Achieving Higher Quality and Cost-Effective Care: State Innovations for Dual Eligibles and Individuals Accessing Long-Term Supports and Services (LTSS) June 14, 2011 Mini-Summit III: Long-Term Care and Dual Eligibles Medicaid Congress 2011 Suzanne S. Gore Director, Integrated Care for Dual Eligibles Center for Health Care Strategies
Overview Why do dual eligibles and LTSS delivery systems have states attention? What does care look like in most states now? State evolution of improved service delivery: Rebalancing LTSS Improving management of LTSS Fully integrated care 2
Why do States Want to Improve Service Delivery for these Populations? Significant number of people Significant amount of money Most importantly ***Significant opportunities exist to improve access, quality, and cost of care for these high-cost, high-need populations*** 3
What does care look like now? WITHOUT INTEGRATED CARE, INDIVIDUALS MAY HAVE: x Three ID cards: Medicare, Medicaid, and prescription drugs x Three different sets of benefits x Multiple providers who rarely communicate x Health care decisions uncoordinated and not made from the patient-centered perspective x Serious consideration for nursing home placement; Medicare/Medicaid only pays for very limited home health aide services Fragmented Complicated & Not Coordinated Difficult to Navigate Not Focused on the Individual Gaps in Care Unmanaged fee-forservice
What care CAN look like: WITHOUT INTEGRATED CARE x Three ID cards: Medicare, Medicaid, and prescription drugs x Three different sets of benefits x Multiple providers who rarely communicate x Health care decisions uncoordinated and not made from the patient-centered perspective x Serious consideration for nursing home placement; Medicare/Medicaid only pays for very limited home health aide services One ID card INTEGRATED CARE One set of comprehensive benefits: primary, acute, prescription drug, long-term care supports and services, and behavioral health services. Single and coordinated care team Health care decisions based on the individual s needs and preferences Availability of flexible, non-medical benefits that help individuals stay in their homes 5
But Change has been Slow Significant administrative hurdles Substantial stakeholder resistance States reluctance to invest in upfront costs Existing vehicles for integration have not achieved broad scale, full integration, or anticipated budget savings. 6
State Evolution of Improved Service Delivery Care is evolving from facility-based fee-forservice to community-based integrated care Many states are taking a step-by-step approach 7
Rebalancing Long-Term Supports and Services 8
Rebalancing LTSS $54B $75B 30% $92B 32% $100B 37% $109B 41% $112B 43% $32B 20% 13% 87% 80% 70% 68% 63% 59% 57% 1990 1995 2000 2002 2004 2006 2007 Institutional Care Home- and Community-Based Care Figure 1: Growth in Medicaid Long-Term Care Expenditures, 1990-2007 Source: KCMU and Urban Institute analysis of HCFA/CMS-64 data. Includes all populations served, including elderly, disabled and MR/DD population, etc. 9
State Efforts to Rebalance LTSS Only five states currently spend more Medicaid LTSS dollars on home- and community-based services (HCBS) than nursing homes (AARP Public Policy Institute): Alaska, California, New Mexico, Oregon, and Washington An array of financial, administrative, bureaucratic, and political obstacles impede states from rebalancing their systems of LTSS. Impact of facility level of care criteria Requires substantial systemic changes 10
State Efforts to Rebalance LTSS: Money Follows the Person 11
Managed Long-Term Supports and Services (MLTS) 12
Current State MLTS Programs Arizona: ALTCS Hawaii: QExA Massachusetts: Senior Care Options Minnesota: Minnesota Senior Health Options New Mexico: CoLTS Tennessee: Choices Texas: Star+Plus Wisconsin: Family Care 13
Mileposts for States Developing MLTS Programs 1. Establish a clear vision 2. Engage stakeholders 3. Develop a uniform assessment tool 4. Structure benefits to incentivize the right care 5. Include attendant care and/or paid family caregivers in the benefit package. 6. Design a program to address varied needs. 6. Plan for shift to risk-based services 8. Include financial incentives to achieve program goals 9. Establish robust monitoring process 10. Include LTSS-focused performance measures. Click here to view Roadmap 14
Communicate a Clear Vision for MLTS Hawaii s QExA Goals: Improve the health status of Seniors and Persons with Disabilities (SPD) Increase use of HCBS by 5% Establish a provider home Empower beneficiaries by promoting independence and choice Assure access to high-quality, cost-effective care (in homes/communities when possible) Coordinate all care (acute, behavioral, LTSS). 15
Structure benefits to appropriately incentivize the right care Tennessee CHOICES: TennCare managed care organizations are responsible and at-risk for providing the full continuum of LTSS services, including nursing facility and HCBS, in addition to all primary, acute, and behavioral health services for eligible members. Care management/coordination is included. Fewest exclusions are the ideal! 16
Include attendant care and/or paid family caregivers in benefit package Arizona s ALTCS program: Includes paid family members as caregivers through traditional attendant or self-directed attendant care program Family members in traditional attendant care program are hired by home health/attendant care agency Training includes CPR, first aid, infection/disease control Spouse as paid caregiver (up to 40 hours per week) recently added to program. 17
Develop financial incentives and a robust monitoring process Very few actuaries have experience in setting rates for MLTS, so states need to develop some capacity for understanding rate development. The rates should include realistic incentives for plans. May include: Incentive payments based on achieving objectives; Case-mix payment system; Penalties for increased reliance on institutions. Most states start with very prescriptive contracts and monitoring practices and over time, may focus on a few high-risk, high-cost areas. 18
Develop LTSS-focused performance measures Many states track process measures (days to assessment; care plan completion). Wisconsin best practice: PEONIES interview Living in a preferred setting; Making one s own decisions; Deciding one s own daily schedule; Maintaining personal relationships; Working or pursuing other interests; Being involved in the community; Having stable/predictable living conditions; Being treated fairly and with respect; Having the amount of privacy desired; Being comfortable with one s health situation; Feeling safe; and Feeling free from abuse and neglect. 19
Integrated Care for Dual Eligibles 20
Evolution of Integrated Care 1990 s Dual Eligible Demonstrations Massachusetts, Minnesota, Wisconsin, and New York 2000 s SNP Programs Texas, Arizona, and New Mexico Programs provide improved care, but these integrated care models are very difficult to implement, replicate, and scale Only about 120,000 dual eligibles are currently enrolled in some kind of integrated care 21
Challenges to Integrating Care Administrative and operational hurdles Stakeholder (advocates, providers) concern/resistance Lack of good data (access to, analysis of and linkage between Medicare and Medicaid) Financial and administrative misalignments between Medicare and Medicaid Enrollment issues Network adequacy (especially LTSS) Difficulties in developing and bringing SNPs to scale 22
A Case Study: Washington Washington Medicaid Integration Partnership Implementation Challenges: Low enrollment (no auto-enrollment for users of LTSS or duals) Bad timing (Part D start-up at same time) Case manager resistance Bad feelings about for-profit health plans All benefits included (plenty of providers mad about change)
Why focus on dual eligibles NOW? Affordable Care Act established the Federal Coordinated Health Care Office and the Center for Medicare and Medicaid Innovation (Innovation Center) Innovation Center awarded15 states with $1M design contracts to develop integrated care programs for duals. Consumers are beginning to see the benefits of integrated care. States are budget-strapped and must have more efficient delivery systems. 24
Emerging Vehicles to Integrate Medicare and Medicaid A. Combining Medicare and Medicaid funding at the state level and providing global payments to contracted entities : E.g., Accountable Care Organizations (ACOs). Health Homes, Managed Care Organizations (MCOs) B. Shared savings for avoided Medicare services C. Expanding ( removing the walls ) to PACE D. Reforming current federal rules and regulations to make existing programs more robust and scalable. (Funding streams combined at entity level not by the state) 25
State Ideas for Integrated Care: A. Combining Medicare and Medicaid Funding Medicare $$ Medicaid FFP $$ State Medicaid Program combines both Medicaid and Medicare $$. Contractor(s) provides medical, LTSS, and BH services Contractor options include (but aren t limited to): MCO ACO Health Home Or contracts directly with providers through a PCCM-type model 26
State Ideas for Integrated Care: B. Shared Savings Model States do not combine Medicare and Medicare funding at the state level States and CMS determine a savings target for Medicare services When states achieve savings target, savings are shared with or reinvested through contracted providers such as physician groups, health systems, or other entity. Example: similar to North Carolina savings arrangement (only state to date; authority via Medicare Health Care Quality [aka 646] Demonstration) 27
State Ideas for Integrated Care: C. Expanding PACE Some states are looking at broadening PACE provisions such as: Lowering the age limit Lowering the level of care criteria Eliminating the walls (i.e., decreasing the focus on adult day health centers while maintaining other key components of PACE) Establishing lower capital requirements for start-up 28
State Ideas for Integrated Care: D. Removing Obstacles to Existing Models Examples of obstacles that states would like to revise include: MA/SNP rate process Marketing and outreach limitations Enrollment rules (opt in vs. opt out) Quality measures Grievance and appeals CMS authority 29
The Stars Have Aligned... Significant interest by states in improving delivery of LTSS and care for dual eligibles Affordable Care Act potentially allows significant innovations in this area Federal funding is available to support state infrastructure development Beneficiaries and advocates are beginning to see that they have a lot to gain from streamlined care. 30
Thank You! 31
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