Quality Improvement in Medicaid: Opportunities for States

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Quality Improvement in Medicaid Opportunities
for States

• Washington Medicaid Quality Management
• All-Plan Meeting
• January 29, 2009
• Alice Lind
• Associate Vice President
• Center for Health Care Strategies

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CHCS Mission

• To improve health care quality for low-income
  children and adults, people with chronic
  illnesses and disabilities, frail elders, and
  racially and ethnically diverse populations
  experiencing disparities in care.
• Our Priorities
• Advancing Health Care Quality and Cost
  Effectiveness
• Reducing Racial and Ethnic Disparities
• Integrating Care for People with Complex and
  Special Needs

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Medicaids Challenges and Opportunities
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Five Steps for Reducing Medicaid
HIGH
Level of Difficulty
LOW
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Medicaid Best Buys

• Targeting Medicaid investments to get the best
  value for every dollar spent in terms of improved
  outcomes and ROI

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Five-Part Strategy for Medicaid Reform

• Care Management for High-Risk Pregnancy
• Care Management for High-Risk Asthma
• Managed Care Models for Aged, Blind and Disabled
  Beneficiaries
• Managed Care Models for Long-Term Care Supports
  and Services
• Care Management for High-Risk, High-Cost Members
  with Multiple Chronic Conditions

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Care Management for High-Risk Pregnancy

• EXAMPLE Through a high-risk prenatal program,
  Monroe Health Plan (NY) estimates saving 2.3
  million in avoided NICU admissions since 1998
  equaling an ROI of more than two dollars for
  every dollar spent on prenatal outreach.

Analysis of NY State SPARCS Data demonstrated no
concurrent changes in NICU admission rates in
upstate New York for Medicaid during these years.
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Care Management for High-Risk Asthma

• EXAMPLE Arkansas reduced hospital days by more
  than 50, ER visit rates by over 60, and total
  medical payments by 35 over a two-year period
  through an asthma care management program
  targeted at high-risk, high-cost cases. These
  savings represented an ROI of more than 6 for
  each dollar invested in the program

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Per Capita Medicaid Spending
Total Per Capita Costs
Percent of Medicaid Population
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Managed Care Models for Aged, Blind and Disabled
Beneficiaries

• States are testing new delivery system models to
  
• Transition aged, blind, disabled beneficiaries
  out of fee-for-service
• Integrate physical and behavioral health care
  services health
• Offer a range of full-risk, partial/no-risk and
  hybrid models

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Dual Eligibles Opportunities to Improve
Care/Control Costs
Medicaid Spending by Group, Services Only, FFY
2005

• Roughly 7.5 million adults are dually eligible
  for Medicaid and Medicare services. These
  individuals equal 14 of Medicaid beneficiaries,
  yet drive almost 44 of total spending.

Total Spending 303.6 billion
SOURCE Urban Institute Analysis for KCMU, May
2008
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CHCS Integrated Care Program (ICP)

• National initiative to help five states develop
  and pilot integrated care models
• State participants Florida, Minnesota, New
  Mexico, New York, and Washington
• ICP states have developed, implemented and/or
  expanded contracts with SNPs
• Major progress in 3 priority areas
• Administrative Simplification
• Rate Setting/Risk Adjustment
• Performance Measurement

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Challenges to Integrating Care

• Administrative and operational hurdles between
  Medicare and Medicaid
• Financial misalignments between Medicare and
  Medicaid that limit shared savings
• Low enrollment to date
• Slow progress in state-SNP relationships
• Difficulties in developing and bringing model
  SNPs to scale

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Opportunities to Integrate Care

• Eliminate barriers that prevent SNPs from
  achieving their potential.
• Create opportunities to enhance SNPs.
• Increase options for integrating care currently
  available to states.
• Ensure that Medicare and Medicaid stakeholders
  are able to share savings generated from the
  integration of services for dual eligibles.
• Work with consumers to support integrated models
  that meet their needs.

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Transforming Care for Dual Eligibles Objectives

• Develop innovative options for integrating care
  across delivery systems for dual eligibles.
• Reduce administrative barriers and create
  cross-stakeholder financial incentives to
  integrate care.
• Establish forums for national and state
  policymakers and industry leaders on how to
  advance integrated care programs.

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Program Overview

• Supported by The Commonwealth Fund.
• 18 month initiative.
• CHCS will select up to 8 states to participate,
  testing SNP and non-SNP models.
• Selected states will receive in-depth, on the
  ground TA around core areas including program
  design care models financing mechanisms
  contracting strategies and working with CMS.
• TA will include face-to-face meetings as well as
  virtual TA (e.g. telephonic).

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Potential Vehicles for Integration Non-SNP
Alternatives
State works alone or with an entity to provide
integrated services, including a mechanism for
sharing in any savings that result from the
arrangement.  Examples include
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Chronic Illness Medicaids Highest-Risk,
Highest-Cost Patients

• High Need Most on Medicaid have a chronic
  condition nearly half of them (46) have more
  than 1
• High Cost Top 4 beneficiaries 50 of spending
• Among the most expensive 1 of Medicaid
  beneficiaries (acute care only)
• Almost 83 have 3 or more chronic conditions
• Over 60 have 5 or more chronic conditions

SOURCE 2001 data, Kaiser Commission on Medicaid
and the Uninsured Kronick RG, Bella M, Gilmer
TP, Somers SA, The Faces of Medicaid II
Recognizing the Care Needs of People with
Multiple Chronic Conditions. Center for Health
Care Strategies, Inc., October 2007
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Faces of Medicaid Comorbidity

• Among the most expensive 1 of Medicaid
  beneficiaries (acute care only)
• Almost 83 have 3 or more chronic conditions
• Over 60 have 5 or more chronic conditions
• . . . and most of them are in
• unmanaged fee-for-service

SOURCE Kronick RG, Bella M, Gilmer TP, Somers
SA, The Faces of Medicaid II Recognizing the
Care Needs of People with Multiple Chronic
Conditions. Center for Health Care Strategies,
Inc., October 2007
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Top Five Diagnostic Triads among the Most
Expensive 5 of Patients
SOURCE Kronick RG, Bella M, Gilmer TP, Somers
SA, The Faces of Medicaid II Recognizing the
Care Needs of People with Multiple Chronic
Conditions. Center for Health Care Strategies,
Inc., October 2007
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CHCS Rethinking Care Program

• Goal Improve quality and control cost growth for
  complex patients with the greatest potential to
  benefit from better care management.
• Objectives
• Identify, stratify and prioritize high
  opportunity patients
• Develop and implement tailored care management
  interventions
• Evaluate quality and cost
• Realign financing to support quality
• Spread promising practices

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Rethinking Care Program Two Main Components

• National Integrated Care Learning Network
• Promote peer exchange
• Build the evidence base (quality and costs)
• Address policy and administrative barriers
• Realign financing to support quality improvement
• Regional Integrated Care Collaboratives
• Demonstrations/evaluations of care models for
  high-need, high-cost patients
• Up to 8 state multi-stakeholder collaboratives
  (e.g., NY, CO)

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Key Components

• Leadership commitment
• Medicaid Director and other partners
• Capacity
• Staffing, data access, analysis
• Targeted intervention
• At least 2 pilots, involving multi-faceted
  intervention(s)
• Well-defined group of high-need, high-cost
  beneficiaries
• Evaluation
• Rigorous evaluation of quality and cost outcomes,
  preferably using a random assignment design
• Local/regional funding support

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CHCS Role

• Project management
• Facilitate pilot development and implementation
• Technical assistance
• Provide guidance on financing, regulatory issues
• Intervention design
• Share best practices/innovations worthy of
  further testing
• Evaluation support
• Coordinate external evaluation

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Participating Regions
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Colorado Regional Integrated Care Collaborative

• Intensive care management pilot at two health
  plans
• Target Population 1,000 high-need, high-cost
  SSI patients
• Goal Improve the quality of care for Colorado
  Medicaids highest-need, highest-cost clients by
  better coordinating physical health, mental
  health, and substance abuse services
• Rigorous evaluation

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New York Chronic Illness Demonstration Projects

• New York Medicaid
• 21 of beneficiaries incur 75 of costs
• High-cost beneficiaries generally fall within six
  categories chronically ill, HIV/AIDS, long-term
  care, alcohol/drug users, chronically mentally
  ill and MR/DD
• Using an integrated network of providers,
  including community-based social service
  providers, to assure facilitated access to
  medical, mental health and substance abuse
  services

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Three Regional Pilots
Central PA Access Plus with a number of counties
and their BH MCO
Southeast PA Keystone Mercy, Magellan, and Bucks,
Delaware and Montgomery Counties
Southwest PA UPMC for You, CCBH and Allegheny
County
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Pennsylvania RCP Intervention Pillars

• Coordination of hospital discharge and
  appropriate follow-up
• Pharmacy management program
• Co-location demonstration project
• Focus on appropriate Emergency Department use for
  behavioral health treatment
• Focus on alcohol and substance abuse treatment/
  care coordination
• Consumer engagement

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Washington Rethinking Care Program

• Project 1 King County Care Partners
• New DSHS Predictive Modeling tool identifies
  clients
• Risk score minimum of 1.5
• Randomized 1000 to treatment and abeyance
• Increased outreach/engagement efforts
• Multidisciplinary approach to care management
• Project 2 To be defined
• Likely focus on mental health users in one
  county, link to medical home through care
  managers

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to improve the quality and efficiency of Medicaid
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find out about new CHCS programs and resources.
Learn about cutting-edge state/health plan
efforts to improve care for Medicaids
highest-risk, highest-cost members.
www.chcs.org