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Stephen Sulkes

Managed Care and Care Coordination:  Ideas from the field. Stephen Sulkes. Barbara LeRoy. Elizabeth Hecht. Helen Hendrickson. New York State “People First” Waiver Program: Glacial Progress Toward a Managed Care Cliff. Stephen Sulkes Strong Center for DD Rochester, NY.

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Stephen Sulkes

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  1. Managed Care and Care Coordination:  Ideas from the field Stephen Sulkes Barbara LeRoy Elizabeth Hecht Helen Hendrickson

  2. New York State “People First” Waiver Program: Glacial Progress Toward a Managed Care Cliff Stephen SulkesStrong Center for DDRochester, NY

  3. NY State Medicaid-$50 billion out of total State budget of $130 billion ~$10 billion spent on DD population NY Times Expose “Triple Aim” Better care Better health outcomes Reduced costs Setting the Scene in NY State

  4. Follow the Money…

  5. Keep following the money…

  6. Overview • State’s Health Reform Landscape • Parallel effort to MRT for DD population re health care delivery transformation: to provide integrated, coordinated & comprehensive services in a more efficient manner that improves outcomes of the population. • 1915(b) and (c) Waiver • (b): Authorize creation of managed care service delivery system for DD populations • (c): Establish specific supports and services that will be provided • Impacted population: all 95,000 persons with DD in New York “People First” Waiver

  7. Goals • Improving access to services (“No Wrong Door”) • Implementing a Uniform Needs Assessment. • Implementing Care Management and Integrated Care Coordination. • Establishing a Sustainable Fiscal Platform. The system would move from a fee-for-service to a capitated reimbursement system that pays for integration and coordination of care. • Incorporating Robust Community Supports. • Reducing Reliance on Institutional Settings. • Enhancing Quality Assurance. “People First” Waiver

  8. DISCOs • DISCOs (Developmental Disabilities Individual Support and Care Coordination Organizations) = the core of OPWDD’s waiver proposal. • essentially a managed care organization – will need Art. 44 licensure • responsible for developing and maintaining a network of providers, coordinating care of their members, ensuring quality standards are met, and serving as the fiscal intermediary (accepting capitated payments and paying contracted providers). • partially- or fully-capitated • Under either model, eventually the only excluded services remaining in Fee-For-Service would be school supported health, early intervention, and certain residential services (OPWDD ICF/DD-DC/SRU). • private or public not-for-profit entities • care coordination experience • Cultural competence • Regions “People First” Waiver

  9. Capitation • Need to demonstrate an ability to manage risk. • Will cover Medicaid services, including care coordination and the person’s individualized budget under the self-direction option. • Rates will account for that DISCO’s member acuity level. • DOH = rate setting authority, working with OPWDD. “People First” Waiver

  10. Historical claim experience • Care coordination/management cost savings, • Administrative costs • Risk retention • (possibly) Quality withholds • Intrastate variations • Geographic region • Medicare status • HCBS waiver status • Residential setting • Individual age DISCO Premium!

  11. Show me the data!

  12. Components: • interRAI ID • Community Health Assessment • Community Mental Health • Self-Reported Quality of LifeTool • Palliative Care Tool • Includes: • Current functional info • Health info • Personal Preferences Assessment Tool: interRAI

  13. Council on Quality Leadership “Personal Outcome Measures®” • Emphasis on Individual, rather than System Evaluation Tool: CQL POMS

  14. Benefits: Partial Capitation

  15. Benefits: Full Capitation

  16. Only UCEDD/only physician on State Planning Committee Organized regional response in collaboration with Finger Lakes Health Systems Agency and Golisano Foundation “Fair broker” Coordinated local Request for Information writing team Explain elements of managed care Consultation to DISCOs Rochester UCEDD Role

  17. Special Olympics/Golisano Foundation Healthy Communities Dental Task Force Obesity Efforts AADMD Hospital discharge planning/readmission prevention effort Education across Medical Center Physician Training Accountable Care Organization Health & Employment efforts Ongoing Rochester UCEDD Health Disparities Effort

  18. Integrated Care for People who are Medicare-Medicaid Enrollees The Michigan Model

  19. Background Definition: Organized and coordinated service delivery for individuals who are dually eligible for both Medicare and Medicaid services and supports. Contract required between CMS, State, ICOs, and local service providers 26 States eligible for the Demonstrations 9 States have signed MOUs (10/2013): MA, IL, OH, NY, WA, CA, VA, MN, SC Michigan: in MOU negotiations (July 2014 start)

  20. MOU Components Assessment & Care Coordination Plan Benefit design Provider Network/Capacity Financing and Payment model Implementation strategy Quality and performance metrics Enrollment process Enrollee protections and appeals

  21. Michigan Model Goals • Seamless service delivery • Reduced fragmentation • Reduced barriers to HCBS • Improved quality • Streamlined administration • Cost effective Michigan Integrated Healthcare Pilot Regions

  22. Michigan’s Guiding Principles Person centered Self-determination Array of services appropriate to needs Accessible network of providers High quality supports and services Information available and coordinated Performance monitoring

  23. Michigan Key Components 207,000 eligible participants (75% of DD population) 4 region pilot (25 counties; n=102,000) ICOs will cover physical health, pharmacy, DME, and LTC PIHPs will cover behavioral health, substance abuse, and community supports & services (I/DD) New CMS Waiver(s) required Care bridge will integrate work of ICOs/PIHPs Passive enrollment w/ monthly opt-out option

  24. Michigan Key Components (con’t) Statewide information dissemination & marketing State level Advisory Council Enrollee participation on governing boards Integrated care ombudsman

  25. Michigan IC Advocacy Network Members • Aging Coalition • Self Advocates • Labor Unions AIDD Network Partners Disability Advocacy Organizations Social Justice THE MICHIGAN OLMSTEAD COALITION Working to Make Community-Based Long Term Care Available To All Who Need

  26. Michigan IC Advocacy Network Activities Weekly meetings Monitor plan, negotiations, & implementation Sit on work groups Testify at hearings Write briefs on issues Provide waiver development oversight Support self-advocates in seeking Advisory roles Inform constituents (email, blog, tweets, calls)

  27. Major Advocacy Issues Choice Person Centered Planning and Care Enrollment Safeguards Full Array of Services and Supports Grievance, Appeals, and Rights Processes Citizen Oversight Independent Evaluation Savings Reinvestment

  28. UCEDD Opportunities Advocacy Sit on work groups to structure State model & waiver(s) Advisory/Oversight committees Training for ICOs, Providers, Benefit Participants, Families Student internships – teaching and monitoring Materials Development and Dissemination Evaluation Technical assistance to recipients/families

  29. Points of Contact within States Medicaid Administration Office DD Services Administration MI Services Administration Office of Aging Departmental Advisory Groups Advocacy Coalitions Legislative Liaisons

  30. Waisman Center UCEDD-ACA Involvement- AUCD November 18, 2013 Elizabeth Hecht Outreach Specialist for Public Policy hecht@waisman.wisc.edu 608-263-7148

  31. Why we became involved in ACA • Opportunity to strengthen a dimension of our involvement in health • Health disparities for people with I/DD • Health disparities and public health data systems • Medical Home training and Learning Collaborative • Specialty clinics • Quality improvement initiatives • Major systems change effort in state

  32. Wisconsin Approach to ACA Governor declined federal planning grants Governor delayed discussion until after supreme court decision and 2012 election Sept 2012-WI declined to chose an EHB plan November 2012- Governor defers to Federal Exchange February 2013- Medicaid expansion rejected, 78,000 will loose Medicaid September 2013- State certification for navigators required

  33. Staying informed • WI Access Network- A diverse coalition of patient advocate, consumer, provider and insurer-based organizations to learn together and create a more unified voice to achieve common goals of expanding access to affordable, quality health care in WI. • Meet bi-monthly-share information, presentations on aspects of ACA, meet with CMS. • Initial focus on Exchanges and EHB • AUCD Health Reform Hub • Information and technical assistance

  34. WI - UCEDD Activities CORE FUNCTION-Community Education Q&A on the ACA for people with disabilities with Survival Coalition http://www.survivalcoalitionwi.org/wp-content/uploads/2012/10/ACA-QA.pdf Waisman Center Policy Seminar on ACA and People with Disability with Connie Garner Webinar on EHB 101 with speakers from Georgetown, Catalyst Center and WI - Office of the Commissioner of Insurance (OCI)

  35. WI - UCEDD Activities, con’t Pre-service education LEND-issue group on ACA Technical Assistance • Support to CYSHCN Network on ACA • OCI issues guidance on habilitation based on paper written by Waisman and DRW (P&A) • Identify and convene disability strategy group • Collaborate with Division of Public Health to draft and administer family survey on ACA • Join regional enrollment network

  36. UCEDD Policy Seminar

  37. UCEDD Webinar

  38. The Future • Shift focus to support individuals and families to maintain and utilize coverage • Monitor emerging issues • Changes in employer coverage • Changes in current plans and premiums • Continue to build relationship with policy-makers • Continue to work with coalitions representing disability perspective

  39. Duals in Massachusetts A Perspective on Implementation Helen M. Hendrickson E.K. Shriver Center Massachusetts Eunice Kennedy Shriver Center

  40. One of 15 states awarded a contract from CMS for a state demonstration to integrate care for dual eligible individuals • Enrollment began on October 1st, 2013 • Three Health ICOs managing care: Commonwealth Care Alliance, Fallon Total Care, and Network Health. • Three-pronged approach to education and outreach, including: • General public awareness • Targeted outreach to key subpopulations • Learning collaborative for ICO staff and providers

  41. Initial Training Topics Training Modalities • Introduction to One Care • Contemporary Models of Disability (Independent Living, The Recovery Model, Self-Determination) • Enrollee Rights and Protections • ADA Compliance • Introduction to Cultural Competency

  42. www. Mass.gov/MassHealth/OneCare/Learning

  43. Initial Webinar Statistics

  44. Webinar Satisfaction Survey Results

  45. In Person Conference October 23, 2013

  46. Future Training Topics • Best practices in delivery of LTSS and other services to maximize independent living • Behavioral Health Integration • Coordination of care within the provider network • Management of depression and alcohol abuse • Health promotion and preventative care

  47. Managed Care and Care Coordination:  Ideas from the fieldQUESTIONS? Stephen Sulkes Barbara LeRoy Elizabeth Hecht Helen Hendrickson

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