managed medicaid: cms 2390 impact

Managed Medicaid: CMS 2390 Impact Donna CostanzaVice President, Value-Based Care Strategic SolutionsConifer Health Solutions

2 ©2016 Conifer Health Solutions, LLC. All Rights Reserved.

Donna CostanzaVice President Strategic Solutions, Conifer Health Value-Based Care

Leads delivery and strategic solutions for clients which are responsible for providing high quality and effective delivery of Conifer Health services and technology to clients

Directs client management, network development and physician alignment strategies

Previously the Chief Operating Officer of Cap Management Systems, leading health plan operations and financial management of over 30 risk-bearing provider organizations and hospitals

Has more than 20 years experience with managed Medicaid, Medicare and commercial programs


Significant Scale Advantage

Service Centers

Headquarters

14,500+ EMPLOYEES20 SERVICES CENTERS

800+ CLIENTS IN43 STATES

BILLION MEDICALLY MANAGED SPEND FOR EMPLOYERS19$ +

Facts based on data ending Q4 2015

5.7MILLION MANAGED LIVES

+MILLION PATIENT TOUCH-POINTS ANNUALLY25+

BILLION NET REVENUE PROCESSED ANNUALLY

28$ +


CMS 2390-P Overview

Major proposed rule to align Medicaid managed care with Medicare Advantage and qualified health plans (QHPs) First significant revisions since 2002

Multiple statutory provisions on beneficiary protections and state and federal oversight for program accuracy and actuarial soundness related to payments

Expands federal role in rate setting at both the managed care organization and at the provider level

Mandates states to launch comprehensive quality strategies

Places special focus on long-term services and supports (LTSS)


What’s driving CMS 2390-P? Explosion of Medicaid managed care populations

Medicaid now accounts for about 16 percent of total personal health care spending in the United States and will soon exceed $500 billion in annual expenditures. Payments for managed care account for 25-30 percent of all Medicaid benefit spending.

71.8% Medicaid enrollees in some type of managed care arrangement

63% of children

48% of adults

33% of people with disabilities

13.9% of seniors

13.2% percent of dual eligibles

Populations enrolled in risk-basedmanaged care


Some variance by markets – but still impacting nearly every care community


Major provisions of CMS-2390-P

Network adequacy – Sets minimum federal network adequacy standards (States may be required to adopt enforcement strategies)

Beneficiary support system State-directed provider payments – CMS would still prohibit states from directing plans to

make provider payments, but would allow them to: Place contracted provider payments under particular (value-based) payment methodologies to

promote quality, or Incent providers to participate in particular initiatives


Major provisions, continued…

Medical loss ratio – Minimum of 85% Actuarial soundness – Significant change. States must certify actual payment

rates to CMS. Information standards – Plans would have to provide enrollees with member

handbooks and formulary information Grievance and appeals – Aligns Medicaid and CHIP grievance and appeals

processes with those that exist for MA and commercial coverage Marketing – Rule would clarify that Medicaid plans that also offer QHPs may

market both at the same time to the same individuals without violating the Medicaid marketing restriction on the sale of private insurance


Major provisions, continued…

Plan choice – Would require states to provide beneficiaries with at least 14 calendar days and appropriate informational notices to make a decision on plan enrollment

Institutions of mental disease – Would permit capitation payments to plans for enrollees who have a short-term stay – 15 days or less – in an IMD

Quality of care – States would mandatorily need to launch comprehensive quality strategies for Medicaid and CHIP programs

Program integrity – Would require states to screen and enroll all Medicaid providers to address what CMS describes as a lack of consistency between managed care and FFS provider screening and enrollment

Prescription drug coverage – CMS proposes to require that states cover, through FFS, any Section 1927 covered outpatient drugs or classes of drugs that are excluded from the managed care contract


Moving from Fee-for-Service to Fee-for-Value

Clinical Integration Upside ACO Full Capitation

Employer ACO

Episodic & Bundled

Payments

Commercial ACO

MSSP ACO

Managed Medicare / Medicaid

Clinically Integrated Network

Upside/Downside ACO Licensed product

NextGen ACO

Increasing expertise needed to manage risk and engage providers


Conifer Health Services Services Union Employer Bundled Services ACO/IPA MSSP RBO

Consulting

Marketing •Payor and Provider Contracting • • • •Provider Network Development • • • •Provider Network Relations •

Data Storage

Data Warehouse • • • • • •Document Intake • • • •Eligibility Enrollment • • • • • •

Member Performance

Member Adherence • • • •Member Engagement • • • •Participant Portal • • • •

Population Health Member Risk Stratification • • • • • •Provider Performance Provider Portal • • •

Reporting

Financial Analytics • • • •Operating Performance •Quality Performance • • • •Regulatory Performance • • •Self-Serve Analytics • • • •

Transactions

Claims Processing • •Concurrent Review • •Credentialing •Grievance and Appeals •Member Enrollment Cards •Provider / Member Call Center • •Referral Determination • •


Success with Managed MedicaidFive Areas for Consideration

• Contracting with Payers• Utilization Management and Care Coordination• Network Design and Adequacy• Risk Experience• Reporting and Compliance


Successful IPAs, Health Systems, and Risk Bearing Organizations:

Operate, control, monitor, track, and trend financial levers which deliver high quality performance to its providers and members Payor Revenue Member Revenue and Expense Provider Expense Benchmark Analysis


Revenue Levers

Revenue Payor Performance Attributed Populations (aid code, risk adjustment factor, age, sex). Incentive Programs (complex case, preventive measures, hierarchical condition codes). Shared Savings Programs (re-admissions, level of care, contracted services).


Insights When Entering Risk Arrangements

Revenue Modeling Percent of Premiums Acuity Level/Risk Adjusted Factors Aid Code Age/Sex Adjustment Per Member Per Month

Expense Modeling Fee Schedules Design Division of Financial Responsibility Analysis Benefit Structure Consideration


Division of Financial Responsibility (DOFR)Group Hospital Blue Shield

Services

Patient Counseling •Podiatry •Pre- and Post-Transplant Services •Radiation Therapy •Acute Detox •Psychiatric / Substance Abuse •Urgent Care Services - Within Group Service Area •

Urgent Care Service - Outside Group Service Area •

Health Care Professional

(inpatient)

Diagnosis, Treatment and Therapy •Emergency Services - Within Service Area •Emergency Services - Outside Service Area •Pathology / Radiology / Anesthesia •Transplant (all inclusive case rates) •Transplant (physician fees excluded from case rate payment) •

Urgent Care Services - Within Group Service Area •

Urgent Care Services - Outside Group Service Area •Visits / Consultations / Surgery •

Facility Services (inpatient)

Emergency Services - Within Service Area •Emergency Services - Outside Service Area •Facility and Supplies •Acute Detox •Psychiatric / Substance Abuse •Take Home Drugs •Transplant (includes kidney) •Urgent Care Services – Within Group Service Area •


Expense Levers

Expense Provider Performance

Physician Performance (HEDIS, HCC, PQRS) Utilization Performance (Referral, Visits) Provider Utilization (ER usage, admissions, LOS)

Patient Performance Quality Performance(Preventive Measures) Complex Care Programs Patient Utilization (ER usage, adherence)


$1.8m Group was losing $1M per year

Placed on Corrective Action by the Department of Managed Healthcare; threat of enrollment freeze and risk de-delegation.

Network maintenance Narrow network and renegotiated

provider contracts

Medical management Improved high-cost

pharmaceutical utilization

Financial risk design Renegotiated health plan

contracts

Increased profitability by shifting from annual loss of $1M to annual profit of $0.8M

90 PCPs receiving capitated payments for 30,000 managed Medicaid patientsThe Client

The Challenge How We Helped The Results

Case Example: Managed Medicaid

PP_ManagedMedicaid_080415


$2k Health plan desired to reduce ER facility expense and offered grant to physicians for reducing

Physician group desired to create an incentive plan to help ER utilization and ensure capture of grant dollars Reduction in

ER utilization

California IPA with 54,000 lives200 primary care physicians serving the dual eligible population in a highly competitive market

The Client

The Challenge How We Helped The Results

Case Example: Medicaid

PP_ManagedMedicaid_080415

Financial risk design Created incentive structure to reduce

ER utilization

Medical Management After-hours access to PCP offices and

contracted with urgent care centers Enrolled top ER users in case

management program

Member engagement Educated patients about correct use of

ER vs urgent care through direct mail

Paid per physician through incentive programs

10%

Questions & Answers