Medicare/Medicaid Integration: Charting the Future Mark R. Meiners Ph. D. National Program Director Robert Wood Johnson

1. Medicare/Medicaid Integration: Charting the Future Mark R. Meiners Ph. D. National Program Director Robert Wood Johnson Foundation Medicare/Medicaid Integration Program New York State Medicaid Managed Care Conference, Beyond Managed Care: Striving for Excellence, Saratoga Springs, NY, May 30-31, 2006

2. Background to MMIP Experiences Robert Wood Johnson Foundation 15 Participating States: CO, FL, MN, NY, OR, TX, WA, WI, VA, CT, MA, ME, NH, RI, VT For Background and Technical Assistance Documents go to: CHPRE.GMU (click: Medicare/Medicaid Integration Program)

3. Why the Interest in Dual Eligibles? Important public financing considerations Cost shifting in both directions Unintended consumer consequences An opportunity to do better with limited resources Managed care implications Aging of the population/Chronic Care Imperative

4. Key Dimensions of Dual Eligible Integrated Care Program Development » Scope and flexibility of benefits - more than M&M fee-for-service » Delivery system - broad, far reaching, options, experience » Care integration - care teams, central records, care coordination. » Program administration - enroll, dis-enroll, integrated data & IS » Quality management and accountability - unified, broad, CQI » Financing and payment - flexible, aligned incentives

5. State Environmental Diversity Major differences in Medicaid programs Wide variations in state managed care infrastructure Differences in state goals and target populations States are in various stages of program development Divergent definitions of integration/coordination

6. Program Development Options Budget Neutral or Cost Saving Statewide or regional pilot (large vs. limited) Mandatory or Optional Duals/Medicaid-only Aged/Disabled Both? Timing? Well, Community Frail, Nursing Home National MCOs or Local Safety-Net Providers Provider Networks – open or closed? Waivers, Risk Adjustment, Enrollment Strategy M/M Coordination or Integration Benefits: Comprehensive/ Carve Outs

7. RWJF Medicare/Medicaid Integration Program Medicare Coordination Managed FFS Medicare Integration • Issues/Features • Medicaid and Medicare reimbursed FFS • No waivers required • Care coordinator link between programs and providers • Use of incentives (fees, co-location, reporting) • Issues/Features • Medicaid LTC capitated • Medicare HMO enroll encouraged • Various Medicaid waivers/authorities • Inability to capture Medicare savings • Case management lacks authority over Medicare • Issues/Features • 222 Medicare payment waiver & • Various Medicaid waivers • One contract for both payers • Flexibility to use savings for non-traditional services • Case management has control over both programs

8. Models: Buy-In Wraparound Capitated Wraparound Three-Party Integrated Plan-Level Integrated Key Considerations: Enrollment Operations Benefits Payments Appeals Part D Implementation CMS Guidance to Integrating Medicare/Medicaid

9. Chronic Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

10. P P P P P P A A A A A A D D D D D D S S S S S S S S S S S S D D D D D D A A A A A A P P P P P P A A A A A A P P P P P P S S S S S S D D D D D D P P P P P P A A A A A A D D D D D D S S S S S S Overall Aim: Implement the CCM for a specific Dual Eligible/Chronic Care Population Community Resources and Policy Organiz-ation of health care Clinical Information Systems Self- Manage- ment Support Delivery System Design Decision Support Develop Strategies for Each Component of the CCM

11. Core Building Blocks Targeting Beneficiaries: Risk vs. Reward Case Management / Care Coordination - Integrating Information Quality Methods and Measures Primary Care / Chronic Care Management

12. Quality/Consumer Focused Care Is the Key: Look at quality from various perspectives (i.e., consumer, provider, payer) Look at entire picture Consider structure, process and outcomes

13. Key Micro Strategy: Primary Care Teamwork Focus on holistic approach encompassing health and welfare (e.g., psychosocial, economic, environmental, social supports) Monitor ongoing health status for early detection of problems Emphasize health education and prevention Support chronic care self management Increase opportunities for communication

14. Summary Thoughts for Discussion Integrated Care Programs need to be expanded and replicated. Special Needs Plan represent both opportunity and challenge to IC. Continuous Quality Improvement Evaluation is necessary going forward.