November 13, 2012

1. Massachusetts Medicaid Delivery Model Advisory CommitteeAssessment of MassHealth MCO and PCC Programs November 13, 2012

2. Agenda

3. Section 1 Introduction

4. Introduction Today’s discussion corresponds to these tasks from Navigant’s scope of work: • Conduct research on Medicaid delivery of care models, including lessons learned from innovation in the MCO and PCC plans in Massachusetts and implications for the future. • Describe the strengths and weaknesses of the MCO and PCC models to inform the state’s vision for health care payment and delivery moving forward, including the impact on patients and providers and long-term sustainability. Today’s discussion addresses these items from the Committee’s vision statement: • Identifying lessons learned from the MCO program and the PCC plan over the past years and implications for the future, including the strengths and weaknesses of the MCO and PCC models in addressing the needs of the new payment and delivery system.

5. Introduction Completed tasks from Navigant’s scope of work: • Identify individuals or organizations with expertise in Medicaid delivery of care models. • Coordinate and lead meetings with various stakeholder groups. • Analyze the experience of other entities and states in initiating and implementing innovative care delivery models. The additional information related to these experiences will be highlighted for the Advisory Committee (this includes state surveys). Ongoing tasks from Navigant’s scope of work: • Model the fiscal impact to the Commonwealth for different delivery of care models, taking into consideration cost drivers and trends, utilization, case mix, and potential for adverse selection. This analysis should consider the impact of National Health Care Reform implementation. • Draft the Advisory Committee’s report of findings and recommendations, including development of an implementation strategy. • Meeting support for the Committee.

6. Section 2 Overview of MassHealth • Key Elements of MCO and PCC Program Designs • MassHealth Demonstrations and Initiatives

7. Key Elements of MassHealth MCO and PCC Program Designs

8. Key Elements of MassHealth MCO and PCC Program Designs

9. MCO Program Administration and Contracting Structure * Four of the five MassHealth MCOs subcontract behavioral health; one MCO provides behavioral health services directly.

10. PCC Program Administration and Contracting Structure

11. MassHealth Demonstration and Initiatives • Dual eligibles demonstration • An integrated care management model scheduled to begin Summer 2013 for 110,000 dual eligible adults ages 21-64. Eligible enrollees will receive Medicaid and Medicare benefits along with behavioral health diversionary services and community support services through Integrated Care Organizations (ICOs). The Commonwealth will contract with ICOs, which will receive a capitated global payment and be required to meet quality benchmarks that enhance patient-centered care and coordination. • Patient centered medical home initiative (PCMHI) • A multi-payer (including MassHealth MCO and PCC and commercial health plans), three-year demonstration project authorized through Legislative directive. PCMHI goals are supporting primary care practices in the transition to PCMHs and evaluating the transformation’s impact on quality and health expenditures. • Primary care payment reform (PCPR) • The goal is to improve access, patient experience, quality and efficiency through care management and coordination, and integration of behavioral health and primary care. PCPR will be implemented in both the MCO and PCC programs with 25 percent of MCO and PCC members enrolled with PCPR providers by July 2013, 50 percent by July 2014 and 80 percent by July 2015.

12. MassHealth Demonstration and Initiatives (cont.) • Pediatric asthma bundled payment pilot • Multiple services patients receive during an episode of care will be bundled into one payment. MassHealth’s first bundled payment initiative, the Pediatric Asthma Bundled Payment Pilot will cover 100-200 asthmatic children and be implemented only in the PCC program. Currently awaiting CMS approval of the evaluation process for the pilot, which will be implemented in two phases. • Delivery system transformation initiatives (DSTI) • Allowed for via MassHealth’s 1115 demonstration extension, participating safety net hospitals will be required to demonstrate quality improvements in order to receive incentive payments. DSTI promotes alternative payment arrangements that reward high-quality, efficient, and integrated systems of care.

13. MassHealth Payment and Delivery system Initiatives* Payment Innovation True Accountable Care Global Payment Duals PCPR PCMHI “Business as Usual” Delivery System Transformation Payment Methodology DSTI Current Market FFS Limited Integration Full Care Integration Degree of Integration *MCO initiatives appear in various places throughout this diagram.

14. Section 3 Lessons Learned from MCO and PCC Programs

15. Lessons Learned from MCO and PCC Programs • PCC and MCO programs take different approaches for the structure, delivery and financing of Medicaid services • This section documents strengths and areas for consideration in relation to how the programs can facilitate MassHealth’s strategies for moving forwardwith payment and delivery system reform • Navigant conducted interviews with leaders from MassHealth, the Health Connector, and the Division of Health Care Finance and Policy (now the Center for Health Information and Analysis) as well as representatives from MBHP and the MassHealth MCOs, and reviewed previously published studies and other available information. Navigant did not perform a comprehensive operational assessment of MassHealth or its contractors. Note: provider interviews are currently being scheduled.

16. MassHealth Reform strategies

17. Strengths and Considerations: The MassHealth MCO program

18. Strengths and Considerations: The MassHealth MCO program *Navigant interview with Dr. Julian Harris on 10/11/12.

19. Strengths and Considerations: The MassHealth MCO program

20. Strengths and Considerations: The MassHealth MCO program

21. Strengths and Considerations: The MassHealth PCC program

22. Strengths and Considerations: The MassHealth PCC program • Community Support Program for People Experiencing Chronic Homelessness (CSPECH) aims to provide housing for homeless individuals with behavioral health issues. MBHP partnered with the Massachusetts Housing and Shelter Alliance and the Department of Transitional Assistance to link MBHP members with housing programs that have available housing vouchers.MBHP is developing a pilot project to encourage the primary behavioral health provider for high-risk members to take a greater level of responsibility for members overall health. MBHP is supplying profiling data to providers, which can later support alternative payment methodologies • *The Massachusetts Child Psychiatry Access Program (MCPAP) extends limited child psychiatry resources using a team-based approach (including a child psychiatrist, a social worker, and a care coordinator) to provide psychiatric telephone consultation to primary care providers. The initiative helps support primary care providers in caring for children with less-complex behavioral health needs. The requirements of MCPAP are detailed in the contract. • .

23. Strengths and Considerations: The MassHealth PCC program

24. Strengths and Considerations: The MassHealth PCC program

25. Section 4 Resources Needed

26. Resources Needed to Support MassHealth’s strategies • This section assess how implementing MassHealth’s strategies may impact resources for MassHealth, its contractors and providers in the following areas: • Contracting • Staffing • IT • Reporting • Quality • Finance • We used a Low, Moderate and High scale to illustrate the impacts

27. Strategy: Facilitate timely use of data and reporting to enable providers to effectively coordinate and manage care for MassHealth recipients

28. Strategy: Facilitate timely use of data and reporting to enable providers to effectively coordinate and manage care for MassHealth recipients (cont’d)

29. Strategy: Facilitate timely use of data and reporting to enable providers to effectively coordinate and manage care for MassHealth recipients (cont’d)

30. Strategy: Facilitate timely use of data and reporting to enable providers to effectively coordinate and manage care for MassHealth recipients (cont’d)

31. Strategy: Effectively engage consumers in their care

32. Strategy: Effectively engage consumers in their care (cont’d)

33. Strategy: Coordinate with community supports, long term care, and public health programs

34. Strategy: Coordinate with community supports, long term care, and public health programs (cont’d)

35. Strategy: Operationalize alternative payments, including calculation and payment of shared savings, quality incentive payments, capitated payments, and other payment structures

36. Strategy: Operationalize alternative payments, including calculation and payment of shared savings, quality incentive payments, capitated payments, and other payment structures

37. Strategy: Operationalize alternative payments, including calculation and payment of shared savings, quality incentive payments, capitated payments, and other payment structures

38. Strategy: Operationalize alternative payments, including calculation and payment of shared savings, quality incentive payments, capitated payments, and other payment structures

39. Strategy: Provide care for specific populations, including those with behavioral health needs, disabilities, low English literacy

40. Strategy: Provide care for specific populations, including those with behavioral health needs, disabilities, low English literacy (cont’d)

41. Strategy: Program evaluation and dissemination of best practices, including strong and standardized quality measurement and reporting

42. Strategy: Program evaluation and dissemination of best practices, including strong and standardized quality measurement and reporting (cont’d)

43. Strategy: Ensure responsible stewardship of resources including efficient contracting

44. Strategy: Ensure responsible stewardship of resources including efficient contracting (cont’d)

45. Strategy: Ensure responsible stewardship of resources including efficient contracting (cont’d)

46. Strategy: Ensure responsible stewardship of resources including efficient contracting (cont’d)

47. Section 5 Gap Analysis

48. GAP Analysis of MAssHealth’s Current Capabilities • Based on the findings identified in the previous two sections, this section • Summarizes MassHealth’s current capacity to move forward and • Indicates where there are gaps. • Identifies improvements needed to achieve the strategies identified by MassHealth. • This section also articulates the priority with which MassHealth should consider addressing the gap for either the MCO or PCC program.

49. Strategy: Facilitate timely use of data and reporting to enable providers to effectively coordinate and manage care for MassHealth recipients • Current Program Capacity: • Contractors are currently providing profiling reports to providers, although metrics and formats vary; some provide access to reports updated in real-time. • Through PCMHI, MassHealth is providing reporting to providers on patient characteristics, utilization and cost. • MassHealth program-wide initiatives to provide enhanced reporting and profiling to providers (via PCPR), are in the planning stages.

50. Strategy: Facilitate timely use of data and reporting to enable providers to effectively coordinate and manage care for MassHealth recipients (cont’d) GAP 1 Significant IT systems and staffing enhancements (for MassHealth, contractors and providers) may be needed to support enhanced data collection and reporting capabilities. MassHealth and its contractors must be able to give providers detailed information about their performance, care costs and trends that impact any shared savings component of their payment arrangements, including specific reports directly to the practices to support clinical care management, emergency department visits, hospital discharges, high risk patients, and member enrollment.