making our health care system work for older adults and people with disabilities john arnold ocvic,...

Making Our Health Care System Work for Older Adults and People With Disabilities

John ArnoldOCVIC, Project [email protected]

614-456-0060 x237

Making a difference TogetherOhio Chapter of GAPNA's 7th Annual Continuing

Education day“Why Your Voice Matters”

March 14, 2015

mailto:[email protected]

2Working together, why your voice matter 3/14/2015John Arnold – Project Director, OCVIC – [email protected]

The Problem

• Limited care coordination• Fragmented Care• Current system is confusing and difficult to

navigate• Multiple health care needs and high cost• The health care and long-term care

systems are not connected very well, even though people use both.


The Need

People with both Medicare and Medicaid are among Ohio’s highest need patients

They are shuttled between multiple doctors who do not communicate with each other or recognize the whole person they are supposed to serve.

As a result, these consumers often suffer from unnecessary tests, contradictory therapies and ineffective treatment.


Dually Eligible in Ohio

Currently Enrolled: 182,000 Ohioans

Total Medicaid En-rollment for State of

Ohio

Dually ElligibleMedicaid Only

9%

91%

Medicaid Spend-ing in Ohio

Dually El-igibleMedicaid Only40

%60%


Dual eligible beneficiaries are a diverse population

Under Age 65

39%Facility

13%

Mental Impairment

49%0 or 1

Chronic Conditions

25%

Age 65-74

26%2 Chronic

Conditions

20%

Age 75-84

21%

Community

87%

No Mental Impairments

51%3 Chronic

Conditions

20%

Age 85+

14% 4 or more Chronic

Conditions

35%

Age Type ofResidence

MentalImpairments

Number of Chronic

Conditions


26%

22%

44%

25%

44%

50%

55%

58%

Dual eligiblebeneficiaries

All other Medicarebeneficiaries

Cognitively or Mentally Impaired

3+ Chronic Conditions

In Fair or Poor Health

Dual Eligible Consumers are sicker than other

Medicare Consumers

Functionally Impaired


Answer

A coordinated, managed care system that brings together all consumer needs and services under

one umbrella called MyCare Ohio

Healthcare doctor & Hospital

Long term Care (Passport,Assisted Living, nursing home care)Behavioral health/mental health


MyCare Ohio

• Demonstration to test integrated care and financing model for individuals with Medicare and Medicaid

• May 2014 to December 2017• Federal and State partnership • How it will work:

– Approved ICDS Plans will provide integrated benefits to Medicare and Medicaid enrollees in seven targeted geographic areas

– Plans must provide all necessary Medicare and Medicaid-covered services, including Medicaid waiver services

– Single identification card to access services


MyCare Ohio

• Three-way contract (Health plan, CMS, State)

• Rolling start in mid-2014; passive enrollment in Medicare delayed until January 1, 2015

• Capitated rates adjusted for State and CMS upfront savings; also quality withhold

• Comprehensive care plans required incorporating client and family goals


Medicare Passive Enrollment (I)

–Beneficiaries must participate in MyCare Medicaid; but Medicare is optional–On 1-1-2015, individuals who have

not indicated a choice, was passively enrolled in MyCare Medicare with the same health plan as their MyCare Medicaid (integrated benefits and funding)


Medicare Passive Enrollment (II)

• Individuals can choose to stay with traditional Medicare or another Medicare Advantage plan

• Beneficiaries can switch from MyCare Medicare to traditional Medicare, or vice versa at anytime

• This is all very confusing to consumers and public education has been poor


MyCare Ohio Demonstration


Health Plans by Region

• Northwest: Aetna and Buckeye• Southwest: Aetna and Molina• West Central: Molina and Buckeye• Central: Aetna and Molina• Northeast Central: CareSource and

United• East Central: CareSource and United• Northeast: Buckeye, CareSource,

United


Who's Eligible?

• Age 18 and older at the time of enrollment• Eligible for full Medicare Parts, A, B, and D

and full Medicaid, and• Reside in an ICDS Demonstration county• Ohio Home Care or Transitions Carve-Out

Waivers• Receive AoD and/or Mental Health Services• Passport or Choices Waiver• Assisted Living Medicaid Waiver receiving

Medicare and Medicaid


You're Not Eligible if You're:

• Under the age of 18• On a delayed Medicaid spend down – (Delayed)• If other third party creditable health care

coverage is available• A person with Intellectual Disabilities (ID)or

Developmental Disabilities (DD) served through an IDD 1915(c) HCBS waiver or an ICF-IDD

• Enrolled in PACE• Participating in the CMS Independence at Home

(IAH) demonstration


The Promise

• Single Point of Contact• Single ID Card for all Medicare and Medicaid

Services• Nurse Advice Live – 24 hours a day, 7 days a

week• Care Team – (Family, doctor(s), Care Coordinator,

MyCare Ohio health plan, anyone else chosen) • Better Care Coordination = Better Health

outcomes• Providers submit claims to 1 place • Focus on Prevention and Wellness


The Promise (II)


Benefits for Primary Care Providers

– Identifiable care manager – phone and email contact• Access to all benefits and services• Opportunity to enhance home and community-

based services

– WEB portal to access patient’s care plan– Assistance for your most complex patients– Opportunity to participate as part of

Integrated Care Team– Potential to shift hospital dollars to

community-based services


Continuity of Care and Transition Requirements

• Health plans must ensure individuals have access to current providers and service levels at the time of enrollment.– Length of transition period differs by service.

• For prescription drugs, Medicare Part D transition requirements apply.– Health Plans must provide a one-time fill- 30 day

supply- of an ongoing medication within the first 90 days of plan membership.

– Residents in long term care facilities can receive multiple fills.


Continuity of Care Requirements (Continued)

• During the transition, Health Plans will advise enrollees and providers that they have received care that would otherwise not have been covered.

• Ongoing basis, Health Plans must contact providers not part of their network with information on being credentialed as in-network providers.

• Health Plans must always reimburse an out-of-network provider of emergent or urgent care.

Details: Plan Payment Requirements

http://medicaid.ohio.gov/Portals/0/Providers/ProviderTypes/Managed%20Care/MyCareOhio/PlanPaymentReqs.pdf


Cost of Inaction


Crisis in Quality

Multiple VisitsMultiple Docs

Multiple Rx Fills

Duplicate Tests &

Procedures

Too Frequently

Hospitalized

Too Frequently Readmitted to Hospital

Little or No Info upon Discharge

Inappropriate Rx


Implementation Issues

• Consumers losing Independent Providers (Homecare and Nurses)

• Non-medical Long-term Services and Support –under 60

• Transportation issues• Primary Care Providers – turning away

patients• Durable Medical Equipment –not authorized


Ohio Consumer Voice for Integrated Care“What we do”

ConsumerAdvisoryCouncil

RegionalNetworks

SWOC, NEOC Central

State –ODMFederal - CMS

Plans


Critical Role of Provider and Consumer Engagement

• Dual eligible patients will benefit from your participation in planning and direct care provision in MyCare Ohio

• If MyCare Ohio is not successful, the alternatives may be less desirable for patients and providers

• Primary care and Geriatrics providers’ clinical leadership, when combined with consumer advocacy efforts, is more likely to have an impact


How can Providers Get Involved?

• Learn about MyCare Ohio• Discuss good and bad observations

with your health system, Area Agency on Aging, health plan medical directors, and State Medicaid office leadership

• Join advocacy organization list-serves• Here’s the sign up link:

http://uhcanohio.org/ocvic/primarycareproviders




What You Can Do?“Vision”

• Be part of the solution • Help recruit consumer spoke persons to share

their story• Identify and help recruit others to join Consumer

Advocate Conference call – (last Friday of every month) The call in number (free call) and participant code is:

• (877) 366-0711• Participant code - 53257144#• Provide a feedback loop to the Plan, Regional and

State Coalitions.


Thank you

John [email protected]

614-456-0060 x237

UHCAN OhioOhio Consumers for Health@UHCANOhio@KathleenOCHC

Visitwww.uhcanohio.co

m/OCVIC

making our health care system work for older adults and people with disabilities john arnold ocvic,...

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