Medical Assistance Program Oversight Council September 13, 2013.

Medical Assistance Program Oversight CouncilSeptember 13, 2013

Transition to Medical ASO - Recap

A Snapshot of the Program

Transition to Medical Administrative Services Organization (ASO)

RationalesContrast with Managed Care Organization

(MCO) arrangementKey strategies

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A Snapshot of the Program

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A Snapshot of the Program: Participation

Overall, Medicaid currently serves 631,782 beneficiaries (17.6% of the state population)

437,652 HUSKY A adults and children 13,436 HUSKY B children 97,203 HUSKY C older adults, blind individuals,

individuals with disabilities and refugees 93,749 HUSKY D low-income adults age 19-64 3,178 limited benefit individuals (includes behavioral

health for children served by DCF, tuberculosis services, and family planning services)

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A Snapshot of the Program: Costs in Context

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Connecticut has:the fourth highest level of health care expenditures at $8,654 per capita, behind only the District of Columbia, Massachusetts, and Alaska [2009 data]the ninth highest level of Medicare costs at $11,086 per enrollee [2009 data]the highest level of Medicaid costs at $7,561 per enrollee [2010 data]

[Kaiser State Health Facts]

A Snapshot of the Program: Costs in Context

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Please note the following per capita break-out of Medicaid costs by recipient group:

$16,955 Aged$25,393 Disabled$3,533 Adult$3,339 Children

[Kaiser State Health Facts, 2010 data]

A Snapshot of the Program: Costs in Context (cont.)

per capita spending for the 32,583 individuals who are age 65 and over and the 24,986 individuals with disabilities under age 65 who are eligible for both Medicare and Medicaid (MMEs) is 55% higher than the national average

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A Snapshot of the Program – health outcomes

Key health indicators for Connecticut Medicaid beneficiaries, including hospital readmission rates and outcomes related to chronic disease, are in need of improvement

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A Snapshot of the Program – health outcomes (cont.)

For example, Connecticut MMEs have complex, co-occurring health conditions

roughly 88% of individuals age 65 and older has at least one chronic disease, and 42% has three or more chronic diseases

58% of younger individuals with disabilities has at least one chronic disease

38% has a serious mental illness (SMI)

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Connecticut MMEs use a disproportionate amount of Medicaid resources and Connecticut is spending much more than the national average on MMEs

the 57,568 MMEs eligible for the Demonstration represent less than 10% of Connecticut Medicaid beneficiaries yet they account for 38% of all Medicaid expenditures

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comparatively high spending alone on MMEs has not resulted in better health outcomes, better access or improved care experience

illustratively, in SFY’10 almost 10% of MMEs were re-hospitalized within 7 days following a discharge, and almost 29% were re-hospitalized within 30 days following a discharge

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MMEs have reported in Demonstration-related focus groups that they have trouble finding doctors and specialists that will accept Medicare and Medicaid, and often do not feel that the doctor takes a holistic approach to their needs

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Transition to Medical ASO:

Rationales

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Important Definitions

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Managed Care: Any arrangement for health care in which an organization acts as intermediary between the person seeking care and the physician

Managed Care Organization (MCO): an umbrella term for health plans that provide health care in return for a predetermined monthly (capitated) fee and coordinate care through a defined network of physicians and hospitals

Important Definitions (cont.)

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Managed Fee-for-Service: an arrangement in which quality and utilization are affected through greater payer-provider collaboration than in traditional fee-for-service programs, but most or all payments for services to beneficiaries remain fee-for-service with little or no insurance risk to providers

Administrative Services Organization (ASO): an entity that is contracted by an organization that funds its health insurance program to perform specific administrative services

Important Definitions (cont.)

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Medicaid State Plan: A written plan between a State and the Federal Government that outlines Medicaid eligibility standards, provider requirements, payment methods, and health benefit packages. A Medicaid State Plan is submitted by each State and approved by the Centers for Medicare and Medicaid Services (CMS).

Context

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Prior to transition, Medicaid medical services were handled as follows:

Individuals covered under HUSKY A & B were served by multiple, at-risk, capitated Managed Care Organizations (MCOs)

Individuals covered under HUSKY C (coverage for older adults and individuals with disabilities) were served in an unmanaged fee-for-service arrangement

Context (cont.)

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Individuals up to 53% of the Federal Poverty Level (FPL) who were historically served by SAGA medical became eligible effective April, 2010 for new HUSKY D (Low Income Adult, LIA) group

Connecticut was the first state in the country to gain CMS approval for an early expansion group

Context (cont.)

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Medicaid behavioral health services had since January 1, 2006 been overseen by the Connecticut Behavioral Health Partnership, and managed by a behavioral health ASO (Value Options)

Medicaid dental services had since September 1, 2008 been managed by a dental ASO (BeneCare)

Rationales for Transition

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Transition to an ASO arrangement would:

build upon a model that had worked successfully for Medicaid behavioral health and dental servicesimprove access to and use of data in support of best use of public resources and transparencycentralize and streamline administration, utilization management and member and provider supports

The Central Hypothesis . . .

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Centralizing management of medical services for all Medicaid beneficiaries in self-insured, managed fee-for-service arrangement with an Administrative Services Organization, as well as use of predictive modeling tools and data to inform and to target beneficiaries in greatest need of assistance, will yield improved health outcomes and beneficiary experience, and will help to control the rate of increase in Medicaid spending.


Contrast with MCO Arrangement

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Contrast with MCO Arrangement

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MCO ASO

Structure Multiple managed care entities

One managed fee-for-service entity

Contract Administrative Department withholds 7.5% of each quarterly administrative payment contingent upon ASO’s success in meeting performance targets related to beneficiary health outcomes and experience of care, as well as provider satisfaction

Payment model

Capitated payment

Managed fee-for-service

Contrast with MCO Arrangement (cont.)

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MCO ASO

Care delivery model

Each MCO handled utilization management (e.g. prior authorization) on its own terms

Utilization management has been standardized for all Medicaid beneficiaries, Intensive Care Management (ICM) is available to all Medicaid beneficiaries

Data Multiple data sets, inconsistent/non-standard reporting of data to Department

One integrated data set is immediately available to Department, provides much greater level of detail and transparency

Contrast with MCO Arrangement (cont.)

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MCO ASO

Provider enrollment

Providers enrolled in one or many MCOs

Enrollment is handled through an online process by the Department’s contractor, HP

Provider rates Established by each MCO (non-standard)

Department uses a standard rate schedule and common service definitions for all services

Provider payment

Each MCO was responsible for payment

Payment is made by HP on a two-week claims cycle


Key Strategies

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Transition to Medical ASO: Direct Access to and Use of Data to Inform Strategies

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Under the ASO arrangement, the Department has direct access to an integrated data set that includes a wealth of claims and encounter data

Claims data consists of the billing codes that physicians, pharmacies, hospitals, and other health care providers submit to Medicaid

Encounter data is defined as data relating to treatment or service rendered by a provider to a patient

Transition to Medical ASO: Data Analytics

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The ASO has unprecedented capability in analyzing data for purposes including, but not limited to:

attribution of members to primary care practicessupporting members through Intensive Care Managementsupporting providers in understanding the needs of the members whom they serve

Transition to Medical ASO: Centralization of Member Services

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Centralization of member services with CHN-CT has enabled streamlined support with:

referral to primary care physicians referral to specialists assistance with prior authorization requirements and

coverage questions building relationships with members throughout their

entire enrollment periods, promoting continuity

Transition to Medical ASO: Centralization of Provider Services

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Centralization of provider services with CHN-CT has improved support with:

Prior authorization requirements Coverage questions Referrals

Transition to Medical ASO: Utilization Management

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CHN-CT has implemented a range of functions relating to utilization management:

prior authorizationutilization reviewspecific programs including a pain

management initiative

Transition to Medical ASO: Predictive Modeling

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Predictive modeling tools and other referral means (e.g. self-report, provider referrals) enable CHN-CT to identify those beneficiaries most in need of care management support

CareAnalyzer logic utilizes the Johns Hopkins University ACG® Predictive Models in conjunction with HEDIS methodology to identify members who may benefit from early intervention and improved coordination of care.

Transition to Medical ASO: Predictive Modeling (cont.)

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Some of the factors considered by the system include: duration (persistence/recurrence over time) severity (likelihood of disability or decreased life-

expectancy and likelihood of hospitalization) etiology diagnostic certainty expected need for specialty care (likelihood that

specialty services will be required) expected need and cost of diagnostic or therapeutic

procedures

Transition to Medical ASO: Intensive Care Management

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CHN has fully implemented a tailored, person-centered, goal oriented care coordination tool that includes assessment of critical presenting needs (e.g. food and housing security), culturally attuned conversation scripts as well as chronic disease management scripts

Additionally, CHN-CT now has in place geographically grouped teams of nurse care managers


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Person-centeredness is defined as an approach that:

provides the member with needed information,

education and support required to make fully informed decisions about his or her care options and, to actively participate in his or her self-care and care planning;


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supports the member, and any representative(s) whom he or she has chosen, in working together with his or her non-medical, medical and behavioral health providers and care manager(s) to obtain necessary supports and services; and

reflects care coordination under the direction of and in partnership with the member and his/her representative(s); that is consistent with his or her personal preferences, choices and strengths; and that is implemented in the most integrated setting.

Transition to Medical ASO: Intensive Care Management (cont.)

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An important feature of ICM is coordination with a co-located unit of Value Options (the behavioral health ASO)

Care managers from CHNCT, DSS and Value Options meet twice weekly to review hospitalizations and planned admissions to identify the appropriate care manager to take responsibility for the member’s care

Transition to Medical ASO: Intensive Care Management (cont.)

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In cases where neither the physical or behavioral diagnosis is primary, both the CHN and the Value Options care manager remain involved

In conclusion . . .

Transitioning Medicaid medical services from MCOs to a single, streamlined ASO platform has improved member and provider support; has through predictive modeling, ICM and data sharing enabled tailored responses to members’ needs; and created a partnership between DSS and CHN that is mission-driven toward improving the health outcomes and satisfaction of those served by Medicaid.

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Questions or comments?

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Medical Assistance Program Oversight Council September 13, 2013.

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