N4A Annual Conference:

July 25, 2016

Kristine Thurston Toppe, MPH

Director, State Affairs, Public Policy

National Committee for Quality Assurance (NCQA)

Becoming a Good MLTSS Partner:

Understanding What States and MCOs Want

Who We Are

Private, independent non-profit health care quality oversight organization founded in 1990

_______________________________________________

MISSION

To improve the quality of health care.

VISION

To transform health care throughquality measurement, transparency, and accountability.

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ILLUSTRATIVE PROGRAMS* HEDIS – Healthcare Effectiveness Data and Information Set

* Health Plan Accreditation * Multicultural Healthcare Distinction

* Disease Management *Utilization Management & Credentialing Certification

* Wellness & Health Promotion Accreditation * Health Plan Rankings * Case Management Accreditation

*ACO Accreditation * Patient-Centered Medical Home * Patient-Centered Specialty Practice

* Patient-Centered Connected Care * Diabetes Recognition * Heart/Stroke Recognition

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41 States Require or Use NCQA Health Plan

Accreditation (June, 2016)

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WA

OR

AZ

NV

WI

NM

NE

MN

KS

FL

CO

IA

NC

MI

PA

ME

VT

OH

RI

NJ

MD

VA

MA

MO

HI

OK

GA

SC

TN

MT

KY

WV

DE

AR

LA

MS AL

NY

INIL

SD

ND

TX

ID

WY

UT

AK

CA

CT

NH

DC

DOl/PEBP (7)

Medicaid (6)

Both DOI/PEBP & Medicaid Require or Use NCQA HPA (28)

Goals for today:

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• Review the evolving LTSS landscape

• Quality in LTSS

• Share experiences from those who are in

the trenches

• Discuss key themes for success in health

plan/CBO partnership

• Tools for success

Value of Implementing Standardized Care

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Projected Managed LTSS Landscape (2014)

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Source: CMS, 2012. The

Growth of MLTSS

Programs: A 2012 Update.

http://www.medicaid.go

v/Medicaid-CHIP-

Program-Information/By-

Topics/Delivery-

Systems/Downloads/MLTS

SP_White_paper_combin

ed.pdf

Current Landscape (cont’d)

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57%43%

LTSS Population

Age 65 + Age 18-64

6.27M4.73M

Total = 11M lives

1. https://www.nhpf.org/library/the-basics/Basics_LTSS_03-27-14.pdf2. https://kaiserfamilyfoundation.files.wordpress.com/2015/12/8617-02-medicaid-and-long-term-services-

and-supports-a-primer.pdfhttp://www.ncsl.org/documents/health/BBurwellFF13.pdf3. http://www.aarp.org/content/dam/aarp/research/public_policy_institute/ltc/2012/across-the-states-

2012-full-report-AARP-ppi-ltc.pdf

• Approximately 11

million adults receive

LTSS1

• Persons age 85 and

over are four times

more likely to need LTSS

compared to those

between 65 to 842

• From 2012 to 2050, the

population age 65 and

older is projected to

more than double, to

89 million3

Current Landscape (cont’d)

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• In 2013, Federal

and state

governments spent

$14 billion on LTSS1

• About 3.76 million

Medicaid enrollees

receive LTSS2

• ¼ of Medicaid LTSS

users receive

services through

managed care

1. https://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/downloads/ltss-expenditures-fy2013.pdf

2. http://www.ncsl.org/documents/health/BBurwellFF13.pdf

Medicaid Managed Care Users of LTSS

Total = 3.76M

Medicaid Enrollees

Medicaid Managed Care Users

25%

940K

75%

3.66M

States

Health

Plan

CBO

Managed LTSSCBO

Fee-for-Service

AZ, CA, DE, FL, HI, IA, ID, IL, KS, LA,

MA, MI, MN, NC, NE, NH, NJ, NM, NY,

OH, OK, PA, RI, TN, TX, WA, WI

Demonstrate ability to

manage population

Roadmap to work together

Deliver high-quality cost-effective care

Demonstrate credibility

Case Management Accreditation for

LTSS

HPA/MBHO LTSS Module

Standard evaluation for how states are delivering LTSS

Personal Care

Transportation

Meals

Service delivery

Service coordination

Erica Anderson, Senior Health Care

Analyst

LTSS Standards and Measures

Guiding Principle:

The Person Must Be At The Center

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NCQA’s Approach

Standards guide design of

integrated person-driven care systems

Process measures assess implementation

Outcome measures assess goal attainment

and person-driven outcomes

Best practices aid

implementation

Evaluating the quality of person-driven care requires a special

approach

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Standards and Measures

Measures evaluate the outcomes

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Standards provide the framework

LTSS Accreditation: What’s Important?

• CBOs and MCOs prioritized and found person-

centered care planning and communicating care

transitions to be most valuable potential standards

• States indicated importance in person-centered care

planning, credentialing and measuring effectiveness

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Case Management – LTSS

Accreditation

CM-LTSS

Accreditation

LTSS 1: Program

Description

LTSS 2: Assessment

Process

LTSS 3: Person-Centered

Care Planning and

Monitoring

LTSS 4: Care Transitions

LTSS 5: Measurement and Quality

Improvement

LTSS 6: Staffing, Training and Verification

LTSS 7: Rights and

Responsibilities

LTSS 8: Delegation of

LTSS

Measures for Managed Long Term

Services and SupportsAssessments, Care Plans and

Sharing Information

• Assessment Composite

• Care Plan Composite

• Shared Care Plan

• Assessment Update

• Care Plan Update

• Re-assessment and care plan

update after discharge

Residence

• Admission to an Institution from

the Community

• Successful Discharge to the

Community after Short-Term

Institution Stay

• Successful Discharge to the

Community after Long-Term

Institution Stay

Revisions

• Falls Risk Assessment and Plan of Care

• Chlamydia Screening and Cervical Cancer Screening

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Measures for LTSS:

Person Directed Outcome Measures

• Measure what’s important to the person, not just what’s

important for the person

• Piloting two approaches used to document goals

– Goal Attainment Scaling

– Prioritized – Patient Reported Outcome Measures

Walk to the store

Keep up with grandchildren

Maintain

independence

Get back to knitting and crafts

Stay as healthy as possible

Live at home

See my friends

Garden

Learning Together

Accreditation Standards

• 10 organizations

– 6 CBOs

– 4 Health Plans

• Informed development of

the standards

• Piloting the standards

• Contributing to an

Implementation Guide

Outcome Measures

• 6 Organizations

– 3 Community based

medical practices

– 3 Health Plans

• Piloting the 2 approaches

to documenting goals

• Developing workflows

• Contributing to a Practice

Change Package

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MyCare Ohio…two years in

July 26, 2016

Working toward a shared vision with

Managed Care Organizations

MLTSS in Ohio

MyCare Ohio rollout began in April

2014 and was implemented in

Cincinnati in 2014

Ohio Department of Medicaid required

MCO’s to contract with the AAA’s for

waiver service coordination at a

minimum

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Cincinnati Region MCO

Partners

Aetna Better Health of Ohio contracts

with COA for both care management

and waiver service coordination

Fully delegated as care management

We serve all My Care Ohio members for

Aetna including those under 60

Molina Healthcare contracts with COA

for only waiver service coordination

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What I’ve learned….

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Factors for Success:

The MCO has to genuinely believe you

add value and want to partner with you

In Ohio, contracting with AAAs was

mandated so you have some MCOs that

aren’t contracting with AAAs because

they want to…..

And that matters

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Why is a true partnership

critical?

You need to have mutual respect for

one another and the value each entity

brings to the partnership

The implementation road can be very

bumpy and members suffer if you are

not working together for the benefit of

the member

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In the beginning….

There were contract negotiations…..

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Why is a true partnership

critical?

Starts at contract negotiations – if the

MCO wants you to be successful they

will be flexible both in rate and

payment terms

When that isn’t happening you MUST

hold your ground unless you are willing to

either lose money or lose leverage

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Contract negotiations

They can’t negotiate standards set by

the State

They won’t negotiate certain items

such as data systems utilized, etc.

You must retain specialized legal

counsel if you want to impact their

contract language

You need to be able to walk away if

the deal doesn’t make sense for you27

Contract negotiations – Cont’d

You need to know what your current

services are costing you

Need to be competitive in the

marketplace

Need to be able to cost out the scope

of services to determine pricing and

pricing alternatives

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Once you have a contract,

what’s next?

Delegation Audits: you must be able to

demonstrate that you have systems,

policies and procedures to properly

perform the delegated functions

Responding to this audit, is critical to your

success and can be labor intensive as

you need to pull data and information from

nearly every aspect of your organization

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Why is this important?

Because it is your first signal at the

amount of regulatory work required of

you.

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Biggest Challenges with My

Care Ohio?

Accuracy of Member Rosters (state/MCO)

are critical to ensure that members

receive services and that AAA is

compensated

Members can change plans EVERY month

If rosters aren’t correct, you can be serving a

member that switched plans and you won’t

get paid - that’s true for all providers

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Accuracy of Rosters

Significant resources dedicated to

reconciliation of rosters and billing

MCO/AAA partnership approach –

team based reconciliation – defining

payment parameters

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Biggest Challenges we have

had working with MCO’s?

Changing Audit Standards – not aligned

with contract requirements

Corrective Action Plans

Increasing our quality assurance and

data reporting infrastructure

Culture change – highly regulated work

Don’t underestimate complexity of

member tracking (rosters, etc.)

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Changing Audit Standards

Alignment of Standards/Expectations

ODM/MCO Contract has standards

MCO/AAA Contract has standards

AAAs provided chart audit standards by

MCO’s. Chart audit standards supplied by

MCO’s were not the same standards

applied by ODM auditors

NCQA standards

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Changing Audit Standards –

Cont’d

Currently we are in the process of

working with our MCO partner to align

the standards

If the plans are NCQA accredited, we

feel it is a necessity for us to be as well

Will ensure that we have the best

systems in place to meet members

needs

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Corrective Action Plans

Any time you aren’t meeting a

standard, you are required to submit

corrective action plans, remediation

plans, etc.

Critical that standards are aligned

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Must be flexible in working

with the MCO’s

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Restructured functions at COA

Train to the Policy

• VP Human Resources & Training

Perform to the Policy

• VP Programs

Audit to the Policy

• VP Business Services

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Quality/Data Infrastructure

Over 6 years ago COA made a significant

investment in developing our quality and

business intelligence infrastructure

The quality oversight required by MCO’s is

extremely high and the burden falls on you

Need to resource this at a significant level

– need to consider when contracting

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Quality/Data Infrastructure

Our MCO partner supplies us with the

raw claims data and we can

manipulate the data to look carefully at

each “frequent flyer” – high utilizers of

emergency room, numerous hospital

admissions, etc.

Need to invest in your own reporting

tools – even if required to use their

systems 40

Culture Change

Provider vs. decision maker

State oversight never to the level of

MCO requirements

Lack of standardization in HCBS led to

more “independence” by clinical staff –

not necessarily a good thing!

Turnover on My Care program higher

than other COA programs

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Successful Partnership Tips

Joint Operating Committee (JOC)

meetings: senior leadership from MCO

and AAA attend

Agenda driven by both entities

Issue log developed/tracked

Escalation of critical issues

Must trust one another

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Successful Partnership Tips

Always remain

member

focused!

We succeed as a system not

as an MCO or a AAA

And we do that by focusing on what is the

best for the member - we all agree on that!

Proprietary and Confidential

Chad Corbett, Vice President

Long Term Care

July 26, 2016San Diego, CA

Becoming a Good MLTSS Partner:Understanding What States and MCOs Want

Proprietary and Confidential

Mercy Care Plan 46Proprietary and Confidential

Mercy Care Plan

Southwest Catholic Health Network Corporation (SCHN) dba Mercy Care Plan

Managed by Aetna Medicaid through a Plan Management Services Agreement

Mercy Care Plan 47Proprietary and Confidential

Mercy Care Plan

• Southwest Catholic Health Network Corporation (“SCHN or “Mercy Care” is an Arizona nonprofit corporation, exempt under IRC €501 (c)(3), which operates under two trade names: Mercy Care Plan (AHCCCS/Medicaid) and Mercy Care Advantage (Medicare).

• Mercy Care operates four health care programs in Arizona: Acute Care (AHCCCS contract)

Arizona Long Term Care System (ALTCS) (AHCCCS Contract)

Developmentally Disabled (ADES contract)

Medicare Special Needs Plan (SNP) (CMS contract)

• Mercy Care Plan has no employees; instead delegates administration and operation to Aetna Medicaid Administrators, LLT under a Plan Management Services Agreement (PMSA).

Mercy Care Plan 48Proprietary and Confidential

Every Medicaid Plan is Different

• States have the flexibility to design and administer programs within broad federal guidelines.

• Remember, if you’ve seen one Medicaid program, you’ve seen one Medicaid program…

• What makes AHCCCS different?o Services covered, populations

covered, children’s programs

Mercy Care Plan 49Proprietary and Confidential

Mercy Care Plan: Long Term Care

• Arizona has been a model for long term care for over 30 years

• Other states pay anywhere from 65% to 85% of Medicaid to long term care facilities

• In Arizona, less than 45% of total dollars spent have gone to long term care facilities

AHCCCSState Agency

for Medicaid Programs

LTC

Mercy Care Plan

Mercy Care Plan 50Proprietary and Confidential

Who Qualifies?

The Arizona Long Term Care System (ALTCS) program is for individuals who are 65 or older, blind, or disabled and need ongoing services at a nursing facility level of care.

However, program participants do not have to reside in a nursing home. Many ALTCS participants live in their own homes or an assisted living facility and receive needed in-home services.

Mercy Care Plan 51Proprietary and Confidential

Key Components:

• A Holistic Approach to Service Delivery Ensure access to the right services and provided at the right time and

place.

We link people, processes, and technology with members to achieve optimal outcomes.

• We facilitate communication, care planning, information sharing, training and service coordination by: Working with Home/Community Based Providers and Patient Centered

Medical Homes

Linking physical health care providers and case managers

Facilitating Holistic Assessments that:

o Include family members

o Implement integrated care plans

o Empower members through Motivational Interviewing

Mercy Care Plan 52Proprietary and Confidential

Key Components (cont.)

• Integrated clinical data analytic tools and information Integration of medical, behavioral health, and pharmacy data

Particularly important for members with medical and behavioral health co-morbidities and complex, high needs.

Health Information Exchange

• Payment Reform Money follows the member

Pay for performance

Align the incentives

• Continuous Quality Improvement Key indicators based on clinical standards and best practices

Use of integrated data to measure performance

Proactive engagement of community and committees

Leadership that is active and visible

Mercy Care Plan 53Proprietary and Confidential

Defining the Roles

Explain what the expectations will be for the contract

Length of Contract

Compliance Deliverables

Explain the “new cultural”

Understand the community that is being served

Role of the Case Manager

Q&A

Thank You!