Acute

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Acute Long-Term Integrated Care Program Design
Issues Mark R. Meiners Ph. D. Director, Center
for Health Policy Research and Ethics College of
Health and Human Services George Mason
University Virginia Department of Medical
Assistance Services, Development of a Blue Print
for Acute and Long-Term Care Integration,
Richmond, VA, Sept. 26, 2006
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Background to MMIP Experiences Robert Wood
Johnson Foundation 15 Participating States CO,
FL, MN, NY, OR, TX, WA, WI, VA, CT, MA, ME, NH,
RI, VT For Background and Technical Assistance
Documents go to CHPRE.GMU.EDU (click
Medicare/Medicaid Integration Program)
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Dual Eligibles as a Percent of Medicare and
Medicaid Enrollment and Spending, 2002
Dual Eligibles as Percent of Medicare
Dual Eligibles as Percent of Medicaid
Total Spending 232.8 Billion
Total Enrollment 51 Million
Total Spending 224.5 Billion
Total Enrollment 41.8 Million
SOURCE Medicare data are from KFF analysis of
Medicare Current Beneficiary Survey 2002 Cost and
Use File. Medicaid data are from KCMU estimates
based on CMS data and Urban Institute estimates
based on an analysis of 2000 MSIS data applied to
CMS-64 FY2002 data.
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Virginia Medicaid Enrollment ExpendituresFY
2005
Aged
10
26
Aged
20
Blind Disabled
Adults
13
Blind Disabled
45
57
Children
Adults
9
21
Children
Recipients
Expenditures
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• Why the Interest in Dual Eligibles?
• Important public financing considerations
• Cost shifting in both directions
• Unintended consumer consequences
• An opportunity to do better with limited
  resources
• Managed care implications
• Aging of the population/Chronic Care Imperative

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Purpose of Todays Discussion

• To identify populations, services, and
  enrollment options that can be covered in a
  managed care environment
• (But first..what is Integrated Care?)

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Key Dimensions of Acute and LTC Integrated Care
Program Development Scope and flexibility of
benefits - more than MM fee-for-service Deliver
y system - broad, far reaching, options,
experience Care integration - care teams,
central records, care coordination. Program
administration - enroll, dis-enroll, integrated
data IS Quality management and accountability
- unified, broad, CQI Financing and payment -
flexible, aligned incentives
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• State Environmental Diversity
• Major differences in Medicaid programs
• Wide variations in state managed care
  infrastructure
• Differences in state goals and target
  populations
• States are in various stages of program
  development
• Divergent definitions of integration/coordination
  

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• Program Development Issues and Options
• Duals/Medicaid-only Aged/Disabled Both?
  Timing?
• Benefits Comprehensive/ Carve Outs
• Well, Community Frail, Nursing Home
• Mandatory or Optional
• Budget Neutral or Cost Saving
• Statewide or regional pilot (large vs. limited)
• National MCOs or Local Safety-Net Providers
• Provider Networks open or closed?
• M/M Integration or Coordination
• Waivers, Risk Adjustment, Enrollment Strategy

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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
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Overall Aim Implement the Chronic Care Model
for ALTCI Eligible Populations
Community Resources and Policy
Clinical Information Systems
Organiz-ation of health care
Self- Manage- ment Support
Delivery System Design
Decision Support
Develop Plan/Do/Study/Act Quality
Improvement Cycles for Each Component of the
Chronic Care Model
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• Core Building Blocks
• Targeting Beneficiaries Risk vs. Reward
• Case Management / Care Coordination
• - Integrating Information
• Quality Methods and Measures
• Primary Care / Chronic Care Management

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• Key Micro Strategy Primary Care Teamwork
• Focus on holistic approach encompassing health
  and welfare (e.g., psychosocial, economic,
  environmental, social supports)
• Monitor ongoing health status for early
  detection of problems
• Emphasize health education and prevention
• Support chronic care self management
• Increase opportunities for communication

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Medicare Special Needs Plans (SNPs)

• Allows a SNP to restrict enrollment for certain
  categories of special needs individuals
• Institutional Beneficiaries (in or expected to
  reside gt90 days Community NHC)
• Dually Eligible (subsets of duals OK now with
  State partner)
• Beneficiaries with Severe and Disabling Chronic
  Conditions (untested to be evaluated on case by
  case e.g. disease specific)
• SNP Lumpers vs. Splitters!

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CMS Guidance to Integrating Medicare/Medicaid

• How to coordinate marketing of Medicare and
  Medicaid to duals.
• How to do streamlined MC enrollment of duals.
• How to do MC quality integration for duals.
• How to support State targeted SNP enrollments.
• Clarity in bidding process to enable State
  savings.
• Model SNP/State/CMS integrated relationship
• Improved quality measures for SNP populations

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Purpose of Todays Discussion

• Covered Population (s)
• Covered Services
• Enrollment Options

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Population(s) That May Be Covered in an
Integrated Care Program

• Dual eligibles (persons eligible for
  Medicare/Medicaid services)
• Non-duals (Medicaid only)
• A specific aid category (Aged, Blind, and
  Disabled)
• Persons who are institutionalized
• Special populations served through the home and
  community-based care waivers
• The elderly or persons who have physical
  disabilities
• Persons with developmental disabilities
• HIV/AIDS
• Alzheimers Disease and related dementia
• Persons dependent on ventilators

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Some Issues to Consider When Determining Which
Population to Include

• Integrated models of care are well suited for
  chronic care populations those with significant
  disability, frailty, and comorbidity
• Capitated managed care has the incentive to
  provide care coordination to its members this
  benefit is not currently available to FFS
  beneficiaries (especially those receiving LTC
  services)
• Beneficiaries and providers will be skeptical
  about the benefits that managed care programs can
  bring, and worry about cuts in their health care
  services in the interest of saving dollars

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Future Direction of Virginias Integrated Care
Program

• Discussion Points for Consideration
• The Department of Medical Assistance shall
  consider including the following individuals
• Dual Eligibles (Medicare/Medicaid Recipients)
• Medicaid Only Recipients
• Certain Medicaid Aide Category Groups, such as
  the Aged, Blind, and Disabled
• Institutionalized Individuals
• Special Populations (HCBS Waiver Participants)

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Panel Discussion Covered Populations
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Services That May Be Covered in an Integrated
Care Program

• Acute care services covered by both Medicare and
  Medicaid
• Medicaid long-term care (LTC) services
• Comprehensive care management
• Behavioral health services

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Medicaid and Medicare Services

• This approach would allow a health plan that
  covers Medicare services to also cover Medicaid
  acute care services to serve provide wraparound
  coverage for those dual eligibles
• Some Medicare sub acute care services get
  confused with LTC benefits
• Skilled Nursing Facility
• Home health
• Hospice
• Many Medicaid acute care services are also
  covered by Medicare
• Hospitalization
• Physicians
• Durable medical equipment
• Pharmacy

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Long-Term Care Services

• Long-Term Care Services have been historically
  excluded from managed care due to the
  extraordinary expenses associated with caring for
  individuals in need of these services
• Institutional Services
• Nursing Facility
• Intermediate Care Facilities for the Mentally
  Retarded (ICF/MR)
• Community Based Services
• Home and Community-Based Waivers (HCBS)

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Behavioral Health Services

• Behavioral health services have been
  traditionally carved out of managed care programs
• For purposes of this discussion, behavioral
  health services are defined as community-based
  mental health services
• Community mental health rehabilitative services
  (commonly called State Plan option services)
• Intensive In-Home Services for Children and
  Adolescents
• Therapeutic Day Treatment for Children and
  Adolescents
• Day Treatment/Partial Hospitalization Services
  for Adults
• Psychosocial Rehabilitation
• Crisis Intervention

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Care Management Services

• Care management services are included as a
  critical component in Virginias current managed
  care system
• Care management provides coordination and support
  to the beneficiary regarding their medical,
  environmental, social needs
• In SFY 05, Virginia paid 13,785,382 for case
  management service for Medicaid beneficiaries in
  the fee-for-service component of the program
  however, it is targeted to certain beneficiaries
• Persons with mental illness
• Persons with mental retardation and developmental
  disabiltiies
• Treatment foster care case management

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Issues to Consider When Determining Range of
Covered Services

• Decisions about service coverage will shape the
  extent to which a managed care program can assist
  with a better and more equitable distribution of
  services, especially LTC services
• If the goal for Virginia is to move toward a full
  integration of Medicare and Medicaid services as
  possible, experts recommend including all
  services in a single managed care benefit package
  to include acute care, long-term care services
  (both HCBS and institutional)
• Including only Medicaid acute care services not
  covered by Medicare in a Medicare managed care
  organization (MCO) benefit package does not
  significantly advance integration, unless it is a
  step toward integrating LTC services

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Future Direction of Virginias Integrated Care
Program

• Discussion Points for Consideration
• The Department of Medical Assistance shall/shall
  not consider including the following services in
  the integrated care program
• Medicaid Acute Care Services
• Medicare and Medicaid Services
• Long-Term Care Services Institutional Care
• Long-Term Care Services Home and
  Community-Based Care
• Behavioral Health Services
• Special Populations (HCBS Waiver Participants)
• Care Management Services

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Panel Discussion Covered Services
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Enrollment Options for an Integrated Care Program

• States enroll participants in integrated care
  programs in one of two ways
• Voluntary Medicaid beneficiaries are given the
  option to participate in an integrated care
  program
• Given the choice to initially enroll
• Mandatory Medicaid beneficiaries are required
  to participate in an integrated program
• Automatically enrolled with no option for
  disenrollment
• Automatically enrolled with an option for
  disenrollment

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Issues to Consider When Deciding How to Enroll
Integrated Care Participants

• Voluntary Enrollment
• Providers and beneficiaries prefer voluntary
  enrollment less resistance
• Rate setting is more difficult for health plans
  when enrollment is voluntary because health care
  costs of those who choose to enroll in an
  integrated care program are very hard to predict
• Generating MCO interest is much more difficult in
  a voluntary program so enrollments tend to be low
  and unpredictable
• Purely voluntary programs often do no generate
  sufficient scale to achieve rebalancing in the
  LTC system

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Issues to Consider When Deciding How to Enroll
Integrated Care Participants

• Mandatory Enrollment
• Provider contracting is easier with mandatory
  programs because providers that do not contract
  with MCOs run the risk of losing patients
• Greater ability for MCOs to set rates and
  determine how many individuals will be using
  services
• Mandatory programs have the greatest potential to
  achieve diversion and high quality outcomes
• Provider and beneficiary opposition may be
  greater if enrollment is mandatory

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Future Direction of Virginias Integrated Care
Program

• Discussion Points for Consideration
• 1) The Department of Medical Assistance shall
  consider voluntary enrollment for the integrated
  care program
• Individuals choose to enroll
• OR
• 2) The Department of Medical Assistance shall
  consider mandatory enrollment for the integrated
  care program
• Individuals are automatically enrolled with no
  option for disenrollment or
• Individuals are automatically enrolled with the
  option for disenrollment

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Panel Discussion Enrollment Options