DRAFT
MaineCare Long Term Strategy
MaineCare Redesign TaskforceOctober 23, 2012
Seema Verma, SVCRobert Damler, Milliman
DRAFT
Expense by Cost Distribution FY2011Bottom 80 -
16%
80-89 per-centile - 14%
90-95 per-centile - 16%
Highest 5% - 54%
Source: MaineCare Redesign Taskforce, Maine by the Numbers, 2012.
DRAFT
Annual Cost Per Member
Top 5% 90 to 95% 80 to 90% Low 80%$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000 $68,562
$21,011
$9,199 $937
Source: MaineCare Redesign Taskforce, Maine by the Numbers, 2012.
Cost PMPM Top 5% 90 to 95% 80 to 90% Low 80%
$5,713 $1,750 $766 $78
DRAFT
Who is the typical consumer?
Top 5% 2nd 5% 80-89% <80%
Age group
18-44 18-44 18-44 Under age 18
RAC SSI disabled SSI disabled
Not receiving AFDC, but
eligible (parents/
caregivers)
Under 19, income
<125% FPL
Clinical condition
Developmental disability
Mental health:
neuroses
Pregnancy with
complications
Preventive/ Admin
encounters
Provider type
Waiver services
PNMI/Waiver
services
Physician/ Hospital
Physician/ Hospital
Source: MaineCare Redesign Taskforce, Maine by the Numbers, 2012.
DRAFT
Previous Options• Option 1: State based (FFS)• Further development of State utilization management
program• Active risk assessment & case management by State• Development of disease-specific management programs• Could develop different benefit packages according to risk
• Option 2: Value based purchasing design• Medical homes, ACOs, incentive payments
• Option 3: Capitation• Population & region, services• Providers, MCO, ACOs, PACE• Models: shared savings, risk adjustment, reinsurance,
etc.
DRAFT
Proposed: Multi-Tiered StrategyBased on Population• Investment in primary care (80% of MaineCare)• Pregnant women• Children• Parents
• Coordinated, quality services for Maine’s most vulnerable citizens (top 20% of MaineCare)• Waiver populations • Institutionalized• Disabled with chronic diseases• Other high risk
• Effective & efficient use of services (100% of Maine Care)• All populations
DRAFT
Investment In Primary Care:Value Based Purchasing • 80% of MaineCare• Target groups:• Non-disabled • Non-elderly populations• Non-institutionalized populations
• Health homes/Primary care case management• Primary care incentive program• Accountable care organizations• Targeted initiatives:• ED• Maternal & child health• Care coordination aimed to assist transitions• Increased promotion/incentive of PMP program to address
narcotic abuse, incentives for using HIE, PA all MRIs and CTs
DRAFT
Goals of Value Based Program
•Pay for outcomes•Pay for quality•Incent consumers to become active
participants in their healthcare consumption
•Design benefits that provide appropriate intensity and levels of care
•Providers coordinate total care resulting in better outcomes at lower costs
DRAFT
Accountable Communities • MaineCare is planning an Accountable Communities Program• Goal is for groups of provider organizations called
accountable care organizations (ACOs) to provide better care to members for lower costs
• ACOs usually formed by different providers working together• Primary care doctors• Specialists• Hospitals• Others
• How does this work?• Type of ACO is unknown• “We want to work with health care providers to plan the
kind of ACOs we will have so that they join us in this project.”• ACOs have to meet quality goals• ACOs will have goals to save money
Source: Value Based Purchasing, Member Services Committee, October 7, 2011
DRAFT
Patient Centered Medical Homes• PCMHs are primary care practices that:• Care for members using a team approach with
communication among physicians & supports• Encourage the member & provider to have a good
relationship• Use information technology to track member data• Make it easier for members to schedule necessary
appointments• Focus on providing better care for members with
serious physical & mental health issues• Currently• 26++ PCMHs• 8 Community Care Teams
Source: Value Based Purchasing, Member Services Committee, October 7, 2011
DRAFT
Primary Care Provider Incentive ProgramThe Primary Care Provider Incentive Payment (PCPIP) program pays bonuses to doctors that achieve certain goals:
1. Seeing MaineCare members at their doctor’s office 2. Primary care over emergency room care3. Quality
“MaineCare has not changed how it does the PCPIP since 2007. Doctors receiving the PCPIP do a much better job seeing MaineCare members at their office now than they used to. But in other areas, the doctors have not improved very much or at all.”
“MaineCare is going to see how it can change the program to make sure that doctors are improving in all areas.”
Source: Value Based Purchasing, Member Services Committee, October 7, 2011
DRAFT
Contracting Strategy
• Continue FFS• Continue PMPM management fee to primary care
medical homes• Quality Incentive Program
• Community coordinators• PMPM fee
• Care Management Organization (CMO)• Manages, utilization, PA etc.• Oversees PCCM• LA model• Shared savings & risk
• Future capitation to ACOs
Louisiana Model• Operates under 1932(a)(1) SPA authority• Mandatory enrollment for disabled & non-
disabled• Excluded populations• Duals
• Voluntary Enrollment (must opt-out)• SSI Children• Foster Children• Children Receiving Special Health Services• Native Americans
• Enrollees have choice between Enhanced PCCM Model & MCO Model
Sources: Louisiana Department of Health and Hospitals, Healthcare Delivery Changes/Birth Outcomes Initiative, 2011; Louisiana State Plan Amendment, 2011; Louisiana Department of Health and Hospitals,
2012.
DRAFT
Louisiana Model• Enhanced PCCM model• Two entities operate PCCM model• Saving targets• Savings shared with providers• If no savings return up to 50% monthly care
management payment made for each member• Example:• Total payments made for care management = $60M• Net loss of $3M• $3M owed to State
• Network of primary care providers only
Sources: Louisiana Department of Health and Hospitals, Healthcare Delivery Changes/Birth Outcomes Initiative, 2011; Louisiana State Plan Amendment, 2011; Louisiana Department of Health and Hospitals,
2012.
DRAFT
DRAFT
Timeline & Implementation
1/12
1/12Care
Coordination Teams
Start
1/13Health Homes Begin
7/13Primary
Care Incentive Program
Spring 2013
Accountable
Communities
Source: Value Based Purchasing, Member Services Committee, October 7, 2011
DRAFT
Cost Distribution for Low 80%*Adult/Child Disabled Other
Hospital $ 88.9 $ 7.7 $ 2.6
Mental health $30.6 $ 10.9 $ 1.5
LTSS/Other $ 29.8 $7.7 $ 9.1
Physician $ 51.9 $ 8.5 $ 9.3
Pharmacy $ 38.8 $9.2 $ 1.8
All other $ 22.3 $ 3.9 $ 1.1
TOTAL $ 262.4 $ 47.9 $ 25.3
Lives 191,916 28,857 37,390
Source: DHSS, SFY 2010 Experience Summary, Cost by Specialty and Grouping 2010.xlsx.
* Reflects State & Federal Expenditures
DRAFTValue Based Purchasing -Projected Cost Savings for Low 80% of Maine Care*
Range from 0.0-4.0% , Depending on type of service
Adult/Child
Disabled Other
Low 80% Total cost $ 262.4 $ 47.9 $ 25.3
Savings $ 6.0 $ 1.0 Unknown
With cost-savings measures, MaineCare could save more than $7.0 in its “Low 80%” population.
Source: DHSS, SFY 2010 Experience Summary, Cost by Specialty and Grouping 2010.xlsx.
* Reflects State & Federal Expenditures
DRAFTPotential Savings (State and Federal expenditures) for Reducing Number of Neonates
Base Admits
Base Spending
Redistributed* Admits
Redistributed* Spending
Normal newborns
3,316 $ 3,750,451 3,887 $ 4,396,035
Neonate 2,854 $ 21,620,671 2,283 $ 17,296,537
TOTAL 6,170 $ 25,371,121 6,170 $ 21,692,571
Neonate % 46%** 37%
Savings from redistributio
n$3,678,550
* Redistributed = If able to prevent 20% of each type of neonate** For comparison, Indiana rates are 17% and Michigan rates are 27%
Source: Maine, SFY 2010, DHHS, admits.xlsx, 2012.
DRAFT
Current Initiative: Emergency Department Project
• MaineCare is working with hospital emergency departments across the State to:• Identify high utilizers• Identify drivers of high utilization• Collaborate with identified member’s
healthcare providers to encourage utilization in more appropriate treatment settings
DRAFT
Emergency Room Utilization Maine – SFY2012
Source: DHHS, 2012.
Number of Visits Individuals Visits Average Visits
0 202,117 - -
1 71,539 71,539 1.0
2 29,562 59,124 2.0
3 14,089 42,267 3.0
4 7,237 28,948 4.0
5-9 10,012 61,671 6.2
10-19 1,993 25,139 12.6
20+ 426 11,025 25.9
TOTAL 336,975 229,713
Less than 6% of the total population on MaineCare is using over 55% of the ER visits
DRAFT
Coordinated Quality Services for Vulnerable Populations
• Service cost for top 5% represents 54% of spending• Focus on preventing next 15% from
becoming the top 5%• Populations include:• Disabled non dual including low 80%• Waiver populations (DD & physically
disabled)• Non dual residential facilities• State funded populations-?• Exempt disabled children?
DRAFT
Intellectual Disability & Developmental Disability HCBS Waiver
Sources: Medicaid_1915(c)_Home _and_Community-Based_Service_Waiver_Participtants,_by_Type_of_Waiver.xls; statehealthfacts.org
Rank Average Expenditures per Waiver Recipient in FY 2009
(State and Federal Expenditures)
25th percentile $ 31,161
50th percentile $ 42,155
US average $42,896
75th percentile $ 51,199
90th percentile $ 68,478 Maine
average$77,736
-------------------------------
Potential savings for
Maine
$ 36M, if 90% percentile
In FY 2009
Lives: 3,904
Spent: $303M
DRAFT
Opportunities
• Provide members with ONE number to call• Provide aggressive case & disease management• Prevent disease progression, avoid
hospitalization and institutionalization• Integrate behavioral health care • Promote home & community based care over
institutionalized care• Continually and periodically re-evaluate clients to
assure service level is appropriate• Identify quality metrics, both process & outcome• Reduce waitlist
DRAFT
MLTSS for Individuals with Developmental Disabilities & Serious Mental Illness
• 8 States currently enroll adults with intellectual/developmental disabilities in a managed long term services & supports (MLTSS) capitated program▫ 4 of these States also enroll children with
developmental disabilities▫ 7 of these States enroll individuals in any
setting type (i.e., ICF/MR & HCBS waiver)
▫ 2 of these States deliver ICF/MR & waiver services outside the MLTSS program & DD enrollees receive all other services through MLTSS
• Persons with serious mental illness (SMI) are included in some programs but generally need to fall into one of the other population groups to be enrolled in MLTSS (i.e., person must have physical, intellectual/developmental or age-related disability in order to enroll)
50%50%
% of States with MLTSS Including DD
DD Not IncludedDD Included
50%50%
% of States with DD MLTSS That Enroll Children
Children EnrolledChildren Not Enrolled
Source: Truven Health Analytics, The Growth of Managed Long-Term Services & Supports (MLTSS) Programs: A 2012 Update. July 2012.
DRAFT
LTSS Carve-Outs
State Services Carved-Out
CA Private duty nursing
HI ICF/MR & MR waiver
MI Acute & medical
NY Primary & acute care
PA Primary & acute care
TX Pharmacy & nursing home to 120 days
TN Pharmacy & dental
WI Primary & acute care, Pharmacy
Source: Truven Health Analytics, The Growth of Managed Long-Term Services & Supports (MLTSS) Programs: A 2012 Update. July 2012.
DRAFT
Requirements for Vendor• Fiscal prudence• Predictable costs• Contain growth rate
• Provide high quality, coordinated & efficient care for recipients• Person-centered• Community integration• More choices
• Assure quality• Work with stakeholders to identify quality metrics and
hold vendors accountable for achievement• Align incentives for providers across services
• Essential providers• Minimum payment to providers
DRAFT
Capitation Features
•Full risk (all services ?)•Risk adjusted to account for institutional
vs. HCBS vs. diagnosis •Performance bonus for meeting quality
incentives•Withhold to assure that certain process
measures are achieved
DRAFT
Cost Distribution – High 5% (Non-Dual)State and Federal Expenditures – SFY 2010
Adult/Child Disabled Other
Hospital $ 120.5 $ 142.8 $ 11.5
Mental health $105.9 $ 68.2 $ 3.0
LTSS/Other $ 29.1 $209.2 $ 22.6
Physician $ 12.2 $ 14.9 $ 1.1
Pharmacy $ 18.7 $36.3 $ 1.8
All other $ 3.7 $ 9.2 $ 0.3
TOTAL $ 290.2 $ 480.6 $ 40.4
Lives 5,752 7,301 1,185
Source: DHSS, SFY 2010 Experience Summary, Cost by Specialty and Grouping 2010.xlsx.
DRAFT
Cost Distribution – Next 15% (Non-Dual)State and Federal Expenditures – SFY 2010
Adult/Child Disabled Other
Hospital $ 144.3 $ 31.2 $ 4.6
Mental health $55.6 $ 23.0 $ 1.7
LTSS/Other $ 26.4 $19.9 $ 3.8
Physician $ 32.2 $ 8.7 $ 1.2
Pharmacy $ 40.0 $26.8 $ 1.6
All other $ 11.2 $ 3.8 $ 0.3
TOTAL $ 309.8 $ 113.4 $ 13.2
Lives 29,185 9,845 1,845
Source: DHSS, SFY 2010 Experience Summary, Cost by Specialty and Grouping 2010.xlsx.
DRAFT
Capitation for MaineCare’s Top 20%• Cost savings estimates for High 5% range from 2.0-7.5%• Cost savings estimates for Next 15% range from 1.0-5.0%
* Estimates are State & Federal
Adult/Child
Disabled Other
Top 5% Total Cost $ 290.2 $ 480.6 $ 40.4
Savings $ 14.1 $ 18.7 Unknown
Next 15% Total Cost $ 309.8 $ 113.4 $ 13.2
Savings $ 9.6 $ 3.5 Unknown
TOTALTop 20%
Total Cost $ 519.0 $522.0 $53.6
Savings $ 23.7* $22.2* UnknownWith cost-savings measures, MaineCare could save more
than $45.9 in its “Top 20%” population.
Source: DHSS, SFY 2010 Experience Summary, Cost by Specialty and Grouping 2010.xlsx.
DRAFT
Implementation Timeline & Issues• Planning & development of waiver• Waiver approval process• Development of RFP & contracting
process• Claims system• DHHS must be able to obtain claims data
from MCOs/ACOs/PACE or other vendor• 18-24 months
DRAFT
Effective Use of Services
•Assure that services are used appropriately
•Reduce waste and inefficiency•Promote quality•Create financial incentives for providers
to achieve quality benchmarks
DRAFT
Effective Use of Services: Strategy
• Reimbursement Strategy• Bed hold days• Readmissions within 7 days:• ME does not reimburse for readmits within
72 hours• Hospital acquired conditions• New policy aligns with Medicare
• Elective C-Section before 39 weeks• Radiology Benefits Manager• Transportation broker (in process)• Behavioral health ????
DRAFT
Medicare HAC Policy• Medicare does not pay for: • The additional costs associated with hospital
acquired conditions (HAC)• “Never Events”
• Under the Affordable Care Act, the Medicare policies were applied to Medicaid with some minor deviations• Medicaid agencies can identify additional HAC
which will not be reimbursed by the State• MaineCare currently applies the Medicare
policies
DRAFT
Maryland’s Hospital Acquired Condition Program
Source: The Maryland Health Services Cost Review Commission - http://www.hscrc.state.md.us/init_qi_MHAC.cfm
• Implemented in 2009• Provides system of payment incentives based on a hospital’s actual number of
complications vs. statewide target rate• Hospital performance rates monitored & payment adjustments made annually based
on performance• Applies across all payers
Overview of Program
• Includes 49 HACs• Developed from list of 64 potentially preventable complications developed by 3M
Health Information SystemsList of HACs
• Hospitals with higher-than-average complication rates receive an overall decrease in payment rates & vice versa (risk-adjustments first made to account for any patient attributes)
• Methodology is revenue neutral; net increase in rates for better performing hospitals funded through reduction in rates for poor performing hospitals
• Annually adjust maximum penalty; was 1% of hospital revenue in FY 2012 & 0.5% in FY 2011
Methodology
• FY 2008: Incidence of HACs present in 53K of 800K inpatient cases totaling $500M in potentially preventable hospital payments
• FY 2009-10: 12% decrease in measured complication rates with associated costs of $62M• Portion may be attributable to hospital coding changes in addition to the new
reimbursement system
Outcomes
DRAFT
Potentially Preventable Readmissions
• Potentially preventable readmissions are hospital readmissions occurring within a short time period that could have reasonably been expected to be prevented through:• Effective use of discharge planning• Coordinated follow-up care
• Nationally 20% of patients are readmitted within 30 days of discharge• Estimated to cost $25B annually
Source: Community Catalyst, Overview: Model Legislation to Reduce Potentially Preventable Readmissions & Complications; October 2011.
DRAFT
Potentially Preventable Readmissions: State Examples
New York Massachusetts
• Effective 7/1/10• Projected $47M in savings 7/10-
3/11• Reduce hospital’s payment based
upon the excess number of potentially preventable readmissions (PPRs)
• Applies to PPRs within 14 days• Excess readmission rate is
difference between observed rate & expected rate
• For excess readmissions, the hospital’s payment for all non-behavioral health related Medicaid discharges is reduced by applying the computed adjustment factor to the applicable case payment or per-diem rate
• Effective 10/1/11• Hospitals above the threshold for
readmissions received 2.2% reduction in their standard payment amount per discharge
• Penalty amount determined using 3M Potentially Preventable Readmission System
• 24 of 65 contracted hospitals were identified to have higher-than-average readmissions• Statewide average is adjusted
for severity of illness & hospital case mix
Sources: http://www.health.ny.gov/regulations/recently_adopted/docs/2011-02-23_potentially_preventable_readmissions.pdf & http://commonhealth.wbur.org/2011/09/hospitals-face-
financial-penalties-for-preventable-readmissions.
Potentially Preventable Readmissions: Medicare Policy• The ACA created the Medicare Hospital Readmissions Reduction Program• Targets readmissions:
• Acute Myocardial Infarction (AMI), Heart Failure (HF), and Pneumonia (PN)• Readmission within 30 days of discharge
• Calculate excess readmission ratio for AMI, HF, and PN• Includes adjustment factors that are clinically relevant (i.e. patient demographics,
comorbidities, patient frailty, etc.)• Measure of a hospital’s readmission performance compared to the national average• Utilizes risk adjustment methodology endorsed by National Quality Forum (NQF)
• Effective 10/1/12: Maximum penalty is 1% of base Medicare reimbursements• October 2013: Increases to 2%• October 2014: Increases to 3%
• 71% of hospitals reviewed to be penalized• 2,217 hospitals nationwide to receive penalties• 1,910 hospitals to receive penalties <1%
• $280M in total penalties• Comprise approximately 0.3% of total amount hospitals are reimbursed by
MedicareSources: http://www.kaiserhealthnews.org/Stories/2012/August/13/medicare-hospitals-
readmissions-penalties.aspx; CMS, Readmissions Reduction Program, 2012.
DRAFT
DRAFT
MaineHospital Admissions & Readmissions
# Initial Admit
s
# Readmit
s
Total # Admits
Initial Admits
Paid
Readmits Paid
Total Admits
Paid
Readmit Rate
(Maine, 2010)
Readmit Rate
(US, 2007)
Behavioral health
3,618 1,645 5,263 $59.7 $31.9 $91.645%
SA = 20.7%MD = 57.2%
SA = 12.3%MD = 11.9%
Maternity 5,947 462 6,409 $30.1 $2.2 $32.3 7.8% 3.8%
Newborn 5,943 227 6,170 $24.6 $0.8 $25.4 4% 2.6%*
Medical/Surgical
10,480 2,259 12,739 $136.5 $30.1 $166.6 21.6% 10.7%
TOTAL 25,998 4,593 30,581 $250.9 $65.0 $315.9
Sources: Maine DHHS, October 2010 – September 2011 Hospital Claim Experience, 2012; AHRQ, All-Cause Hospital Readmissions among Non-Elderly Medicaid Patients,
2007, 2010.
* This rate is for children under 1 year of age
If Maine could cut medical/surgical readmission rates in half, the program would save $15.0
million (State and Federal expenditures).
DRAFT
Elective Inductions Prior to 39 Weeks
State Example: Ohio
• Put a “hard stop” to elective inductions prior to 39 weeks gestation
• Savings gained from:• Shorter labors• Reduced c-section rate• Better birth outcomes
• Potential savings: $850K State & Federal1
• Challenges• How to implement?• OH & UT required hospital to
enter week’s gestation in order to schedule induction
• PA as potential alternative
Estimated Savings
Induction Rate Prior to Pilot
Induction Rate Post
Implementation
$10M 25-30% 0-2.5%
1 MaineCare has ~5,400 births/yr. Estimated 25% elective induction rate. Reduction to 2.5% assumed.
Source: DHHS, 2012.
DRAFT
Radiology Cost Control
• State strategies for containing radiology costs & ensuring the appropriate delivery of services have included:• Radiology Benefit Managers• Clinical decision support models• Real-time online interactive PA
DRAFT
Radiology Cost ControlRadiology Benefits Management (RBM)• Role: • To ensure imaging needed for potential
diagnosis• Pros: • Potential utilization & cost reductions of 8-20%• Successful RBM programs could save $13-24
billion by 2020 • Cons: • Costs shifted to providers• Getting prior authorization for all imaging
services places administrative burden on providers
Sources: CaretoCare, Achieving Cost Savings and Patient Safety through Radiology Benefit Management, 2010; Magellan Health Services, Independent study estimates significant savings to Medicare through RBM programs, 2011; Lee, Rawson, & Wade, Radiology benefit managers:
cost saving or cost shifting?, 2011.
DRAFT
Radiology Benefits Manager: North Carolina
Source: North Carolina Department of Health & Human Services - http://www.ncdhhs.gov/dma/services/radiology.htm
• NC operates a statewide PCCM Program• Implemented a RBM in 2009• All PAs handled through RBM & appeals handled by StateOverview• All outpatient, non-emergent, diagnostic imaging services
including:• CT• MR• PET• Ultrasound
Services requiring PA
• Inpatient• Emergency Room• 23 Hour Observation
Services not requiring PA
• Duals• Enrollees with TPL• PACE• Family Planning Waiver• SCHIP
Populations excluded
DRAFT
Radiology Cost ControlClinical Decision Support• Clinical decision support (CDS) is an alternative to
utilization reviewers & Radiology Benefit Managers• “Clinical decision support (CDS) is the use of health
IT to provide clinicians and/or patients with clinical knowledge and patient-related information, intelligently filtered or presented at appropriate times, to enhance patient care. (HRSA)”
• Providers guided to order the appropriate test through an interactive electronic question set vs. receiving a PA denial
• Can be integrated into EHRs or accessed via the Web
http://www.diagnosticimaging.com/practice-management/content/article/113619/1750408 http://www.diagnosticimaging.com/radblog/display/article/113619/1932985
http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/EvaluatingOptimizingandSustaining/decisionsupport.html
DRAFTClinical Decision Support for Radiology: Minnesota• Minnesota implemented CDS pilot
in 2007 & expanded as statewide option in 2010
• Implemented by Institute for Clinical Systems Improvement (ICSI)• Non-profit organization
representing 64 medical groups & sponsored by 5 health plans
• Implemented clinical criteria based on American College of Radiology standards
• Review is given in real-time & “decision support number” is given & required to process the claim
http://www.diagnosticimaging.com/practice-management/content/article/113619/1750408 http://www.diagnosticimaging.com/radblog/display/article/113619/1932985
•Over ½ of all scans in MN are ordered
through this process•Increase in scans
ordered•2003-2006: 8%•2007-2012: 1%
•Time expended by medical group staff
•Pre-pilot: 308 hrs•Post: 5 hrs
•None of the 4,500 pilot
practices requested return to traditional
PA when pilot concluded
DRAFT
Radiology Clinical Decision Support: State Example• April 2011: New York Medicaid
implemented a collaborative, non-denial Radiology Benefits Manager
• Applies to outpatient non-emergency advanced imaging for FFS• Duals & MCO enrollees
excluded• Utilize RadConsultTM
• Provides peer consultation & evidence-based medical criteria
http://www.health.ny.gov/health_care/medicaid/program/update/2011/jan11mu.pdf http://www.healthhelp.com/dr-hiatt/detail/collaborative-utilization-management-of-advanced-
diagnostic-imaging-for-med
•5% reduction inadvanced diagnosticimaging•Consults per 1,000 members:
•June 2011: 89.58%•Feb 2012:
85.53%
DRAFTReal-Time Online Interactive Radiology PA: State Example
• Iowa Medicaid implemented Clear Coverage (a McKesson product)
• Online interactive PA system using InterQual criteria for certain elective outpatient radiology tests
• PA not required for inpatient or ER procedures
• Requests that meet criteria are automatically approved in real-time
Provider answers questions on patient’s health status on web-based
program
Program utilizes InterQual criteria to identify what imaging studies are
medically appropriate
Program identifies which imaging studies require PA
Program identifies what level of benefits are available
Sources: http://www.ime.state.ia.us/Providers/PriorAuthorization.html & McKesson, Iowa Medicaid Enterprise & IFMC: Automatic Prospective Utilization Management of Diagnostic
Imaging at the Point of Care, 2011.
DRAFT
Iowa’s Radiology Management: Outcomes
• The program achieved cost savings within 10 months• Annual estimated savings of
$2.4M attributed to:• $1.3M due to physicians
canceling requests found non-medically appropriate
• $0.6M due to denials• $0.5M vs. adding 7 full-time
employees for manual PA reviews
• The volume of manual reviews has been reduced
Of 50,ooo PA requests:• 40%: Instant automated approval• 8%: Cancelled by provider when
notified clinical evidence not aligned with request• 4%: Denied as medically inappropriate
Sources: http://www.ime.state.ia.us/Providers/PriorAuthorization.html & McKesson, Iowa Medicaid Enterprise & IFMC: Automatic Prospective Utilization Management of
Diagnostic Imaging at the Point of Care, 2011.
DRAFT
Federal Waivers• Waiver authority• Dependent on strategy• What populations• What method is being used• Managed care• Other?
• What flexibilities are needed?• Statewideness• Mandatory/Voluntary enrollment• Defined network, limited choice of contractors• Benefits
• Timing (length of approval process)• Budget tests• Budget neutrality• Cost effectiveness
DRAFT
Stakeholder Submissions
•1) Integrated chronic care management for high cost cases, 1915 waiver populations
•2) Independent administration of HCBS, children ID/DD,& Adults in LTC
•3) Population Based Integrated Services Model for Medicaid Eligible Individuals with a Serious Mental Illness and Chronic Co-Morbid Medical Conditions
•
Long-Term Strategies Summary
ItemCurrent Initiativ
e
State & Federal Savings
State Savings
Investment in primary care
Value-based purchasing $5.2M $1.98M
Value-based purchasing with risk $7.0M $2.66MReduce neonates & Increase normal
births$3.7M $1.41M
ER utilization X
Coordinated, quality services for Maine’s most vulnerable citizens
Capitation $45.9M $17.44M
Effective & efficient use of services
Readmissions $15.0M $5.7M
HAC X
Elective Inductions $850K $323K
Radiology X
DRAFT
Authorities for Managed CareAuthority Description Limitations
Section 1115
Gives Secretary of HHS broad authority to approve
demonstration programs that test innovative Medicaid policy.
Proposal must be truly innovative, not simply
replicating an idea already demonstrated elsewhere.
Section 1915(a)
Statutory authority to enter into contracts with
organizations to provide services already offered under
the state plan.
Voluntary enrollment only;Existing services only;Number of qualified
contractors may not be limited.
Section 1915(b)Waiver authority for mandatory
enrollment in managed care.
With exceptions for rural areas, must offer at least 2
options.
Section 1932(a)Statutory authority for
mandatory enrollment in managed care.
Certain groups are exempted from mandatory enrollment;
with exceptions for rural areas, must have at least 2 options.
Exempted groups include:• Special Needs Children• American Indians/Alaskan
Natives• Dual EligibleSource: L&M Policy Research, MLTSS Federal Authorities.
DRAFT
Authorities for Long Term Services & SupportsAuthority Description Limitations
Section 1915(c)
Waiver authority to offerHCBS to beneficiaries who would
otherwise meet institutionallevel of care.
Beneficiary must meetinstitutional level of care.
Section 1915(i)
Statutory authority to offer HCBS as a state plan service, whether or not
a beneficiary meets institutional level of care.
State may not limit the number of eligible participants or have a
waiting list. Service must be offered statewide.
Section 1915(j)
Statutory authority to offer self-directed personal assistance
services option in a 1915(c) waiver program, or under state plan personal assistance services.
Not a service authorization per se, but rather a delivery option for
services otherwise provided under the state plan.
Section 1915(k)
Statutory authority to offer attendant services and supports
controlled by the beneficiary (Community First Choice Option).
State may not limit the number of eligible participants or have a
waiting list. Service must be offered statewide.
Other State Plan Services
States must offer certain services (such as nursing home and home
health) and may offer optional services (such as personal care and
targeted case management).
State plan services must be offered to all eligible beneficiaries without waiting lists. Services must be
offered statewide.Source: L&M Policy Research, MLTSS Federal Authorities.
DRAFT
Authorities for MedicareAuthority Description Limitations
Section 1859
Statutory authority for Medicare Advantage
plans to create specialty plans targeted to special
needs individuals, including those who are
dually enrolled in Medicare and Medicaid.
Voluntary enrollment only; authority applies to Medicare Advantage plans (not to the State Medicaid agency); all Medicare Advantage rules must be met.
Sections 1894 and 1934
Statutory authority to offer PACE, which
combines Medicare and Medicaid services.
Voluntary enrollment only; PACE model only.
Section 1115A
Gives Center for Medicare and Medicaid
Innovation broad authority to test
innovative models that decrease costs and
maintain or improve quality.
Proposed model must be innovative and fit within the statutory priorities of CMMI (Center for Medicare & Medicaid Innovation) at CMS.
Source: L&M Policy Research, MLTSS Federal Authorities.
DRAFT
Developmentally Disabled & SMI LTSS: State Examples
State PopulationsMedicaid Authority
Geographic Reach
Mandatory or Voluntary
Services included in Capitation
Outcomes
AZ •Children•Adults < 65with PD •Adults < 65 with ID/DD•Adults 65+
1115 Statewide Mandatory •Primary •Acute •Behavioral •Rx Drugs •NF •ICF/MR •HCBS waiver- like services
Peer reviewed study found substantial cost savings & nursing home avoidance.
MI •Children & adults withintellectual/development
aldisabilities •Children
withserious emotional disturbance
•Adults withSMI
1915(b) & 1915(c)
Statewide Mandatory • Behavioral• NF• ICF/MR• Personal care• Targeted case management• HCBS waiver for persons with DD
Carve-outs: primary & acute medical services & prescription drugs.
No formal evaluation conducted
DE •All SSIchildren &adults
exceptICF/MR & inDDMR
1915(c)
1115 Statewide Mandatory •Primary •Acute •Behavioral •NF •HCBS waiver- like services
Carve-out: Rx Drugs
N/A: recently implemented
Source: Truven Health Analytics, The Growth of Managed Long-Term Services & Supports (MLTSS) Programs: A 2012 Update. July 2012.
DRAFT
State PopulationsMedicaid Authority
Geographic Reach
Mandatory or Voluntary
Services included in Capitation
Outcomes
WA •Adults 21-64
with SSI•Adults 65+
1932(a) 1 of 39 counties
Voluntary
Note: people with DD receiving Medicaid personal care receive all services through WMIP except for certain services provided by the DDD (i.e., supported employment) Those receiving LTSS through DDD waivers receive their medical, mental health and chemical dependency services through WMIP, but continue to receive waiver services through the DDD waivers .
• Primary• Acute• Behavioral• Rx• NF (up to 6 mos, then no longer at risk)• Community based services
2010 Evaluation: Medicaid cost savings not demonstrated. Mortality rates & inpatient hospital admissions somewhat lower (no statistical significance found). Significantly lower growth in prescriptions for mental illness.
Sources:“WMIP: Medical Care, Behavioral, Health, Criminal Justice, and Mortality Outcomes for Disabled Clients Enrolled in Managed Care,” David Mancuso, Melissa Ford Shah, Barbara Felver, Daniel Nordlund, Washington Department of Social and Health Services,
Research and Data Analysis Division, December 2010 & Truven Health Analytics, The Growth of Managed Long-Term Services & Supports (MLTSS) Programs: A 2012 Update. July 2012.
Developmentally Disabled & SMI LTSS: State Examples
DRAFT
State PopulationsMedicaid Authority
Geographic Reach
Mandatory or Voluntary
Services included in Capitation
Outcomes
WI • Adults <65
with PD or ID/DD•Adults 65+
1915(b) & 1915(c)
57 of 72 counties
Voluntary – Opt In
• Behavioral health not provided inpatient or by physician• NF• ICF/MR• Personal Care• HCBS
Carve-outs: Primary & acute medical care & Rx HCBS waiver services only available to members with nursing home LOC
2011 Evaluation: Several MCOs with operating deficits; 3 identified at risk of insolvency. Improved access to long-term care. Cost-effectiveness determined difficult to assess.
Sources:. “An Evaluation: Family Care” 2011-2012 Joint Legislative Audit Committee, Report 11-5, April 2011 . Truven Health Analytics, The Growth of Managed Long-Term Services & Supports
(MLTSS) Programs: A 2012 Update. July 2012.
Developmentally Disabled & SMI LTSS: State Examples
DRAFT
State PopulationsMedicaid Authority
Geographic Reach
Mandatory or Voluntary
Services included in Capitation
Outcomes
PA Targets autism only
1915(a) 4 of 67 counties
Voluntary – Opt In
• Primary• Behavioral health• Dental• ICF/MR• Targeted case management• Adult day• OT/PT/ST
Carve-outs: inpatient, ambulatory surgical center, home health, clinic, transportation, renal dialysis, lab, x-ray, Rx
No formal evaluations
NC Children & adults with SED, DD, mental illness or substance abuse
1915(b) & 1915(c)
Scheduled to be Statewide in 2013
Mandatory •Inpatient & outpatient behavioral health• PRTF• ER visits for
BH• ICF/MR• HCBS for DD• Therapeutic
foster care• Residential
child care
No formal evaluations
Source: Truven Health Analytics, The Growth of Managed Long-Term Services & Supports (MLTSS) Programs: A 2012 Update. July 2012.
Developmentally Disabled & SMI LTSS: State Examples
DRAFT
StateDate of
InceptionMedicaid Authority
Geographic Reach
Mandatory or Voluntary
Services included in Capitation
Outcomes
HI •Children•Adults
<65 with PD•Adults
<65 with
ID/DD•Adults
65+
1115 Statewide Mandatory •Primary •Acute •Behavioral
•Rx Drugs • NF • DD/ID Waiver Enrollees must enroll in one of the 2 plans but waiver services carved-out & provided by Dept. of Health• Additional BH services for adults with SMI or children with SED excluded from cap rates
No formal evaluation conducted yet
Source: Truven Health Analytics, The Growth of Managed Long-Term Services & Supports (MLTSS) Programs: A 2012 Update. July 2012.
Developmentally Disabled & SMI LTSS: State Examples
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