Medicaid and the Bus Pass Problem · Medicaid and the Bus Pass Problem ... drive their health, ... The Upside Down Idea •Financial sustainability of capitated, ...

PRESENTED BY:

Medicaid and the Bus Pass Problem

September 2016

Cardinal Innovations Healthcare

Richard F. Topping, Chief Executive Officer

Leesa Bain, Vice President, Care Coordination & Quality Management

Medicaid Health Plans of America mhpa2016

Conflict of Interest Disclosure: Faculty/Planning Committee/Reviewers/Staff

Participating speakers in “Healthcare is not a Medical Problem, it’s a Bus Pass Problem” have no conflict of interest to disclose relative to the content of the

presentation.

Medicaid managed care isn’t about successfully managing patients and their healthcare costs.

It’s about populations with complex needs, the social determinants that drive their health, and the locally delivered services and supports that

can improve their wellness.

Successfully managing Medicaid is about solving the Bus Pass Problem.

A man walks into a hospital…

• He’s a plan member, admitted for a long, expensive stay

• Admitted through the ED

• Arrived at the ED via EMS

• EMS called after he decompensated in his home

• He decompensated because he did not take his medication

• He did not take his medication because he did not see his doctor

• He did not see his doctor because he lives in a rural area and does not have a car

• His county offers subsidized local transportation for a small fee

A $100,000 hospitalization can be avoided with a $25 bus pass

Cardinal Innovations Healthcare

• 1 million members

• $1B in annual revenue

• Headquartered in Charlotte, NC

• Exclusively focused on special populations

• Founded in 1974 as a county mental health provider, began managed-care operations in 2005

• Manage Medicaid, state and local government-funded services

Largest Specialty Medicaid Plan in U.S.

Demographics, Fishes and Loaves

• Medicaid in 1965• Welfare benefit for specific, limited populations

• Publicly administered

• Medicaid in 2016• Means-tested benefit for entire population

• Privately managed

• Jointly Financed• All, 9, 4, 3 or 2 for 1 FMAP

From Safety Net to One-Fifth of All Americans

Child’s Play

By The Numbers

• Insures 1 in 5 Americans

• Finances $1 of every $6 of health spending nationally

• Cover 50% of all births

• 25% of all behavioral health

• 50% of all services and supports for the disabled and the elderly

• 35% of safety-net hospital revenues

• 40% of health center revenues

• Approximately $550B total spending in 2016 (2)

Sources: (1) Kaiser Family Foundation, “Medicaid at 50.” (2) CMS, “2014 Actuarial Report to Congress.”

Medicaid at 50 (1)

Back to the Future

• 25% of Medicaid enrollees are disabled or elderly• The disabled drive 42% of all spending

• The elderly drive 21% of all spending

• 63% total, or $347B per year

• 14% of enrollees are disabled or elderly that are dually eligible for both Medicaid and Medicare

• Duals drive 40% of all spending

• $220B per year is attributable to fewer than 10 million (of 70 million) enrollees

Source: Kaiser Family Foundation, “Medicaid at 50.”

The Disabled and the Elderly

Back to the Future

The Challenge Abides

• Cost of Medicaid coverage for children and non-disabled adults is lower per enrollee relative to other payers

• Program is bigger and broader

• Challenge for Medicaid at 50 is same as it was for Medicaid at 1

• High-need, high-cost, at-risk, complex populations

The Disabled and the Elderly

The Upside Down Idea

• Financial sustainability of capitated, privately managed Medicaid was well established by 2000s (after a rough start in the 1990s)

• Traditional path of new or emerging markets: start easy

• Special populations carved-out

• Attempt to build a viable managed-care model and infrastructure for complex populations

• Create the “hard” Medicaid market, merge it with the “easy” market

• New York and North Carolina

“Easy” vs. “Hard” Medicaid

12

North Carolina Pilot

• 1915(b)/(c) combination waiver

• Health care and home and community based services and supports

• 5 counties

• Enrollees with mental health, substance use and/or intellectual and developmental disabilities

• Inpatient included

• Physical health, pharmacy excluded

PBH ‘Hard’ Medicaid Pilot

13

Ain’t It the Truth

• 1% of plan members drive 52% of service costs

• For that 1% of plan members, between 83%-87% of their total cost of care – including non-managed physical and pharmacy –is for specialty services

• Efficacy and cost of specialty services is directly correlated to non-healthcare community and social services

• Employment, housing, education, transportation, “connectedness”

• Virtually no capitation rate would be sufficient, nor any regulatory scheme feasible, for the plan to be viable

Cardinal Innovation’s Experience

14

Along Came A Bus

15

Get the Member on the Bus

• Plan as coordinator, not just payer

• Leverage healthcare and non-healthcare, paid and unpaid

• Partnerships are key

• Community-based and adaptable

• Stakeholders as customers

• Non-traditional programs

• Person-centered

• Clinical and financial risk tolerance

16

Leave the Driving to Them

Specialty Plan Considerations

• Workforce• Medical and clinical vs. social services and customer support

• Geography and footprint• Efficiencies vs. local presence and relationships

• P&L• 1% vs. 99%• Service vs. administrative revenue

• Regulatory and Contracting• Vendor vs. partner

• Market• Expertise and profitability vs. share and leverage

17

It’s Not Your Father’s Medicaid Plan

Cardinal Innovations

• In-person, case management for complex populations

• Funded administratively

• Approximately half of Cardinal Innovations’ workforce

• Mix of clinical and social services expertise

• Assigned locally

• Responsible for coordinating in-network healthcare AND any other available supports that meet members’ needs

• Engaged at the member, family, stakeholder and community level

Care Coordination

18

Leesa Bain

Vice President, Care Coordination & Quality Management

Care Coordination Staff

Other , 72, 23%

RN-Registered Nurses, 7, 2%

SW-Social Workers (Licensed), 77,

25%

QP-Qualified Professionals, 155,

50%

Total Staff = 311

RN

QP

SW

Other

Integrated Care Team

Member

Community Care Coordinators

Population Health Specialists

System of Care Specialists

Clinical Support Specialist

Residential Placement Specialist

Primary Care Provider

Peer Support Specialist

Supports Intensity Scale Team

Family members, caregivers, etc.

Transitions to Community Living

Acute Transitional Nurses

Care Coordination Roles

• High Volume Hospitals• Transitions• Medication Reconciliation

System of Care Clinicians*

IDD Care Coordinators

Transitions to Community Living*

Monitoring Specialists

Population Health Specialists

Qualified Professionals

Licensed Clinicians

Registered

Nurses

Acute Transitional Care Nurses

MHSUD Child Residential Specialists

MHSUD Care Coordinators

* Includes Some Licensed Professionals

Operational Foundation

23

• Focus on quality of

relationships with members

• Person-centered approach

• Data driven approach to care

• Training and onboarding

• Geographic alignment

Operational Foundation

24

• Technology tools

• Population health

• Case referral and assignment

• Physical health integration

Complex Management Principles

• Proactive assessments

• Specific triggers

• Data-driven service development

• Training

Provider Outreach

• Closed network

• Submit treatment justification and plan

• Provider plans inform care coordination work with member and families

• Utilization review to determine usage and effectiveness

Provider Accountability

• Actively seek identification of gaps and opportunities

• Develop new services to support unmet needsInnovation

• Proactive multi-agency case staffing

• Collaboration to achieve complementary solutions

• Focus on treating the whole person

Partnerships with Members and Stakeholders

Complex Medicaid Management

• Dually diagnosed: both MHSUD and IDD combined

• MHSUD or IDD with multiple physical comorbidities

• Children and youth with residential treatment needs

• Individuals with frequent crisis service utilization: both ED and Inpatient

• Incarcerated, or recently incarcerated individuals with identified behavioral

health needs

• Complex co-occurring medical and psychiatric conditions

• Department of Justice Settlement participants

Transitions Management

• Medication Reconciliation concerns

• Limited support systems and connection to resources

• Provider visit scheduled for 3 weeks from discharge date

• Lack of communication between settings

• Last minute discharge planning

• Health literacy concerns

• Failed follow-up

Critical Connections

• Department of Social Services

• Juvenile Justice Substance Abuse Mental Health Partnership

• Drug Treatment Court

• City and County School Systems

• Detention Centers

• Hospital Facilities

• Developmental Centers

“Bus Pass Interventions”

• Assist in obtaining gainful employment

• Engage with resources for housing, transportation,

medication

• Community Engagement

• Increase Natural Supports – identify supports that exist for

our members or create new supports that will exist even

after paid supports are no longer needed

Benefits To Our Members

• Highly skilled clinical infrastructure

• Consistency of assessment and interventions

• Management of continuum of care, regardless of setting

• Education on self-management pathways to become an

active participant in their health

Benefits To Our Members

• Integrated focus on both physical and behavioral

co-morbidities

• Support from Population Management “light touch”

engagement

• High quality customer service

• Proactive approach versus a reaction to crises

• Members will achieve better outcomes

Medicaid and the Bus Pass Problem