DHCS Update: Major Initiatives and Strategies Towards Standardization Sarah C. Brooks, Deputy Director Health Care Delivery Systems Department of Health Care Services ICE 2015 Annual Conference November 12, 2015 1 Presentation Outline Medi Cal Managed Care Expansion Overview Updates on Current Major Initiatives o 1115 Waiver Renewal, Coordinated Care Initiative (CCI), Health Homes Strategies Towards Questions/Open Discussion 2 Medi Cal Today Of the nearly 13 million beneficiaries in the Medi Cal program, more than 9.5 million are in managed care. o This represents approximately 80% of the total population, largely due to: Various population transitions Affordable Care Act (ACA) expansion 3 1
Population Transitions to Managed Care 2011 Medi Cal only Seniors and Persons with Disabilities (SPDs) transitioned 2012 Community Based Adult Services (CBAS) became a managed care benefit 2013 2014 Healthy Families Program transitioned (SCHIP) Expansion into 28 rural counties Medicaid optional expansion implemented Coordinated Care Initiative (duals demonstration & LTSS ) implemented Transition of SPDs in 28 rural counties 4 New Integrated Services New services have also been integrated into the managed care plans, such as: o Community based adult services (CBAS) o Outpatient mental health services o Behavioral health treatment (BHT) services o Managed Long Term Services and Supports (MLTSS) in CCI counties 5 Section 1115 Waiver Renewal Update DHCS reached conceptual agreement with the Centers for Medicare & Medicaid Services (CMS) on: o A Global Payment Program o An incentive program for designated public hospital systems and district/municipal public hospitals o Dental Transformation Initiative o Whole Person Care Pilots o Two independent reports on uncompensated care o Independent evaluation of beneficiary access and network adequacy o DHCS received an extension of the existing Bridge to Reform Waiver until December 31. o $6.2 billion in federal funding over five years 6 2
Coordinated Care Initiative (CCI) Update CCI Implementation Challenges Enrollment Data Health Risk Assessment (HRA) Data Transition from Passive to Active Enrollment o New Resource Guide & Choice Book o Outreach Efforts 7 Coordinated Care Initiative (CCI) Update CCI Overview o 3 year Duals Demonstration in collaboration with CMS that combines Medicare and Medi Cal benefits, known as Cal MediConnect (CMC) o Mandatory enrollment of all Medi Cal beneficiaries (including dual eligibles) into managed care for all Medi Cal benefits o Inclusion of Managed Long Term Services and Supports (MLTSS) in managed care In Home Supportive Services (IHSS): personal care for beneficiaries needing help to live safely at home; in a health plan, beneficiaries will keep their IHSS providers and can still hire, fire, and manage them Community Based Adult Services (CBAS): adult day health care provided at special centers; health plans will contract for CBAS Multipurpose Senior Services Program (MSSP): provides social and health care coordination services for beneficiaries 65 and older; health plans will work with MSSP providers to provide this service Nursing home care: long term care provided in a facility; health plans will work with beneficiaries, doctors, and the nursing home to coordinate care 8 Coordinated Care Initiative (CCI) Update Passive enrollment complete in 5 CCI counties o Orange County complete in July 2016 o Santa Clara County complete in December 2015 o Beneficiaries newly eligible for Medi Cal still select an MLTSS plan 9 3
CMC Enrollment Data As of October 1 st 10 CMC Projected Enrollment 11 CMC Implementation Challenges CMC is the first program of its kind attempting to: o Combine Medicare and Medicaid benefits into ONE managed care plan and integrate LTSS into managed care Medicaid plans The CMC eligible population is inherently difficult to reach: o Lower health literacy rates and skeptical of managed care Certain providers are fatigued and fear the changes required by CMC: o Adverse to change from fee for service to managed care Attempts to tell the story of CMC have had limited success 12 4
Data Analysis Doing our own data analysis and working with many partners to better understand who is opting out and why as well as how the program is working for enrollees o DHCS analysis of opt out enrollees o Stratify data by language, ethnicity, and geographic region to identify where there are potential target areas o SCAN funded efforts and evaluation o Rapid Cycle Polling Project Showed that most beneficiaries were generally satisfied with their health services and that those who encountered issues were similar to those of opt outs and beneficiaries in non participating counties: http://www.thescanfoundation.org/sites/default/files/mark_dicamillo_findings_fro m_wave_1_rapid_cycle_polling.pdf o Cal MediConnect Evaluation Reported that most CMC beneficiaries are satisfied with their care coordinators but don t value Health Risk Assessments (HRAs): http://www.thescanfoundation.org/sites/default/files/carrie_graham_evaluation_ of_calmediconnect.pdf 13 Data Analysis Initial Findings Enrollment Confusion o Notification process o Transition process care disruption and/or negative interactions with plan o Confusion about enrollment options and meaning of opting out Benefits o Enrollees are generally having a good experience in their Cal MediConnect plan and are satisfied with their care o Lack of awareness of the benefits of Cal MediConnect, including availability or care coordinator o Lack of awareness of continuity of care protections Providers o Beneficiaries have provider loyalty o Lack of awareness and understanding of continuity of care provisions o Providers spreading anti enrollment campaigns 14 Opt Out Data All Eligible Beneficiaries October 2015 Overall County Enrolled Opt Out Disenrolled 3 Other Disenrolled 4 Los Angeles 21% 54% 10% 15% Riverside 47% 34% 7% 12% San Bernardino 45% 36% 7% 12% San Diego 34% 38% 8% 19% Santa Clara 1 43% 39% 9% 9% San Mateo 2 82% 13% 5% 0% Orange 5 27% 69% 4% 0% Total 30% 47% 9% 14% Total w/o LA 43% 37% 8% 12% 1. Santa Clara began enrollment in January 2015. 2. San Mateo is responsible for its own enrollment. IHSS data is not available for this reporting period. 3. Member requested disenrollment through the State s enrollment broker or COHS after the enrollment effective date. 4. Member disenrolled due to actions outside of the State s enrollment broker/cohs control. 5. Cal Optima began enrollment in July 2015. Cal Optima will passively enroll its eligible D SNP and LIS members into CMC effective 1/1/2016. 15 5
Opt Out Data IHSS vs. Non IHSS October 2015 IHSS NON IHSS Enrolled Opt Out Disenrolled* Enrolled Opt Out Disenrolled* Los Angeles 11% 65% 9% 27% 47% 10% Riverside 37% 41% 8% 51% 31% 7% San Bernardino 37% 42% 8% 48% 33% 7% San Diego 24% 47% 8% 37% 36% 8% Santa Clara 32% 47% 11% 47% 36% 8% *Disenrolled includes involuntary disenrollments 16 Health Risk Assessments (HRA) CMC plans use a Health Risk Assessment (HRA) to evaluate an enrollee s current status and establish a platform to begin building care management and to develop the enrollee s individual care plan. The HRA identifies an enrollee s needs for: o Primary care o Acute care o Long term services and supports o Behavioral health o Functional needs 17 HRA Dashboard Most recent HRA Dashboard was released in October 2015 o Data from April 2014 June 2015 89% of HRAs completed within 90 days of enrollment o Beneficiaries who were able to be reached and willing to participate o 38% of beneficiaries unreachable/10% unwilling to participate The unreachable population was initially thought to be due to having outdated beneficiary contact information, but the data aligns with the evaluation findings some beneficiaries don t want to participate in HRAs and instead prefer to coordinate their care themselves. 18 6
Coordinated Care Initiative (CCI) Update Ongoing work to support the transition o New Resource Guide & Choice Book Developed a combined Cal MediConnect and Medi Cal Managed Care Plan Resource Guide and Choice Book for beneficiaries gaining full scope Medicare and Medi Cal eligibility in CCI counties and existing full dual eligibles who move into a CCI county o Beneficiary Outreach Developed new beneficiary toolkit that is more focused on the benefits of the program and educates beneficiaries on managed care Using enrollment data to target high opt out populations to work with local entities and community based organizations on specific outreach Collaboration with health plans to increase beneficiary outreach 19 Coordinated Care Initiative (CCI) Update Ongoing work to support the transition o Provider Outreach Collaborating with organization to get information to providers for example, the Network of Ethnic Physician Organizations (NEPO) Events for physicians in LA and Orange Counties Chinese, Armenian, African American, Korean, and Indian Developing a case management toolkit for social workers, case managers, and hospital discharge planners assist beneficiaries Tools to help them navigate the program when problems arise 20 Health Homes Update RFI Managed Care Plans o On October 9, a Request for Interest (RFI) to Medi Cal Managed Care Plans (MCPs) was released to gauge their interest and capability to implement the Health Home Program (HHP) in the 2 nd half of 2016. o The deadline for plans to submit the RFI was October 30. RFI Community Based Providers o In counties identified for initial implementation, DHCS will release an RFI to community based providers to allow self assessment of their interest and capability to provide HHP services. 21 7
Health Homes Update RFP Managed Care Plans o On December 15, DHCS is planning to release an RFP to interested MCPs. o The RFP will include additional information developed by DHCS such as eligibility criteria, population data, case manager ratios, and the results of the provider RFI responses. o MCPs will have until February 5, 2016 to respond to the RFP. 22 Health Homes Update Proposed Initial Implementation o Per federal requirements, in order for an MCP in a county to implement HHP, all MCPs in that county must implement at the same time. o Implementation counties will be selected based on information provided in the RFI/RFP responses. o Implementation activities will include notices to beneficiaries, HHP network adequacy and readiness activities, and other MCP preparations. For more information, please see the HHP concept paper located here: http://www.dhcs.ca.gov/services/pages/healthhomesprogram.aspx 23 Strategies Towards 1. Standardized reporting and instructions 2. DHCS contracts with MCPs Standardization across all plan models where applicable Strengthened enforcement language 3. Systematic monitoring processes 60 monitoring elements to provide oversight over the managed care program in areas including: Network access, network composition, audits/surveys, quality, grievances and appeals, data, population transitions and addition of new benefits The DHCS Monitoring Overview Report can be found here: http://www.dhcs.ca.gov/services/documents/mcag/mmcmonitoringrpt.pdf 24 8
Strategies Towards 4. Driving quality improvement Strengthen monitoring efforts Standardized reporting to make data across plans comparable Formal Corrective Action Plan (CAP) process for medical audits/surveys, HEDIS quality, and encounter data Partnership with the Department of Managed Health Care (DMHC) for joint network review process 25 Strategies Towards 4. Driving quality improvement DHCS Quality Strategy/Medi Cal Managed Care Quality Strategy alignment Improve patient safety Deliver effective, efficient, affordable care Engage persons and families in their health Advance prevention Eliminate health disparities 26 Strategies Towards 4. Driving quality improvement Improving HEDIS performance Rapid cycle quality improvement Quality of Care Corrective Action Plan (CAP) Aggregated Quality Factor Score (ACFS) Demographic factor analysis Sharing best practices 27 9
Strategies Towards 4. Driving quality improvement Improving encounter data quality Encounter Data Improvement Project Quality Measures for Encounter Data (QMED) Corrective Action Plan (CAP) process Included in Medi Cal Managed Care Performance Dashboard 28 5. Transparency Strategies Towards Medi Cal Managed Care Performance Dashboard Continuity of Care webpage Monitoring Project Health Plan Report Cards 29 Questions/Open Discussion 10