mainecare long term strategy mainecare redesign taskforce october 23, 2012 seema verma, svc robert...

DRAFT

MaineCare Long Term Strategy

MaineCare Redesign TaskforceOctober 23, 2012

Seema Verma, SVCRobert Damler, Milliman

DRAFT

Expense by Cost Distribution FY2011Bottom 80 -

16%

80-89 per-centile - 14%

90-95 per-centile - 16%

Highest 5% - 54%

Source: MaineCare Redesign Taskforce, Maine by the Numbers, 2012.

DRAFT

Annual Cost Per Member

Top 5% 90 to 95% 80 to 90% Low 80%$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000 $68,562

$21,011

$9,199 $937


Cost PMPM Top 5% 90 to 95% 80 to 90% Low 80%

$5,713 $1,750 $766 $78

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Who is the typical consumer?

Top 5% 2nd 5% 80-89% <80%

Age group

18-44 18-44 18-44 Under age 18

RAC SSI disabled SSI disabled

Not receiving AFDC, but

eligible (parents/

caregivers)

Under 19, income

<125% FPL

Clinical condition

Developmental disability

Mental health:

neuroses

Pregnancy with

complications

Preventive/ Admin

encounters

Provider type

Waiver services

PNMI/Waiver

services

Physician/ Hospital

Physician/ Hospital


DRAFT

Previous Options• Option 1: State based (FFS)• Further development of State utilization management

program• Active risk assessment & case management by State• Development of disease-specific management programs• Could develop different benefit packages according to risk

• Option 2: Value based purchasing design• Medical homes, ACOs, incentive payments

• Option 3: Capitation• Population & region, services• Providers, MCO, ACOs, PACE• Models: shared savings, risk adjustment, reinsurance,

etc.

DRAFT

Proposed: Multi-Tiered StrategyBased on Population• Investment in primary care (80% of MaineCare)• Pregnant women• Children• Parents

• Coordinated, quality services for Maine’s most vulnerable citizens (top 20% of MaineCare)• Waiver populations • Institutionalized• Disabled with chronic diseases• Other high risk

• Effective & efficient use of services (100% of Maine Care)• All populations

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Investment In Primary Care:Value Based Purchasing • 80% of MaineCare• Target groups:• Non-disabled • Non-elderly populations• Non-institutionalized populations

• Health homes/Primary care case management• Primary care incentive program• Accountable care organizations• Targeted initiatives:• ED• Maternal & child health• Care coordination aimed to assist transitions• Increased promotion/incentive of PMP program to address

narcotic abuse, incentives for using HIE, PA all MRIs and CTs

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Goals of Value Based Program

•Pay for outcomes•Pay for quality•Incent consumers to become active

participants in their healthcare consumption

•Design benefits that provide appropriate intensity and levels of care

•Providers coordinate total care resulting in better outcomes at lower costs

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Accountable Communities • MaineCare is planning an Accountable Communities Program• Goal is for groups of provider organizations called

accountable care organizations (ACOs) to provide better care to members for lower costs

• ACOs usually formed by different providers working together• Primary care doctors• Specialists• Hospitals• Others

• How does this work?• Type of ACO is unknown• “We want to work with health care providers to plan the

kind of ACOs we will have so that they join us in this project.”• ACOs have to meet quality goals• ACOs will have goals to save money

Source: Value Based Purchasing, Member Services Committee, October 7, 2011

DRAFT

Patient Centered Medical Homes• PCMHs are primary care practices that:• Care for members using a team approach with

communication among physicians & supports• Encourage the member & provider to have a good

relationship• Use information technology to track member data• Make it easier for members to schedule necessary

appointments• Focus on providing better care for members with

serious physical & mental health issues• Currently• 26++ PCMHs• 8 Community Care Teams


DRAFT

Primary Care Provider Incentive ProgramThe Primary Care Provider Incentive Payment (PCPIP) program pays bonuses to doctors that achieve certain goals:

1. Seeing MaineCare members at their doctor’s office 2. Primary care over emergency room care3. Quality

“MaineCare has not changed how it does the PCPIP since 2007. Doctors receiving the PCPIP do a much better job seeing MaineCare members at their office now than they used to. But in other areas, the doctors have not improved very much or at all.”

“MaineCare is going to see how it can change the program to make sure that doctors are improving in all areas.”


DRAFT

Contracting Strategy

• Continue FFS• Continue PMPM management fee to primary care

medical homes• Quality Incentive Program

• Community coordinators• PMPM fee

• Care Management Organization (CMO)• Manages, utilization, PA etc.• Oversees PCCM• LA model• Shared savings & risk

• Future capitation to ACOs

Louisiana Model• Operates under 1932(a)(1) SPA authority• Mandatory enrollment for disabled & non-

disabled• Excluded populations• Duals

• Voluntary Enrollment (must opt-out)• SSI Children• Foster Children• Children Receiving Special Health Services• Native Americans

• Enrollees have choice between Enhanced PCCM Model & MCO Model

Sources: Louisiana Department of Health and Hospitals, Healthcare Delivery Changes/Birth Outcomes Initiative, 2011; Louisiana State Plan Amendment, 2011; Louisiana Department of Health and Hospitals,

2012.

DRAFT

Louisiana Model• Enhanced PCCM model• Two entities operate PCCM model• Saving targets• Savings shared with providers• If no savings return up to 50% monthly care

management payment made for each member• Example:• Total payments made for care management = $60M• Net loss of $3M• $3M owed to State

• Network of primary care providers only

Sources: Louisiana Department of Health and Hospitals, Healthcare Delivery Changes/Birth Outcomes Initiative, 2011; Louisiana State Plan Amendment, 2011; Louisiana Department of Health and Hospitals,

2012.

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DRAFT

Timeline & Implementation

1/12

1/12Care

Coordination Teams

Start

1/13Health Homes Begin

7/13Primary

Care Incentive Program

Spring 2013

Accountable

Communities


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Cost Distribution for Low 80%*Adult/Child Disabled Other

Hospital $ 88.9 $ 7.7 $ 2.6

Mental health $30.6 $ 10.9 $ 1.5

LTSS/Other $ 29.8 $7.7 $ 9.1

Physician $ 51.9 $ 8.5 $ 9.3

Pharmacy $ 38.8 $9.2 $ 1.8

All other $ 22.3 $ 3.9 $ 1.1

TOTAL $ 262.4 $ 47.9 $ 25.3

Lives 191,916 28,857 37,390

Source: DHSS, SFY 2010 Experience Summary, Cost by Specialty and Grouping 2010.xlsx.

* Reflects State & Federal Expenditures

DRAFTValue Based Purchasing -Projected Cost Savings for Low 80% of Maine Care*

Range from 0.0-4.0% , Depending on type of service

Adult/Child

Disabled Other

Low 80% Total cost $ 262.4 $ 47.9 $ 25.3

Savings $ 6.0 $ 1.0 Unknown

With cost-savings measures, MaineCare could save more than $7.0 in its “Low 80%” population.


* Reflects State & Federal Expenditures

DRAFTPotential Savings (State and Federal expenditures) for Reducing Number of Neonates

Base Admits

Base Spending

Redistributed* Admits

Redistributed* Spending

Normal newborns

3,316 $ 3,750,451 3,887 $ 4,396,035

Neonate 2,854 $ 21,620,671 2,283 $ 17,296,537

TOTAL 6,170 $ 25,371,121 6,170 $ 21,692,571

Neonate % 46%** 37%

Savings from redistributio

n$3,678,550

* Redistributed = If able to prevent 20% of each type of neonate** For comparison, Indiana rates are 17% and Michigan rates are 27%

Source: Maine, SFY 2010, DHHS, admits.xlsx, 2012.

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Current Initiative: Emergency Department Project

• MaineCare is working with hospital emergency departments across the State to:• Identify high utilizers• Identify drivers of high utilization• Collaborate with identified member’s

healthcare providers to encourage utilization in more appropriate treatment settings

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Emergency Room Utilization Maine – SFY2012

Source: DHHS, 2012.

Number of Visits Individuals Visits Average Visits

0 202,117 - -

1 71,539 71,539 1.0

2 29,562 59,124 2.0

3 14,089 42,267 3.0

4 7,237 28,948 4.0

5-9 10,012 61,671 6.2

10-19 1,993 25,139 12.6

20+ 426 11,025 25.9

TOTAL 336,975 229,713

Less than 6% of the total population on MaineCare is using over 55% of the ER visits

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Coordinated Quality Services for Vulnerable Populations

• Service cost for top 5% represents 54% of spending• Focus on preventing next 15% from

becoming the top 5%• Populations include:• Disabled non dual including low 80%• Waiver populations (DD & physically

disabled)• Non dual residential facilities• State funded populations-?• Exempt disabled children?

DRAFT

Intellectual Disability & Developmental Disability HCBS Waiver

Sources: Medicaid_1915(c)_Home _and_Community-Based_Service_Waiver_Participtants,_by_Type_of_Waiver.xls; statehealthfacts.org

Rank Average Expenditures per Waiver Recipient in FY 2009

(State and Federal Expenditures)

25th percentile $ 31,161


US average $42,896


90th percentile $ 68,478 Maine

average$77,736

-------------------------------

Potential savings for

Maine

$ 36M, if 90% percentile

In FY 2009

Lives: 3,904

Spent: $303M

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Opportunities

• Provide members with ONE number to call• Provide aggressive case & disease management• Prevent disease progression, avoid

hospitalization and institutionalization• Integrate behavioral health care • Promote home & community based care over

institutionalized care• Continually and periodically re-evaluate clients to

assure service level is appropriate• Identify quality metrics, both process & outcome• Reduce waitlist

DRAFT

MLTSS for Individuals with Developmental Disabilities & Serious Mental Illness

• 8 States currently enroll adults with intellectual/developmental disabilities in a managed long term services & supports (MLTSS) capitated program▫ 4 of these States also enroll children with

developmental disabilities▫ 7 of these States enroll individuals in any

setting type (i.e., ICF/MR & HCBS waiver)

▫ 2 of these States deliver ICF/MR & waiver services outside the MLTSS program & DD enrollees receive all other services through MLTSS

• Persons with serious mental illness (SMI) are included in some programs but generally need to fall into one of the other population groups to be enrolled in MLTSS (i.e., person must have physical, intellectual/developmental or age-related disability in order to enroll)

50%50%

% of States with MLTSS Including DD

DD Not IncludedDD Included

50%50%

% of States with DD MLTSS That Enroll Children

Children EnrolledChildren Not Enrolled

Source: Truven Health Analytics, The Growth of Managed Long-Term Services & Supports (MLTSS) Programs: A 2012 Update. July 2012.

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LTSS Carve-Outs

State Services Carved-Out

CA Private duty nursing

HI ICF/MR & MR waiver

MI Acute & medical

NY Primary & acute care

PA Primary & acute care

TX Pharmacy & nursing home to 120 days

TN Pharmacy & dental

WI Primary & acute care, Pharmacy


DRAFT

Requirements for Vendor• Fiscal prudence• Predictable costs• Contain growth rate

• Provide high quality, coordinated & efficient care for recipients• Person-centered• Community integration• More choices

• Assure quality• Work with stakeholders to identify quality metrics and

hold vendors accountable for achievement• Align incentives for providers across services

• Essential providers• Minimum payment to providers

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Capitation Features

•Full risk (all services ?)•Risk adjusted to account for institutional

vs. HCBS vs. diagnosis •Performance bonus for meeting quality

incentives•Withhold to assure that certain process

measures are achieved

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Cost Distribution – High 5% (Non-Dual)State and Federal Expenditures – SFY 2010

Adult/Child Disabled Other

Hospital $ 120.5 $ 142.8 $ 11.5

Mental health $105.9 $ 68.2 $ 3.0

LTSS/Other $ 29.1 $209.2 $ 22.6

Physician $ 12.2 $ 14.9 $ 1.1

Pharmacy $ 18.7 $36.3 $ 1.8

All other $ 3.7 $ 9.2 $ 0.3

TOTAL $ 290.2 $ 480.6 $ 40.4

Lives 5,752 7,301 1,185


DRAFT

Cost Distribution – Next 15% (Non-Dual)State and Federal Expenditures – SFY 2010

Adult/Child Disabled Other

Hospital $ 144.3 $ 31.2 $ 4.6

Mental health $55.6 $ 23.0 $ 1.7

LTSS/Other $ 26.4 $19.9 $ 3.8

Physician $ 32.2 $ 8.7 $ 1.2

Pharmacy $ 40.0 $26.8 $ 1.6

All other $ 11.2 $ 3.8 $ 0.3

TOTAL $ 309.8 $ 113.4 $ 13.2

Lives 29,185 9,845 1,845


DRAFT

Capitation for MaineCare’s Top 20%• Cost savings estimates for High 5% range from 2.0-7.5%• Cost savings estimates for Next 15% range from 1.0-5.0%

* Estimates are State & Federal

Adult/Child

Disabled Other

Top 5% Total Cost $ 290.2 $ 480.6 $ 40.4


Next 15% Total Cost $ 309.8 $ 113.4 $ 13.2


TOTALTop 20%

Total Cost $ 519.0 $522.0 $53.6

Savings $ 23.7* $22.2* UnknownWith cost-savings measures, MaineCare could save more

than $45.9 in its “Top 20%” population.


DRAFT

Implementation Timeline & Issues• Planning & development of waiver• Waiver approval process• Development of RFP & contracting

process• Claims system• DHHS must be able to obtain claims data

from MCOs/ACOs/PACE or other vendor• 18-24 months

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Effective Use of Services

•Assure that services are used appropriately

•Reduce waste and inefficiency•Promote quality•Create financial incentives for providers

to achieve quality benchmarks

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Effective Use of Services: Strategy

• Reimbursement Strategy• Bed hold days• Readmissions within 7 days:• ME does not reimburse for readmits within

72 hours• Hospital acquired conditions• New policy aligns with Medicare

• Elective C-Section before 39 weeks• Radiology Benefits Manager• Transportation broker (in process)• Behavioral health ????

DRAFT

Medicare HAC Policy• Medicare does not pay for: • The additional costs associated with hospital

acquired conditions (HAC)• “Never Events”

• Under the Affordable Care Act, the Medicare policies were applied to Medicaid with some minor deviations• Medicaid agencies can identify additional HAC

which will not be reimbursed by the State• MaineCare currently applies the Medicare

policies

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Maryland’s Hospital Acquired Condition Program

Source: The Maryland Health Services Cost Review Commission - http://www.hscrc.state.md.us/init_qi_MHAC.cfm

• Implemented in 2009• Provides system of payment incentives based on a hospital’s actual number of

complications vs. statewide target rate• Hospital performance rates monitored & payment adjustments made annually based

on performance• Applies across all payers

Overview of Program

• Includes 49 HACs• Developed from list of 64 potentially preventable complications developed by 3M

Health Information SystemsList of HACs

• Hospitals with higher-than-average complication rates receive an overall decrease in payment rates & vice versa (risk-adjustments first made to account for any patient attributes)

• Methodology is revenue neutral; net increase in rates for better performing hospitals funded through reduction in rates for poor performing hospitals

• Annually adjust maximum penalty; was 1% of hospital revenue in FY 2012 & 0.5% in FY 2011

Methodology

• FY 2008: Incidence of HACs present in 53K of 800K inpatient cases totaling $500M in potentially preventable hospital payments

• FY 2009-10: 12% decrease in measured complication rates with associated costs of $62M• Portion may be attributable to hospital coding changes in addition to the new

reimbursement system

Outcomes

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Potentially Preventable Readmissions

• Potentially preventable readmissions are hospital readmissions occurring within a short time period that could have reasonably been expected to be prevented through:• Effective use of discharge planning• Coordinated follow-up care

• Nationally 20% of patients are readmitted within 30 days of discharge• Estimated to cost $25B annually

Source: Community Catalyst, Overview: Model Legislation to Reduce Potentially Preventable Readmissions & Complications; October 2011.

DRAFT

Potentially Preventable Readmissions: State Examples

New York Massachusetts

• Effective 7/1/10• Projected $47M in savings 7/10-

3/11• Reduce hospital’s payment based

upon the excess number of potentially preventable readmissions (PPRs)

• Applies to PPRs within 14 days• Excess readmission rate is

difference between observed rate & expected rate

• For excess readmissions, the hospital’s payment for all non-behavioral health related Medicaid discharges is reduced by applying the computed adjustment factor to the applicable case payment or per-diem rate

• Effective 10/1/11• Hospitals above the threshold for

readmissions received 2.2% reduction in their standard payment amount per discharge

• Penalty amount determined using 3M Potentially Preventable Readmission System

• 24 of 65 contracted hospitals were identified to have higher-than-average readmissions• Statewide average is adjusted

for severity of illness & hospital case mix

Sources: http://www.health.ny.gov/regulations/recently_adopted/docs/2011-02-23_potentially_preventable_readmissions.pdf & http://commonhealth.wbur.org/2011/09/hospitals-face-

financial-penalties-for-preventable-readmissions.

Potentially Preventable Readmissions: Medicare Policy• The ACA created the Medicare Hospital Readmissions Reduction Program• Targets readmissions:

• Acute Myocardial Infarction (AMI), Heart Failure (HF), and Pneumonia (PN)• Readmission within 30 days of discharge

• Calculate excess readmission ratio for AMI, HF, and PN• Includes adjustment factors that are clinically relevant (i.e. patient demographics,

comorbidities, patient frailty, etc.)• Measure of a hospital’s readmission performance compared to the national average• Utilizes risk adjustment methodology endorsed by National Quality Forum (NQF)

• Effective 10/1/12: Maximum penalty is 1% of base Medicare reimbursements• October 2013: Increases to 2%• October 2014: Increases to 3%

• 71% of hospitals reviewed to be penalized• 2,217 hospitals nationwide to receive penalties• 1,910 hospitals to receive penalties <1%

• $280M in total penalties• Comprise approximately 0.3% of total amount hospitals are reimbursed by

MedicareSources: http://www.kaiserhealthnews.org/Stories/2012/August/13/medicare-hospitals-

readmissions-penalties.aspx; CMS, Readmissions Reduction Program, 2012.

DRAFT

DRAFT

MaineHospital Admissions & Readmissions

# Initial Admit

s

# Readmit

s

Total # Admits

Initial Admits

Paid

Readmits Paid

Total Admits

Paid

Readmit Rate

(Maine, 2010)

Readmit Rate

(US, 2007)

Behavioral health

3,618 1,645 5,263 $59.7 $31.9 $91.645%

SA = 20.7%MD = 57.2%

SA = 12.3%MD = 11.9%

Maternity 5,947 462 6,409 $30.1 $2.2 $32.3 7.8% 3.8%

Newborn 5,943 227 6,170 $24.6 $0.8 $25.4 4% 2.6%*

Medical/Surgical

10,480 2,259 12,739 $136.5 $30.1 $166.6 21.6% 10.7%

TOTAL 25,998 4,593 30,581 $250.9 $65.0 $315.9

Sources: Maine DHHS, October 2010 – September 2011 Hospital Claim Experience, 2012; AHRQ, All-Cause Hospital Readmissions among Non-Elderly Medicaid Patients,

2007, 2010.

* This rate is for children under 1 year of age

If Maine could cut medical/surgical readmission rates in half, the program would save $15.0

million (State and Federal expenditures).

DRAFT

Elective Inductions Prior to 39 Weeks

State Example: Ohio

• Put a “hard stop” to elective inductions prior to 39 weeks gestation

• Savings gained from:• Shorter labors• Reduced c-section rate• Better birth outcomes

• Potential savings: $850K State & Federal1

• Challenges• How to implement?• OH & UT required hospital to

enter week’s gestation in order to schedule induction

• PA as potential alternative

Estimated Savings

Induction Rate Prior to Pilot

Induction Rate Post

Implementation

$10M 25-30% 0-2.5%

1 MaineCare has ~5,400 births/yr. Estimated 25% elective induction rate. Reduction to 2.5% assumed.

Source: DHHS, 2012.

DRAFT

Radiology Cost Control

• State strategies for containing radiology costs & ensuring the appropriate delivery of services have included:• Radiology Benefit Managers• Clinical decision support models• Real-time online interactive PA

DRAFT

Radiology Cost ControlRadiology Benefits Management (RBM)• Role: • To ensure imaging needed for potential

diagnosis• Pros: • Potential utilization & cost reductions of 8-20%• Successful RBM programs could save $13-24

billion by 2020 • Cons: • Costs shifted to providers• Getting prior authorization for all imaging

services places administrative burden on providers

Sources: CaretoCare, Achieving Cost Savings and Patient Safety through Radiology Benefit Management, 2010; Magellan Health Services, Independent study estimates significant savings to Medicare through RBM programs, 2011; Lee, Rawson, & Wade, Radiology benefit managers:

cost saving or cost shifting?, 2011.

DRAFT

Radiology Benefits Manager: North Carolina

Source: North Carolina Department of Health & Human Services - http://www.ncdhhs.gov/dma/services/radiology.htm

• NC operates a statewide PCCM Program• Implemented a RBM in 2009• All PAs handled through RBM & appeals handled by StateOverview• All outpatient, non-emergent, diagnostic imaging services

including:• CT• MR• PET• Ultrasound

Services requiring PA

• Inpatient• Emergency Room• 23 Hour Observation

Services not requiring PA

• Duals• Enrollees with TPL• PACE• Family Planning Waiver• SCHIP

Populations excluded

DRAFT

Radiology Cost ControlClinical Decision Support• Clinical decision support (CDS) is an alternative to

utilization reviewers & Radiology Benefit Managers• “Clinical decision support (CDS) is the use of health

IT to provide clinicians and/or patients with clinical knowledge and patient-related information, intelligently filtered or presented at appropriate times, to enhance patient care. (HRSA)”

• Providers guided to order the appropriate test through an interactive electronic question set vs. receiving a PA denial

• Can be integrated into EHRs or accessed via the Web

http://www.diagnosticimaging.com/practice-management/content/article/113619/1750408 http://www.diagnosticimaging.com/radblog/display/article/113619/1932985

http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/EvaluatingOptimizingandSustaining/decisionsupport.html

DRAFTClinical Decision Support for Radiology: Minnesota• Minnesota implemented CDS pilot

in 2007 & expanded as statewide option in 2010

• Implemented by Institute for Clinical Systems Improvement (ICSI)• Non-profit organization

representing 64 medical groups & sponsored by 5 health plans

• Implemented clinical criteria based on American College of Radiology standards

• Review is given in real-time & “decision support number” is given & required to process the claim

http://www.diagnosticimaging.com/practice-management/content/article/113619/1750408 http://www.diagnosticimaging.com/radblog/display/article/113619/1932985

•Over ½ of all scans in MN are ordered

through this process•Increase in scans

ordered•2003-2006: 8%•2007-2012: 1%

•Time expended by medical group staff

•Pre-pilot: 308 hrs•Post: 5 hrs

•None of the 4,500 pilot

practices requested return to traditional

PA when pilot concluded

DRAFT

Radiology Clinical Decision Support: State Example• April 2011: New York Medicaid

implemented a collaborative, non-denial Radiology Benefits Manager

• Applies to outpatient non-emergency advanced imaging for FFS• Duals & MCO enrollees

excluded• Utilize RadConsultTM

• Provides peer consultation & evidence-based medical criteria

http://www.health.ny.gov/health_care/medicaid/program/update/2011/jan11mu.pdf http://www.healthhelp.com/dr-hiatt/detail/collaborative-utilization-management-of-advanced-

diagnostic-imaging-for-med

•5% reduction inadvanced diagnosticimaging•Consults per 1,000 members:

•June 2011: 89.58%•Feb 2012:

85.53%

DRAFTReal-Time Online Interactive Radiology PA: State Example

• Iowa Medicaid implemented Clear Coverage (a McKesson product)

• Online interactive PA system using InterQual criteria for certain elective outpatient radiology tests

• PA not required for inpatient or ER procedures

• Requests that meet criteria are automatically approved in real-time

Provider answers questions on patient’s health status on web-based

program

Program utilizes InterQual criteria to identify what imaging studies are

medically appropriate

Program identifies which imaging studies require PA

Program identifies what level of benefits are available

Sources: http://www.ime.state.ia.us/Providers/PriorAuthorization.html & McKesson, Iowa Medicaid Enterprise & IFMC: Automatic Prospective Utilization Management of Diagnostic

Imaging at the Point of Care, 2011.

DRAFT

Iowa’s Radiology Management: Outcomes

• The program achieved cost savings within 10 months• Annual estimated savings of

$2.4M attributed to:• $1.3M due to physicians

canceling requests found non-medically appropriate

• $0.6M due to denials• $0.5M vs. adding 7 full-time

employees for manual PA reviews

• The volume of manual reviews has been reduced

Of 50,ooo PA requests:• 40%: Instant automated approval• 8%: Cancelled by provider when

notified clinical evidence not aligned with request• 4%: Denied as medically inappropriate

Sources: http://www.ime.state.ia.us/Providers/PriorAuthorization.html & McKesson, Iowa Medicaid Enterprise & IFMC: Automatic Prospective Utilization Management of

Diagnostic Imaging at the Point of Care, 2011.

DRAFT

Federal Waivers• Waiver authority• Dependent on strategy• What populations• What method is being used• Managed care• Other?

• What flexibilities are needed?• Statewideness• Mandatory/Voluntary enrollment• Defined network, limited choice of contractors• Benefits

• Timing (length of approval process)• Budget tests• Budget neutrality• Cost effectiveness

DRAFT

Stakeholder Submissions

•1) Integrated chronic care management for high cost cases, 1915 waiver populations

•2) Independent administration of HCBS, children ID/DD,& Adults in LTC

•3) Population Based Integrated Services Model for Medicaid Eligible Individuals with a Serious Mental Illness and Chronic Co-Morbid Medical Conditions

•

Long-Term Strategies Summary

ItemCurrent Initiativ

e

State & Federal Savings

State Savings

Investment in primary care

Value-based purchasing $5.2M $1.98M

Value-based purchasing with risk $7.0M $2.66MReduce neonates & Increase normal

births$3.7M $1.41M

ER utilization X

Coordinated, quality services for Maine’s most vulnerable citizens

Capitation $45.9M $17.44M

Effective & efficient use of services

Readmissions $15.0M $5.7M

HAC X

Elective Inductions $850K $323K

Radiology X

DRAFT

Authorities for Managed CareAuthority Description Limitations

Section 1115

Gives Secretary of HHS broad authority to approve

demonstration programs that test innovative Medicaid policy.

Proposal must be truly innovative, not simply

replicating an idea already demonstrated elsewhere.

Section 1915(a)

Statutory authority to enter into contracts with

organizations to provide services already offered under

the state plan.

Voluntary enrollment only;Existing services only;Number of qualified

contractors may not be limited.

Section 1915(b)Waiver authority for mandatory

enrollment in managed care.

With exceptions for rural areas, must offer at least 2

options.

Section 1932(a)Statutory authority for

mandatory enrollment in managed care.

Certain groups are exempted from mandatory enrollment;

with exceptions for rural areas, must have at least 2 options.

Exempted groups include:• Special Needs Children• American Indians/Alaskan

Natives• Dual EligibleSource: L&M Policy Research, MLTSS Federal Authorities.

DRAFT

Authorities for Long Term Services & SupportsAuthority Description Limitations

Section 1915(c)

Waiver authority to offerHCBS to beneficiaries who would

otherwise meet institutionallevel of care.

Beneficiary must meetinstitutional level of care.

Section 1915(i)

Statutory authority to offer HCBS as a state plan service, whether or not

a beneficiary meets institutional level of care.

State may not limit the number of eligible participants or have a

waiting list. Service must be offered statewide.

Section 1915(j)

Statutory authority to offer self-directed personal assistance

services option in a 1915(c) waiver program, or under state plan personal assistance services.

Not a service authorization per se, but rather a delivery option for

services otherwise provided under the state plan.

Section 1915(k)

Statutory authority to offer attendant services and supports

controlled by the beneficiary (Community First Choice Option).

State may not limit the number of eligible participants or have a

waiting list. Service must be offered statewide.

Other State Plan Services

States must offer certain services (such as nursing home and home

health) and may offer optional services (such as personal care and

targeted case management).

State plan services must be offered to all eligible beneficiaries without waiting lists. Services must be

offered statewide.Source: L&M Policy Research, MLTSS Federal Authorities.

DRAFT

Authorities for MedicareAuthority Description Limitations

Section 1859

Statutory authority for Medicare Advantage

plans to create specialty plans targeted to special

needs individuals, including those who are

dually enrolled in Medicare and Medicaid.

Voluntary enrollment only; authority applies to Medicare Advantage plans (not to the State Medicaid agency); all Medicare Advantage rules must be met.

Sections 1894 and 1934

Statutory authority to offer PACE, which

combines Medicare and Medicaid services.

Voluntary enrollment only; PACE model only.

Section 1115A

Gives Center for Medicare and Medicaid

Innovation broad authority to test

innovative models that decrease costs and

maintain or improve quality.

Proposed model must be innovative and fit within the statutory priorities of CMMI (Center for Medicare & Medicaid Innovation) at CMS.

Source: L&M Policy Research, MLTSS Federal Authorities.

DRAFT

Developmentally Disabled & SMI LTSS: State Examples

State PopulationsMedicaid Authority

Geographic Reach

Mandatory or Voluntary

Services included in Capitation

Outcomes

AZ •Children•Adults < 65with PD •Adults < 65 with ID/DD•Adults 65+

1115 Statewide Mandatory •Primary •Acute •Behavioral •Rx Drugs •NF •ICF/MR •HCBS waiver- like services

Peer reviewed study found substantial cost savings & nursing home avoidance.

MI •Children & adults withintellectual/development

aldisabilities •Children

withserious emotional disturbance

•Adults withSMI

1915(b) & 1915(c)

Statewide Mandatory • Behavioral• NF• ICF/MR• Personal care• Targeted case management• HCBS waiver for persons with DD

Carve-outs: primary & acute medical services & prescription drugs.

No formal evaluation conducted

DE •All SSIchildren &adults

exceptICF/MR & inDDMR

1915(c)

1115 Statewide Mandatory •Primary •Acute •Behavioral •NF •HCBS waiver- like services

Carve-out: Rx Drugs

N/A: recently implemented


DRAFT


Geographic Reach



Outcomes

WA •Adults 21-64

with SSI•Adults 65+

1932(a) 1 of 39 counties

Voluntary

Note: people with DD receiving Medicaid personal care receive all services through WMIP except for certain services provided by the DDD (i.e., supported employment) Those receiving LTSS through DDD waivers receive their medical, mental health and chemical dependency services through WMIP, but continue to receive waiver services through the DDD waivers .

• Primary• Acute• Behavioral• Rx• NF (up to 6 mos, then no longer at risk)• Community based services

2010 Evaluation: Medicaid cost savings not demonstrated. Mortality rates & inpatient hospital admissions somewhat lower (no statistical significance found). Significantly lower growth in prescriptions for mental illness.

Sources:“WMIP: Medical Care, Behavioral, Health, Criminal Justice, and Mortality Outcomes for Disabled Clients Enrolled in Managed Care,” David Mancuso, Melissa Ford Shah, Barbara Felver, Daniel Nordlund, Washington Department of Social and Health Services,

Research and Data Analysis Division, December 2010 & Truven Health Analytics, The Growth of Managed Long-Term Services & Supports (MLTSS) Programs: A 2012 Update. July 2012.


DRAFT


Geographic Reach



Outcomes

WI • Adults <65

with PD or ID/DD•Adults 65+

1915(b) & 1915(c)

57 of 72 counties

Voluntary – Opt In

• Behavioral health not provided inpatient or by physician• NF• ICF/MR• Personal Care• HCBS

Carve-outs: Primary & acute medical care & Rx HCBS waiver services only available to members with nursing home LOC

2011 Evaluation: Several MCOs with operating deficits; 3 identified at risk of insolvency. Improved access to long-term care. Cost-effectiveness determined difficult to assess.

Sources:. “An Evaluation: Family Care” 2011-2012 Joint Legislative Audit Committee, Report 11-5, April 2011 . Truven Health Analytics, The Growth of Managed Long-Term Services & Supports

(MLTSS) Programs: A 2012 Update. July 2012.


DRAFT


Geographic Reach



Outcomes

PA Targets autism only

1915(a) 4 of 67 counties

Voluntary – Opt In

• Primary• Behavioral health• Dental• ICF/MR• Targeted case management• Adult day• OT/PT/ST

Carve-outs: inpatient, ambulatory surgical center, home health, clinic, transportation, renal dialysis, lab, x-ray, Rx

No formal evaluations

NC Children & adults with SED, DD, mental illness or substance abuse

1915(b) & 1915(c)

Scheduled to be Statewide in 2013

Mandatory •Inpatient & outpatient behavioral health• PRTF• ER visits for

BH• ICF/MR• HCBS for DD• Therapeutic

foster care• Residential

child care

No formal evaluations



DRAFT

StateDate of

InceptionMedicaid Authority

Geographic Reach



Outcomes

HI •Children•Adults

<65 with PD•Adults

<65 with

ID/DD•Adults

65+

1115 Statewide Mandatory •Primary •Acute •Behavioral

•Rx Drugs • NF • DD/ID Waiver Enrollees must enroll in one of the 2 plans but waiver services carved-out & provided by Dept. of Health• Additional BH services for adults with SMI or children with SED excluded from cap rates

No formal evaluation conducted yet



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