitalization, nursing home placement
California s Past Efforts AB 1040 LTC Integration Pilot Projects (1995) Governor Schwarzenegger Initiatives 2005 2006 Roadblocks to success Political issues Devil you know is better than the devil you don t State leadership
Overview: California s Current Efforts Dual Eligible Integration Demonstration-as signed into law SB 208 (statutes of 2010) authorizing legislation 4 counties selected as pilots to integrate Medi-Cal/Medicare medical and LTSS benefits Los Angeles, San Diego, San Mateo, Orange (with proposed expansion in year 1 to Alameda, Riverside, San Bernardino, Santa Clara) Governor Brown s Coordinated Care Initiative Proposed as part of 2012-13 Budget Expands Duals Demonstration to 8 counties in 2013; remaining counties by 2015 Mandates LTSS as part of Medi-Cal managed care Expands Medi-Cal managed care to rural California
California s Dual Eligible Integration Demonstration: Key Elements Passive enrollment with 6-month lock-in Enrollment begins in March-June 2013 Dual eligibles can opt-out for Medicare benefits; will be mandated to enroll in Medi-Cal managed care for Medi-Cal benefits If duals don t choose to opt-out, they will be passively enrolled PACE is an enrollment option Carve out of certain populations: developmental disabilities, specified 1915(c) waiver enrollees, children, ESRD Person-centered care coordination: Role of assessment and interdisciplinary care team Universal assessment process (to be developed)
LTSS Integration: What s In Community-Based Adult Services (starting July 2012) Multipurpose Senior Services Program MSSP will be phased-out as a waiver program by 2015 IHSS Other LTSS In Lieu of Institutional Care Nursing Facility Coordination with behavioral health Coordination with other HCBS outside of Medi-Cal The rate development process will play a role in determining the extent to which health plans can increase access to HCBS.
Where Are We Now? California submits Demonstration proposal to federal Centers for Medicare/Medicaid Services Proposal posted for 30-day comment period MOU process between state/feds begins mid-july Duals Demonstration Stakeholder Workgroups Workgroup process informs elements of the demonstration. For more info, see www.calduals.org Governor Brown s Coordinated Care Initiative (CCI) Legislature deliberated CCI as part of budget Trailer Bill outlines policy provisions of the proposal Other related pending legislation: SB 1503
Dual Eligibles How to Ensure Opportunity= Success?
Dual Eligibles: System Pathways to Success Stakeholder engagement state and local level Systems take time to develop Important to recognize services outside of Medi-Cal (e.g., transportation, housing) Create communication channels: Consumers, LTSS providers, medical community and managed care Understand cultural differences: medical model v. social model Create new opportunities for partnership public/private
Dual Eligibles: Discussion Points Where is the state currently missing opportunities for broader public/private partnership? How can new opportunities be developed within AAAs? What are some actions that can be taken at the local level through AAAs to engage health plans with the LTSS community? How can Area Agencies on Aging maximize opportunities in the Dual Eligible Integration Demonstration? What is missing in the current demonstration where AAAs can add value? How, if at all, does reauthorization of the Older Americans Act fit into the broader discussion?
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