partners in a state pasrr program the delaware experience 2014 pasrr webinar... · partners in a...
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Managed Care Organizations (MCO’s):
Partners in a State PASRR Program
The Delaware Experience
Presented by: Mary Murabito, RNNursing Supervisor, PASRR Unit
Delaware Division of Medicaid and Medical Assistance
Frank L. Tetrick, III, MAPASRR Technical Assistance Center
November 18, 2014
Webinar Focus Areas
Growth in Managed Care Organizations (MCO) in LTSS
Impact of MCO role on PASRR partnership model
The Delaware experience
History
Goals and objectives
MCO engagement strategies
Delaware lessons learned
Moving forward strategies
Fee for Service
Health care providers are paid for each service (like an office
visit, test, or procedure). States may develop their payment
rates based on:
The costs of providing the service
A review of what commercial payers pay in the private
market
A percentage of what Medicare pays for equivalent services
Managed Long Term Services
and Supports
(MLTSS) refers to the delivery of long term services and
supports through capitated Medicaid managed care
programs.
MLTSS offers States a broad and flexible set of program
design options, and may be used as an overarching structure
to promote initiatives such as Money Follows the Person,
participant-directed services, the Balancing Incentive
Program, etc.
MCO’s: A Growing Force in LTSS Care
• Growth of MCO in LTSS
• States including NF’s in the capitation
• Likely continued shift to NF’s in a comprehensive capitation managed care model
• Broader role of MCO’s in all areas: Resource CMS 2012 Managed Care Enrollment Report http://www.medicaid.gov/medicaid-chip-program-information/by-topics/data-and-systems/medicaid-managed-care/medicaid-managed-care-enrollment-report.html
AZ
NC
WI NY
CA
21 States Had MLTSS as of 9/14
N
M
M
N
MI
IL
WA
KS
TN
TX
PA
FL
DE
MA
HI
RI
Contractors include private plans
Contractors are government- or provider-based
AZ
NC
WI NY
CA VA
OHIL
PA
TX
MN
MI
N
M
KS
TN
FL
NJ
Truven Health Analytics: October 1, 2014 Presentation to AHIP Conference on Medicaid.
MLTSS Programs Operating as of 10/7/14: Selected Characteristics
State and Program NF in Cap Rate?Persons in ICF or IDD waiver Enrolled? ICF/IID in Cap Rate? IDD Waiver in Cap Rate?
IDD Capitated Services Contractor
AZ ALTCS Yes Yes Yes Yes (1115) State IDD agencyCA MediConnect (duals) and MLTSS (Medicaid-only) Yes No
DE Diamond State Health Plan-Plus Yes No No NoFL LTC Managed Care Yes NoHI QUEST Integration Yes Yes No No
IL Integrated Care Program Yes No
IL Medicare-Medicaid Alignment Initiative Yes NoKS KanCare Yes Yes Yes Yes Health PlansMA Senior Care Options Yes NoMA One Care Yes No
MI Medicaid Managed Specialty Support and Services Yes Yes Yes Yes
County-based contractors with exclusive service areas.
MN Senior Health Options Yes, for the first 180 days (then FFS)No
MN Senior Care Plus Yes, for the first 180 days (then FFS)No
NJ FamilyCare MLTSS
Yes, for people newly eligible for NF after 7/1/14. (People in NFs on 7/1/14 remain FFS for 2 years) No
NM Centennial Care Yes Yes No No
NY MLTC Partial CapPending, subject to agreement with CMS No
NY MA Plus Yes No
NC MH/DD/SAS Waiver No Yes Yes YesQuasi-govt. entities with exclusive service areas.
OH MyCare Yes NoPA Adult Community Autism Program (ACAP) No Yes Yes Yes Autism providerRI Medicaid Integrated Adult Care in Rhody Health Options Yes NoTN CHOICES Yes No
TX Star+Plus Pending. Will be added 3/15. No
VA Commonwealth Coordinated Care Yes No
WI Family Care Yes Yes Yes YesCounty-based contractors.
WI Family Care Partnership Yes Yes Yes YesProvider-based contractors.
Data provided by Truven Health Analytics – permission required for any other use
LTSS Users in MLTSS Projected to
Double this Year
Year StatesLTSS
Enrollees
2004 8 105,000
2012 16 389,000
2013 19 554,000
2014 (projected) 21 1,170,000
Sources: 2004 and 2012: The Growth of MLTSS Programs: A 2012 Update
(Truven Health for CMS)
2013 and 2014: Truven Health estimates.
PASRR Partnership Roles and
Responsibilities – Then & Now
Traditional models suggest a hierarchical and silo’s approach to managing a process that is highly interdependent.
The emergence of MCO’s creates an opportunity to redefine the extended network that makes PASRR work.
PASRR Roles & Responsibilities
A Traditional Model
PASRR Technical Assistance Center -
PTAC
An Extended Network Model for
State PASRR Programs
PASRR Technical Assistance Center -
PTAC
The Individual
The Delaware Experience
Capitalizing on the MCO movement
to expand the PASRR Partnership
Where We Started
Prior to MLTSS
• Fragmented - Carved out of Managed Care
• Heavily institutional
• Limited options and choices
• Fee for Service
• Customer dissatisfaction
13
Community
Waivers,
3000
Nursing
Home
Populations,
3500
The Delaware MLTSS
Objectives
• Increase options for those who need Long Term Care
(LTC) by expanding access to Home and Community
Based Services (HCBS)
• Increase coordination of care and supports
• Create a budget structure that allows resources to shift
from institutions to community-based services
• Give consumers more choice and a greater voice
14
History: A Fast Timeline
2011 Start
February
• Kick Off
• Initial Steering Committee Meeting
March
• Program Design
• Communication Plan
April
• Governor's Commission
• System Design
15
2011 Steps
16
May
• MCO Discussions
June
• Application Submitted to CMS
• Stakeholder Communications thru December
Dec• CMS Waiver Approval
2012 – The Final Stretch
17
Jan
• Notification and enrollment of members
Mar• MCO Readiness Review
April• Program Implementation
The MCO’s
United Health Care
4/1/2012
Delaware Physician’s Care Inc. (Aetna)
4/1/12 – 12/31/14 (Participation ends on 12/31/14)
Highmark Blue Cross Blue Shield – Healthy Options
1/1/15
Managed / Integrated Long Term Care
Integrates Nursing Facility (NF) services and Home and
Community Based Services (HCBS) for the elderly and
adults with physical disabilities into the existing managed
care delivery system
What is Diamond State
Health Plan Plus?
19
Included Populations
• Nursing Home Residents
• Elderly and Disabled Waiver Participants
• AIDS Waiver Participants
• Other Full Duals (Medicaid / Medicare)
20
Benefit Comparison
Diamond State Health Plan• Acute Care Services• Inpatient Hospitalization• Outpatient visits• 30 day institutional care• Behavioral health• Limited case management• Limited durable medical
equipment
DSHP - Plus• Case management services• Nursing facility care• Assisted living care• Personal care services• Respite care• Day habilitation• Cognitive services• Consumer directed attendant
care• ADL Services• Nutritional supplement• Specialized durable equipment• Transition services• Behavioral health
MCO Engagement:
Delaware Division of Medicaid and Medical
Assistance MCO Strategies
Primary areas of interest that drove strategy
Avoid further silo of entities
Address providers concerns of managed care process and MCO’s
Reinforce existing efforts to improve the States PASRR process
Build greater collaboration amongst the extended PASRR network
Enhance specialized services efforts
PASRR Technical Assistance Center -
PTAC
Engagement Strategy:
Avoiding Silos and Hierarchical Model
Road show activities - Targeted to specific audiences (providers/NF/Hospitals/Physicians)
History
Direction
Opportunity to engage MCO’s
Q&A
PTAC consultant meetings with SMA/MHA/IDA/MCO’s
Focus on common objectives
Quarterly Pre-admission screening / MCO meetings
PASRR Technical Assistance Center -
PTAC
Engagement Strategy:
Reinforcing PASRR Activities and
Collaboration
Statewide PASRR Workgroup Meetings
• SMA/SMHA/SIDA/Division of LTC
Residents Protection
• Plan to move to quarterly calls
• New focus on “targeted strategic meetings”
PASRR Technical Assistance Center -
PTAC
New contract language is more specific to
specialized services:1. Emphasis on MCO coordination with SMHA,SIDA, NF,
providers on SS that are identified within the contract.
2. Emphasis on MCO “coordination” of SS that are not provided in
the benefit package.
3. MCO case manager ensures that PASRR is completed prior to
admission and RR addressed on significant change of status.
Emphasizing A Shared Commitment to
Specialized Services
Lessons Learned
Early engagement
Emphasis on partnership
Model the partnership
Bridge silos – shared ownership
Continued emphasis on quality reviews
Moving Forward in Delaware:
Strengthening PASRR
1. Several key principles for
strengthening the new PASRR
partnership.
2. Continued engagement with PTAC to
support Delaware efforts.
A Common PASRR Agenda
Work towards partnership developing a
common agenda for change, including a
shared understanding of the problem and
a joint approach to solving it through
agreed upon actions.
Common PASRR Progress Measures
Look for ways for consistent data collection
and measuring efforts across all the
participants and use data to help each entity
succeed in their unique efforts.
That we understand what’s working, what’s not
working, and most importantly: why?
Mutually Reinforcing Activities
That we maintain continuous
engagement and open dialogue that
creates a mutual support culture for all
PASRR partners.
Communications
That we maintain open and continuous
communication to build trust, assure
mutual objectives, and create common
motivation.
Backbone Organization
That we maintain a core of
knowledgeable and skilled people to help
us maintain our focus on continuous
improvement in our PASRR process.
Summary
1. MCO role in LTSS growth will continue
and early engagement in PASRR is
valuable.
2. Silo partnership model no longer represents
PASRR reality.
3. Addition of MCO’s creates opportunity to
strengthen all relationships and improve
states ability to divert and serve PASRR
eligible populations.
Contact Information
Mary Murabito: [email protected]
PASRR Office: 302-424-7120
Frank L. Tetrick [email protected]
Cell:804-436-5836
Questions / Recommendations