Long-Term Services and Supports Study Committee: Person-Centered Medicaid Managed Care Barbara R. Sears, Director Ohio Department of Medicaid July 12, 2018 1
Health Care System Choices Fee-for-Service Challenges Provider-centered care Fragmented care Multiple, separate providers Volume driven No accountability Institutional bias Limited benefits Provider access challenges Complicated benefit overlap Rapid cost growth MLTSS Solutions Person-centered care Coordinated care Coordinated care teams Value and outcome driven Performance measures Continuum of care Enhanced benefits Access to providers required Simplified processes Sustainable growth over time 2
Advantages for individuals enrolled in MLTSS Provide benefits of care coordination Promote the health, safety and well-being of Medicaid individuals through care management Give individuals more choice Expand community LTSS options, and streamline and standardize the way people access them Pay for value Create a system that rewards providers for keeping patients as healthy as possible, and managing chronic conditions when necessary Improve quality of care and achieve better outcomes Strengthen the focus on quality measurement, including both quality of life and quality of care, in order to achieve better delivery systems and better outcomes Increase accountability Focus on the entire person and integrate services around the person s needs Create a more sustainable program Ensure long-term financial sustainability of the system 3
Waiver Trends in Ohio 4
Waiver Enrollment Calendar Year Assisted Living Choices PASSPORT Ohio Home Care Transitions Aging Carve Out MyCare Ohio 2014 5,791 498 42,641 10,024 2,749 25,555 2015 4,206 NA 27,581 7,290 1,491 30,024 2016 4,572 NA 28,036 7,155 NA 31,201 2017 5,075 NA 29,026 7,198 NA 32,553 5
Average Processing Time Average number of days from assessment of need to waiver enrollment Calendar Year Assisted Living PASSPORT Ohio Home Care MyCare Ohio 2014 58 47 63 78 2015 53 43 63 21 2016 44 40 40 24 2017 42 35 35 20 6
Waiver Services Authorizations Percent of members who experienced an adverse action Calendar Year Assisted Living PASSPORT Ohio Home Care MyCare Ohio 2014 9% 20% 15% <1% 2015 10% 18% 16% 1% 2016 10% 18% 17% 1% 2017 12% 19% 12% 1% Assisted Living: N = Number of individuals who experienced a denial of waiver services, service reductions, and terminations issued; D = unduplicated client count PASSPORT: N = Number of individuals who experienced a denial of waiver services, service reductions, and terminations issued; D = unduplicated client count Ohio Home Care: N = Number of individuals who experienced a denial or reduction of service; D = unduplicated client count MyCare Ohio: N = number of individuals who experienced a denial, reduction, termination or suspension of service; D unduplicated client count 7
National Core Indicators for Aging and Disabilities 2016-2017 8
National Core Indicators Aging Disabilities (NCI-AD) 21 states are currently participating in this effort Voluntary initiative that allows states to assess the performance of their programs and delivery systems that serve older adults and individuals with disabilities Primary aim is to obtain valid and reliable data from members that provides states with a view of how publicly funded services impact the quality of life and outcomes for service recipients 1554 total face-to-face interviews were completed with individuals in all waivers in Ohio Full report for 2016-2017 is available on the NCI-AD website (https://nci-ad.org/states/oh/) 9
Proportion of people who always get enough assistance with everyday activities when they need it 10
Proportion of people who always get enough assistance with self-care when they need it 11
Proportion of people whose services meet all their needs and goals 12
Proportion of people who can choose or change their services 13
2017 MyCare Ohio Care Management Survey 14
Overview/Background ODM collaborated with Health Services Advisory Group, Inc. (HSAG) to develop the 2017 Care Management Survey instrument that addressed:» experience with the care manager;» care plan involvement; and» member demographics and reported health status. Survey findings provided ODM with a better understanding of MyCare Ohio plans care management program operations and service delivery from the members perspective. 15
Survey Findings Approximately 70 percent of respondents reported being satisfied with their care manager. Approximately 68 percent of respondents reported that a care plan was developed for them. Of the 68 percent:» Approximately 92 percent reported participating in the development of their care plan.» Approximately 90 percent reported knowing the goals of their care plan.» Approximately 95 percent reported that their care manager reviewed their care plan with them.» Approximately 96 percent reported understanding their care plan. 16
Survey Findings Results suggest that the MyCare Ohio plans are establishing good relationships with their members, reviewing their needs, and suggesting appropriate services for them.» All of the plans scored approximately 90 percent or above for each composite item evaluated for the Relationship with Care Manager composite measure which indicates that their care manager explained things to them in a way that could be understood, treated them with respect, and listened carefully to them. Care managers could be more aware of members health care needs.» Approximately 53 percent of respondents indicated that their care manager did not always seemed to know about their health care needs. Better communication of member information between care managers during care manager transitions.» For respondents that did not change their care manager in the last 6 months, about 46 percent of respondents stated that they had to report information about themselves to their new care manager. Respondents reported high levels of participation in various aspects of their care plan. In addition, approximately 78 percent reported receiving a copy of their care plan. 17
2017 MyCare Care Management Reviews 18
Overview ODM partners with its external quality review vendor, HSAG, to evaluate care management performance of each MyCare Ohio plan by reviewing individual case files. Four reviews conducted in CY 2017» Evaluation period is August 2016 to September 2017» Approximately 640 cases reviewed (community well + waiver beneficiaries) Results are used to:» Identity strengths and areas needing attention» Report federal waiver assurances to CMS 19
CY 2017 Review 4 Results Areas of Strength Person-centered care planning Based on the most recent assessment Included prioritized measureable goals, interventions, and anticipated outcomes with completion timeframes Identified and prioritized the beneficiary s concerns, strengths, and preferences for care (e.g., cultural considerations) Communication plan developed with the member, including the method of preferred contact and a scheduled that was based on the beneficiary s needs Waiver service coordination Service plan adequately addressed his/her assessed needs Included strategies to address and mitigate health, safety, and welfare risk factors Back up plan was documented for the beneficiary in the event providers did not show up Interdisciplinary care team formulated with the beneficiary and was based on the beneficiary s needs and preferences. 20
Care Management Area for Improvement Cases reviewed where services were delivered in accordance with waiver plan 2016 - care management review results identified an area for improvement with identifying and closing gaps in waiver service. 2017 - ODM enhanced plan accountability by adding a contract measure focusing on addressing gaps in care. Observed a 14 percentage point increase for the program between last review of CY 2016 and last review of 2017. 21
2017 Healthcare Effectiveness Data and Information Set (HEDIS) Results 22
MyCare Ohio 2017 HEDIS (CY 2016) Results National Comparisons 59% of MyCare Ohio statewide HEDIS results exceeded the 75 th national NCQA Medicaid percentile» Compared to other Medicaid health plans on a national level, 59% of MyCare Ohio plans HEDIS results are in the top 25% 50% of the MyCare Ohio statewide HEDIS results exceeded the 90 th national NCQA Medicaid percentile» Compared to other Medicaid health plans on a national level, 50% MyCare Ohio plans HEDIS results are in the top 10% *MyCare Ohio HEDIS Survey Results for the Opt-In Population 23
MyCare Ohio Compared to National Committee for Quality Assurance Benchmark NR measure not reported for the measurement year *MyCare Ohio HEDIS Survey Results for the Opt-In Population 24
Identifying and addressing areas of improvement Improvement projects Selected by ODM Can be focused on clinical or non-clinical areas Intended to achieve significant and sustained improvements over time Use rapid cycle continuous quality improvement methods (popularized by the Institute for Healthcare Improvement) Hypertension Control Improvement Project: Focused on reducing disparities in hypertension control Partnership between ODM, primary care clinical, managed care plans, Case Western Reserve University, and the Ohio Colleges of Medicine Resource Center Pilot initiated in January 2018, with 11 primary care clinics partnered with the plans Monthly webinars with clinics and managed care plans, and monthly practice coaching *MyCare Ohio HEDIS Survey Results for the Opt-In Population 25
Consumer Assessment of Healthcare Providers & Systems (CAHPS) Results 26
Member Satisfaction Measure Responses 2015 2016 2017 2015 vs. 2017 Getting Needed Care Getting Appointments and Care Quickly Doctors who Communicate Well Customer Service Care Coordination Composite Getting Needed Prescription Drugs Rating of Health Plan Rating of Health Care Quality Always Always Always Always Always Always 9 to 10 9 to 10 56 52 N/A 71 70 78 51 56 62 52 78 73 72 80 58 61 63 59 79 79 73 80 66 63 +7 +7 - +8 +3 +2 +15 +7 Sometimes/Never Sometimes/Never Sometimes/Never Sometimes/Never Sometimes/Never Sometimes/Never 0 to 6 0 to 6 16 21 N/A 10 11 6 19 14 11 21 6 10 10 4 14 11 11 17 5 5 8 5 9 12-5 -4 - -5-3 -1-10 -2 Note: The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey is conducted annually to assess the experiences of beneficiaries in capitated model demonstrations. The table above provides the 2015, 2016, and 2017 survey results for the top and bottom response categories on select CAHPS measures. Medicare-Medicaid Plan National Average Data Source: CMS MyCare Ohio CAHPS Survey Results for the Opt-In Population 27
Nursing Home Minimum Data Set (MDS) Measures 28
Nursing Home Minimum Data Set Measures CY 2016 MyCare Ohio vs Fee for Service MDS Measure MyCare Ohio FFS Percentage Difference Falls with Injury 2.98% 3.57% Pressure Ulcers 3.80% 4.20% Catheter Left in Bladder 1.24% 1.56% Physically Restrained 0.25% 0.36% Urinary Tract Infection 2.83% 3.35% 0.59% fewer MyCare Ohio members had falls with injury compared to fee for service. 0.40% fewer MyCare Ohio members had pressure ulcers compared to fee for service. 0.32% fewer MyCare Ohio members had catheter left in bladder compared to fee for service. 0.11% fewer MyCare Ohio members were physically restrained compared to fee for service. 0.52% fewer MyCare Ohio members had urinary tract infections compared to fee for service. 29
MyCare Ohio Rebalancing Measures 30
MyCare Ohio Enrollment Rebalancing Enrollment Rebalancing Percent of NFLOC Members in an Institutional Setting This chart illustrates the percentage of NFLOC members in a nursing facility (NF) between the MyCare program and a FFS Equivalent population. Enrollment rebalancing in MyCare outpaced the FFS Equivalent population. This implies that the MyCare program resulted in a 2.0% increase in the number of members transitioning to the community. 31
MyCare Ohio Fiscal Impacts Enrollment Rebalancing For each individual receiving long-term services and supports* who moves from a nursing facility setting to a waiver setting, the average cost savings per member per month is approximately $3,000.** Based on an estimated 4% total rebalancing achieved by the MyCare Ohio managed care plans, there is an estimated annual savings of approximately $60 million for the program. Since the MyCare Ohio managed care plans have achieved an estimated 2% incremental rebalancing, there is an estimated annual savings of approximately $30 million above what would have been achieved under the traditional Medicaid fee-forservice program. *Includes members in a nursing facility and those receiving waiver services **Per July 2017 Effective MyCare Capitation Rates and Assumed Enrollment Mix 32
MLTSS Fiscal Analysis 33
MLTSS Fiscal Projections: State and Federal Combined Values are in $ millions and have been rounded Fiscal Impacts are illustrated on an incurred basis, FFS runout is not included in the estimates Projections exclude expenses associated with the health insurer provider fee (HIPF) The MLTSS population was identified based on information provided by ODM The cost associated with these members based on vendor file data from SFY 2017 34
MLTSS Fiscal Projections: State Only Funds Values are in $ millions and have been rounded State only values assume Ohio Federal Medical Assistance Percentage (FMAP) of 63.1% Fiscal Impacts are illustrated on an incurred basis, FFS runout is not included in the estimates Projections exclude expenses associated with the health insurer provider fee (HIPF) The MLTSS population was identified based on information provided by ODM The cost associated with these members based on vendor file data from SFY 2017 35
Addressing Redundancies in Current System 36
Next Steps Partner with the Ohio Department of Aging to modernize Ohio s 1915(c) waivers Take this opportunity to align waiver functions based on lessons learned from MyCare Ohio Work to achieve operational and administrative efficiencies throughout all of our waivers Build a rational, sustainable delivery system that is not fragmented and works well for members and providers that will serve as a sound foundation for implementing MLTSS in the future Extend the MyCare Ohio program for an additional three years to allow those individuals to continue to receive the benefits of care coordination 37
MyCare Ohio Enrollment Rebalancing Enrollment Rebalancing Percent of NFLOC Members in an Institutional Setting This chart illustrates the percentage of NFLOC members in a nursing facility (NF) between the MyCare program and a FFS Equivalent population. Enrollment rebalancing in MyCare outpaced the FFS Equivalent population. This implies that the MyCare program resulted in a 2.0% increase in the number of members transitioning to the community. 38