LTSS Integration in Health Plans and Health Systems Long-Term Quality Alliance Annual Meeting September 19, 2014 UnitedHealthcare’s Experience • UnitedHealthcare Community & State serves more than 4 million members in Medicaid and Medicare programs • We have responsibility for MLTSS in half of our states – Nearly all have integrated approaches to LTSS 2 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. Integrating LTSS in managed models • Integrating social and functional services that are at the core of LTSS is fundamental to a managed approach to LTSS • The most effective models integrate comprehensive benefit design • An ability to leverage benefit flexibility is vital to an integrated model 3 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. Health plans don’t have to do it all AAAs Community resources should be leveraged to maximize resources and expertise HHs CILs ACOs The key is to not replace fragmentation with more fragmentation 4 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. Our role as the integrator • The health plan has a key role in establishing the foundation to ensure integration • Health plans should fill in gaps, remove barriers, and support system transformation without unnecessarily replacing services provided by experienced organizations • Relationships between entities should be unique and leverage the strengths of each organization • Program payment – including downstream payments – should ensure adequate funding to fuel innovation while aligning incentives to improve member experience and outcomes 5 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. AETNA MEDICAID LTSS Integration in Health Plans and Health Systems Fragmented Expenditures for LTSS $192 Billion AETNA MEDICAID Aetna Inc. 7 Aetna’s LTSS Integrated Care Goal De fragmentize care whenever possible Include management and support across the care continuum • LTSS • HCBS → in-home or alternative residential facility • Nursing Facility (NF) • Medical • Behavioral • Coordination of non-covered services and supports AETNA MEDICAID Aetna Inc. 8 Integrated Care Strategy: Person Centered Care Individualized case manager Face-to-face assessment - Bio-psychosocial needs - Personal preferences - Identification of supports - Condition specific assessment as needed Develop collaborative goals to support - member needs - personal preferences - care provided by family/others (unpaid care) AETNA MEDICAID Aetna Inc.9 9 Guiding Principles for Person Centered Integrated Care Integrated, holistic approach Support member in the least restrictive environment Early intervention early when changes occur Facilitate effective transitions between systems of care Engage members early, recognizing strengths, capacities while addressing critical physical, behavioral, environmental and social needs Employ evidence based practices to create optimal outcomes for members Provide access to a continuum of care, based on complexities of individual member needs Support, not supplant informal supports (self directed care) AETNA MEDICAID Aetna Inc. 10 Aetna’s Integrated Person Centered Care Model LTSS and Behavioral Health Networks Non-covered Community Resources Medical Networks Case Manager Quality Management Member / Case & Families Caregivers Pharmacy Local Transition & Diversion Programs Grievances & Appeals Network and Provider Services 11 Opportunities to Mitigate Challenges • Early intervention for change in condition/circumstances • Member driven integrated care teams • Person centered plan of care • Back up/contingency plans • Risk mitigation agreements • Cost effectiveness studies AETNA MEDICAID Aetna Inc. 12 AETNA MEDICAID Aetna Inc. 13 Barriers to ACO-LTSS Integration Terrence A. O’Malley, MD Massachusetts General Hospital Partners HealthCare System, Inc. What we have here… Is a failure to Communicate • PHS is not ready to listen to LTSS • Focused instead on learning to be an ACO – – – – Governance IT integration Primary Care infrastructure Management of High Risk patients • Not sure LTSS have anything to say – No compelling data on the “value” of LTSS – No quantitative impact on readmissions, VBP – Most LTSS providers don’t know the cost of services ACO patients who need LTSS • Individuals with complex medical, behavioral, functional and social needs • High cost/High Risk: Duals, Medicare >6 chronic conditions, Chronically mentally ill • Receive care from multiple providers, in multiple sites across prolonged episodes of care • Require attention to transitions of care, longitudinal coordination of care, medication management and referral management • Share a common pattern: High admission rates, High ER use, High LTPAC use, High impact of the social determinants of health such as housing, transportation, home based supports. Building a common IT platform • IT integration of LTSS with the rest of health care providers requires five components: – An electronic highway that connects all parties – Low cost access ramps to the highway for those without EHRs and millions to spend – Trucks to carry the information reliably between sites – Cargo to put in the trucks, ie information, that is valuable to the sites and standardized so it can be used everywhere – A compelling business case for this exchange Putting the Pieces Together • Highways: HIE build-out continues across the country • On and Off Ramps: free, open source, Java based software which allows non-EHR users to send and receive standardized messages • New trucks: Consolidated CDA, the required health care data exchange standard stipulated in MU 2. A significant improvement in flexibility • High value cargo: standardized demographics, functional status, cognitive status, nutritional needs, treatment plans, medication lists, care plans • The business cases: what does LTSS know that ACO providers need to know? What do ACO providers know that LTSS needs?