New York State Care Management for High Need High Cost Populations Presented by: Greg Allen,...
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Transcript of New York State Care Management for High Need High Cost Populations Presented by: Greg Allen,...
New York State Care Management for High Need High Cost Populations
Presented by:Greg Allen, Director of Financial Planning and PolicyNew York State DOH October 26, 2011
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"It is of compelling public importance that the State
conduct a fundamental restructuring of its Medicaid
program to achieve measurable improvement in
health outcomes, sustainable cost control and a
more efficient administrative structure."
- Governor Andrew M. Cuomo, January 5, 2011
Governor’s Vision for Reform
MRT Phase IMajor Reform Elements
(1) Global Medicaid Cap Two-year state share actual dollar cap.
Four-year state share spending cap linked to growth in CPI-Medical.
Industry challenge to control costs.
“Super powers” established to ensure that cap is not exceeded.
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(2) Care Management for All Begins three-year phase-in to access to “care
management for all” Medicaid members.
New York is getting out of the fee-for-service (FFS) business.
Over the next three years, new models of care management will be developed to ensure that special populations obtain the services they need (i.e., self-direction).
Over the next three to five years, develop more “fully-integrated” care management models. 5
(3) Major Expansion of PCMH and Launch of Health HomesUp to one million New York Medicaid
members could be enrolled in PCMHs or Health Homes.
Health Homes will be more expansive than PCMH and will target high-need/high-cost populations.
PCMH and Health Homes will be fully-integrated with care management.
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Integrated Care Management for All
Vision for the Future
Care Management for AllThe MRT has set New York on a multi-year path
to care management for all.
Care management for all is not traditional mandatory managed care in which states rely solely on insurance companies.
New York’s vision is that virtually every member of the Medicaid program will be enrolled in some kind of care management organization.
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Care Management for AllSome care management organizations will
be traditional insurance companies while others will be provider-based plans uniquely designed to meet the needs of special populations.
New York sees full capitation as its preferred financial arrangement but is open to other financing systems, especially for special populations.
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Care Management for AllNew York realizes that a period of transition
is necessary to achieve its ultimate goal of fully-integrated care management for the entire Medicaid program.
Fully-integrated means that a single care management organization would be responsible for managing the complete needs of the member (acute, long-term and behavioral care).
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Care Management for AllIt will take more than three years to reach this
final destination and existing care management organizations will need to evolve while new organizations will need to be created.
New York will use a wide range of care management tools including BHOs, existing health plans, managed long-term care plans and special needs plans to ensure it reaches its goal of eliminating FFS Medicaid within three years.
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Care Management Evolution Cycle
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COMMON QUESTION: How do Health Homes, PCMHs, and other Phase I strategies
fit within Care Management for All?
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Managed Care
PCMH
IDS
ACO
Health Home
BHO
Care Management for All The Vision
Medicaid and Dual Population 5 million
Mainstream HMO
RiskManagement Approach
Sub population
High Needs/High Cost
Duals/Non-Duals
Children/Families
Childless Adults
Partial Benefit
Mainstream HMO
Non Long Term Care
Long Term Care
Mainstream HMO
BH SNP AIDS SNP
Mainstream HMO LTC SNP (former
MLTCP) Possible Other Model
Possible FFS or other TPA
CareManagement Approach
HH
PCMH
IDS/ACO
HH
Self Direct
ed
IDS/ACO
PCMH
ACO
HH PCMH
ACO
HH
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CMS Medicaid Director Letter
“The goal in building “health homes” will be to
expand the traditional medical home models to build
linkages to other community and social supports,
and to enhance coordination of medical and
behavioral health care, in keeping with the needs of
persons with multiple chronic illnesses.”
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• All Other Chronic
Conditions• 306,087
Recipients• $698 PMPM
• Mental Health and/or Substance Abuse
• 408,529 Recipients• $1,370 PMPM
• Long Term Care
• 209,622 Recipients• $4509 PMPM
• Developmental Disabilities
• 52,118 Recipients• $10,429 PMPM
$6.5 Billion50% Dual10% MMC
$10.7 Billion
77% Dual18%
MMC
$2.4 Billion20% Dual
69% MMC
$6.3 Billion16% Dual61% MMC
HH Populations - 2010
$25.9 Billion
Total Complex
N=976,356$2,338 PMPM
32% Dual51% MMC
Out of the Behavioral Health and Chronic (n = 715K) Medical Cohorts in 2009:Just under 74,000 members were 0-20 years
oldApproximately 41,000 were in NYC 38,000 had a primary diagnosis in the Mental
Disorders spectrum
Children and Health Home
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HH Quality MeasuresGoal 3: Improve Outcomes for persons with Mental Illness and/or Substance Use Disorders
Mental Health Utilization(HEDIS 2012 – Use of Services) The number and
percentage of members receiving the following mental health services during the measurement year. Any serviceInpatientIntensive outpatient or partial hospitalizationOutpatient or ED
HH Quality MeasuresGoal 3: Improve Outcomes for persons with Mental Illness and/or Substance Use DisordersFollow Up After Hospitalization for Mental IllnessFollow up After Hospitalization for Alcohol and
Chemical Dependency DetoxificationAntidepressant Medication ManagementFollow Up Care for Children Prescribed ADHD
MedicationAdherence to Antipsychotics for Individuals with
SchizophreniaAdherence to Mood Stabilizers for Individuals with
Bipolar I Disorder
Implementation Status Enrollment target – January 2012 For Phase One
Phase One Counties – Bronx, Brooklyn, Nassau, Monroe, Warren, Washington, Essex, Hamilton, Saratoga, Clinton, Franklin, St. Lawrence, Schenectady
Phase two – April 2012, Phase Three – June 2012
CMS and SAMSHA Consults occurred with State HH Team - DOH, OMH, OASAS and Aids Institute
Working with MRT children’s behavioral health subcommittee and other children’s providers on building health homes that are tailored to the needs of the under 21 population
Draft quality measures have been developed with expert stakeholder group
Draft rates and finance model has been developed with State agencies – revising now based on feedback from expert panel.
Final State Plan submitted – much work up front with CMS on draft SPA.
NYS Health Home Website (links to many relevant materials):
http://nyhealth.gov/health_care/medicaid/program/medicaid_health_homes/index.htm
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Join the Health Home Listserv and get updated health home information. Go to: http://nyhealth.gov/health_care/medicaid/program/medicaid_health_homes/index.htm.
Questions or comments regarding NYS implementation of Health Homes can be directed to [email protected].
Questions?
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