Managed Care - EFE

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June 27, 2012
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Presented by:
Melissa O. Picciola,
Equip for Equality

The concept of managed care in the Medicaid
context is no different than in the private
insurance market
◦ A.K.A. Coordinated Care, Integrated Care

Most states have a Medicaid Managed Care
program (all but Alaska, New Hampshire,
Wyoming)
◦ 71% of the Medicaid population (and growing)
◦ Until recently, people with disabilities were not
widely included in Managed Care programs
◦ Recent Federal support (CMS, ACA)

Capitated, Full-Risk
◦ Managed Care Organization (MCO) is paid fixed
monthly premium per member and assumes fullrisk for delivery of services (PMPM)

Non-Capitated
◦ Providers are paid an additional fee for coordinating
care for members

Other Models
◦ Partial Risk
◦ Managed Care Community Networks (MCCN)

In January 2010, the Illinois Legislature
passed a Medicaid Reform Bill.
◦ Requires that 50% of Medicaid clients be enrolled in
coordinated care programs by 2015
◦ Coordinated Care defined broadly to include either
capitated, full-risk payment or other risk-based
payment arrangements
 Not just traditional managed care companies, but also new alternative models of
care organized and managed by hospitals, Physician groups, Federally Qualified
Health Centers (FQHC) or social service organizations
◦ Requires payments to be made based on
performance related to health outcomes
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HFS created Innovations Project to comply
The Innovations Project consists of several phases
through which the State seeks a redesigned health
care delivery system that is more patient-centered
with a focus on improved health outcomes,
enhanced patient access, and patient safety.
To achieve these goals, the State seeks entities to
coordinate care across the spectrum of the
healthcare system with a particular emphasis on
managing transitions between levels of care and
coordination between physical and mental health
and substance abuse.


Integrated Care Program
Phase I of the Innovations Project
◦ Coordinated Care Entities & Managed Care
Community Networks: statewide


Medicaid-Medicare Alignment Initiative
Others:
◦ Children?
◦ Voluntary MCOs
◦ Primary Care Case Management

Implemented May 2011 for adult Medicaidonly enrollees known as Aged, Blind, Disabled
◦ Adults with disabilities and older adults not
enrolled in Medicare
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Two companies selected: Aetna and IlliniCare
Service Package I includes all acute medical
and behavioral healthcare
Service Package II & III: Includes all long
term-care and waiver services
◦ To be implemented Fall 2012

Solicits proposals from Coordinated Care
Entities and Managed Care Community
Networks to coordinate care for Medicaid
individuals
◦ Must include portion of AABD Population
◦ Statewide initiative, not including ICP clients
◦ Voluntary enrollment with 12 month lock-in

Will award 10 contracts in Cook County and
10 Contracts outside of Cook County
◦ Received 75 letters of intent in February 2012
◦ Proposals due June 15, 2012

Provider groups and other organizations: must include PCPs,
hospitals, mental health and substance abuse providers
◦ May include others and offer other services outside of care coordination

Receives enhanced fee for care coordination
◦ Does not assume full risk
 Medical services remain Fee-For-Service
 Proposal must be cost-neutral over 3 years
◦ 3 financial models available:
 Care Coordination Fee: PMPM fee
 Shared Savings: Over baseline established by HFS/CMS
 Other Payment methodology: Proposed by CCE

Only for adults already enrolled in Illinois Health Connect
◦ 1.8 million adults as of May 2012

Entity, other than HMO, that is owned, operated, or governed
by providers and provides all Medicaid-covered services
◦ May include others and offer other services

Full-risk, capitated payment
◦ Assume full-risk for all acute medical and behavioral healthcare
 May include dental and pharmacy
 May include long-term care and waiver services

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Enrollees do not have to be enrolled in Illinois Health
Connect, but may be
HFS has filed proposed rules amending the financial
requirements for a MCCN
◦ Essentially lowering financial thresholds and allowing HFS to limit
enrollment

Up to 5 (at least 2), risk-based contracts
awarded to HMOs and MCCNs to provide all
Medicare and Medicaid Covered Services to
dual-eligibles
◦ Individuals with Developmental Disabilities that receive services in an
institutional setting or through a HCBS waiver are excluded
◦ Excludes those already enrolled in CCE or MCCN
◦ Full-risk, capitated payment
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Implementation by January 2013
Greater Chicago and Central Illinois
◦ 2 separate solicitations

Enrollment is Passive, but voluntary
◦ No lock-in period; i.e. can disenroll at any time

Studies have shown that managed care
models have had positive impact on access
and continuity of care while reducing overall
medical costs
◦ Avoid unnecessary medical services
◦ Provide coordination and integration of services
 Decrease “silos”

Pay for Performance Measures and Bonus
Payments for achieving certain outcomes
◦ Encourages providers to be accountable and allows
states to set benchmarks
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Incentive to care for the whole individual
◦ Focus on overall health and prevention

Prompt Provider Payment!
◦ More predictable costs for Illinois

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Encourage use of home and communitybased alternatives to institutional care
Providing individualized case management
services and disease management services
◦ For some individuals, for the first time in their lives

Little to no evidence and no model regarding
managed care for people with disabilities
◦ Particularly those with developmental disabilities
and others who require long-term care

Medical Model v. Person-Centered Model
◦ Treated as a diagnosis and not as a person
◦ Care is already coordinated by the individual
◦ Loss of consumer control

Problems with access and disruptions of care
◦ Especially in early stages of program
◦ ICP experienced problems with hospital network
◦ Access to specialists may be restricted

Prior Authorization and Utilization Review
translate into restricting benefits
◦ Cost savings are realized through restriction of
services

Increased bureaucracy at every stage
◦ State shifts responsibility for program

How will long-term care services be
integrated?
◦ Personal Assistant services and SEIU contract
◦ Will those living in institutions really be given a
choice?

How does this affect Illinois’ stated
commitment to rebalancing?
◦ Will causing MCOs to contract with institutional
providers create a conflict of interest that will
prevent rebalancing?

How does managed care interact with
Williams, Ligas, and Colbert?
◦ HFS has so far been vague but offered assurances
that individuals will not be denied any services to
which they are entitled.

How will recent changes to the Medicaid
program affect the ICP and subsequent
programs?
◦ Additional restrictions on benefits
◦ Prior Approval Process

Continue to be diligent and educated
advocates
◦ Stay informed and know what changes will affect
individuals
◦ Be ready to pursue grievance and appeals when
services are denied or restricted
◦ Become involved in consumer advisory councils and
know who to call with questions and concerns

CMS Innovations Dual Eligible
Demonstrations
◦ http://www.innovations.cms.gov/initiatives/StateDemonstrations/index.html

HFS Care Coordination Innovations Project
◦ http://www2.illinois.gov/hfs/PublicInvolvement/cc/
Pages/default.aspx

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