stephen sulkes
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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. - PowerPoint PPT PresentationTRANSCRIPT
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Stephen Sulkes
Barbara LeRoy
Elizabeth Hecht
Helen Hendrickson
Managed Care and Care Coordination: Ideas from the field
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Stephen SulkesStrong Center for DDRochester, NY
New York State “People First” Waiver Program:
Glacial Progress Toward a Managed Care Cliff
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*Setting the Scene in NY State
*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
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*Follow the Money…
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*Keep following the money…
OVERALL MEDICAID UTILIZATION TRENDS for People with DD
(SFY 05-06 v. SFY 09-10)
METRIC SFY 05-06 SFY 09-10% CHANGE
OVER 5 YEARS
ANN GROWTH
RATE
EXPENDITURE (State, local & Federal) $8,033,131,667 $10,217,391,898 27% 6.2%
MEMBER YEARS 89,987 100,512 12% 2.8%
PER MEMBER PER YEAR (PMPY) $89,270 $101,653 14% 3.3%
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*“People First” WaiverOverview
*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
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*“People First” WaiverGoals
*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.
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*“People First” Waiver
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
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*“People First” WaiverCapitation
*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.
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*DISCO Premium!
*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
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*Show me the data!
2009 2010 2011People 89196 90176 90219PMPM RangeDay Hab $558-909 $585-969 $642-999Res Hab $1354-
2227$1413-2318 $1395-2240
ICF/DD $375-1663 $412-1765 $360-1647
Total $3282-6161
$3450-6465 $3453-6321
Avg Per year: $39K – 74K $41K – 76K $41K – 76K
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*Assessment Tool: interRAI
*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
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*Evaluation Tool: CQL POMS
*Council on Quality Leadership “Personal Outcome Measures®”
*Emphasis on Individual, rather than System
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Family and individual support, integration and community habilitation, flexible goods and services, Home and Community-based clinical and behavioral supports Adult Day Health Care / Assisted Living Facility / ICF-DD Clinic Social Worker Day Treatment Dentistry DME and Hearing AIDS Home Care (Nursing, Home Health Aide, PT, OT, SP, Medical Social Services) Non Emergency Transportation Nutrition OASAS Inpatient OMH Institutional Program (PC/RTF) & private psychiatric hospitalizations Optometry/Eyeglasses OT, PT, SLP (in any venue) Personal Care Personal Emergency Response System Podiatry Psychotherapy Respiratory Therapy Skilled Nursing Facility / Specialty Hospital
*Benefits: Partial Capitation
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*Benefits: Full CapitationAll services required in partially capitated rate PLUS:
Chronic Renal DialysisEmergency TransportationInpatient Hospital Services (excluding private LT psychiatrichospitalizations)Laboratories ServicesOutpatient Hospital and Freestanding Clinic Services not identified in partially capitated ratePharmacyPhysician Services including services provided in an office setting, clinic, facility, or in the home.Radiology and Radioisotope ServicesRural Health Clinic Services
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*Rochester UCEDD Role
*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
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*Ongoing Rochester UCEDD Health
Disparities Effort
*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
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THE MICHIGAN MODEL
Integrated Care for People who are Medicare-Medicaid Enrollees
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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 Demonstrations9 States have signed MOUs (10/2013): MA, IL, OH,
NY, WA, CA, VA, MN, SCMichigan: in MOU negotiations (July 2014 start)
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MOU Components
Assessment & Care Coordination PlanBenefit designProvider Network/CapacityFinancing and Payment modelImplementation strategyQuality and performance metricsEnrollment processEnrollee protections and appeals
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Michigan Model Goals
Seamless service delivery
Reduced fragmentation Reduced barriers to
HCBS Improved quality Streamlined
administration Cost effective
Michigan Integrated Healthcare Pilot Regions
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Michigan’s Guiding Principles
Person centeredSelf-determinationArray of services appropriate to needsAccessible network of providersHigh quality supports and servicesInformation available and coordinatedPerformance monitoring
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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 LTCPIHPs will cover behavioral health, substance
abuse, and community supports & services (I/DD)
New CMS Waiver(s) requiredCare bridge will integrate work of ICOs/PIHPsPassive enrollment w/ monthly opt-out option
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Michigan Key Components (con’t)
Statewide information dissemination & marketing
State level Advisory CouncilEnrollee participation on governing boardsIntegrated care ombudsman
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Michigan IC Advocacy Network Members
Social JusticeAIDD Network Partners
Disability Advocacy Organizations
THE MICHIGAN OLMSTEAD COALITION
Working to Make Community-Based Long Term Care Available To All Who
Need Aging Coalition
Self Advocates
Labor Unions
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Michigan IC Advocacy Network Activities
Weekly meetingsMonitor plan, negotiations, & implementationSit on work groupsTestify at hearingsWrite briefs on issuesProvide waiver development oversightSupport self-advocates in seeking Advisory rolesInform constituents (email, blog, tweets, calls)
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Major Advocacy Issues
ChoicePerson Centered Planning and
CareEnrollment SafeguardsFull Array of Services and
Supports Grievance, Appeals, and
Rights ProcessesCitizen OversightIndependent EvaluationSavings Reinvestment
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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
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Points of Contact within States
Medicaid Administration Office
DD Services Administration
MI Services Administration
Office of AgingDepartmental Advisory
GroupsAdvocacy CoalitionsLegislative Liaisons
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Waisman Center UCEDD-ACA Involvement-
AUCD November 18, 2013Elizabeth HechtOutreach Specialist for Public [email protected]
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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
Why we became involved in ACA
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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
Wisconsin Approach to ACA
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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
Staying informed
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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)
WI - UCEDD Activities
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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
WI - UCEDD Activities, con’t
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UCEDD Policy Seminar
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UCEDD Webinar
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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
The Future
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Duals in MassachusettsA Perspective on Implementation
Helen M. HendricksonE.K. Shriver Center Massachusetts
Eunice Kennedy Shriver Center
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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
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Initial Training Topics
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
Training Modalities
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Live Webinars
Recorded Webinars
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www. Mass.gov/MassHealth/OneCare/Learning
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Event Date Live Event Attested
Intro to One Care 5/23/13 95 443
Models of Disability 6/13/13 69 132
Enrollee Rights 9/26/13 89 84 (live only)
ADA Compliance 10/17/13 79 100 (live only)
Cultural Competency 11/14/13 NA NA
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Initial Webinar Statistics
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Webinar Satisfaction Survey Results
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Shared Learning One Care Conference October 23, 2011 Survey Respondent Totals (Average Scores)
(96 Total Evaluations – Raw data is available)
Plenary: a paradigm change in disability healthcare: what was and what we hope will be
Score (1= Unsatisfactory; 5= Excellent)
- Robin Callahan, MA, Burton D. Pusch, RhD & Judith Steinberg, MD, MPH
1. Please evaluate the OVERALL quality of this CEU/CME session. 4.27
2. How well did the presentation describe the goals and vision for the One Care Initiative?
4.43
3. How useful was the discussion of the implications of the term “paradigm shift” for care of people with disabilities?
4.36
4. How effective were the presenters? 4.43
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In Person Conference October 23, 2013
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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
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Future Training Topics
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Stephen Sulkes
Barbara LeRoy
Elizabeth Hecht
Helen Hendrickson
Managed Care and Care Coordination: Ideas from the fieldQUESTIONS?