SCDuESouth Carolina Dual

Eligible Demonstration

Integrating Care for Medicare-Medicaid EnrolleesTuesday, October 15, 20134pm

Presenters: Teeshla Curtis, Program Manager;Sam Waldrep, Senior Consultant; and Dr. Michael Musci

GOALS FOR THIS SESSION

To provide an overview of the South Carolina Department of Health and Human Services’ (SCDHHS) South Carolina Dual Eligible Demonstration (SCDuE)

To describe how the Demonstration aligns with South Carolina’s health reform strategies for clinical integration

History and Background

HISTORY

Medicare and Medicaid programs signed into law July 30, 1965

1965 “three-layer cake” – Medicare Part A hospital services; Medicare Part B physician and other outpatient services; and Medicaid expanding federal support for health care services for poor elderly, disabled, and families with dependent children

Not initially designed to integrate and coordinate services for individuals served by both program

HISTORY

During the first year of Medicare, superior health care has been provided for millions of aged Americans, and health standards have been raised for all Americans. This has come about because of cooperation between the federal government, physicians, insurance carriers, and the states. It would not have been possible without the strong support of each of these groups. We have forged a partnership for a healthier America. Statement By the President on the First Anniversary of Medicare – July 1, 1967

DUAL ELIGIBLES

10.2 million Americans are eligible for Medicare and Medicaid (known as Medicare-Medicaid enrollees or “dual eligibles”)

7.4 million are “full duals”

17.7% increase, from 8.6 million to 10.2 million between 2006 and 2011 (One in five Medicare enrollees)

In comparison, the number of Medicare-only beneficiaries grew by only 12.5%

Sources: Data Analysis Brief Medicare-Medicaid Dual Enrollment from 2006 through 2011, Prepared by Medicare-Medicaid Coordination Office, February 2013.

The face of South Carolina’s Medicare-Medicaid enrollees 65+ is:

75% Female51% African-American1-2 chronic conditions

Most common conditions: diabetes and heart disease

75% not using LTSS

Source: Centers for Medicare & Medicaid Services. (n.d.). Medicare-Medicaid enrollee state profile. Retrieved from http://www.integratedcareresourcecenter.com/PDFs/StateProfileSC.pdf

STATE PROFILE

Chronic Disease Prevalence by Enrollment Group

Source: Centers for Medicare & Medicaid Services. (n.d.). Medicare-Medicaid enrollee state profile. Retrieved from http://www.integratedcareresourcecenter.com/PDFs/StateProfileSC.pdf

FULL BENEFIT MEDICARE-MEDICAID ENROLLEES’ USE OF

FEE-FOR-SERVICE MEDICAID-FUNDED

LTSS

Source: Centers for Medicare & Medicaid Services. (n.d.). Medicare-Medicaid enrollee state profile. Retrieved from http://www.integratedcareresourcecenter.com/PDFs/StateProfileSC.pdf

PURPOSE OF SCDUE

This Demonstration will provide a new health care option for South Carolina’s seniors with both Medicare and Medicaid. This program will make it easier for Medicare-Medicaid enrollees to receive all Medicare and Medicaid services through a single entity that is accountable for the quality and cost of these services.

The Demonstration proposes:• To integrate and coordinate care for beneficiaries

with both Medicare and Medicaid; and• To purchase quality health outcomes through a

person-centered model that delivers care at the right time and in the most appropriate setting.

PURPOSE OF SCDUE

Goals• Improve health outcomes• Delay the need for nursing facility care• Reduce avoidable emergency department visits and

hospital readmissions• Increase access to home and community based services

Covered Services• Medicaid services, including:

• Behavioral health

• Home and community based services

• Nursing facility services

• Medicare services, including:• Primary and acute care

• Part D (prescription drugs)

• Skilled nursing facilities

Status Update and Overview

STATUS UPDATE

The SCDuE team is in the process of finalizing the Memorandum of Understanding (MOU) between the State and CMS.

The MOU will outline the operational details of the Demonstration including changes the State has incorporated since the initial submission of its proposal in May 2012.

Participating health plans will be selected later this fall.

Healthy Connections Mission:

…to purchase the most health for our citizens in need at the least possible cost to the

taxpayer.

Health Reform in South Carolina

3 Pillar Strategy

Payment Reform

ClinicalIntegration

Hot Spots&

Disparities

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PAYMENT REFORM

SCDHHS SCDuEControl health care spending to allow:

o Increased investment in education, infrastructure and economic growth;

o A shift in health care spending to more productive health and health care services;

o Increased coverage/treatment of vulnerable, high-needs populations; and

o Excess costs and inefficiencies to be pushed out.

Encourage a managed and coordinated environment through:

o Blending of Medicare & Medicaid into a single capitated payment;

o Alignment of initiatives;o Incentives for appropriate

utilization of long term care services (i.e., home and community-based services vs. nursing facility );

o Purchasing quality health outcomes; and

o Continued emphasis on rebalancing long-term care.

https://msp.scdhhs.gov/scdue/

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CLINICAL INTEGRATION

SCDHHS SCDuECreation of a system of care management that:

o Provides optimal incentives for patient-centered care;

o Provides disincentives for activities that do not contribute to improved health;

o Emphasizes research & benchmarking to inform wise-minded policies; and

o Recognizes the importance of care coordination.

Integration of existing silos in Primary Care, Long-Term Care and Behavioral Health that:

o Blends Medicare & Medicaid services;

o Promotes the use of electronic applications (e.g., EMR, telemonitoring, telepsychiatry); and

o Emphasizes a multidisciplinary care team approach at the PCMH level.

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HOT SPOTS & DISPARITIES

SCDHHS SCDuEOur goals are to focus on localized needs to:

o Improve overall health outcomes;

o Provide the right care at the right place at the right time; and

o Address disparities that are especially relevant for our State’s Medicaid population.

In focusing on high-need populations, the Demonstration will:

o Concentrate on health disparities in the target population, such as hypertension and diabetes;

o Focus on behavioral health issues often overlooked for a geriatric population; and

o Avoid inappropriate utilization of more costly institutional services.

https://msp.scdhhs.gov/scdue/

“At the core of our mission are seniors and persons with living disabilities.”

- Anthony Keck, SCDHHS Director

CURRENT SYSTEM

Fragmented

Not Coordinated

Complicated

Difficult to Navigate

Not Focused on the Individual

Gaps in Care

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INTEGRATED CARE

One set of comprehensive benefits: primary & acute care , prescription drug, and long-term supports and services

One ID card

Single and coordinated care team

Health care decisions based on beneficiary needs and preferences

Provide flexible, non-medical benefits that help individuals stay in the community

PERSON-CENTERED

Improve both the quality of care and the quality of life

Foster patient-provider communication and relationships

Enhance health literacy to support informed decision making

Participant’s strengths, capacities, preferences, and personal outcomes are identified and documented

PERSON-CENTERED

I decide where and with whom I live. I make decisions regarding my supports and services. I work or do other activities that are important to me. I have relationships with family and friends I care about. I decide how I spend my day. I am involved in my community. My life is stable. I am respected and treated fairly. I have privacy. I have the best possible health. I feel safe. I am free from abuse and neglect.

Source: (Ingram, 2013). Integrated Care Transformation: State Accomplishments, Challenges and Opportunities for the Future [PowerPoint Slides]. Improving New Systems of Innovation for Dual Eligibles.

Care Coordination

CARE COORDINATION

Patient Center Medical Home model, lead by primary care provider

Multidisciplinary team structure with provider input and/or direct involvement

Transition planning (e.g., transitions between acute care settings and the community or nursing facilities)

Bi-directional communications between health plans and providers

Person-centered approach

CARE COORDINATION

Universal Assessment Tool

Individualized care plan involving participant and/or her caregiver

Designated care coordinator linking participant, PCP, family/caregiver ensuring care coordination and the communication of barriers and needs

CARE COORDINATION

Access to a single, toll-free point of contact for all questions;

Development of an Individualized Care Plan that is periodically reviewed and updated;

Disease self-management and coaching; and

Medication review, including reconciliation during transitions of care setting.

Provider Reimbursement

Structure

RATE STRUCTURE

Blended capitation rate: Medicare Part A, Part B, Part D, Medicaid

Medicaid Rate Cells• Nursing Facility• Home and Community Base Services Plus• Home and Community Base Services • Community

PAYMENTS

Provider reimbursements negotiated by provider with contracted health plans

Pay for Performance

Care transition related incentives

Reimbursements should not be identical to FFS model

Shared goals based on outcomes

Eligibility and Enrollment

SCDuE Demonstration Proposal

Target Population - Full-Benefit Duals- Age 65+- Non-institutional- Non-PACE- Non-DDSN waiver- Not enrolled in

Hospice- Not receiving ESRD

services

Total Full-Benefit DualsDemonstration Eligible

- 131,090- 53,600

Financial Model - Capitated- Coordinated and

Integrated Care Organization (CICO)

Geography - Statewide- Regional Phase-in

Implementation Dates - July 1, 2014- Opt-in period followed

by passive enrollment

1. The Henry J. Kaiser Family Foundation. (2013, August 1). State demonstration proposals to integrate care and align financing for dual eligible beneficiaries. Retrieved from http://kff.org/medicaid/fact-sheet/state-demonstration-proposals-to-integrate-care-and-align-financing-for-dual-eligible-beneficiaries/

Overview & Background

ELIGIBILITY OVERVIEW

Demonstration population inclusion criteria:• Individuals 65 years and older• Full-benefit dual eligible• Individuals receiving Home and Community Based Services (HCBS) waivers (i.e.,

HIV, Vent, and Community Choices)

Excluded populations (at time of enrollment):• Residing in a nursing facility;• Enrolled in hospice;• Receiving End-Stage Renal Disease (ESRD) services;• Enrolled in a Program of All-Inclusive Care for the Elderly (PACE); or• Enrolled in Department of Disabilities and Special Needs (DDSN) operated

waiver serving adults (ID/RD, HASCI, and Community Supports).

Enrollment includes an opt-in period following by passive enrollment. The Demonstration is voluntary; beneficiaries can opt-out as well as change plans at any time.

ENROLLMENT

Opt-in statewide enrollment: July 1, 2014 - December 31, 2014

Passive enrollment:

Wave 1 – January 1, 2015Wave 2 – March 1, 2015Wave 3 – May 1, 2015

NEXT STEPS

Signing of MOU

Release of Demonstration name

New SCDuE website launch

Provider forums – November 2013

Start of Readiness Review Process

NEXT STEPS

Integrated Care Workgroup MeetingThursday, October 17

10am – 12noonLexington Richland Alcohol and Drug Abuse Council

(LRADAC)2711 Colonial Drive, Columbia, SC 29203

Questions?

Thank You

CONTACT INFORMATION

Nathaniel J. Patterson, MHADirector, Health ServicesSC Dept. of Health & Human Services1801 Main StreetColumbia, SC 29201(803) 898-2018 | Office(803) 255-8209 | Faxpattnat@scdhhs.gov

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SCDuE Websitehttps://msp.scdhhs.gov/scdue/

Teeshla CurtisSCDuE Program ManagerSC Dept. of Health & Human Services1801 Main StreetColumbia, SC 29201(803) 898-0070 | Office(803) 255-8209 | Faxcurtist@scdhhs.gov

________________________________

SCDuE E-mail Addressscdue@scdhhs.gov