Medicaid and the Bus Pass Problem PRESENTED BY: Cardinal Innovations Healthcare Richard F. Topping, Chief Executive Officer Leesa Bain, Vice President, Care Coordination & Quality Management September 2016
Medicaid Health Plans of America mhpa2016 Conflict of Interest Disclosure: Faculty/Planning Committee/Reviewers/Staff Participating speakers in Healthcare is not a Medical Problem, it s a Bus Pass Problem have no conflict of interest to disclose relative to the content of the presentation.
Medicaid managed care isn t about successfully managing patients and their healthcare costs. It s about populations with complex needs, the social determinants that drive their health, and the locally delivered services and supports that can improve their wellness. Successfully managing Medicaid is about solving the Bus Pass Problem.
A man walks into a hospital He s a plan member, admitted for a long, expensive stay Admitted through the ED Arrived at the ED via EMS EMS called after he decompensated in his home He decompensated because he did not take his medication He did not take his medication because he did not see his doctor He did not see his doctor because he lives in a rural area and does not have a car His county offers subsidized local transportation for a small fee A $100,000 hospitalization can be avoided with a $25 bus pass
Cardinal Innovations Healthcare Largest Specialty Medicaid Plan in U.S. 1 million members $1B in annual revenue Headquartered in Charlotte, NC Exclusively focused on special populations Founded in 1974 as a county mental health provider, began managed-care operations in 2005 Manage Medicaid, state and local government-funded services
Demographics, Fishes and Loaves From Safety Net to One-Fifth of All Americans Medicaid in 1965 Welfare benefit for specific, limited populations Publicly administered Medicaid in 2016 Means-tested benefit for entire population Privately managed Jointly Financed All, 9, 4, 3 or 2 for 1 FMAP
Child s Play
By The Numbers Medicaid at 50 (1) Insures 1 in 5 Americans Finances $1 of every $6 of health spending nationally Cover 50% of all births 25% of all behavioral health 50% of all services and supports for the disabled and the elderly 35% of safety-net hospital revenues 40% of health center revenues Approximately $550B total spending in 2016 (2) Sources: (1) Kaiser Family Foundation, Medicaid at 50. (2) CMS, 2014 Actuarial Report to Congress.
Back to the Future The Disabled and the Elderly 25% of Medicaid enrollees are disabled or elderly The disabled drive 42% of all spending The elderly drive 21% of all spending 63% total, or $347B per year 14% of enrollees are disabled or elderly that are dually eligible for both Medicaid and Medicare Duals drive 40% of all spending $220B per year is attributable to fewer than 10 million (of 70 million) enrollees Source: Kaiser Family Foundation, Medicaid at 50.
Back to the Future
The Challenge Abides The Disabled and the Elderly Cost of Medicaid coverage for children and non-disabled adults is lower per enrollee relative to other payers Program is bigger and broader Challenge for Medicaid at 50 is same as it was for Medicaid at 1 High-need, high-cost, at-risk, complex populations
The Upside Down Idea Easy vs. Hard Medicaid Financial sustainability of capitated, privately managed Medicaid was well established by 2000s (after a rough start in the 1990s) Traditional path of new or emerging markets: start easy Special populations carved-out Attempt to build a viable managed-care model and infrastructure for complex populations Create the hard Medicaid market, merge it with the easy market New York and North Carolina 12
North Carolina Pilot PBH Hard Medicaid Pilot 1915(b)/(c) combination waiver Health care and home and community based services and supports 5 counties Enrollees with mental health, substance use and/or intellectual and developmental disabilities Inpatient included Physical health, pharmacy excluded 13
Ain t It the Truth Cardinal Innovation s Experience 1% of plan members drive 52% of service costs For that 1% of plan members, between 83%-87% of their total cost of care including non-managed physical and pharmacy is for specialty services Efficacy and cost of specialty services is directly correlated to non-healthcare community and social services Employment, housing, education, transportation, connectedness Virtually no capitation rate would be sufficient, nor any regulatory scheme feasible, for the plan to be viable 14
Along Came A Bus 15
Get the Member on the Bus Leave the Driving to Them Plan as coordinator, not just payer Leverage healthcare and non-healthcare, paid and unpaid Partnerships are key Community-based and adaptable Stakeholders as customers Non-traditional programs Person-centered Clinical and financial risk tolerance 16
Specialty Plan Considerations It s Not Your Father s Medicaid Plan Workforce Medical and clinical vs. social services and customer support Geography and footprint Efficiencies vs. local presence and relationships P&L 1% vs. 99% Service vs. administrative revenue Regulatory and Contracting Vendor vs. partner Market Expertise and profitability vs. share and leverage 17
Cardinal Innovations Care Coordination In-person, case management for complex populations Funded administratively Approximately half of Cardinal Innovations workforce Mix of clinical and social services expertise Assigned locally Responsible for coordinating in-network healthcare AND any other available supports that meet members needs Engaged at the member, family, stakeholder and community level 18
Leesa Bain Vice President, Care Coordination & Quality Management
Care Coordination Staff Total Staff = 311 Other Other, 72, 23% QP QP-Qualified Professionals, 155, 50% RN-Registered Nurses, 7, 2% SW-Social Workers (Licensed), 77, 25% SW RN
Integrated Care Team Family members, caregivers, etc. Community Care Coordinators Population Health Specialists Supports Intensity Scale Team System of Care Specialists Acute Transitional Nurses Member Transitions to Community Living Peer Support Specialist Clinical Support Specialist Primary Care Provider Residential Placement Specialist
Care Coordination Roles Registered Nurses Licensed Clinicians Qualified Professionals Acute Transitional Care Nurses MHSUD Care Coordinators System of Care Clinicians* High Volume Hospitals Transitions Medication Reconciliation MHSUD Child Residential Specialists IDD Care Coordinators Transitions to Community Living* Monitoring Specialists * Includes Some Licensed Professionals Population Health Specialists
Operational Foundation Focus on quality of relationships with members Person-centered approach Data driven approach to care Training and onboarding Geographic alignment 23
Operational Foundation Technology tools Population health Case referral and assignment Physical health integration 24
Complex Management Principles Provider Outreach Provider Accountability Proactive assessments Specific triggers Data-driven service development Training Closed network Submit treatment justification and plan Provider plans inform care coordination work with member and families Utilization review to determine usage and effectiveness Innovation Actively seek identification of gaps and opportunities Develop new services to support unmet needs Partnerships with Members and Stakeholders Proactive multi-agency case staffing Collaboration to achieve complementary solutions Focus on treating the whole person
Complex Medicaid Management Dually diagnosed: both MHSUD and IDD combined MHSUD or IDD with multiple physical comorbidities Children and youth with residential treatment needs Individuals with frequent crisis service utilization: both ED and Inpatient Incarcerated, or recently incarcerated individuals with identified behavioral health needs Complex co-occurring medical and psychiatric conditions Department of Justice Settlement participants
Transitions Management Medication Reconciliation concerns Limited support systems and connection to resources Provider visit scheduled for 3 weeks from discharge date Lack of communication between settings Last minute discharge planning Health literacy concerns Failed follow-up
Critical Connections Department of Social Services Juvenile Justice Substance Abuse Mental Health Partnership Drug Treatment Court City and County School Systems Detention Centers Hospital Facilities Developmental Centers
Bus Pass Interventions Assist in obtaining gainful employment Engage with resources for housing, transportation, medication Community Engagement Increase Natural Supports identify supports that exist for our members or create new supports that will exist even after paid supports are no longer needed
Benefits To Our Members Highly skilled clinical infrastructure Consistency of assessment and interventions Management of continuum of care, regardless of setting Education on self-management pathways to become an active participant in their health
Benefits To Our Members Integrated focus on both physical and behavioral co-morbidities Support from Population Management light touch engagement High quality customer service Proactive approach versus a reaction to crises Members will achieve better outcomes
Medicaid and the Bus Pass Problem