REVIEW OF KANCARE: HEALTH PLAN IMPROVEMENT ACTIVITIES

REVIEW OF KANCARE: HEALTH PLAN IMPROVEMENT ACTIVITIES February 2018

INTRODUCTION KanCare, the state of Kansas managed Medicaid program, reached the end of its five-year demonstration period under an 1115 CMS waiver at the end of 2017. CMS granted a one-year extension for the program, which contracts with three managed care organizations (MCOs) to provide health care for the state s Medicaid enrollees, covering more than 415,000 Kansans. Numerous reports have been published on KanCare, but a concise picture of the program s performance is still needed. This report, the last of three, focuses on the three MCOs efforts related to coordinating and integrating care for their Medicaid populations under KanCare. These efforts include performance improvement projects (PIPs) centered around well-child visits, substance use disorder (SUD) treatment, follow-up care for members with mental health disorders, and HPV immunizations. In addition, each KanCare plan utilizes various pay-for-performance (P4P) measures outlined by the state and other quality measures in an effort to successfully coordinate and integrate care for their members. The three MCOs also use various methods to reach out to their member and provider populations to encourage better integration and utilization of care. SUMMARY OF PREVIOUS REPORTS Two previous reports highlighted KanCare s observed performance relative to its stated goals concerning cost, utilization patterns, health care quality, and program access over the program s four completed operating years from 2013 through 2016. Leavitt Partners first review of KanCare, published in November 2017, focused on KanCare s efforts to control Medicaid costs and shift members utilization patterns. The first report showed that the state s actual costs under KanCare have been lower than projections made in 2012 for scenarios both without and with the program. Although costs increased for some groups of members, they decreased for others and the average per-member per-month (PMPM) cost declined under KanCare from $625 in 2013 to $563 in 2016 ($7,500 to $6,756 annually, respectively). Additionally, shifts in utilization patterns toward primary care and federally qualified health centers (FQHCs) and away from hospital inpatient utilization occurred during KanCare s first year. The second report, published in January 2018, focused on health care quality and access to care for Kansas Medicaid population. During the program period, KanCare plans demonstrated improvement in several P4P quality measures related to diabetes management, tobacco use, and monitoring chronic medications, with slight decreases in performance for prenatal care, postpartum checkups, and flu shots. Generally, both members and providers satisfaction with the health plans rose slightly over the program period, with further room for improvement. In terms of access, MCO provider networks have grown overall during the KanCare years, with significant gains in access to specialists in many counties. Patients perceptions of their access to general care under KanCare are above the national median, but they reported a strong negative trend in access to SUD services. KANCARE S GOALS Under KanCare, the state contracts with three health plans to provide Medicaid managed care services to members Amerigroup (a subsidiary of Anthem), Sunflower State Health Plan (a subsidiary of Centene Corp.), and UnitedHealthcare of the Midwest. KanCare requires the MCOs to report quality and performance measures, and currently places up to two percent of their revenue at risk if they fail to meet quality benchmarks for physical health, behavioral health, and long-term care. The Kansas Department of Health and Environment (KDHE) articulated four general goals that the state hopes to achieve through KanCare: (1) control Medicaid costs, (2) improve the quality of care, (3) provide integration and coordination of care, and (4) establish long-lasting reforms to sustain health improvements and provide a model for Medicaid reforms for other states. 1 KanCare included objectives for care coordination and integration to improve care across the whole spectrum of physical, behavioral and mental health, substance use disorders, and long-term services and supports (LTSS). In addition, KanCare MCOs aim to support members in the communities where they live as much as possible. KDHE hypothesized that KanCare would improve care coordination and integration of services. The program would do this by reducing the percentage of members in institutional settings through providing alternative REPORT 3. HEALTH PLAN IMPROVEMENT ACTIVITIES 2

KanCare Hypotheses for Improving Care Coordination and Integration: 1- Reduce the percentage of members in institutional settings by providing additional HCBS and supports to members, allowing them to move out of the institutional setting when appropriate and desired. 2- Improve quality by integrating and coordinating services and eliminating current silos between physical, behavioral, and LTSS. 3- Provide coordination to members with developmental disabilities, which would improve access to health services and improve the health of those members. home and community-based services (HCBS) for them. By supporting members in their communities, KanCare would allow them to avoid or delay institutional care settings or move out of these care settings when appropriate and desired. KDHE also hypothesized that KanCare would improve care quality by integrating and coordinating services and eliminating previous silos between physical, behavioral, and LTSS. Finally, the state set an objective that KanCare would provide integrated care coordination to members with developmental disabilities, which would improve access to health services and improve the health of those members. 2 These objectives aimed to make the state s Medicaid program more cost-effective and sustainable while improving members care. DATA SOURCES This report draws from quarterly and annual reports required as part of the Section 1115 demonstration requirements. KDHE s Division of Health Care Finance compiles these reports, contracting with the Kansas Foundation for Medical Care (KFMC) as the external quality review organization and Section 1115 demonstration evaluator. The KDHE reports provide data on utilization, costs, quality metrics, and access measures for each completed year of KanCare, with some data running through the end of 2016. In addition, Leavitt Partners conducted interviews by phone with senior management from each of KanCare s three MCOs with oversight and a working knowledge of their organizations various KanCare initiatives. Discussions centered around the MCOs activities related to coordinating care for their Medicaid populations, including PIP, efforts to improve on P4P and other quality measures, and provider and member outreach. The report relies largely on the information provided in these interviews. PLAN ACTIVITIES DURING KANCARE As previously discussed, the state of Kansas set several objectives for Medicaid under KanCare, including general goals such as improving care quality and lowering costs, institutional requirements for standards of care and processing, and specific target objectives on P4P measures designated for important aspects of care. Each MCO reported that it had designed its own strategies and initiatives to implement KanCare s requirements and to reach objectives such as P4P targets. While each MCO differs in its emphasis on various aspects of administering a managed care program, each health plan s general approach to KanCare falls under the three following categories: member engagement, provider engagement, and internal structures and policies. MEMBER ENGAGEMENT In addition to all Medicaid benefits offered pre-kancare, each MCO reports that it provides a unique mix of valueadded benefits under the program. MCOs report that these benefits are designed to support healthy lifestyles and prevent future health care costs, especially for at-risk populations such as pregnant women and those with chronic conditions. Value-added benefits include ancillary care benefits such as adult dental services, memberships to various community organizations, informational brochures, cell phones and wireless services, and coupons or rewards programs for healthy food and health products. The MCOs disbursed approximately 1.9 million total units of value- REPORT 3. HEALTH PLAN IMPROVEMENT ACTIVITIES 3

Table 1. Top Three Value-Added Services by Year 2013-2016 MCO TOP VALUE-ADDED SERVICE 2013 3 TOP VALUE-ADDED SERVICE 2014 4 TOP VALUE-ADDED SERVICE 2015 5 TOP VALUE-ADDED SERVICE 2016 6 AMERIGROUP Adult Dental Care Adult Dental Care Adult Dental Care Adult Dental Care Member Incentive Member Incentive Member Incentive Member Incentive Mail Order OTC Mail Order OTC Mail Order OTC Mail Order OTC SUNFLOWER CentAccount Debit Card CentAccount Debit Card CentAccount Debit Card CentAccount Debit Card Dental Visits for Adults Dental Visits for Adults Dental Visits for Adults Dental Visits for Adults Safelink/Connections Plus Cell Phones Smoking Cessation UNITED HEALTHCARE Additional Vision Services Baby Blocks and Rewards Source: KDHE annual reports. Smoking Cessation Baby Blocks and Rewards Smoking Cessation Baby Blocks and Rewards Adult Dental Services Adult Dental Services Adult Dental Services Adult Dental Services Incentive for KAN Be Healthy Screening Rewards for Preventive Visits & Health Actions Rewards for Preventive Visits & Health Actions Rewards for Preventive Visits & Health Actions added benefits, valued at almost $18.7 million, between 2013 and the end of 2016. The value-added benefits with greatest use in terms of dollar value have been the adult dental services, which include preventive services, and cash-based rewards programs (Table 1). Additionally, each MCO reports engaging in targeted member outreach. The premise is that establishing relationships between the health plans and their members makes it easier to identify patients key health issues or barriers to care. High-touch customer outreach campaigns involve extensive contact with specific high-risk patients, linking them to other resources and addressing social determinants of health that they may need assistance with. These efforts range from helping members receive their driver s license to providing groceries or helping with housing or rent. In addition to high-touch services, the MCOs also invest in relatively low-touch mailing or marketing campaigns to reach a wide swath of members for a particular health initiative, usually focused on specific populations (i.e., teenage children and their parents) and care quality metrics (i.e., immunization rates). For example, some MCO campaigns that target specific patients include phone calls and mailers describing cervical and breast cancer screening, educational outreach to new mothers informing them on the need for postpartum visits, and vaccination programs that work to find those who are not getting vaccinated through an established outreach program. PROVIDER ENGAGEMENT KanCare MCOs report using several methods to engage with their provider networks, which are comprised of physician groups varying in size, target patient mixes, and the groups perceived ability to engage in value-based payment arrangements. MCOs reported engaging with their providers in several ways, including seeking their input on existing or potential new initiatives and reducing their reporting burden. MCOs report that providers, in turn, have responded more positively over time. The plans also provide PMPM payments that use a shared savings approach to incentivize providers to include population health and conduct practice transformation. KanCare plans use value-based contracting with some providers as a method to get them on board with quality improvement and the overall objectives of KanCare. Plans reported efforts to tailor contracts to provider preferences and promote these contracts whenever possible. INTERNAL STRUCTURES AND COLLABORATION In response to KanCare s P4P and PIP requirements, KanCare plans developed new policies and procedures in order to meet the program s goals. These efforts REPORT 3. HEALTH PLAN IMPROVEMENT ACTIVITIES 4

included breaking down barriers between historically siloed departments and working across functional areas to address the same set of P4P measures. In addition, the plans reported setting up training for all customer- and provider-facing staff on P4P measures. KanCare plans set up teams and began working across departments to ensure staff knew about the new projects and quality measures and understood how they could work together to better ensure success. MEETING KANCARE S OBJECTIVES CONTROL PROGRAM COSTS One objective of KanCare is to slow the growth of the state s Medicaid costs. While KDHE predicted it would save around $850 million in total Medicaid costs over the program s five years, Medicaid expenditures were even lower than projected, roughly doubling the anticipated savings. KanCare MCOs activities related to controlling program costs center on improving utilization, providing member services and supports, and offering education and outreach to both providers and members. As mentioned in the first report, during the years for which data are already available, utilization patterns moved toward community settings and away from more costly hospital-based facilities and nursing facilities, a positive step toward reducing the total cost of care. For example, members in nursing facilities who are likely to thrive at home with proper support are assigned to a care coordinator and a dedicated staff that works with them to transition the member into the community. In addition, the KanCare plans work with providers in several ways aimed at lowering costs, such as sharing data on population health with federally qualified health centers (FQHCs), community mental health centers (CMHCs), and rural health centers (RHCs). Through these data-sharing partnerships, areas in need of improvement have been identified in the state s Medicaid population, including medically needy non-dual eligible adults, longterm care populations, children, and those covered under the developmental disability waiver. IMPROVE QUALITY OF CARE Performance Improvement Projects (PIPs) The purpose of a PIP is to assess and improve processes, and thereby outcomes of care. KanCare MCOs have established numerous programs in an effort to improve quality performance and the health of their members. Each MCO chose a different PIP to target its efforts related to specific Healthcare Effectiveness Data and Information Set (HEDIS) measures: Amerigroup Implementing targeted interventions to improve well-child visit rates in the third through sixth years of life. Sunflower Providing care coordination to members diagnosed as needing AOD (alcohol and other drug) treatment to improve member initiation and engagement of AOD services. United Providing timely and appropriate aftercare appointments for members hospitalized for select mental health disorders in order to increase member compliance with follow-up care. REPORT 3. HEALTH PLAN IMPROVEMENT ACTIVITIES 5

In addition, all three KanCare MCOs collaborate on a joint PIP that attempts to improve human papillomavirus (HPV) immunization rates to at least the national median. In line with the state s goal of improving outcomes through improving processes, the three plans chose projects they perceived to have a meaningful impact on health measures and outcomes. In order to be successful, these PIPs require significant outreach to gain buy-in from both providers and members. MCOs mailed reports to providers to help them better understand where gaps in care existed and how they might address them. They also developed member incentive programs to encourage member participation in PIPs, aligning these projects with their value-added services. In addition, organizations such as the Center for Disease Control and Prevention (CDC), the American Cancer Society, and the University of Kansas offered provider education for the collaborative HPV PIP. Nurse analysts visited provider offices, local health departments, and FQHCs/RHCs to discuss HPV and early and periodic screening, diagnostic, and treatment (EPSDT) requirements, as well as HEDIS-specific measures and how to successfully reach the goal of increasing the rate of HPV vaccination in Kansas. KanCare MCOs reported that the greatest challenge they faced was to better understand the underlying reasons why their chosen PIP quality metrics had such poor results in the first place, whether it was due to customer behavior, poor health literacy, lack of provider support, etc. After identifying the key issues, the MCOs then had to design and implement solutions to improve results while also monitoring the unintended consequences of their efforts. For example, the MCOs learned that some of the largest barriers to the HPV immunization initiative had to do with public sentiment around this specific immunization. In the past, messaging had focused on the transmission of HPV rather than the fact that the immunization prevents cancer. KanCare MCOs reframed their messaging to better focus on educating patients and providers about the benefits of HPV vaccines. KanCare plans are still learning about the challenges facing their members in these specific performance areas and are integrating this learning into new or more targeted interventions as they move forward with their PIPs. During 2016, time was set aside at quarterly interagency meetings on KanCare for each MCO to discuss their progress on their chosen PIP. Feedback from state agencies and KFMC has encouraged the MCOs to provide more specific information about their interventions and implementation in the future, with the goal of better tracing the links between interventions and outcomes. Pay-for-Performance (P4P) In its proposal for KanCare, the state hypothesized that it could improve quality of care by holding MCOs accountable for outcomes and performance measures tied to financial incentives. Thus, KanCare requires the MCOs to report quality and performance measures and holds up to two percent of their revenue at risk if they fail to meet quality benchmarks for physical health, behavioral health, and long-term care. MCOs metrics on P4P measures are key indicators of care quality in designated areas of particular interest to the state. KanCare plans were expected to first achieve numbers above the national median on these measures, and then improve by five percent each following year. As mentioned in the second report, the MCOs performance on these P4P measures varied during the first three years of the program, with improvements in some areas and slight declines in others. P4P measures indicate how well the MCOs are doing with respect to diabetes management, tobacco cessation, substance use disorder (SUD) treatment, immunizations, prenatal and postpartum care, and other areas of physical and behavioral health of importance to the state. From 2013 to 2015 (the most recent year for which data is available), KanCare plans demonstrated improvement in P4P quality related to diabetes management, tobacco use, and monitoring chronic medications. KanCare plans also experienced slight decreases in performance for prenatal care, postpartum checkups, and flu shots and mixed results for SUD treatment. MCOs efforts to meet P4P measures often require reshaping the way departments interact and approach these measures. KanCare plans report focusing on collaboration within plan departments, including customer service, medical management, quality outreach, provider relations, and more. Collaboration between departments on P4P measures became an integral part of KanCare plans. REPORT 3. HEALTH PLAN IMPROVEMENT ACTIVITIES 6

Other Quality Measures KanCare plans have several value-based payment (VBP) reimbursement models in place including models for their primary care providers, CMHCs, pediatric practices, obstetricians, and nursing facilities. Most of these VBP reimbursement models use upside gainsharing methods, where providers have an opportunity to gain an incentive bonus based on certain quality metrics. The obstetrician program, for example, focuses on two primary aims: a bonus incentive paid per activity when providers submit a member s notice of pregnancy documentation, and completion of this documentation ensuring this is completed within the first trimester. The plans note that they are trying to ensure their larger volume obstetrician providers recognize the importance of early care for pregnant women. The primary care and pediatric models focus on a per-member incentive based on activities such as A1C testing and immunizations, while nursing facilities are rewarded for positive outcomes, such as fall prevention. OUTSTANDING CONCERNS WITH THE PROGRAM HOME AND COMMUNITY-BASED SERVICES (HCBS) REMEDIATION PLAN The home and community-based services (HCBS) waiver remediation process establishes requirements for the qualities of settings where individuals live or receive Medicaid-funded HCBS. KanCare s goal is for members to receive these services in a manner that protects individual choice and encourages community integration. The HCBS waiver remediation process in Kansas created some policy changes and clarifications for KanCare plans. These changes centered around several operational areas, including administrative authority, person-centered planning processes, provider access and network adequacy, and participant protections. CMS required Kansas to develop a corrective action plan (CAP) outlining the activities it would take to address the issues CMS identified, and the state promptly responded. The CAP directs KDHE to work closely with the Kansas Department for Aging and Disability Services (KDADS) to address the following key areas: Monitoring and reporting of MCO data; Standard operating procedures (SOPs) regarding MCO data analysis and communication; Training staff responsible for the state contract review annual report development; Roles and responsibilities, including updating position descriptions of each agency; and Stakeholder engagement through new policies and procedures on programmatic communications. Overall, KanCare plans report that they have responded to the concerns coming out of the remediation plan and adhered to HCBS policies and procedures. WAIVER PROGRAM WAIT TIMES States may restrict how many individuals are accepted into their waiver programs in a given year. When more individuals apply for waiver services than there are available spaces, states may place them on a waiting list. KanCare MCOs report that they include two primary programs that help individuals on the state s waiting lists for intellectual/developmental disabilities (I/DD) and physically disabled home and community-based services (PD HCBS) access. The first includes a care coordination program where representatives contact each member on the state s waiting list once or twice a year. During these calls, the plans identify patients needs and offer support with finding providers or local community resources that may address them. The MCOs also provide education and information about employment supports that may be available and the state s WORK program (package of benefits that provides personal and other services for employed individuals with disabilities). If a member qualifies for the program, they may access needed caregiver supports without waiting. The second program involves an I/DD respite initiative for children and adults who are on the state s waiting list for the I/DD HCBS waiver. The plans offer up to 16 hours per year of paid respite support for the family members or friends who are currently helping to meet the member s needs. The plans also offer this population support at doctor appointments when their family member or REPORT 3. HEALTH PLAN IMPROVEMENT ACTIVITIES 7

caretaker is unavailable and provide support to the patient in understanding their doctor s consultation and any necessary follow-up care. CONCLUSION In its proposal for the program, the state believed that it could improve care coordination and integration by providing additional HCBS and supports to members, by eliminating the current silos between physical health, behavioral health, and LTSS, and by providing integrated care coordination to members with developmental disabilities. This report provides a review of KanCare s three MCOs efforts on care coordination and performance improvement projects. Since the inception of the program, KanCare s MCOs have focused on improving care coordination and performance. Each MCO engages in targeted member outreach and provides a unique mix of value-added benefits under the program. KanCare plans are also engaging in targeted communications and support to improve their relationship with providers, and the plans have reported that providers are responding more positively. To address KanCare s goal of controlling Medicaid costs, the plans have worked to transition specific populations needing long-term care back into the community. KanCare plans also developed population health data sharing collaborations with FQHCs, CMHCs, and RHCs. Through each plan s targeted PIPs, P4P metrics, valuebased payment models, and other quality metrics, the MCOs have aimed to generate important performance improvements throughout the program period. KanCare plans report that they are committed to developing effective programs and initiatives for their members while continuing to solicit feedback to further improve their efforts, including feedback obtained through the HCBS remediation plan. BIBLIOGRAPHY 1. Kansas Department of Health and Environment Division of Health Care Finance. Quarterly Report to CMS Regarding Operation of 1115 Waiver Demonstration Quarter Ending 3.31.2013. 2. Kansas Department of Health and Environment Division of Health Care Finance. Annual Report to CMS Regarding Operation of 1115 Waiver Demonstration Year Ending 12.31.2013, p. 2-3. 3. Ibid. 4. Kansas Department of Health and Environment Division of Health Care Finance. Annual Report to CMS Regarding Operation of 1115 Waiver Demonstration Year Ending 12.31.2014 5. Kansas Department of Health and Environment Division of Health Care Finance. Annual Report to CMS Regarding Operation of 1115 Waiver Demonstration Year Ending 12.31.2015 6. Kansas Department of Health and Environment Division of Health Care Finance. Annual Report to CMS Regarding Operation of 1115 Waiver Demonstration Year Ending 12.31.2016 REPORT 3. HEALTH PLAN IMPROVEMENT ACTIVITIES 8

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