Transcript Slide 1

Minnesota’s Alternative
Demonstration for People with
Medicare and Medicaid
Special Needs Plans and Integrated Care
System Partnerships
2013 Age and Disabilities Odyssey
June 18, 2013
Pamela Parker, MPA
Special Needs Purchasing
Minnesota Department of Human Services
[email protected]
651-431-2512
OVERVIEW
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Why Integrate Medicare and Medicaid
Minnesota’s Integrated Programs and Results
History of Integration
New CMS Integration Initiatives and Challenges
Finding the Best Platform for Integration
Status of MN Dual Demo for Seniors and People with
Disabilities
Minnesota’s Payment and Delivery Health Reform Initiatives
Integrated Care System Partnerships (ICSPs)
Clinical Measurement for ICSPs
Summing Up
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Why We Need Medicare/Medicaid Integration
for People with Dual Eligibility
• Without partnering with Medicare, States can do little to impact
preventive, primary, acute care and post acute care and costs..
• Decisions made by primary, acute and post acute care providers paid
under Medicare also drive State Medicaid and LTSS costs.
• Care for people with dual eligibility is fragmented and not optimal.
• Services to the 10 million people with dually eligibility make up more
than a third of all Medicare and Medicaid expenditures and are expected
to increase disproportionately.
• Shared State and Federal goal to improve care quality and make care
more seamless, appropriate and accessible for people with dual
eligibility is an imperative.
• Combining Medicare/Medicaid primary, acute and LTSS financing in
aligned contracts is necessary for creation of provider level payment
incentives that can improve care and costs across settings and
financing sources.
• CMS Medicare-Medicaid Coordination Office (MMCO) is sponsoring new
opportunities for States to tackle these issues through demonstrations
to align Medicare and Medicaid.
Integrated Programs in MN
• Medicaid managed care since 1985, about 600,000 total
enrollees. About 88,000 elderly and disabled included. Seniors
since 1983, people with disabilities since 2001.
• 90% of seniors (49,000) enrolled in managed long term care,
includes all home and community based and behavioral health
services. 70% of seniors enrolled in FIDE SNPs. Average age
80. 70% eligible for LTSS.
• Two options:
– Minnesota SeniorCare Plus (MSC+): 12,500 seniors in same 8 Medicaid
MCOs, mandatory enrollment unless enrolled in MSHO, Medicare largely
FFS.
– Minnesota Senior Health Options (MSHO): 36,500 dual seniors in 8 fully
integrated Medicare/Medicaid FIDE SNPs, voluntary alternative to
mandatory enrollment in MSC+
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Integrated Programs in MN
• 43% of people with disabilities (39,500) enrolled in Special
Needs BasicCare sponsored by 5 Medicaid Managed Care
Organizations (MCOs), LTSS carved out, all behavioral health
included.
– Only 3% in 3 integrated SNPs, 5 other SNPs dropped Medicare SNP for
disability group.
• MSHO now moving back to Medicare/Medicaid Demonstration
status under new CMS demonstration parameters.
• Also pursuing separate Demonstration for people with
disabilities
– Will describe that briefly but not the focus of this presentation
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MSHO (Statewide-87
MSC+ (Statewide-87 counties)
counties)
1915(b)(c )
1915 (a)(c)
Enrollment
65+
Voluntary 35,800
Duals only
Medicare
Services
All Medicare services including Medicare A/B services through
Part D drugs through Medicare Medicare FFS.
Dual Eligible Fully Integrated
Special Needs Plan (FIDE-SNP) Part D drugs through separate
Medicare drug plan
Medicaid
Basic Care
Services
Medicaid state plan services
(includes PCA) and remaining
drugs through same SNP
Medicaid Long Elderly Waiver (EW) through
Term Care
SNP plus 180 days of nursing
Services
home care
Mandatory 12,800
Duals and non duals
Medicaid only plan provides state
plan (includes PCA) and remaining
drugs
EW through same plan plus 180
days of nursing home care
Results Indicators for MSHO Seniors
• Contract Requirements for Care Coordination: All members are
assigned individual care coordinators. The State sets uniform
standards, audit protocols and criteria for assessment, care plans
and care coordination. Audit reports, independent onsite reviews
and corrective actions are used to follow up.
• Encounter Data Analysis: Shows annual assessment and
individualized care coordination has significantly increased
access to HCBS.
• AARP Scorecard: MN has been #1 for HCBS Access. Medicaid
long term care for seniors has been rebalanced since the start of
managed LTC programs (Sources: 1996 Medicaid Forecast, July 2012 Medicaid
enrollment by living arrangement).
– Nursing home admissions average about 7% across the senior programs
with an average length of stay of about 150 days per year.
– About 41% of nursing home admissions return to the community.
– About 60% of all EW expenditures are for Assisted Living which is by far
the largest single EW service expenditure
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Results Indicators for MSHO Seniors
• HEDIS: 98% of MSHO seniors have annual primary care visits.
• Dual Data Base: Despite much higher chronic disease rates, acute
care hospital admits/episode rates for community seniors by risk
adjusted categories are lower in MSHO than for regular Medicare
members in FFS or other Medicare Advantage. (Source: JEN iMMRSMN)
• STARS: MSHO D-SNPs have had average Star ratings of 4.0 Stars
(2012)
• CAHPS: MSHO is highest rated Medicaid program. Includes care
coordination questions
• Disenrollment Rates: Despite voluntary enrollment, MSHO
disenrollment is < 2%.
• Payment Incentives: Contracts include significant payment withhold
tied to timely assessment, financial incentives for provision of LTSS
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and Health Care Home (HCH) payment flexibility
Enrollment by Setting of Care 1996 and 2012
Total 55,047
60,000
Total 49,667
50,000
34.5%
29.9%
40,000
26.3%
30,000
Community
Nursing Facility
Elderly Waiver
60.6 %
20,000
39.2
10,000
9.5%
0
Community
1996
14,837
2012
19,023
Nursing Facility
30,104
14,459
Elderly Waiver
4,726
21,565
History of Integration and New
Integration Initiatives
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History of Integration Efforts
1970-1990:
Formation of On-Lok and PACE
1985-2007:
Social HMO Demo (transitioned to SNPs in 2007)
1987:
Evercare begins in MN
1980s:
MN Managed Care contracts include
Medicare/Medicaid services to duals through
Medica/Evercare and Health Partners/Social HMO
First MN proposal to CMS for integrated Medicare and
Medicaid program for people with dual status, two more
proposals follow
1991:
1995:
CMS approves first State “Dual Demo” in MN
1997-2004:
Two additional State Demos implemented in WI and
MA
History of Integration Efforts
2005:
2010:
2011:
2011:
CMS requires the 3 State Dual Demos to transition to
D-SNP
ACA provides additional authority to CMS for new
Medicare-Medicaid Coordination Office (MMCO) to
align Medicare/Medicaid for people with dual status
CMS awards 15 states planning contracts for new
dual demos
CMS issues Capitated and FSS Financial Alignment
Demo (FAD) opportunities to States beyond the
original 15 states, 36 States respond
2012-13:
OR, MN, HI, TN and AZ drop out of FAD
2013:
CMS approves FAD MOUs for MA, WA, IL, OH, CA,
VA
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The Impossible Dream: CMS MMCO
Dual Demo Challenges
• Set consistent national standards on key elements but
allow flexibility to accommodate State variations
• Make Medicare and Medicaid bureaucracies do something
different at both Federal and State levels
• Resolve innumerable devilish operational details for both
Medicare and Medicaid at both State and CMS levels
• Meet high and often conflicting expectations and
demands from Congress, MedPAC, 30+ States, multiple
consumer and provider stakeholders, plans and financial
investors!
• Manage tensions around Federal vs State control
CMS MMCO Dual Demo Challenges
• Evaluate results in 3 years and meet CMS standards for
rapid cycle improvement potential
• Achieve significant enrollment and significant savings
• Position demos for potential permanent platform
• Chart course for dual demos among many competing
FFS based provider initiatives as well as ongoing
Medicare Advantage/Part D competition
• CMS MMCO has done astonishing work but this is a
gargantuan task, the biggest challenges lie ahead!
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Status of State Integration Efforts
Medicaid Managed LTSS Only
AZ, HI, KS, NM, PA, TN
Both Medicaid Managed LTSS and Medicare-Medicaid Care Coordination
Initiative
CA, DE, FL, IL, MA, MI, MN, NH, NJ, NY, NC, OH, TX, WA, WI
Medicare-Medicaid Care Coordination Initiative:
*: Financial Alignment (FA) demonstration proposal approved by CMS
**: Initiatives other than FA demonstration
W: No longer pursuing FA demonstration
AZ(W), CA*, CO, CT, DE, FL**, HI(W), ID, IL*, IA, IN**, MA*, MI, MN(W)**, MO,
NH**, NJ**, NM(W), NY, NC, OH*, OK, OR(W), RI, SC, TN(W), TX, VA*, VT, WA*,
WI
Source: NASUAD Integration Tracker May 2013
http://www.nasuad.org/medicaid_integration_tracker.html
Still Searching for the Right Platform
• PACE: Enrollment limited to community “nursing home
certifiable”, staff model means changing doctors, expensive and
inflexible care coordination model
• SNPs: Lack of operational alignment with Medicaid, lacks direct
communications/role for State, constant conflicts with state policy
around enrollment, procurement timelines, quality reporting,
assessment timelines, grievance and appeals, marketing, etc.
• FAD: Key states (OR, MN, AZ, TN, NM, HI) with large MLTSS
programs and/or high degrees of SNP integration dropped out for
financial and administrative reasons
• MedPAC: New recommendations to give integrated SNPs
permanent status and facilitate more integration
• Many states still working with SNP based models
• All 5 approved Dual Demos have delayed most enrollments to 2014
Typical SNPs vs. Integrated SNPs
Non-Integrated SNP Features
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Separate assessments and Models for Care
(MOC) for Medicare and Medicaid
Misaligned enrollments
Two enrollment forms to sign
Separate accretion and deletion dates
Two cards and sets of member materials,
provider directories, etc.
Separate reviews of member materials,
State vs RO
Two sets of notices (likely misleading)
Separate PIPs and QI
Typically must have Medicare denial or
appeal before Medicaid service picks up
May handle claims twice, once for
Medicaid, once for Medicare
Providers normally bill twice
Two different member service responses
May have conflicts between Medicare and
Medicaid networks
MN Integrated SNP Features
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Integrated person centered care
coordination, assessments and MOC
Same enrollment requirements for both
programs (State as TPA)
One integrated enrollment form
Same accretion and deletion dates for all
Medicare and Medicaid services
Coordinated member materials review with
State, SNPs and RO
One card and EOC, directories, materials,.
One set of integrated notices
Integrated QA, PIPs and QI
Integrated coverage decisions and
coverage flexibility for Medicare and
Medicaid, waivers of 3 day hospital stays,
in lieu of hospital days, etc.
Integrated provider billing
Integrated member services
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Integrated provider networks
Update on MN Dual
Demonstration Alternative
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MN Alternative Dual Demo Proposal
• One of 15 Original Dual Demo states
• Stakeholder involvement for refocusing dual programs over
past 24 months
• Stakeholder groups at State level and at each plan level
required
• Submitted proposal for both Capitated FAD and Original Demo
• Withdrew Capitated FAD in June, 2012 with CMS understanding
and support
– Capitated FAD savings not viable due to 15 year history of
integration
• Many FAD features already similar to current MN programs
• Much integration possible through SNP model
• But State needs a role with Medicare, and Medicare needs to
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tweak SNP model to allow continued integrated
MN Alternative Alignment Demo
• MSHO Seniors: State proposing alternative “Demonstration to Align
Administrative Systems for Improvements in Beneficiary Experience” Builds
on current SNP platform along with some FAD parameters
– No new procurement/applications needed, builds on current D-SNPs
– Current SNP and Medicaid financing and rates
• Goals:
– Improve SNP platform to align with and support State Payment and
Delivery Reforms as developed through stakeholder efforts
– Provide State a clearer joint role with CMS in Medicare SNP oversight
– Preserve/enhance integrated administrative and operational features and
reduce reliance on informal CMS Medicare SNP policy agreements which
often change and threaten disintegration
– Improve integrated D-SNP administrative efficiency and alignment for
beneficiaries
• Status: CMS Memorandum of Understanding (MOU) close to final, implement
in 2013-2014
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Proposed Demo Alignment Areas
• Enrollments
– Retain State TPA role, ensure facilitation of integrated enrollment
forms and dates
– Medicaid eligibility verification needed before Medicare enrollment is
complete
• Networks
– Coordinate Medicare and Medicaid network adequacy standards
– State involvement in exceptions process
• Models of Care and Assessment
– Assure continued integration of assessments (365 day issue)
– Reduce duplication between MOCs and S&Ps
• Member Materials
– Retain integrated Evidence of Coverage, Summary of Benefits,
member notices and communications,
– Use new models from FAD where possible
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Proposed Demo Alignment Areas
• Quality Oversight
– Test more targeted duals outcome measures (also working with NCQA on
this)
– Test alternative Stars Measures
– HOS languages relevant to populations served
– Consolidate CAHPs reporting with shared analytic data with state
• Retain Integrated Benefit Determinations and Provider Billing
– Clarify bid audit instructions
• Premium Protection for Beneficiaries
– Exploring mechanisms such as increasing in de-minimus premium levels
(CMS objecting thus far)
– Waive Part D co-pays as under FAD (no response from CMS on this yet)
• Integrated Appeals and Grievances
– Align State and CMS timelines (using FAD rules)
– Simplify member materials
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MN’s Alternative Demo: People with
Disabilities 18-64
• Seeking separate MOU for dually eligible people with disabilities ages 18-64
• SNP model has not been financially viable in MN for this group
• 5 SNPs for this population dropped out of Medicare due to bids generating
premiums duals cannot pay, so seeking Medicare FFS demo option
• Would include dual eligibles in both FFS and in Special Needs Basic Care
(SNBC), a Medicaid managed care program that enrolls about half of the
Medicaid disability population (45,000)
• SNBC integrates behavioral health but LTSS remains FFS
• Builds on current Medicaid State Plan Health Care Delivery Systems (HCDS),
an innovative provider direct contracting option (Medicaid ACO type system)
• HCDS organizations currently serve enrollees in both FFS and Medicaid MCOs
including SNBC members
• Goal is to incorporate Medicare into HCDS model
• Feasibility currently under discussion with CMS
Payment and Delivery
Reform:
Integrated Care System
Partnerships
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MN Payment/Delivery Reform Initiatives
• Health Care Home (HCH): Medicaid benefit provides additional payments to
clinics and practitioners certified by MDH
• Multi Payer Advanced Primary Care Practice (MAPCP) Demo: 8 state demo
providing added Medicare payments to HCH for FFS patients including duals
• Private Sector and Medicare ACOs: History of HMO/Provider ACO type
subcontracting, also 3 Medicare Pioneer ACOs
• Health Care Delivery System (HCDS): Primary/acute Medicaid ACO like delivery
models operating in and outside of managed care
• State Innovation Model (SIM): State’s CMS proposal accelerates adoption of ACO
models (HCDS, Medicare ACOs, etc.) to improve care coordination, population
health, patient experience and costs by building on the foundation of programs
such as HCH/MAPCP
• Dual Demo Integrated Care System Partnerships (ICSPs): SIM/HCDS aligned
proposals for provider payment and delivery reforms within D-SNPs.
– Combined Medicare and Medicaid provides incentives for provider level payment
and delivery reforms stimulating subcontracting arrangements across all services.
– Encourages involvement of long term care providers under shared pooled
incentives.
– Tied to quality and financial performance metrics
Payment/Delivery Reforms for MSHO Seniors
• SNPs provide MSHO care coordination directly or through contracts with
counties, Care Systems/Health Care Homes or community case management
organizations. Unlike typical HCBS case management, care coordination models
include clinical support for care coordinators to increase monitoring of chronic
medical conditions.
• SNPs and providers rely on integrated benefit determinations and the flexibility
provided in Medicare Advantage to provide additional care coordination, waive 3
day hospital stays, provide in lieu of days, substitute services and support
increased use of physician extenders in order to obtain these results.
• Under MSHO, integrated financing has resulted in creative “Care System” (miniACO like) subcontracts for integrated service delivery and payment reforms
across Medicare, Medicaid, primary acute and long term care with a range of
arrangements such as:
– Shared incentive pools or performance based payments with LTC providers
– Combined Medicare and Medicaid care coordination PMPM payments
– Combined Medicare and Medicaid primary care, Health Care Home and care
coordination PMPM payments
– Total cost of care sub-capitations or virtual sub-capitations with shared
performance pools across all services
• State goal is to increase the use of these payment and delivery reforms
• Cooperation of Medicare SNPs and the Dual Demo are key to that goal.
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Integrated Care System
Partnerships
• New 2013 contract provisions for SNP/MCOs participating in
MSHO/MSC+/SNBC
• Builds from current MCO/Provider “Care System” contracting
arrangements (current providers may convert to ICSPs)
• Combined Medicare and Medicaid financing provides incentives
for provider level payment and delivery reforms stimulating new
subcontracting arrangements and affiliations across services.
• All models to incent improved health outcomes and choice of care
setting
• Seniors: Encourages involvement of long term care providers
under shared pooled incentives or payment reform models
• People with Disabilities: Encourages coordination of physical and
behavioral health for people with disabilities in SNBC
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Integrated Care System
Partnerships
• All proposals subject to State contract requirements for care
coordination, quality metrics, financial performance measurement
and reporting
• Tied to a range of quality and financial performance metrics
– Clinical workgroups developed quality measure options
– Measures will differ between systems based on many factors:
size, population served, setting of care, geographic area, etc.
– ICSPs can propose alternative measures
• Financial metrics proposed according to broad State parameters
• SNP/MCO/Provider proposals due July 2013, review of proposals by
State, provider contracts by October/13, implementation of new
arrangements no later than January 2014.
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Revised Dual Demo Original Design Model: Special Needs Plan/Medicare Medicaid Integrated Care Organizations
CMS Medicare Contract and
Payment to SNP
Medicare Primary and Acute
Acute
Care
State Medicaid Contract
and Payment to MCO/SNP
Medicaid State Plan and
LTSS
Virtual Care Systems
Communication Tools
Model 1
MSC+:
Medicaid
coordinates
with Original
Medicare
SNP MMICO DEMO PLANS
Special Needs Plan Medicare
and Medicaid Integrated
Care Organizations
Contract Requirements and
Risk
-Demo under Medicare Advantage Special Needs Plan
(SNP) platform and paymentstructures
-Includes Medicare, Part D, current Medicaid State
plan and LTSS (seniors) starting 2013
-SNBC TBD for 2014 Phase 2
-MOU to outline State/CMS oversight roles
- CMS acknowledgement of State payment and
delivery reform goals
-“Rules for duals” supports features needed to
continue and improve integrated operational features
including quality and outcomes measurement and
integrated benefit determinations, provider billing
and protection from premiums for enrollees
Acronyms
CD-Chemical Dependency
CMS=Centers for Medicare and Medicaid
FFS=fee for service
HCH=Health Care Home
HH=Health Home
ICSP=Integrated Care System Partnership
LTSS=Long Term Services and Supports
MMICO=Medicare Medicaid Integrated Care Organization
MSC+=Minnesota SeniorCare Plus
MSHO=Minnesota Senior Health Options
NF= Nursing Facility
PAC=Post Acute Care
SNBC=Special Needs BasicCare
SNP=Medicare Advantage Special Needs Plan
SMI=Serious Mental Illness
TCOC= Total Cost of Care
8/13/2012
Model 3: Specialized ICSPs
Mental, Chemical and
Physical Health
-DHS establishes criteria for
integrated chemical, mental
and physical health care
system models for people with
SMI enrolled in SNBC under the
demonstration
- DHS issues RFP
-Requires partnership between
county, MMICO, primary care,
chemical and mental health
providers
- Could also include non-dual
SNBC members
-Additional details TBD with
Chemical and Mental Health
and Continuing Care
-Exploring Health Homes
and/or HCH as part of model
- Standardized outcome
measures
-Dependent on viable Medicare
financing under demo for dual
eligibles with disabilities
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Model 2: Integrated Care
System Partnerships (ICSP)
DHS establishes criteria for model
options for ICSPs including:
-Primary care/payment reforms
-Integrated care delivery
-TCOC accountability and options for
risk/gain sharing arrangements
--Opportunities for
PAC/NF/LTSS/MH/CDproviders
-HCH Certification/Transition to HCH
-Enrollee choice of ICSP
-Incentives to serve people across all
settings
-Standardized outcome measures
New ICSPs
-DHS Issues RFPs to stimulate
additional ICSPs
-Provider/MMICO Partnership
required for response
-DHS sets payment and risk/gain
options and parameters
Existing Care Systems
-DHS evaluates current care systems
arrangements, those meeting or
exceeding criteria would be
considered ICSPs
-Transition to HCH if not already HCH
-Standardized outcome measures
PAC/NF
LTSS
Care Coordination
MMICO/Counties/
Tribes/Community
Organizations
HCH/Clinic
and/or HH
Chemical &
Mental
Health
Acute
Care
Market Incentives
and Stimulation
ICSP Models 2 and 3 Payment Options
Model Features
Payment Type A
Performance
rewards:
performance pool
or P4P
Payment Type B
Primary Care/Care Coordination
Payment Reform (PMPM or
partial sub-capitation for primary
care and care coordination)
MCO manages various provider
contracts with LTC providers and/or
Primary Care Providers designed to
incent improved health outcomes and
consumer choice of community and
institutional settings.
X
X
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MCO contracts with primary care under
primary care payment reform models
that include care coordination and
health care home or health care home
alternative payments
X
X
?
MCO delegates care management to
Provider Care System/Collaborative
(primary care providers with long term
care providers) using
risk/gain/performance payment model
across services.
Payment Type C
Sub-capitation or Virtual Capitation
for Total Costs of Care Across
multiple defined services including
primary, acute and Long Term Care
Payment
Type D
Alternative
Proposals
X
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MCO contracts with providers to provide X
financial and/or performance incentives
for Chemical and Behavioral Health
coordination or integration can include
HCH or Health Homes(mainly for SNBC)
X
X
X
Care Coordination
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Quality Metrics
Financial Performance
DHS Review
Reporting Requirements
X
X
X
X
X
Complex Measurement Environment
• Overlapping and unaligned measurement requirements from CMS and State
levels for both plans and provider
• CMS SNP and Part D requirements (STARS: HEDIS/CAHPs/HOS, S&Ps, MOC)
often not relevant or applicable to people with dual status
– State Medicaid requirements (HEDIS, CAHPs, Home and Community Based
Services, EQRO, State Contract and Performance Withhold measures)
– CMS Provider Measures: PQRS, CQMs, MDS, OASIS, ACOs
– MN based provider performance measures (Minnesota Community
Measurement, Health Care Homes, SQRMs, ACOs/HCDS, ICSPs)
– Dual Demonstration Measures
• Dual Demo Plan level measures and performance withholds
• Dual Demo Provider level (ICSPs) measures
• CMS Dual Demo Evaluation (over 100 measures being applied to FAD)
• How can plans and providers best focus efforts on the small but important
population of people with dual eligibility in the midst of these complex
requirements?
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Medicaid
HEDIS
Measures
Medicare
HOS
Medicare
HEDIS
Measures
Other
Star
CMS
Quality
Ratings Adminis
Medicare
CAHPS
Survey
SNP
Structure
and
Process
Measures
SNP
Model
of Care
trative
Data
Required Federal Reporting
for Medicare-Medicaid
SNPs
Slide Source: Alisha B. Simon, MDH 14
State
HEDIS
Contract
Withholds
State LTSS
Medicaid
CAHPS
Statewide Quality
Reporting and
Measurement
Minnesota
System (SQRMS)
Community
Measurement
Health Care
Home
Health Care
Measures
Delivery
System
Measures
Provider/Physician Group/
Facility Level
State Reporting Requirements
Health Plan Level
Measurement Challenges
• Many current measures and accepted benchmarks are not
appropriate for, or exclude old-old and younger disabled or those
with multiple complex conditions
• Recent progress (e.g. NQF MAPs) but we still lack sufficient
consensus or experience with specific measures for these
populations and many proposed measures are still in
development/discussion phases
• Members include many subpopulations with highly variable care
trajectories, difficult to risk adjust let alone measure and assign
benchmarks/expectations
• Small numbers further complicate measurement
• Difficult to define meaningful outcome measures for some highly
variable domains of care (such as care coordination), but process
measures are resource intensive and also may cause controversy
(for STARS CMS wants outcome not process measures)
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Measurement Challenges
• Baseline and benchmark data may not exist, Medicare data still
difficult to access, unclear data sources for some measures
• Outside of HCBS survey measures of consumer satisfaction,
attributing outcomes to any specific home and community
based services is extremely problematic (i.e. Assisted Living,
PCA, chore services, adult day care, home delivered meals,
consumer directed options)
• Utilization of consumer directed options not as good a measure
for seniors, fewer use it due to percieved management burdens
• Multiple levels of providers with overlapping responsibility make
it difficult to assign accountability (PCP, Specialists, Rehab,
S/NFs, Residential vs SNP level?)
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Minnesota’s Proposed ICSP Measures
Measure Identification and Development Process
• RFPI to solicit public input to best practices in mid January
• January 28, 2013: Policy Symposium to discuss best practices
• Mid February: RFPI comments due
• Clinical workgroup of SNP Medical Directors and QA staff
• Alignment discussions with local and national measurement experts (NCQA, Health
Department, Minnesota Community Measurement, Stratis QIO, Board on Aging, etc)
• Discussion with Provider Care Systems
• Discussion with Stakeholders groups
Proposed ICSP Measures for all populations/settings
• Hospital Utilization
• Plan All Cause Readmissions
• Potentially Preventable Readmissions
• Ambulatory Care Sensitive Conditions Admission Rates
• Ambulatory Care and ED Visits
Especially for MSHO Institutional Members
• Use of Antipsychotics for People with Dementia
• Falls with Fx
• Pressure Ulcers
• S&P: Evidence of POLST with person specific goals for residents with 90 day+ stays
• S&P: Follow Triage Protocol prior to sending to ED or inpatient stay
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Minnesota’s Proposed ICSP Measures
Especially for MSHO Community Frail Elderly (average age 80+)
• Flu Shots/Pneumococcal Vaccination Status
• Use of High Risk Medication in the Elderly
• Annual Monitoring of Patients on Persistent Meds
• Medication Reconciliation Post Discharge
• Care of Older Adults
• S&P: Reduced Risk of Falls/Falls Screenings Fall Risk Management
• Best Practice Incentive S&P: Care Transitions (TBD)
• *Best Practice Incentive S&P: Evidence of Functional Assessment Response by PCP
• *Best Practice Incentive S&P: Evidence of ongoing PCP/Care Coordinator Communication
• *Best Practice Incentive S&P: Evidence of Integrated Care Plan for Community Members
* Potential collaboration with NCQA
Especially for People with Disabilities 18-64 in SNBC (all settings)
• Anti-Depressant Medication Management
• Follow Up after Hospitalization related to Mental Illness (and Substance Abuse)
• Adult Access to Preventive/Ambulatory Health Services
• Basic Preventive Screenings (Cholesterol, Colorectal Cancer, Breast Cancer, Flu Shots)
• Screenings for Clinical Depression and Follow Up
• Pressure Ulcers
• S&P: Evidence of Behavioral and Physical Health Integration, Communications and Care
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Planning (TBD)
Summing It Up
• National effort for improved alignment and delivery system
integration of Medicare and Medicaid for people with dual status,
CMS is implementing new initiatives in many states, MN in the
lead.
• MSHO will return to demo status
• Not much will visibly change from current program, but program
will support new delivery system mechanisms and give the State
role in SNP oversight
• State pursuing a different demonstration for people with
disabilities based on HCDS model, early in process but stay tuned
• SIM will provide framework for new payment and delivery reform
efforts in MN
• MSHO/SNBC aligning with new delivery systems through
formation of new ICSPs and HCDS
• ICSPs expected to further integrate primary care, behavioral
health and LTSS care coordination mechanisms
• ICSPs will link clinical and financial performance
• Measurement will be challenging and will have to evolve over
time!
Minnesota Medicare Medicaid
Integrated Programs and Dual Demo
Contact Information:
Pamela Parker, MPA, Manager
[email protected]
651-431-2512
Sue Kvendru, Seniors Managed Care Coordinator
[email protected]
651-431-2517
Deb Maruska, Project Manager, Dual Demo/Disability Managed Care
[email protected]
651-431-2516
Dual Demo Stakeholders Website:
www.dhs.state.mn.us/DualDemo
Disability Managed Care Stakeholders Group
www.dhs.state.mn.us/SNBC
MSHO SNPs/MSC+ MCOs
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•
•
•
•
•
•
•
Blue Plus
Health Partners
Itasca Medical Care
Medica
Metropolitan Health Plan
Prime West
South Country Health Alliance
UCare Minnesota
* All plans offer both MSHO SNP and MSC+
Medicaid plans
44
SNBC SNPs/MCOs
• Medica
• Metropolitan Health Plan *
• Prime West*
• South Country Health Alliance*
• UCare Minnesota
* Offers Medicare Dual Eligible SNP for
SNBC
45